PsychReview

TYPESOFTREATMENTMODALITIES
A.Milieutherapy
1. The planned use of people, resources, and activities in the environment to assist in improving
interpersonalskills,socialfunctioning,andperformingtheactivitiesofdailyliving
2. The focus is on the here and now (i.e., assisting the client in dealing with the realities of today
ratherthanfocusingonsituationsandbehaviorsofthepast).
3.Ituseslimitsetting.
4.Itinvolvestheclientinmakingdecisionsaboutherorhisowncare.
5. It uses activities that support group sharing, cooperation, and compromise (e.g., unitgoverning
groups). 6. Nursing interventions support client privacy and autonomy and provide clear
expectations.
B.Behaviormodification
1. This process is used to change ineffective behavior patterns; it focuses on the consequences of
actionsratherthanonpeerpressure.
2.Positivereinforcementisusedtostrengthendesiredbehavior(e.g.,aclientispraisedorgivena
tokenthatcanbeexchangedforatreatordesiredactivity).
3. Negative reinforcement is used to decrease or eliminate inappropriate behavior (e.g., ignoring
undesirablebehavior,removingatokenorprivilege,givingatimeout).
4.Rolemodelingandteachingnewbehaviorsareimportantinterventions.
C.Familytherapy
1.Thisformofgrouptherapyidentifiestheentirefamilyastheclient.
2.Itisbasedontheconceptofthefamilyasasystemofinterrelatedpartsformingawhole.
3.Thefocusisonthepatternsofinteractionwithinthefamily,notonanyindividualmember.
4.Thetherapistassiststhefamilyinidentifyingtherolesassignedtoeachmemberbasedonfamily
rules.
5.Lifescripts(livingoutparentsdreams)andselffulfillingprophecies(unconsciouslyfollowingwhat
onethinksshouldhappen,thereforesettingituptohappen)areidentified.
6.Congruentandincongruentcommunicationpatternsandbehaviorsareidentified.
7.Thegoalistodecreasefamilyconflictandanxietyandtodevelopappropriaterolerelationships.
D.Crisisintervention
1. This form of therapy is directed at the resolution of an immediate crisis, which the individual is
unabletohandlealone.
2.Acrisismaydevelopwhenpreviouslylearnedcopingmechanismsareineffectiveindealingwith
thecurrentproblem.
3.Theindividualisusuallyinastateofdisequilibrium.
4.Ifaclientisinapanicstateasaresultofthedisorganization,beverydirective.
5.Focusontheproblem,notthecause.
6.Identifysupportsystems.
7.Identifyfastcopingpatternsusedinotherstressfulsituations.
8.Thegoalistoreturnindividualtoprecrisisleveloffunctioning.
9.Crisisinterventionisusuallylimitedto6weeks.
E.Cognitivetherapy
1.Itisdirectedatreplacingaclientsirrationalbeliefsanddistortedattitudes.
2.Itisfocused,problemsolvingtherapy.
3.Thetherapistandclientworktogethertoidentifyandsolveproblemsandovercomedifficulties.
4.Itisshorttermtherapyof2to3monthsduration.
5.Itinvolvescognitiverestructuring.
F.Electroconvulsivetherapy(ECT)

1.Itinvolvestheuseofelectricallyinducedseizuresforpsychiatricpurposes.Itisusedwithseverely
depressedclientswhofailtorespondtoantidepressantmedicationsandtherapy.Itmaybeusedwith
extremelysuicidalclientsbecause2weeksareneededforantidepressantstotakeeffect.
2.NursingcarepriortoECT
a.Prepareclientbyteachingwhatthetreatmentinvolves.
b.Avoidusingthewordshockwhendiscussingthetreatmentwithclientandfamily.
c.Ananticholinergic(e.g.,atropinesulfate)isusuallygiven30minutesbeforetreatmenttodry
oralsecretions.
d.Aquickactingmusclerelaxant(e.g.,succinylcholine[Anectine])isgiventoclientbeforethe
ECT.Thishelpstopreventboneormuscledamage.
e.Haveanemergencycart,suctionequipment,andO2availableintheroom.
3.NursingcareafterECT
a.Maintainpatentairway;clientisinanunconsciousstateimmediatelyfollowingECT.
b.Checkvitalsignsevery15minutesuntilclientisalert.
c.ReorientclientafterECT(confusionislikelyuponawakening).
d.CommoncomplaintsafterECTinclude:
(1)Headache
(2)Musclesoreness
(3)Nausea

G.Groupintervention
1.Thisprocessisusedwithtwoormoreclientswhodevelopinteractiverelationshipsandshareat
leastonecommongoalorissue.
2.Thetypesofgroupsareasfollows:
a.Thegroupmaybeclosed(setgroup)oropen(newmembersmayjoin).
b.Thegroupmaybesmallorlarge(>10members).
c.Therearemanytypesofgroups(psychoeducation,supportivetherapy,psychotherapy,self
help).
d.Commonnurseledinterventiongroupsincludethosethatfocusonmedications,symptom
management,angermanagement,andselfcare.
3.Thephasesingroupsareasfollows:
a.Theinitial,ororientation,phaseischaracterizedby:
(1)Highanxiety
(2)Superficialinteractions
(3)Testingthetherapisttoseeifheorshecanbetrusted
b.Themiddle,orworking,phaseischaracterizedby:
(1)Problemidentification
(2)Thebeginningofproblemsolving
(3)Thebeginningofthegroupsenseofwe
c.Theterminationphaseischaracterizedby:
(1)Evaluationoftheexperience
(2)Theexpressionoffeelingsrangingfromangertojoy
4.Theadvantagesofgroupsare:
a.Thedevelopmentofsocializingtechniques
b.Theopportunitytotrynewbehaviors
c.Thepromotionofafeelingofuniversality(i.e.,notbeingalonewithproblems)

d.Theopportunityforfeedbackfromthegroup,whichmaycorrectdistortedperceptionse.
Theopportunityforclientstolookatalternativewaysofanalyzinganddealingwithproblems
Anxiety Description: Anxiety is unexplained discomfort, tension, apprehension, or uneasiness, which occurs
whenapersonfeelsathreattoself.Thethreatmayberealorimaginedandisaverysubjectiveexperience.
LEVELSOFANXIETY
A.Mildanxiety
1.Isassociatedwithdailylife;motivateslearning
2.Producesincreasedlevelsofsensoryawarenessandalertness
3.Allowsforthoughtsthatarelogical;clientisabletoconcentrateandproblemsolve
4.Allowsclienttoappearcalmandincontrol
B.Moderateanxiety
1.Continuestomotivatelearning
2.Allowsclienttobeattentiveandabletofocusandproblemsolve
3.Dullsperceptionsofsensorystimuli;clientbecomeshesitant
4.Causesclientsspeechrateandvolumetoincrease;clientbecomeswordy
5.Causesclienttobecomerestless(frequentbodymovementsandgestures)
6.Maybeconvertedintophysicalsymptoms,suchasheadaches,nausea,ordiarrhea
C.Severeanxiety
1.Stimulatesfightorflightresponse
2.Causessensorystimuliinputtobedisorganized
3.Maycauseperceptionstobedistorted
4.Impairsconcentrationandproblemsolvingability
5.Resultsinselectiveattention,focusingononlyonedetail
6.Resultsintheverbalizationofemotionalpain(e.g.,Ineedhelp.Icantstandthis)
7.Causestremors,increasedmotoractivity(e.g.,pacing,wringinghands)
D.Panic
1. Causes perceptions to be grossly distorted; client is unable to differentiate real from unreal 2.
Causesclienttobeunabletoconcentrateorproblemsolve;causeslossofrational,logicalthinking3.
Causesclienttofeeloverwhelmed,helpless
4.Causeslossofcontrol,inabilitytofunction
5. Can elicit behavior that may be angry and aggressive or withdrawn, with clinging and crying 6.
Requiresimmediateintervention

GENERALIZED ANXIETY DISORDERS Description: Unrealistic, excessive, or persistent (lasting 6 months or

longer) anxiety and worry about two or more life circumstances. Previously learned coping mechanisms are

inadequate to deal with this level of anxiety. Multiple theories exist concerning cause, including (but not
limitedto)neurobiochemicalandpsychodynamictheories.
NursingAssessment
A.Severeanxiety
B.Motortension
1.Restlessness
2.Quicklyfatigued
3.Feelingsofshakiness
4.Tension
C.Autonomichyperactivity
1.Shortnessofbreath
2.Heartpalpitations
3.Dizziness
4.Diaphoresis
5.Frequenturination
D.Vigilanceandscanning
1.Difficultyconcentrating
2.Sleepdisturbance
3.Irritability,quicktobecomeangry
E.Onedge,appearanceofbeingnervous
F.Lowselfesteem
Analysis(NursingDiagnoses)
A.Anxietyrelatedto
B.Ineffectivecopingrelatedto
C.Disturbedsleeppatternrelatedto
D.Imbalancednutrition:lessthan/morethanbodyrequirementsrelatedto
NursingPlansandInterventions
A.Assessclientsoastorecognizeanxietyandlabelthefeeling(e.g.,Whatareyoufeelingnow?).
B.Helpclienttoidentifytherelationshipbetweenthestressorandthelevelofanxiety.
C.Provideopportunitiestolearnandtestvariousadaptivecopingresponses.
D.Encourageexercise,deepbreathingtechniques,visualization,relaxationtechniques,andbiofeedback.
E.Decreaseenvironmentalstimuli.
PANICDISORDERSANDPHOBIAS
A.Therearediscreteperiodsofintensefearordiscomfortthatareunexpectedandmaybeincapacitating.
B.Itischaracterizedbyanirrationalfearofanexternalobject,activity,orsituation.
C.Itisachronicconditionthathasexacerbationsandremissions.
D.Theclienttransfersanxietyorfearfromitssourcetoasymbolicobject,idea,orsituation.
E.Theclientrecognizesthatthefearisexcessiveandunrealisticbutcanthelpit.
CommonPhobias
A.Acrophobia:fearofheights
B.Agoraphobia:fearofcrowdsoropenplaces
C.Claustrophobia:fearofclosedinplaces
D.Hydrophobia:fearofwater
E.Nyctophobia:fearofthedark
F.Thanatophobia:fearofdeath

NursingAssessment
A.Copingstylesused(seeTable73):
1.Displacement
2.Projection
3.Repression
4.Sublimation
B.Autonomichyperactivity
C.Panicattacksthatusuallypeakat10minutesbutcanlastupto30minutes,withagradualreturntonormal
functioning
D.Disruptioninpersonallifeaswellasworklife
E.Possibleuseofalcoholanddrugstodecreaseanxiety
Analysis(NursingDiagnoses)
A.Ineffectivecopingrelatedto
B.Socialisolationrelatedto

NursingPlansandInterventions
A.Establishtrust;listen,useacalmapproachanddirect,simplequestions.Remainwithclient;donotleave
alone.
B.Provideasafeenvironment.
C.Drawclientsattentionawayfromfearedobjectorsituation.
D.Discusswiththeclientalternativecopingstrategiesandencourageuseofsuchalternatives.
E.Suggestsubstitutionofpositivethoughtsfornegativeones.
F.Assistindesensitizingclient.
G.Graduallyandsystematicallyintroducetheclienttotheanxietyproducingstimuli.
H.Pairtheanxietyproducingstimuliwithanotherresponsesuchasrelaxationorexercise.
I.Encouragethesharingoffearsandfeelingswithothers.
J.Administerantianxietymedicationsasprescribed(Table74).

TABLE74AntianxietyDrugs

K.Administerselectiveserotoninreuptakeinhibitors(SSRIs)orothermedicationsasprescribed.
L.Teachtodecreaseintakeofcaffeineandnicotine.
OBSESSIVECOMPULSIVE DISORDER Description: Anxiety associated with repetitive thoughts (obsession) or
irresistible impulses (compulsion) to perform an action; fear of losing control is a major symptom of this
disorder.
NursingAssessment
A.Useofcopingstylestocontrolanxiety(seeTable73)
1.Repression
2.Isolation
3.Undoing
B.Magicalthinking(beliefthatonesthoughtsorwishescancontrolotherpeopleorevents)
C.Evidenceofdestructive,hostile,aggressive,anddelusionalthoughtcontent
D.Difficultywithinterpersonalrelationships
E.Interferencewithnormalactivities(e.g.,aclientwhomustwashherhandsallmorningandcannottake
herchildrentoschool)
F. Safety issues involved in repetitive performance of the ritualistic activity (e.g., dermatitis occurring as a
resultofthecontinuouswashingofhands)
G.Recurringintrusivethoughts
H.Recurring,repetitivebehaviorsthatinterferewithnormalfunctioning
Analysis(NursingDiagnoses)
A.Socialisolationrelatedto

B.Ineffectivecopingrelatedto
NursingPlansandInterventions
A.Provideforclientsphysicalneeds.
B.Allowperformanceofthecompulsiveactivitywithattentiongiventosafety(e.g.,skinintegrityofahand
washer).
C.Exploremeaningandpurposeofthebehaviorwithclient.
D.Avoidpunishingandcriticizing.
E.Establishroutinetoavoidanxietyproducingchanges.
F.Assistclientwithlearningalternativemethodsofdealingwithstress.
G.Avoidreinforcingcompulsivebehavior.
H.Limittheamountoftimeforperformanceofritual,andencourageclienttograduallydecreasethetime.I.
Administerantianxietymedicationsasprescribed(seeTable74).
J.AdministerSSRIsandtricyclicantidepressantsasprescribed.

POSTTRAUMATIC STRESS DISORDER Description: Severe anxiety, which results from a traumatic experience
(e.g.,war,earthquake,rape,incest)
NursingAssessment
A.Anxiety;levelproportionaltotheperceiveddegreeofthreatexperiencedbytheclient
B.Anxietymanifestedinsymptomaticbehaviors
1.Intrusivethoughts
2.Flashbacksoftheexperience
3.Nightmares
4.Emotionaldetachment
C.Responsestoanxietysuchas
1.Shock
2.Anger
3.Panic
4.Denial
D.Selfdestructivebehavior,suchassuicidalideationandsubstanceabuse
E.Visibleremindersoftrauma(e.g.,scars,physicaldisabilities)
Analysis(NursingDiagnoses)
A.Posttraumasyndromerelatedto
B.Ineffectivecopingrelatedto

C.Riskforotherdirected/selfdirectedviolencerelatedto
NursingPlansandInterventions
A.Provideconsistent,nonthreateningenvironment.
B.Implementsuicidalandhomicidalprecautionsifassessmentindicatesrisk.
C.Listentoclientsdetailsofeventstoidentifythemosttroublingaspectofevents.
D.Assistclienttodevelopobjectivityinperceivingeventandidentifyareasofnocontrol.
E. Assist client to regain control by identifying past situations that have been handled successfully. F.
Administer antianxiety and antipsychotic medications as prescribed so as to decrease anxiety, manage
behavior,andproviderest.

SomatoformDisorders
A. A group of disorders characterized by the expression of unexplained physical symptoms that have no
physicalbasis.
B.Thephysicalsymptomisthoughttobeanunconsciousexpressionofaninternalconflict.
C.Somatoformdisordersoccurmoreofteninwomenandbeginbefore30yearsofage.
D. Children may learn that physical complaints are an acceptable coping strategy and are rewarded by
receivingattentionforthisbehavior.Thisisreferredtoasasecondarygain.
E. These clients may abuse analgesics without relief from pain or discomfort. They may accumulate
prescriptionsbydoctorshoppingtorelievephysicalsymptoms.
TYPESOFSOMATOFORMDISORDERS
A.Somatizationdisorder
1. Recurrent somatic complaints for which frequent medical attention is sought but no medical
pathologyispresent
2.Example:aclientwhocomplainsofchestpainsbuthasanormalECGandnormalcardiacenzymes
B.Hypochondriasis
1.Thebeliefinandfearofhavingadisease,includingmisinterpretationofphysicalsignsasproofof
thepresenceofthedisease
2. Example: A client has a rash that is quite minor but insists that he has a serious disease such as
lupus.
C.Conversiondisorder
1.Adisordercharacterizedbytransferringamentalconflictintoaphysicalsymptomforwhichthereis
noorganiccause
2.Example:blindness,paralysis,seizures,deafness,andpseudocyesis(falsepregnancy)
NursingAssessment
A.Preoccupationwithpainorbodilyfunctionforatleast6monthsduration
B.Historyoffrequentdoctorshopping
C.Absenceofemotionalconcernregardingthephysicalimpairment
D.Mayreportexcessivedysmenorrhea
E.Vitalsignsmaybeelevatedasinapanicattack

F.Fearofhavingaseriousdisease
G.Excessiveuseofanalgesics
H.Ruminationaboutphysicalsymptoms
I. Drug abuse; drug screening needed to determine presence of abuse and, if present, the level of
abuse
J.Depressionandpresenceofsuicidalideation
K.Socialoroccupationalimpairment
L.Presenceofblindness,deafness,paralysis,orseizuressuggestiveofaneurologicdisease
Analysis(NursingDiagnoses)
A.Chronicpainrelatedto
B.Ineffectivecopingrelatedto
C.Disturbedpersonalidentityrelatedto
NursingPlansandInterventions
A.Conveyanonjudgmentalattitude.
B.Recorddurationandintensityofpainwithattentiontofactorsthatprecipitateonset.
C.Encourageexpressionofangryfeelings.
D.Implementsuicideprecautionsifindicated.
E. No one medication is particularly recommended. Comorbid disorders such as anxiety and
depressionaretreatedwithdisorderspecificmedications.
F.Focusinteractionsandactivitiesawayfromselfandpain.
G.Helpclientidentifyconnectionbetweenpainandanxiety.
H.Increasetimeandattentiongiventoclientasrewardfornotfocusingonselforphysicalsymptoms.
I. Help client identify needs met by the sick role (e.g., attention and freedom from responsibility)
(Table75).

J. Encourage use of anxietyreducing techniques such as deep breathing, visualization, meditation,

exercise,andrelaxation.

DissociativeDisorders
A.Thesedisordersinvolvealterationinthefunctionofconsciousness,personality,memory,oridentity.B.
Dissociativedisordersmaybesuddenandtemporaryorgradualandchronic.
C.Personsafflictedwiththesetypesofdisordershandlestressfulsituationsbysplittingfromthesituation
andgoingintoafantasystate.
TYPESOFDISSOCIATIVEDISORDERS
A.Psychogenicamnesia
1.Itisthesuddentemporaryinabilitytorecallextensivepersonalinformation.
2. It usually occurs after a traumatic event, such as a threat of death or injury, an intolerable life
situation,oranaturaldisaster.
3.Itisthemostcommondissociativedisorder.
B.Psychogenicfugue
1.Itischaracterizedbyapersonsuddenlyleavinghomeorworkwiththeinabilitytorecallhisorher
identity,sothisinvolvesflightaswellaslossofmemory.
2.Thisdisorderrarelyoccurs.
3.Excessiveuseofalcoholmaycontributetoafuguestate.
C.Dissociativeidentitydisorder
1.Itisthepresenceoftwoormoredistinctpersonalitieswithinanindividual.
2.Thepersonalitiesemergeduringstress.
D.Depersonalization
1.Itischaracterizedbyatemporarylossofonesrealityandtheabilitytofeelandexpressemotions.
2.Clientexpressesafearofgoingcrazy.
3.Clientdescribesasenseofstrangenessinthesurroundingenvironment.
NursingAssessment
A.Depression,moodswings,insomnia,potentialforsuicide
B.Varyingdegreesoforientation
C.Varyinglevelsofanxiety
D.Impairmentofsocialandoccupationalfunctioning
E.Alcoholordrugabuse(Drugscreeningisnecessarytodeterminepresenceandlevelofabuse.)
Analysis(NursingDiagnoses)
A.Ineffectivecopingrelatedto
B.Potentialforselfdirected/otherdirectedviolencerelatedto
NursingPlansandInterventions
A.Reduceenvironmentalstimulationtodecreaseanxiety.

B.Staywithclientduringperiodsofdepersonalization.(Theclientisoftenfearful,andthenursespresence
assistsinprovidingsupportandcomfortduringfearfulepisode.)
C.Demonstrateacceptanceofclientsbehaviorduringvariousexperiencesandpersonalities.
D.Documentemergenceofdifferentpersonalities,ifpresent.
E.Implementsuicideprecautionsifassessmentindicatesrisk.
F.Encourageclienttoidentifystressfulsituationsthatcauseatransitionfromonepersonalitytoanother.
G.Helpclienttoidentifyeffectivecopingpatternsusedinotherstressfulsituations.
H.Assistclientinusingnewalternativecopingmethods.

PersonalityDisorders
CLUSTERA:PARANOID
Description:Itischaracterizedbysuspicious,strangebehaviorthatmaybeprecipitatedbyastressfulevent.It
maymanifestasintensehypochondriasis.
A.Paranoidpersonality
1.Displayspervasiveandlongstandingsuspiciousness
2.Mistrustsothers;issuspicious,fearful
3.Projectsblameforownproblemsontoothers
4.Isintouchwithreality
5.Verbally:useshostile,accusatorydialoguethatisrealitybased
6.Nonverbally:appearssuspicious,tense,distant,watchful,andangry
7. Example: a teacher who always suspects students of cheating during an exam or obtaining test
questionspriortotheexam
B.Schizoidpersonality
1.Issociallydetached,shy,introverted
2.Avoidsinterpersonalrelationships,lackssocialskills
3.Iscold,quiet,andaloof;hasfewfriends
4.Isemotionallydetached,introverted,unresponsive,andhasautisticthinking
5.Verbally:sayslittle,appearswithdrawnandseclusive
6.Nonverbally:isdull,humorless,andhaslittleexpression
7.Example:Acomputerprogrammerwhoworksdayandnight,hisonlyrelationshipbeingwithhis
computer
C.Schizotypalpersonality
1.Hasinterpersonaldeficits
2.Haseccentricitiesandoddbeliefs
3.Issociallyisolated
4.Example:Apersonwhospendshourswalkingthestreetsandwearsahatwithallkindsofthings
hangingfromitandallsortsofmismatchedclothing
NursingAssessment
A.Determinedegreeofsuspiciousnessandmistrustofothers.

B.Assessdegreeofanxiety.
C.Determinewhetherdelusionsarepresent:
1.Referenceorcontrol
2.Persecution
3.Grandeur
4.Somatic
D.Assessdegreeofinsecurity.
Analysis(NursingDiagnoses)
A.Riskforselfdirectedviolencerelatedto
B.Riskforotherdirectedviolencerelatedto
C.Socialisolationrelatedto
NursingPlansandInterventions
A.Establishtrust.B.
Betruthfulandhonest;followthroughoncommitments.
C.Assistclienttoidentifysituationsthatprovokeanxietyandaggressivebehaviors.
D.Avoidconfrontationwiththeclientoverdelusions.
E.Helpclienttofocusonthefeelingsthatcausethedelusions.
F.Assistinidentifyingthoughts,perceptions,andownconclusionsaboutreality.
G.Avoidtalkingandlaughingwhereclientcanseebutnothearyou.
H.Engageinnoncompetitiveactivitiesthatrequireconcentration.
I.Involveclientintreatmentplan.
J.Promotefamilyinvolvementintherapy,teaching,andmedicationcompliance.
CLUSTERB:DRAMATIC,EMOTIONAL
A.Antisocialpersonality
1.Showsaggressiveactingoutbehaviorpatternwithoutanyremorse
2.Iscleverandmanipulativeinordertomeetownselfcenteredneeds
3.Lackssocialconscienceandabilitytofeelremorse;isemotionallyimmatureandimpulsive
4. Has ineffective interpersonal skills that impair the forming of close and lasting relationships 5.
Verbally: is disparaging, humiliating, and belligerent toward those perceived as a threat 6.
Nonverbally:iscold,callous,andinsensitivetoothers;candisplaysociallygraciousbehaviorsinorderto
meetownneeds
7.Example:aprisoninmatewhotriestogetspecialprivilegesbybribingtheguards(i.e.,actingoutthe
roleofaconartist)
B.Borderlinepersonality
1.Hasdisturbancesregardingselfimageandsexual,social,andoccupationalroles
2.Showsimpulsive,selfdamagingbehavior;makessuicidalgestures
3.Isotherdirected,overlydependentonothers
4.Isunabletoproblemsolveorlearnfromexperience
5.Tendstoviewothersaseitherallgoodorallbad(e.g.,splittingbehavior)
6. Verbally: is selfcritical, demanding, whiny, manipulative, and argumentative and can become
verballyabusive
7.Nonverbally:hashighlychangeableandintenseaffect,impulsivebehaviors
8.Example:ateenagegirlwhothreatenstocommitsuicidewhenherboyfriendleaves,butin6weeks
hasnewboyfriendandisclingingtohim
C.Histrionicpersonality
1.Seeksattentionbyoverreactingandexhibitinghyperexcitableemotions

2.Isoverlydramatic,seeksattention,andtendstoexaggerate
3.Haschaoticrelationships,demonstratesangryoutburstsortantrums
4.Verbally:isloud,excitable,overreactive,attemptstodrawattentiontoself
5. Nonverbally: is immature, selfcentered, dependent on attention and care from others, seductive
andflirty
6.Example:ahostessatapartywhoisoverlyexcitedtoseetheguestsandwelcomestheminaloud,
showymannerthatdrawsattentiontoherself
D.Narcissisticpersonality
1.Perceivesselfasallpowerfulandimportant,iscriticalofothers,arrogant
2.Hasexaggeratedfeelingofselfimportanceandselflove
3.Needsattentionandadmiration
4.Ispreoccupiedwithpowerandappearance
5.Exploitsothers
6. Verbally: talks about self incessantly and does whatever necessary to draw attention to self 7.
Nonverbally:isinattentiveandindifferenttoothers,appearsconcernedonlywithself
8.Example:astarfootballplayerwhosesuccesshasgonetohishead
CLUSTERC:ANXIOUS,FEARFUL
A.Avoidantpersonality
1.Issociallyinhibited
2.Feelsinadequate
3.Ishypersensitivetonegativecriticism,rejection
4.Longsforrelationships
5. Example: a man who refuses to play on the employees softball team because he is afraid his
teammateswillmakefunofhim
B.Dependentpersonality
1.Hasunreasonablewishesandwants,andexpressesneedsinademanding,whiningmannerwhile
professingindependenceanddenyingdependentbehavior
2.Ispassive,withoutacceptingresponsibilityforconsequencesofhisorherownbehavior
3.Haslowselfesteem,seesselfasstupid,unabletomakedecisions
4.Isdependentonotherstomeethisorherneeds
5.Verbally:isselfdepreciating,demandingotherstomeetneeds
6.Nonverbally:appearsdull,uninterestedinothers,dissatisfiedwithself
7.Example:Anadultwhoexhibitsadolescenttypebehavior,wantsotherstotakecareofhimorher
whileatthesametimedeclaringindependence
C.Obsessivecompulsivepersonality
1.Attemptstocontrolselfthroughthecontrolofothersortheenvironment
2.Showsinattentiontonewfactsordifferentviewpoints
3.Iscoldandrigidtowardothers
4.Isaperfectionist,inflexible,andstubborn
5.Actswithblindconformityandobediencetorules
6.Isexcessivelyneatandclean
7.Ispreoccupiedwithworkefficiencyandproductivity
8. Verbally and nonverbally: expresses disapproval of those whose behaviors and standards are
differentfromown
9.Example:anursewhoinsiststhatallstaffonhisorherunitwearafreshlystarcheduniformevery
dayandhasnotoleranceforthosewhoarenotasprofessionalasheorsheis
NursingAssessment
A.Assessdegreeofsocialimpairment.

B.Determinedegreeofmanipulativebehavior.
C.Assessdegreeofanxiety.
D.Determinetheriskforselforotherdirectedviolence.
Analysis(NursingDiagnoses)
A.Disturbedpersonalidentityrelatedto
B.Ineffectivecopingrelatedto
C.Socialisolationrelatedto
D.Riskforselfdirected/otherdirectedviolencerelatedto
NursingPlansandInterventions
A.Establishtrust;usestraightforwardapproach.
B.Protectclientfrominjurytoselfandothers.
C.Assistclienttorecognizemanipulativebehavior.
D.Focusonclientsstrengthsandaccomplishments.
E.Setlimitsonmanipulativebehaviorswhennecessary.
F.Reinforceindependent,responsiblebehaviors.
G.Assistclienttorecognizetheneedtorespecttheneedsandrightsofothers.H.Encouragesocialization
withotherstoimproveskills.

EatingDisorders
ANOREXIANERVOSA
A. This psychiatric disorder involves a voluntary refusal to eat and maintain minimal weight for height and
age.
B.Adistortedbodyimageandfearofbecomingobesedrivetheexcessivedietingandexercise.
C.Areported15%to20%ofthosediagnoseddie.
D.Itismorecommoninfemalesthaninmales.
E.Itoccursprimarilyinadolescentsandyoungadults.
F. It is often associated with parentchild conflicts about dependency issues. Children often feel as though
theirbodiesandweightaretheironlyareasofcontrol.
G.Possiblecauses
1.Adysfunctionalfamilysystem
2.Unrealisticexpectationsofperfection
3.Ambivalenceaboutmaturationandtheassumptionofindependence
NursingAssessment
A.Weightlossofatleast15%ofidealororiginalbodyweight

B.Excessiveexercise
C.Apathyaboutphysicalconditionandinordinatepleasureinweightloss
D.Skeletalappearance(usuallyhiddenbybaggyclothes)
E.Distortedbodyimage(usuallyseesselfasfat)
F.Lowselfesteem
G.Hairlossanddryskin
H.Irregularheartbeat,decreasedpulse,andBPresultingfromdecreasedfluidvolume
I.Amenorrheaforatleast3months
J.Delayedpsychosexualdevelopment(adolescents)ordisinterestinsex(adults)
K.Dehydrationandelectrolyteimbalance(decreasedpotassium,sodium,andchloride)resultingfrom:
1.Dietpillabuse
2.Enemaandlaxativeabuse
3.Diureticabuse
4.Selfinducedvomiting
Analysis(NursingDiagnoses)
A.Imbalancednutrition:lessthanbodyrequirementsrelatedto
B.Disturbedpersonalidentityrelatedto
C.Interruptedfamilyprocessrelatedto
NursingPlansandInterventions
A.Monitorweight,vitalsigns,andelectrolytes(especiallypotassium,thyroidlevels,andcalcium/phosphorus
forosteoporosis).
B.Provideastructured,supportiveenvironment,especiallyduringmealtimes.
C.Setatimelimitforeating.
D.Carefullymonitorfoodandfluidintake.
E.Bealerttoclientschoosinglowcaloriefoods.
F.Bealerttopossiblediscardingoffoodthroughothersorinpockets,wastebaskets,ordrawers.
G.Monitorclientaftermealsforpossiblevomiting.
H.Monitoractivityleveltopreventexcessiveexercise.
I.Usepositivereinforcementtobuildselfesteemanddeveloparealisticbodyimage.
J.Deviseabehaviormodificationprogramifindicated.
1.Includeanestablishedweightgoalandweighonaregularschedule.
2. Weigh in same clothes, with back to scale; this prevents manipulation and arguing about exact
weight.
3.Praiseweightgainratherthanfoodintake.
K.Focusinteractionsawayfromfoodandeating.
L.Administerantidepressantmedicationsasindicated
M.Teachclientthatsuddenwithdrawalfrommedicationsmaycauseseizures,
N.Encouragefamilytherapy.
O.Providesnacksbetweenmeals.
P.Monitoractivityandassessforweakness,fatigue,andpathologicfractures.
Q.Providesafeenvironmentandassessforsuicideideation.Implementsuicideprecautionsifnecessary.R.
Assessforwaterloadingpriortoweighing.
BULIMIANERVOSA
A.Aneatingdisordercharacterizedbyeatingexcessiveamountsoffoodfollowedbyselfinducedpurgingby
vomiting,misuseoflaxatives,diureticsorothermedications,fasting,and/orexcessiveexercise.
B.Bulimicclientsusuallyreportalossofcontrolovereatingduringthebingeing.

NursingAssessment
A.RefertoAnorexiaNervosa,NursingAssessment.
B.Diarrheaorconstipation,abdominalpain,andbloating
C.Dentaldamageduetoexcessivevomiting(Gastrichydrochloricaciderodesdentalenamel.)
D.Sorethroatandchronicinflammationoftheesophageallining,withpossibleulceration
E.Financialstressorsrelatedtofoodbudget
F.Concernswithbodyshapeandweight;bulimicsusuallyarenotunderweight.
Analysis(NursingDiagnoses)
A.Disturbedpersonalidentityrelatedto
B.Interruptedfamilyprocessrelatedto
C.Ineffectivecopingrelatedto
D.Riskforselfdirectedviolencerelatedto
NursingPlansandInterventions
A.Monitorweight,vitalsigns,andelectrolytes(especiallypotassium).
B.Provideastructured,supportiveenvironment,especiallyaroundmealtime.
C.Monitorclientaftermealsforpossiblevomiting.
D.Assistclienttolearnstrategies,otherthaneating,fordealingwithfeelings.
E.Encourageclienttoexpressfeelingsofanger.
F.Discussstrategiestostopvomitingandlaxativeuse.
G.Usepositivereinforcementtobuildselfesteemanddeveloparealisticbodyimage.
H.Administerantidepressantmedicationsasindicated.
I.Promotefamilytherapy.

Mood Disorders Definition: Disturbances in mood manifested by extreme sadness or extreme elation
DEPRESSIVEDISORDERSDefinition:Pathologicgriefreactionsrangingfrommildtoseverestates
SymptomsofVaryingDegreesofDepression
A.Mild
1.Feelingsofsadness
2.Difficultyconcentratingandperformingusualactivities
3.Difficultymaintainingusualactivitylevel
B.Moderate
1.Feelingsofhelplessnessandpowerlessness
2.Decreasedenergy
3.Sleeppatterndisturbances
4.Appetiteandweightchanges
5.Slowedspeech,thought,movement(mayalsobeagitatedandhyperactive)

6.Ruminationonnegativefeelings
C.Severe
1.Feelingsofhopelessness,worthlessness,guilt,shame
2.Despair
3.Flataffect
4.Indecisiveness
5.Lackofmotivation
6.Changeinphysicalappearance(slumpedposture,unkempt)
7.Suicidalthoughts
8.Possibledelusionsandhallucinations
9.Sleepandappetitedisturbances
10.Lossofinterestinsexualactivity
11.Constipation

NursingAssessment
A.Determinetypeofdepression.
1.Exogenous:causedbyareactiontoenvironmentalorexternalfactors
2. Endogenous: caused by an internal biologic deficiency (biogenic amines at receptor sites in the
brain)
B.Determinethedegreeofdepression.
C.Determinecurrentsuiciderisk(seeCareoftheSuicidalClient).
D.Arrangeforlabtests.
1.Dexamethasonesuppressiontest(DST)
a.Itisanindirectmarkerofdepression.
b.Itisconsideredpositive(abnormal)ifpostDSTcortisollevelisgreaterthan5mg/dl.2.
Biogenicamines
a.Adecreasedserotoninisindicativeofdepression.
b.Adecreasednorepinephrinelevelisindicativeofdepression.
Analysis(NursingDiagnoses)
A.Riskforselfdirectedviolencerelatedto
B.Disturbedpersonalidentityrelatedto
C.Selfcaredeficit(specify)relatedto
D.Disturbedsleeppatternrelatedto
E.Imbalancednutrition:lessthan/morethanbodyrequirementsrelatedto
F.Activityintolerancerelatedto
G.Ineffectivecopingrelatedto
NursingPlansandInterventions

A.Directlyaskclientaboutfeelingsandplanstoharmself.
B.Implementsuicideprecautionsifassessmentindicatesrisk(seeCareoftheSuicidalClient).
C.Monitorsleep,nutrition,andeliminationpatterns.
D.AssistclientwithADLs.
E.Initiateinteractionwithclient(usenondemandingapproach).
F.Insistonparticipationinactivities.Donotgivetheclientachoiceaboutparticipatinginactivities;(e.g.,Its
timetogotothegymforbasketball).
G.Observeforsuddenelevationinmood;mayindicateincreasedriskforsuicide.
H.Assistclientinidentifyingasupportsystem.
I.Encouragediscussionoffeelingsofhelplessness,hopelessness,loneliness,andanger.
J.Administerantidepressantmedicationasindicated.
K.Sitinsilenceifclientisnontalkative.
L.Spendtimewithclientandreturnwhenpromised.
Antidepressants,selectiveserotoninreuptakeinhibitors(SSRIs)
citalopramhydrobromide
escitalopramoxalate
fluoxetinehydrochloride
paroxetinehydrochloride/paroxetinemesylate
sertralinehydrochloride
INDICATIONS Major depression, obsessivecompulsive disorder, bulimia nervosa, premenstrual dysphoric
disorders,panicdisorders,posttraumaticstressdisorder(sertraline)
ACTIONSSRIsselectivelyinhibitthereuptakeofserotoninwithlittleornoeffectsonotherneurotransmitters,
suchasnorepinephrineordopamine,intheCNS.
ADVERSE REACTIONS Common adverse effects include headache, tremor, dizziness, sleep disturbances, GI
disturbances,andsexualdysfunction.Lesscommonadverseeffectsincludebleeding(ecchymoses,epistaxis),
akathisia,breasttendernessorenlargement,extrapyramidaleffects,dystonia,fever,hyponatremia,maniaor
hypomania, palpitations, serotonin syndrome, weight gain or loss, rash, urticaria, or pruritus.
CONTRAINDICATIONS AND CAUTIONS Contraindicated in patients hypersensitive to these drugs or their
components.Usecautiouslyinpatientswithhepatic,renal,orcardiacinsufficiency.Inpregnantwomen,use
drug only if benefits outweigh risks; use of certain SSRIs in the first trimester may cause birth defects.
NeonatesborntowomenwhotookanSSRIduringthethirdtrimestermaydevelopcomplicationsthatwarrant
prolonged hospitalization, respiratory support, and tube feeding. In breastfeeding women, use isnt
recommended. SSRIs appear in breast milk and may cause diarrhea and sleep disturbance in neonates.
However,risksandbenefitstoboththewomanandinfantmustbeconsidered.Childrenandadolescentsmay
be more susceptible to increased suicidal tendencies when taking SSRIs or other antidepressants. Elderly
patientsmaybemoresensitivetotheinsomniaceffectsofSSRIs.
Antidepressants,tricyclic
amitriptylinehydrochloride
doxepinhydrochloride
imipraminehydrochloride/imipraminepamoate
nortriptylinehydrochloride
INDICATIONSDepression,anxiety(doxepinhydrochloride),enuresisinchildrenolderthanage6(imipramine),
neuropathicpain
ACTIONTricyclicantidepressantsmayinhibitreuptakeofnorepinephrineandserotonininCNSnerveterminals
(presynapticneurons),thusenhancingtheconcentrationandactivityofneurotransmittersinthesynapticcleft.
Tricyclic antidepressants also exert antihistaminic, sedative, anticholinergic, vasodilatory, and quinidinelike
effects.

ADVERSEREACTIONSAdversereactionsincludeanticholinergiceffects,orthostatichypotension,andsedation.
The tertiary amines (amitriptyline, doxepin, and imipramine) exert the strongest sedative effects; tolerance
usuallydevelopsinafewweeks.TricyclicantidepressantsmaycauseCVeffects,suchasTwaveabnormalities,
conductiondisturbances,andarrhythmias.
CONTRAINDICATIONSANDCAUTIONSContraindicatedinpatientshypersensitivetothesedrugsandinpatients
withurineretentionorangleclosureglaucoma.Tricyclicantidepressantsarecontraindicatedwithin2weeksof
MAO inhibitor therapy. Use cautiously in patients with suicidal tendencies, schizophrenia, paranoia, seizure
disorders,CVdisease,orimpairedhepaticfunction.Inpregnantandbreastfeedingwomen,safetyhasntbeen
established; use cautiously. In children younger than age 12, tricyclic antidepressants arent recommended.
Elderlypatientsaremoresensitivetotherapeuticandadverseeffects;theyneedlowerdosages.
Antidepressants,Other
buPROPionhydrochloride/buPROPionhydrobromide
duloxetinehydrochloride
mirtazapine
trazodonehydrochloride
venlafaxinehydrochloride
INDICATIONS Major depressive disorder (bupropion, duloxetine), depression; generalized anxiety disorder
(duloxetine, venlafaxine); fibromyalgia, neuropathic pain related to diabetic peripheral neuropathy, chronic
musculoskeletalpain(duloxetine);insomnia,preventionofmigraine(trazodone);panicdisorder,socialanxiety
disorder,hotflashes(venlafaxine)
ACTION Other antidepressant drugs include aminoketones, serotoninnorepinephrine reuptake inhibitors,
tetracyclicantidepressants,andtriazolopyridinederivatives.Muchabouthowthesedrugsworkhasyettobe
fullyunderstood.
ADVERSE REACTIONS Headache, dizziness, insomnia, suicidal thoughts or behavior, dry mouth, constipation,
abnormal dreams (bupropion), seizures (bupropion), arrhythmias (bupropion), hypoglycemia (duloxetine).
CONTRAINDICATIONSANDCAUTIONSContraindicatedinpatientshypersensitivetodrugorwithin14daysof
MAO inhibitor therapy. Use cautiously in patients at risk for suicide. Use cautiously in patients with recent
historyofMI,unstableheartdisease,renalorhepaticimpairment,ahistoryofseizures,headtrauma,orother
predispositiontoseizures,andinthosebeingtreatedwithdrugsthatlowerseizurethreshold(bupropion).Use
cautiouslyinpatientswithahistoryofmaniaorseizures,patientswhodrinksubstantialamountsofalcohol,
patients with hypertension, patients with controlled angleclosure glaucoma, and those with conditions that
slow gastric emptying (duloxetine). Use cautiously in patients with conditions that predispose them to
hypotension,suchasdehydration(mirtazapine).Usecautiouslyinpatientswithcardiacdiseaseorintheinitial
recoveryphaseofMI(trazodone).Usecautiouslyinpatientswithrenalimpairment,diseasesorconditionsthat
could affect hemodynamic responses or metabolism, and in those with history of mania or seizures
(venlafaxine).

CAREOFTHESUICIDALCLIENT
SuicidePrecautions

A.Obtainhistory;aprevioussuicideattemptisamostsignificantriskfactor.Otherriskgroupsincludethose
with biologic and organic causes of depression, such as substance abuse, organic brain disorders, or other
medicalproblems.
B.Beawareofthemajorwarningsignsofanimpendingsuicideattempt:
1.Aclientbeginsgivingawayhisorherpossessions.
2.Apreviouslydepressedclientbecomeshappy.Heorshehasmadethedecisiontocommitsuicide,is
nolongerdebatingthepossibility,andhasfiguredouthowtoaccomplishthesuicide.
EvaluateIntent
A.Directlyasktheclientabouthisorherintent.Example:Doyoueverthinkaboutharmingyourself?
B. If a client is currently contemplating suicide, ask about his or her plans for carrying out the attempt.
Example:Doyouhaveaplanforharmingyourself?
C. Identify the method chosen; the more lethal the method, the higher the probability that an attempt is
imminent.Whatisyourplanforharmingyourself?Example:Aclientmentionsashotgunandplanstoputit
tohisheadandpullthetrigger.
D.Determinetheavailabilityofthemethodchosen.Ifthemethodisreadilyavailable,theattemptismore
likely.Example:Theclienthasaloadedshotguninhisroom,soitisreadilyavailable.
NursingInterventions
A.Expressconcernfortheclient.Example:Iamveryconcernedthatyouarefeelingsobadthatyouwantto
harmyourself.
B.Telltheclientthatyouwillsharethisinformationwiththestaff.Example:Ineedtosharethiswiththe
staffsothatwecanprovideforyoursafetyuntilyouarefeelingbetter.
C.Offertheclienthope.Example:Yourefeelingbadatthismoment,butthesefeelingswillpass.Wehave
medicationsandtreatmentsthatcanhelpyouthroughthebadtimes.
D.Staywiththeclient.Neverleaveasuicidalclientalone.Legally,thenurseshouldfollowthepolicyofthe
institutionregardingsuicidalclientsandshouldbeabletodemonstratethatthesepolicieswerecarriedout.
Followtheagencypolicyregardingtheremovalofpotentiallyhazardousobjectssuchasrazors,etc.

BIPOLARDISORDER,ORMANICDEPRESSIVEILLNESS
A. It is an affective disorder that is manifested by mood swings involving euphoria, grandiosity, and an
inflatedsenseofselfworth.Thisdisordermayormaynotincludesuddenswingstodepression.
B.Inordertobediagnosedwithabipolardisorder,accordingtotheDSMIVTRclassification,aclientmust
have at least one episode of major depression. A client may cycle, going from elevation to depression, with
periodsofnormalactivityinbetween.
CharacteristicsofVaryingDegreesofMania
A.Mild
1.Feelingofbeingonahigh
2.Feelingsofwellbeing
3.Minoralterationsinhabits
4.Usuallydoesnotseektreatmentbecauseofpleasurableeffect
B.Moderate
1.Grandiosity
2.Talkativeness
3.Pressuredspeech
4.Impulsiveness
5.Excessivespending
6.Bizarredressandgrooming
C.Severe
1.Extremehyperactivity
2.Flightofideas
3.Nonstopactivity(e.g.,running,pacing)
4.Sexualactingout;explicitlanguage
5.Talkativeness
6.Overresponsivenesstoexternalstimuli
7.Easilydistracted
8.Agitationandpossiblyexplosiveness
9.Severesleepdisturbance
10.Delusionsofgrandeurorpersecution
NursingAssessment
A.Determinelevelofdepressionexhibited.
B.Determinelevelofmaniaexhibited.

C.Assessnutritionandhydrationstatus.
D.Assessleveloffatigue.
E.Assessdangertoselfandothersinrelationtolevelofimpulseimpairmentpresent.
Analysis(NursingDiagnoses)
A.Riskforselfdirected/otherdirectedviolencerelatedto
B.Selfcaredeficit(specify)relatedto
NursingPlansandInterventions
A.Maintainclientsphysicalhealth:providenutrition,rest,andhygiene.
B. Provide safe environment (grandiose thinking and poor impulse control can result in accidents and/
altercationswithotherclients).
C.Decreaseenvironmentalstimulation(e.g.,placeinprivateroomorseclusionroom).
D.Implementsuicideprecautionsifassessmentindicatesrisk.
E.Useconsistentapproachtominimizemanipulativebehavior.
F.Usefrequent,briefcontactstodecreaseanxiety.
G.Implementconstructivelimitsetting.
H.Avoidgivingattentiontobizarrebehavior(e.g.,dressandlanguage).
I.Trytomeetneedsassoonaspossibletokeepclientfrombecomingaggressive.
J.Providesmall,frequentfeedingsoffoodthatcanbecarried(e.g.,smallfingersandwiches).
K.Engageinsimple,active,noncompetitiveactivities.
L.Avoiddistractingorstimulatingactivitiesintheeveningtohelppromotesleepandrest.
M.Praiseselfcontrol,acceptablebehavior.
N.Promotefamilyinvolvementintherapy,teaching,andmedicationcompliance.
O.Administerlithium,sedatives,andantipsychoticsasprescribed(Table77).
TABLE77MoodStabilizingDrugs

Antipsychotics
aripiprazole
clozapine
haloperidol/haloperidoldecanoate
olanzapine/olanzapinepamoate
quetiapinefumarate
risperidone
ziprasidonehydrochloride/ziprasidonemesylate
INDICATIONSSchizophrenia(aripiprazole,clozapine,olanzapine,quetiapine,risperidone,ziprasidone);bipolar
mania (aripiprazole, olanzapine, quetiapine, ziprasidone); psychotic disorders (haloperidol); adjunctive
treatmentofmajordepressivedisorder(aripiprazole,quetiapine);irritabilityassociatedwithautisticdisorder
(aripiprazole,risperidone);Tourettesyndrome(haloperidol)
ACTIONQuinolinonederivativesarethoughttoexertpartialagonistactivityatD2andserotonin1Areceptors
and antagonist activity at serotonin 2A receptors. Dibenzapine derivatives bind selectively to dopaminergic
receptors in the CNS and interfere with adrenergic, cholinergic, histaminergic, and serotonergic receptors.
Phenylbutylpiperadine derivatives probably exert antipsychotic effects by blocking postsynaptic dopamine
receptorsinthebrain.Dibenzothiazepineandbenzisoxazolederivativesblockdopamineandserotonin5HT2
receptors.
ADVERSEREACTIONSDrowsiness;sedation;insomnia;agitation;nervousness;hostility;increasedsuiciderisk
(aripiprazole, risperidone, ziprasidone); seizures (clozapine, haloperidol); leukopenia (clozapine, haloperidol,
olanzapine, quetiapine); neuroleptic malignant syndrome (haloperidol, olanzapine, quetiapine, risperidone);
torsadesdepointes(haloperidol).
CONTRAINDICATIONS AND CAUTIONS Contraindicated in patients hypersensitive to drug. Use in pregnancy
only if the potential benefit to the mother justifies the risk to the fetus. Neonates exposed to antipsychotic
drugs during the third trimester of pregnancy are at risk for developing extrapyramidal signs and symptoms
andwithdrawalsymptomsfollowingdelivery.Usecautiouslyinelderlyanddebilitatedpatientsandinpatients
withhistoryofseizuresorEEGabnormalities,severeCVdisorders,allergies,glaucoma,orurineretention.

ThoughtDisorders
SCHIZOPHRENIA Description: Psychiatric disorder characterized by thought disturbance, altered affect,
withdrawal from reality, regressive behavior, difficulty with communication, and impaired interpersonal
relationships(seeTypesofSchizophrenia)
TypesofSchizophrenia
A.Catatonic
1.Stupor(decreaseinreactiontotheenvironment)ormutism
2.Rigidity(maintenanceofapostureagainsteffortstobemoved)
3.Posturing(waxyflexibility)
4.Negativism(resistancetoinstructions)
5.Excitement(severelyagitated,outofcontrol)
6.Potentialforviolencetoselforothersduringstupororexcitement
B.Disorganized
1.Incoherence
2.Flatorinappropriateaffect
3.Disorganized,uninhibitedbehavior
4.Unusualmannerisms
5.Sociallywithdrawn
6.Nodelusionspresent
C.Paranoid
1.Systematizeddelusions,hallucinationsrelatedtoasingletheme,orboth
2.Ideasofreference(misconstruingtrivialeventsandremarksbygivingthempersonalsignificance)3.
Potentialforviolenceifdelusionsareactedupon
D.Residual
1.Sociallywithdrawn
2.Inappropriateaffect
3.Eccentricorpeculiarbehavior
4.Absenceofprominentdelusionsandhallucinations
5.Nocurrentpsychoticbehaviorexhibited
E.Undifferentiated
1.Prominentdelusionsandhallucinations
2.Incoherenceandgrosslydisorganizedbehaviors
3.Failuretomeetanyofthecriteriafortheothertypes

NursingAssessment
A.Assessfordisturbanceinthoughtprocess.
1.Interpretcontentofinternalandexternalstimuli.

a.Symbolism:meaninggiventowordsbyclienttoscreenthoughtsandfeelingsthatwouldbe
difficulttohandleifstateddirectly
b. Delusions: fixed false beliefs that may be persecutory, grandiose, religious, or somatic in
nature
c.Ideasofreference:beliefthatconversationsoractionsofothershavereferencetotheclient
2.Noteform:constructionofverbalcommunication.
a. Looseness of association: lack of clear connection from one thought to the next b.
Tangential or circumstantial speech: failing to address the original point, giving many
nonessentialdetails
c.Echolalia:constantlyrepeatingwhatisheard
d.Neologism:creatingnewwords
e.Preservation:repeatingsamewordorphraseinresponsetodifferentquestions
f.Wordsalad:speakingajumbledmixtureofrealandmadeupwords
3.Noteprocess:flowofthoughts.
a.Blocking:gaporinterruptioninspeechduetoabsentthoughts
b.Concretethinking:thinkingbasedonfactversusabstractandintellectualpoints
B.Assessfordisturbanceinperception.
1.Hallucinations:falsesensoryperception,usuallyauditoryorvisualinnature
2.Illusions:misinterpretationofexternalenvironment
3.Depersonalization:perceivesselfasalienatedordetachedfromrealbody
4.Delusions:false,fixedbeliefsthatcannotbechangedbyreason
C.Assessfordisturbanceinaffect(feelingsormood).
1.Bluntedorflat
2.Inappropriate
3.Incongruentwithcontextofsituationorevent
D.Assessfordisturbanceinbehavior.
1.Incoherentanddisorganized
2.Impulsive,uninhibited
3.Posturing,unusualmannerisms
4.Socialwithdrawal,neglectofpersonalhygiene
5.Exhibitingechopraxia:repetitionofanotherpersonsmovements
E.Assessfordisturbanceininterpersonalrelationships.
1.Difficultyestablishingtrust
2.Difficultywithintimacy
3.Fearandambivalencetowardothers
Analysis(NursingDiagnosis)
A.Disturbedsensoryperceptionrelatedto
NursingPlansandInterventions
A.Establishtrust.
B.Sitwithmuteclients.
C.Providesafeandsecureenvironment.
D.AssistwithphysicalhygieneandADLs.
E.Usematteroffact,nonjudgmentalapproach.
F.Useclear,simple,concretetermswhentalkingwithclient.
G.Acceptandsupportclientsfeelings;useclarification.
H.Reinforcecongruentthinking.Stressreality.
I.Avoidarguingandavoidagreeingwithinaccuratecommunications.
J.Setlimitsonbehavior.
K.Avoidstressfulsituations.

L.Structuretimeforactivitiessoastolimittimeforwithdrawal.
M.Encourageclienttoidentifypositivecharacteristicsrelatedtoself.
N.Praisesociallyacceptablebehavior.
O.Avoidfosteringadependentrelationship.
P.Promotefamilyinvolvementintherapy,teaching,andmedicationcompliance.

DELUSIONAL DISORDERS Description: Characterized by suspicious, strange behavior, which may be

precipitatedbyastressfulevent.Maymanifestasintensehypochondriasis.
NursingAssessment
A.Determinedegreeofsuspiciousnessandmistrustofothers.
B.Assessdegreeofanxiety.
C.Determinewhetherdelusionsarepresent.
1.Referenceorcontrol
2.Persecution
3.Grandeur
4.Somatic
D.Assessdegreeofinsecurity.
Analysis(NursingDiagnoses)
A.Riskforselfdirectedand/orotherdirectedviolencerelatedto
B.Socialisolationrelatedto
NursingInterventionsforDelusionalandHallucinatingClients

Substance Abuse Description: Regular use of substances that affect the central nervous system, resulting in
behavioralchanges;thechemicalsinvolvedproducephysiologicandpsychologicaldependence.
ALCOHOLISMThisisadrinkingpatternthatinterfereswithphysical,social,familial,vocational,andemotional
functioning.
NursingAssessment
A.Patternsindicativeofalcoholism:
1.Episodicdrinking(binges)
2.Continuousdrinking
3.Morningdrinking
4.Increaseinfamilyfightingaboutdrinking
5.Increaseinabsencesfromworkorschool,especiallyMondays
6.Blackouts
7.Hidingdrinkingpattern
8.Legalproblems(DUIs)
9.Healthproblemssuchasgastritis
B.Familyhistoryofalcoholismorsubstanceabuse
C.Dependency,yetresentfulnessofauthority
D.Impulsive,abusivebehavior
E.Impairedjudgment,memoryloss
F.Incoordination,slurredspeech
G.Moodvaryingbetweeneuphoriaanddepression
H. Intoxication as determined by blood alcohol level (BAL; 0.10% or greater is considered intoxication.) I.
PreviousexperiencewithtreatmentcentersorAlcoholicsAnonymous(AA)
J.Alcoholwithdrawalsymptoms:
1.Beginshortlyafterdrinkingstops,asearlyas4to6hoursafter
2.Anxiety,nausea,insomnia,tremors,hyperalertness,andrestlessness
3.Suddenorgradualincreaseinallvitalsigns
4.Deliriumtremens(DTs);mayappear12to36hoursafterlastdrink:
a.Tachycardia,tachypnea,diaphoresis
b.Markedtremors
c.Hallucinations

d.Paranoia
5.Grandmalseizures(possible)
K.Chronicalcoholrelatedillnesses:
1.Chronicgastritis
2.Cirrhosisandhepatitis
3. Korsakoff syndrome: organic syndrome that frequently follows delirium tremens; associated with
chronicalcoholism
4. Wernicke syndrome: a severe disorder (encephalopathy) occurring in chronic alcoholics; probably
duetoadeficiencyofvitaminB1(thiamin);mayescalateKorsakoffsyndrome;istreatedwiththiamine
chloride
5.Malnutritionanddehydration
6.Pancreatitis
7.Peripheralneuropathy
Analysis(NursingDiagnoses)
A.Riskforinjuryrelatedto
B.Ineffectivefamilycopingrelatedto
C.Imbalancednutrition:lessthanbodyrequirementsrelatedto
D.Situationallowselfesteemrelatedto
NursingPlansandInterventions
A.Maintainsafety,nutrition,hygiene,andrest.
B.Implementsuicideprecautionsifassessmentindicatesrisk.
C.Providecareduringwithdrawal.
1.Monitorvitalsigns,I&O,electrolytes.
2.Observeforimpendingdeliriumtremens.
3.Preventaspiration;implementseizureprecautions.
4.Reduceenvironmentalstimuli.
5.Medicatewithantianxietymedication,usuallyLibriumorAtivan.
6.Providehighproteindietandadequatefluidintake(limitcaffeine).
7.Providevitaminsupplements,especiallyB1andBcomplex.
8.Provideemotionalsupport.
D.Rehabilitation:
1.Usedirect,matteroffact,nonjudgmentalattitude.
2.Confrontdenialandrationalization(maincopingstylesusedbyalcoholics).
3.Confrontmanipulations;setfirmlimitsonbehavior.
4.Setshortterm,realisticgoals.
5.Helpincreaseselfesteem.
6.Explorewaystoincreasefrustrationtolerancewithoutalcohol.
7.Identifywaystodecreaseloneliness.
8.Encourageclienttoacceptresponsibilityforownbehavior.
9.Identifyavailabilityofsupportsystems(family,friends,church,AA).
10.Identifyactivitiesandfriendshipsnotrelatedtodrinking.
11.Providegroupandfamilytherapy;referfamilytoAlAnonfamilygroupsorAlAteen.
E. Provide client and family teaching regarding the side effects of Antabuse if it is used as a deterrent to
drinking.
DRUGABUSEDescription:Stateofdependencyproducedbyrepeateduseofasubstancethatcausesaltered
perceptionormood,orboth

NursingAssessment
A.Patternofdruguse
1.Whatdrugsareused?
2.Whatisthedrugofchoice?
3.Howmuchisusedandhowoften?
4.Howlonghasthedrugbeenused?
B.Physicalevidenceofdrugusage
1.Needletrackmarks
2.Cellulitisatpuncturesite
3.Poornutritionalstatus
4.Inflammationofnasalpassages
C.Possiblecausesofdrugdependency
1.Desiretoescaperealityandproblems
2.Lowselfesteem
3.Peerorculturepressure
4.Inherentsusceptibilitytodrugdependence
D.Symptomsofwithdrawalandoverdoseareparticularforthedrugused.
Analysis(NursingDiagnoses)
A.Riskforinjuryrelatedto
B.Riskforinfectionrelatedto
C.Disturbedpersonalidentityrelatedto
NursingPlansandInterventions
A. Assess level of consciousness and vital signs. (Rapid withdrawal can be fatal for persons addicted to
barbiturates,antianxietymedications,andhypnotics.)
B.MonitorI&Oandelectrolytes.
C.Implementsuicideprecautionsifassessmentindicatesrisk.
D.Provideadequatenutrition,hydration,andrest.
E.Administermedicationsaccordingtodetoxificationprotocolofmedicalunit.
F.Phenothiazinesmaybeusedtodecreasethediscomfortofwithdrawal.
G.Confrontdenial(maincopingstyleusedbysubstanceabusers).
1.Focusonsubstanceabuseproblem.
2.Confronttheplacingofblameonexternalproblems.
H.Reinforcerealityinsimple,concreteterms.
I.Encourageverbalexpressionofangeranddepression.
J.Assistwithidentificationofstressorsandareasofconflict.
K.Encourageexplorationofalternativecopingstrategies.
L.Positivelyreinforceinsightintobehaviorpatterns.
M.Helpidentifyanappropriatesupportsystem.
N.Providesupporttosignificantothers.
O.TeachdangerofAIDSandotherbloodrelateddiseases.
Abuse
CHILDABUSEDescription:Includesphysicalandmentalinjury,sexualabuse,andneglect
NursingAssessment
A.Mostimportantindicatorsofchildabuse:
1.Injuriesnotcongruentwiththechildsdevelopmentalageorskills
2.Injuriesnotcorrelatedwiththestatedcause

3.Delayinseekingmedicalcare
B.Bruisesinunusualplacesandinvariousstagesofhealing
C.Bruises,weltscausedbybelts,cords,etc.
D.Burns(cigarette,iron);immersionburns(symmetricalinshape)
E.Whiplashinjuriescausedbybeingshaken
F.Baldpatcheswherehairhasbeenpulledout
G.Fracturesinvariousstagesofhealing
H.Failuretothrive,unattendedtophysicalproblems
I.Torn,stained,bloodyunderclothes
J.Lacerationsofexternalgenitalia
K.Bedwetting,soiling
L.Sexuallytransmitteddiseases
M.Parentseeingchildasdifferentfromotherchildren
N.Parentusingchildtomeetownneeds
O.Parentseldomtouchingorrespondingtochild;maybeverycriticalofchild
P.Childappearingfrightenedandwithdrawninthepresenceofparentorotheradult
Q.Familyhistoryoffrequentmoves,unstableemployment,maritaldiscord,andfamilyviolence
R.Oneparentansweringallthequestions
Analysis(NursingDiagnoses)
A.Fearrelatedto
B.Impairedparentingrelatedto
C.Interruptedfamilyprocessrelatedto
NursingPlansandInterventions
A.Nursesarelegallyrequiredtoreportallcasesofsuspectedchildabusetotheappropriatelocalorstate
agency.
B.Takecolorphotographsofinjuries.
C. Document factual, objective statements about childs physical condition, childfamily interactions, and
interviewswithfamily.
D.Establishtrust,andcareforthechildsphysicalproblems;thesearetheprimaryandimmediateneedsof
thesechildren.
E.Recognizeownfeelingsofdisgustandcontemptfortheparents.
F.Utilizeprinciplesofcrisisintervention.
G.Assistchildandfamilytodevelopselfesteem.
H.Teachbasicchilddevelopmentandparentingskillstofamily.
I.Supporttheneedforfamilytherapy.
INTIMATEPARTNERVIOLENCE
A. It is a criminal act of physical, emotional, economic, or sexual abuse between an assailant and a victim,
whomostcommonlyare,orwere,inanintimaterelationship(maybemaritalordating).
B.Abuseisusuallyatensionreleasingactionaswellasalackofimpulsecontrol.
C.Assailantmaycomefromafamilyinwhichbatteringandphysicalviolencewerepresent.
D.Personsactmoreviolentlywhendrinkingorusingdrugs.
E.Therelationshipisusuallycharacterizedbyextremejealousyandissuesofpowerandcontrol.
F.Womeninabatteringrelationshipmaylackselfconfidenceandfeeltrapped.Theymaybeembarrassed
abouttheirsituation,whichresultsinisolationanddependencyontheabuser.
G.Abuseoftenbeginsduringpregnancyoroccursmorefrequentlyduringpregnancy.
NursingAssessment

A.Delaybetweentimeofinjuryandtimeoftreatment
B.Anxiouswhenansweringquestionsaboutinjury
C.Abdominalinjuriesduringpregnancy
D.Lookstoabuserforanswerstoquestionsrelatedtoinjuries
E.Depressionorsuicidalideation
F.Feelingofresponsibilityforprovokingpartner
G.Lowselfesteem
H.Abrasions,cuts,lacerations,sprains,blackeyes
I.Psychosomatic(somatoform)complaints
J.Concurrentuseofalcohol,drugs
Analysis(NursingDiagnoses)
A.Disturbedpersonalidentityrelatedto
B.Disabledfamilycopingrelatedto
C.Fearrelatedto
D.Riskforinjuryrelatedto
E.Powerlessnessrelatedto
NursingPlansandInterventions
A.Establishtrust;usenonjudgmentalapproach.
B.Treatphysicalwoundsandinjuries.
C. Document factual, objective statements about clients physical condition, injuries, and interaction with
partnerorfamily.
D.Determinepotentialforfurtherviolence.
E.Providecrisisintervention.
F.Assistwithreferraltoshelterifnecessaryordesired,withadultsconsent.
G.Assistclientwithcontactingauthoritiesifchargesaretobepressed.
H.Interviewabusedpartnerwhentheabuserisnotpresent.
ELDERABUSE
A. It is an act that causes physical, verbal, financial, or psychosocial injury or exploitation as well as the
physicalneglectofanagedadult.
B. Abuse of the elderly is underreported; the estimated number varies from 1% to 10% of the elderly
population.
C.Themajorityoftheabuseiscommittedbyspousesandchildrenbutothercaregiversareguiltytoo.
NursingAssessment
A.Bruisesontheupperarms(bilaterally,resultingfrombeingshaken)
B.Brokenbonescausedbyfalls(resultingfrombeingpushed)
C.Dehydrationormalnourishment
D.Overmedication
E.Poorphysicalhygiene,impropermedicalcare
F.Withdrawnbehavior,feelingsofhopelessness,helplessness
G.Behaviorthatmaybedemanding,belligerent,andaggressive
H.Repeatedvisitstohealthcareagencyforinjuriesandfalls
I.Injuriesthatdonotcorrelatewithstatedcause
J.Misuseofmoneybychildrenorlegalguardians
Analysis(NursingDiagnoses)
A.Fearrelatedto

B.Interruptedfamilyprocessrelatedto
C.Riskforinjuryrelatedto
NursingPlansandInterventions
A.Establishtrust;usenonjudgmentalapproach.
B.Meetphysicalneeds,treatwoundsandinjuries.
C. Document factual, objective statements about clients physical condition, injuries, and interaction with
significantotherandfamily.
D.Reportsuspectedabusetotheappropriatelocalorstateauthorities.
E.Arrangecommunityresourcestoproviderespitecareforthecaregiver.
F.Arrangevisitingnurses,nutritionservices,oradultdaycareifpossible.
RAPEANDSEXUALASSAULTDefinition:Crimeinvolvinglackofconsent,force,andsexualpenetration;anactof
aggression,notpassion
NursingAssessment
A.Physicalassessmentwithcarefuldocumentationofinjuries
B.Emotionalstatus:selfblame,anxiety,fear,humiliation,disbelief,andanger
C.Copingbehaviors
D.Identificationofsupportsystem
E.Detailsoftheassault
Analysis(NursingDiagnoses)
A.Rapetraumasyndromerelatedto
B.Powerlessnessrelatedto
C.Fearrelatedto
D.Riskforinjuryrelatedto
NursingPlansandInterventions
A.Communicatenonjudgmentalacceptance.
B.Providephysicalcaretotreatinjuries.
C.Giveclear,conciseexplanationsofallprocedurestobeperformed.
D.Documentfactualobjectivestatementsofphysicalassessment;recordclientsexactwordsindescribing
theassault.
E.Notifypoliceandencouragevictimtoprosecute.
F.Collectandlabelevidencecarefullyinthepresenceofawitness.
G.Notifyrapecrisisteamorcounselorifavailableinthecommunity.
H.Allowdiscussionoffeelingsabouttheassault.
I.Adviseofpotentialforvenerealdisease,pregnancy,andHIV.
J.Provideinformationaboutmedicalcareavailable.
K.Supportclient,family,andfriends.
ChildhoodandAdolescentDisorders
ATTENTIONDEFICIT (HYPERACTIVITY) DISORDER (ADD/ ADHD) Description: Developmentally inappropriate
attention,impulsiveness,andhyperactivity
NursingAssessment
A.Physicalassessment
B.Moreprevalentinboys
C.Failuretolistentoandfollowinstructions

D.Difficultyplayingquietlyandsittingstill
E.Disruptive,impulsivebehavior
F.Distractibilitytoexternalstimuli
G.Excessivetalking
H.Shiftingfromoneunfinishedtasktoanother
I.Underachievementinschoolperformance
Analysis(NursingDiagnoses)
A.Riskforinjury:traumarelatedto
B.Socialisolationrelatedto
C.Interruptedfamilyprocessrelatedto
NursingPlansandInterventions
A.Decreaseenvironmentalstimuli.
B.Setlimitsonbehaviorwhenindicated.
C.Provideasafe,comfortableenvironment.
D.Initiateabehaviorcontracttohelpchildmanageownbehavior.
E.Administermedicationsasprescribed
CONDUCT AND OPPOSITIONAL DEFIANT DISORDERS Definition: Conduct disorder is an antisocial behavior
characterizedbyviolationoflaws,societalnorms,andthebasicrightsofotherswithoutfeelingsofremorseor
guilt.Definition:Oppositionaldefiantdisorderischaracterizedbybehaviorthatfailstoadheretoestablished
norms,butdoesnotviolatetherightsofothers.
NursingAssessment:ConductDisorder
A.Physicalfighting
B.Runningawayfromhome
C.Lying,stealing
D.Crueltytoanimals
E.Frequenttruancy
F.Vandalism,arson
G.Useofalcohol,drugs
NursingAssessment:OppositionalDefiantDisorder
A.Argumentativeness
B.Blamingothersforownproblems
C.Defyingrulesandauthority
D.Usingobscenelanguage
E.Actingresentful,vindictive
Analysis(NursingDiagnoses):ConductandDefiantDisorders
A.Riskforotherdirectedviolencerelatedto
B.Chroniclowselfesteemrelatedto
C.Ineffectivefamilycopingrelatedto
NursingPlansandInterventions:ConductandDefiantDisorders
A.Assessverbalandnonverbalcuesforescalatingbehaviorsoastodecreaseoutbursts.
B.Useanonauthoritarianapproach.
C.Avoidaskingwhyquestions.
D.Initiateashowofforcewithachildwhoisoutofcontrol.

E.Useaquietroomwhenexternalcontrolisneeded.
F.Clarifyexpressionsorjargonifmeaningsareunclear.
G.Teachtoredirectangryfeelingstosafealternative,suchasapilloworpunchingbag.
H.Implementbehaviormodificationtherapyifindicated.
I.Roleplaynewcopingstrategieswithclient.

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