Foundations of Psychiatric Mental Health Nursing
· The WHO defines health as a state of complete
physical, mental, and social wellness, not merely the
absence of disease or infirmity.
· Mental health is influenced by individual factors,
including biologic makeup, autonomy, and
independence, self-esteem, capacity for growth, vitality,
ability to find meaning in life, resilience or hardiness,
sense of belonging, reality orientation, and coping or
stress management abilities; by interpersonal factors,
including effective communication, helping others,
intimacy, and maintaining a balance of separateness
and connectedness; and by social/cultural factors,
including sense of community, access to resources,
intolerance of violence, support of diversity among
people, mastery of the environment, and a positive yet
realistic view of the world (damn, that was a mouthful!).
· The APA (2000) defines a mental disorder as “a
clinically significant behavioral or psychological
syndrome or pattern that occurs in an individual and
that is associated with present distress or disability or
with a significantly increased risk of suffering death,
pain, disability, or an important loss of freedom”.
· Deviant behavior does not necessarily indicate a mental
Diagnostic and statistical manual of mental disorders
· The DSM-IV-TR is a taxonomy published by the APA.
The DSM-IV-TR describes all mental disorders, outlining
specific criteria for each based on clinical experience
· The DSM-IV-TR has 3 purposes:
o To provide standardized nomenclature and
language for all mental health professionals.
o To present defining characteristics or symptoms
that differentiates specific diagnoses.
o To assist in identifying the underlying causes of
· A multiaxial classification system that involves
assessment on several axes, or domains of information,
allows the practitioner to identify all the factors that
relate to a persons condition.
o Axis I is for identifying all major psychiatric
disorders except MR and personality disorders.
Examples include depression and schizophrenia.
o Axis II is for reporting mental retardation and
personality disorders as well as prominent
maladaptive personality features and defense
o Axis III is for reporting current medical conditions
that are potentially relevant to understanding or
maintaining the person’s mental disorder as well
as medical conditions that might contribute to
understanding the person.
o Axis IV is for reporting psychosocial and
environmental problems that may affect the
diagnosis, treatment, and prognosis of mental
disorders. Included are problems with the primary
support group, the social environment, education,
occupation, housing, economics, access to health
care, and the legal system.
o Axis V presents a Global Assessment of
Functioning which rates the person’s overall
psychological functioning on a scale of 0 to 100.
This represents the clinician’s assessment of the
person’s current level of functioning.
· All clients admitted to a hospital or psychiatric
treatment will have a multiaxis diagnosis from the DSM-IV-
Period of Enlightenment and Creation of Mental
· In the 1790’s Phillippe Pinel in France and Willian Tukes
of England formulated the concept of asylum as a safe
refugee or haven offering protection at institutions
where people had been beaten, whipped, and starved
for their mental illness.
· In the US, Dorothea Dix (1802-1887) began a crusade
to reform the treatment of mental illness after a visit to
the Tukes’ institution in England. She was instrumental
in opening 32 state hospitals that offered asylum to the
· 100 years after establishment of the first asylum, state
hospitals were in trouble. Attendants were accused of
abusing the residents, the rural locations of the
hospitals were viewed as isolating patients from their
families and homes, and the phrase insane asylum took
on a negative connotation.
Development of Psychopharmacology
· In the 1950’s the development of psychotropic drugs
were used to treat mental illness.
· Chlorpromazine (Thorzine), an antipsychotic drug, and
lithium, an anti-manic agent, were the first drugs to be
· 10 years later, monoamine oxidase inhibitors,
haloperidol (Haldol), an antipsychotic; tricyclic
antidepressants; and antianxiety agents
(benzodiazepines), were introduced.
· Because of these new drugs, hospital stays were
shortened, and many people were well enough to go
Move toward Community Mental Health
· The enactment of the Community Mental Health
Centers Act came about in 1963.
· Deinstitutionalization, a deliberate shift from
institutional care in state hospitals to community
· In addition to deinstitutionalization, federal legislation
was passed to provide an income for disabled persons:
SSI and SSDI. This allowed people with mental illnesses
to be more independent financially and not to rely on
family for money.
Mental Illness in the 21st Century
· The Department of Health and Human Services (DHHS)
estimates that 56 million Americans have a diagnosable
· The term Revolving door effect is used to explain
how people with severe and persistent mental illness
have shorter hospital stays, but they are admitted more
frequently. People with severe and persistent mental
illness may show signs of improvement in a few days
but are not stabilized. Thus, they are discharged into
the community without being able to cope with
community living. Substance abuse issues cannot be
dealt with in the 3-5 days typical for admissions in the
current managed care environment.
· Many providers believe today’s clients are to be more
aggressive than those in the past. Between 4% and 8%
in clients seem in Psychiatric ER’s are armed. People
not receiving adequate mental health care commit
about 1,000 homicides each year.
· In state prisons, 1 in 10 prisoners take psychotropic
medications and 1 in 8 receives counseling or therapy
for mental health issues.
· 85% of the homeless population has a psychiatric
illness and/or a substance abuse problem.
· The United States has the largest percentage of
mentally ill citizens (29.1%) and provided care for only
1 in 3 people who needed it (Bijl et al., 2003).
· Persons with minor or mild cases are most likely to
receive treatment while those with severe and
persistent mental illness were least likely to be treated.
Cost containment and managed care
· Managed Care is a concept designed to purposely
control the balance between the quality of care
provided and the cost of that care. In a managed care
system, people receive care based on need rather than
· Case management or management of care on a case-by-
case basis represented an effort to provide
necessary services while containing costs. The client is
assigned a case manager, a person who coordinates all
types of care needed by the client.
· In 1996, Congress passed the Mental Health Parity Act,
which eliminated annual and lifetime dollar amounts for
mental health care for companies with more than 50
employees. However, substance abuse was not covered
by this law, and companies could limit the number of
days in the hospital or the number of clinic visits per
year. Thus, parity did not really exist.
Psychiatric Nursing Practice
· In 1873, Linda Richards improved nursing care in
psychiatric hospitals and organized educational
programs in state mental hospitals in Illinois. Richards
is called the first American psychiatric nurse.
· The first training of nurses to work with persons with
mental illness was in 1882. The care focused on
nutrition, hygiene and activity. Nurses adapted medical-surgical
principles to the care of clients with psychiatric
disorders and treated them with tolerance and
· Treatments such as insulin shock therapy (1935),
psychotherapy (1936), and electroconvulsive therapy
(1937) required nurses to use their medical skills more
· John Hopkins was the first school of nursing to include a
course on psychiatric nursing in its curriculum.
· In 1950, the National League for Nursing (which
accredits nursing programs) required schools to include
an experience in psychiatric nursing.
· In 1973, the ANA developed Standards of care, which
states the responsibilities for which nurses are
· Psychiatric nursing practice has been profoundly
influenced by Hildegard Peplau and June Mellow, who
wrote about the nurse-client relationship, anxiety, nurse
therapy, and interpersonal nursing therapy.
Psychiatric Mental Health Nursing Phenomena of
· The maintenance of optimal health and well-being and
the prevention of psychobiologic illness.
· Self-care limitations or impaired functioning related to
mental and emotional distress.
· Deficits in the functioning of significant biologic,
emotional, and cognitive symptoms.
· Emotional stress or crisis components if illness, pain,
· Self-concept changes, developmental issues, and life
· Problems related to emotions such as anxiety, anger,
sadness, loneliness, and grief.
· Physical symptoms that occur along with altered
· Alterations in thinking, perceiving, symbolizing,
communicating, and decision making.
· Difficulties relating to others
· Behaviors and mental states that indicate the client is a
danger to self or others or has a significant disability.
· Interpersonal, systemic, sociocultural, spiritual, or
environmental circumstances or events that affect the
mental or emotional well-being of the individual, family,
· Symptom management, side effects/toxicities
associated with psychopharmacologic intervention, and
other aspects of the treatment regimen.
Standards of Psychiatric mental health clinical
· Standard I. Assessment
o The psychiatric-mental health nurse collects
· Standard II. Diagnosis
o The psychiatric-mental health nurse analyzes the
data in determining diagnoses.
· Standard III. Outcome identification.
o The psychiatric-mental health nurse identifies
expected outcomes individualized to the client.
· Standard IV. Planning.
o The psychiatric-mental health nurse develops a
plan of care that prescribes interventions to attain
· Standard V. Implementation
o The psychiatric-mental health nurse implements
the interventions identified in the plan of care.
· Standard Va. Counseling
o The psychiatric-mental health nurse uses
counseling interventions to assist clients in
improving or regaining their previous coping
abilities, fostering mental health, and preventing
mental illness and disability.
· Standard Vb. Milieu Therapy
o The psychiatric-mental health nurse provides
structures, and maintains a therapeutic
environment in collaboration with the client and
other health care practitioners.
· Standard Vc. Self-care activities.
o The psychiatric-mental health nurse structures
interventions around the client’s activities of daily
living to foster self-care and mental and physical
· Standard Vd. Psychobiologic Interventions.
o The psychiatric-mental health nurse uses
knowledge of psychobiologic interventions and
applies clinical skills to restore the client’s health
and prevent further disability.
· Standard Ve. Health teaching.
o The psychiatric-mental health nurse, through
health teaching, assists clients in achieving,
satisfying, productive, and healthy patterns of
· Standard Vf. Case Management.
o The psychiatric-mental health nurse provides case
management to coordinate comprehensive health
services and ensure continuity of care.
· Standard Vg. Health promotion and maintenance.
o The psychiatric-mental health nurse employs
strategies and interventions to promote and
maintain mental health and prevent illness.
Areas of practice
o Interventions and communication techniques
o Problem solving
o Crisis intervention
o Stress management
o Behavior modification
· Milieu therapy
o Maintain therapeutic environment
o Teach skills
o Encourage communication between clients and
o Promote growth through role modeling
· Self-care activities
o Encourage independence
o Increase self-esteem
o Improve function and health
· Psychobiologic interventions
o Administer medications
· Health teaching
· Case management
· Health promotion and maintenance
Advanced level functions
· Prescriptive authority for drugs (in many states)
· Self-awareness is the process by which the nurse
gains recognition of his or her own feelings, beliefs, and
Neurobiologic Theories and Psychopharmacology
The Nervous system and how it works
· The cerebrum is the center for coordination and
integration of all information needed to interpret and
respond to the environment.
· The cerebellum is the center for coordination of
movements and postural adjustments.
· The brain stem contains centers that control
cardiovascular and respiratory functions, sleep,
consciousness, and impulses.
· The limbic system regulates body temperature,
appetite, sensations, memory, and emotional arousal.
· Neurotransmitters are the chemical substances
manufactured in the neuron that aid in the transmission
of information throughout the body.
o They either excite or stimulate an action in the
cells (excitatory) or inhibit or stop an action
o After neurotransmitters are released into the
synapse (point of contact between the dendrites
and the next neuron) and relay the message to the
receptor cells, they are either transported back
from the synapse to the axon to be stored for later
use (reuptake) or are metabolized and inactivated
by enzymes, primarily monoamine oxidase
· Dopamine, a neurotransmitter located primarily in the
brain stem. Dopamine is generally excitatory and is
synthesized from tyrosine, a dietary amino acid.
o Antipsychotic medications work by blocking
dopamine receptors and reducing dopamine
· Norepinephrine and Epinephrine
o Norepinephrine, the most prevalent
neurotransmitter, is located primarily in the brain
stem. It plays a role in mood regulation.
o Epinephrine is also known as noradrenaline and
adrenaline. Epinephrine has limited distribution in
the brain but controls the fight-or-flight response
in the peripheral nervous system.
o A neurotransmitter found only in the brain, is
derived from tryptophan, a dietary amino acid.
o The function of serotonin is mostly inhibitory,
involved in the control of food intake, sleep and
wakefulness, temperature regulation, pain control,
sexual behavior, and regulation of emotions.
o Some antidepressants block serotonin reuptake,
thus leaving it available longer in the synapse,
which results in improved mood.
o The role of histamine in mental illness is under
o Acetylcholine is a neurotransmitter found in the
brain, spinal cord, and peripheral nervous system.
It can be excitatory or inhibitory. It is synthesized
from dietary choline found in red meat and
vegetables and has been found to affect the sleep-wake
cycle and to signal muscles to become
o Studies have shown that people with Alzheimer’s
disease have decreased acetylcholine secreting
o Glutamate is an excitatory amino acid that at high
levels can have major neurotoxic effects.
· Gamma-Aminobutyric Acid (GABA)
o GABA is a major inhibitory neurotransmitter in the
brain and has been found to modulate other
neurotransmitter systems rather than to provide a
o Drugs that increase GABA function such as
benzodiazepines are used to treat anxiety and to
Neurobiologic causes of mental illness
· Current theories and studies indicate that several
mental disorders may be linked to a specific gene or
combination of genes but that the source is not solely
genetic; nongenetic factors also play important roles.
· Two genetic links to Alzheimer’s disease are
chromosomes 14 and 21.
· The Human Genome Project, funded by NIH and the US
Department of Energy, is the largest of its kind. It has
identified all human DNA. In addition, the project also
addresses the ethical, legal, and social implications of
human genetics research.
Stress and the Immune system (Psychoimmunology)
· This is a relatively new field of study, which examines
the effect of psychological stressors on the body’s
Infection as a possible cause
· Some researchers are focusing on infection as a cause
of mental illness. Studies such as this are promising in
discovering a link between infection and mental illness.
The Nurse’s role in research and education
· The nurse must ensure that client’s and families are
well informed about progess in these areas and must
also help them to distinguish between facts and
hypotheses. The nurse can explain if or how new
research may affect a client’s treatment or prognosis.
The nurse is a good resource for providing information
and answering questions.
· Efficacy refers to the maximal therapeutic effect that a
drug can achieve.
· Potency describes the amount of the drug needed to
achieve that maximum effect; low-potency drugs
require higher doses to achieve efficacy, whereas high-potency
drugs achieve efficacy at lower doses.
· Half Life is the time it takes for half of the drug to be
removed from the bloodstream. Drugs with shorter half-life
may need to be given three or four times a day, but
drugs with a longer half-life may be given once a day.
· The FDA may issue a black-box warning when a drug is
found to have serious or life-threatening side effects.
This means that package inserts must have a
highlighted box, separate from the text, which contains
a warning about the serious side-effects.
· Also known as neuroleptics, are used to treat the
symptoms of psychosis, such as the delusions and the
hallucinations seen in schizophrenia, schizoaffective
disorder, and the manic phase of bipolar disorder.
· Antipsychotic’s work by blocking receptors of the
· Dopamine receptors are classified into subcategories
(D1, D2, D3, D4, and D5) and D2, D3, and D4 have
been associated with mental illness.
· The typical antipsychotic drugs are potent antagonists
(blockers) of D2, D3, and D4. This makes them effective
in treating target symptoms but also produces many
extrapyramidal side effects because of the blocking of
the D2 receptors.
· Newer, atypical antipsychotic drugs such as clozapine
(Clozaril) are relatively weak blockers of D2, which may
account for the lower incidence of extrapyramidal side
· The newer antipsychotics also inhibit the reuptake of
serotonin, increasing their effectiveness in treating the
depressive aspects of schizophrenia.
Extrapyramidal Side Effects
· (EPS) are the major side effects of antipsychotic drugs.
They include acute dystonia (prolonged involuntary
muscular contractions that may cause twisting of the
body parts, repetitive movements, and increased
muscular tone), pseudoparkinsonism, and akathisia
(intense need to move about). Blockage of the D2
receptors in the midbrain region of the brain stem is
responsible for the development of EPS. Included in the
o Torticollis : twisted head and neck
o Opisthotonus : tightness of the entire body with
head back and an arched neck.
o Oculogyric crisis : eyes rolled back in a locked
· Immediate treatment with anticholinergic drugs usually
brings rapid relief.
· Pseudoparkinsonism , or drug-induced Parkinsonism if
often referred to by the generic label of EPS. Symptoms
include a stiff, stooped posture; mask-like facies;
decreased arm swing; a shuffling. festinating gait;
drooling; tremor; bradycardia; and coarse pill rolling
movements of the thumb and fingers while at rest.
· Treatment of these symptoms can include adding an
anticholinergic agent or amantadine, which is a
dopamine agonist that increases transmission of
dopamine blocked by the antipsychotic drug.
Neuroleptic Malignant syndrome
· (NMS) is a potentially fatal idiosyncratic reaction to an
antipsychotic. Death rates have been reported at 10%
· Symptoms include rigidity, high fever; autonomic
instability such as unstable blood pressure, diaphoresis,
and pallor; delirium; and elevated levels of enzymes,
particularly creatine and phosphokinase.
· Clients with NMS are confused and often mute; they
may fluctuate from agitation to stupor.
· Dehydration, poor nutrition, and concurrent medical
illness all increase the risk of NMS.
· Treatment includes immediate discontinuation of the
antipsychotic and the institution of supportive medical
care to treat dehydration and hyperthermia.
· (TD) is a syndrome of permanent involuntary
movements. This is most commonly caused by the
long-term use of antipsychotic drugs.
· There is no treatment available.
· The symptoms of TD include involuntary movements of
the tongue, facial, and neck muscles, upper and lower
extremities, and truncal musculature. Tongue thrusting
and protruding, lip smacking, blinking, grimacing, and
other excessive unnecessary facial movements are
· One TD has developed, it is irreversible.
· Some antipsychotics produces agranulocytosis. This
develops suddenly and is characterized by:
o Ulcerative sore throat
· The drug must be discontinued immediately if the WBC
drops by 50% or to less that 3,000.
· Although the mechanism of action is not completely
understood, antidepressants somehow interact with the
two neurotransmitters, norepinephrine and serotonin.
· Antidepressants are divided into four groups:
o Tricyclic and the related cyclic antidepressants
o Selective serotonin reuptake inhibitors (SSRIs)
o MAO inhibitors (MAOIs)
o Other antidepressants such as venlafaxine
(Effexor), bupropion (Wellbutrin), duloxetine
(Cymbalta), trazodone (Desyrel), and nefazodone
· MAOIs have a low incidence of sedation and
anticholinergic effects, they must be used with extreme
caution for several reasons:
o A life-threatening side effect, hypertensive crisis,
may occur if the client ingests food containing
tyramine (an amino acid) while taking MAOIs.
Mature or aged cheeses
Aged meats (sausage, pepperoni)
ALL tap beers and microbrewery beer.
Sauerkraut, soy sauce, or soybean
Yogurt, sour cream, peanuts, MSG
o MAOIs cannot be given in combination with other
MAOIs, tricyclic antidepressants, Demerol, CNS
depressants, and hypertensives, or general
o MAOIs are potentially lethal in overdose and pose
a potential risk for clients with depression who
may be considering suicide.
· SSRIs, venlafaxine, nefazodone, and bupropion are
often better choices for those who are potentially
suicidal or highly impulsive because they carry no risk
of lethal overdose in contrast to the cyclic compounds
and the MAOIs. However, SSRIs are only effective for
mild to moderate depression.
· The major actions of antidepressants are with the
monoamine neurotransmitter systems in the brain,
particularly norepinephrine and serotonin.
o Norepinephrine, serotonin, and dopamine are
removed from the synapses after release by
reuptake into presynaptic neurons. After reuptake,
these three neurotransmitters are reloaded for
subsequent release or metabolized by the enzyme
o The SSRIs block the reuptake of serotonin; the
cyclic antidepressants and venlafaxine block the
reuptake of norepinephrine primarily and block
serotonin to some degree; and the MAOIs interfere
with enzyme metabolism.
Mood stabilizing drugs
· Mood stabilizing drugs are used to treat bipolar disorder
by stabilizing the client’s mood, preventing or
minimizing the highs and lows that characterize bipolar
illness, and treating acute episodes of mania.
· Lithium is considered the first-line agent in the
treatment of bipolar disorder.
o Lithium normalizes the reuptake of certain
neurotransmitters such as serotonin,
norepinephrine, acetylcholine, and dopamine. It
also reduces the release of norepinephrine through
competition with calcium.
o Lithium produces its effects intracellularly rather
than within neuronal synapses.
o Lithium serum levels should be about 1.0 mEq/L.
Levels less than 0.5 mEq/L are rarely therapeutic,
and levels of more than 1.5 mEq/L are usually
o If Lithium levels exceed 3.0 mEq/L, dialysis may be
· The mechanism of action for anticonvulsants is not
clear as it relates to their off-label use as mood
o Valporic acid and topiramate are known to
increase the levels on the inhibitatory
neurotransmitter, GABA. Both are thought to
stabilize mood by inhibiting the kindling process.
The kindling process can be described as the
snowball-like effect seen when minor seizure
activity seems to build up into more frequent
and severe seizures. In seizure management,
anticonvulsants raise the level of the
threshold to prevent these minor seizures. It
is suspected that this same kindling process
may occur in the development of full-blown
mania with stimulation by more frequent,
Antianxiety drugs (Anxiolytics)
· Benzodiazepines mediate the actions of the amino acid
GABA, the major inhibitory neurotransmitter in the
brain. Because GABA receptor channels selectively
admit the anion chloride into neurons, activation of
GABA receptors hyperpolarizes neurons and thus is
· Benzodiazepines produce their effects by binding to a
specific site on the GABA receptor.
· Today, the primary use of stimulants is for ADHD in
children and adolescents, residual attention deficit
disorder in adults, and narcolepsy.
· Stimulants are often termed indirectly acting amines
because they act by causing release of the
neurotransmitters (norepinephrine, dopamine, and
serotonin) from presynaptic nerve terminals as opposed
to having direct agonist effects on the postsynaptic
receptors. They also block the reuptake of these
· By blocking the reuptake of these neurotransmitters
into neurons, they leave more of the neurotransmitter
in the synapse to help convey electrical impulses in the
· I’m not going to go much into this. Just know that
clients from various cultures may metabolize
medication at different rates and therefore require
alterations in standard dosages.
Psychosocial Theories and Therapy
Sigmund Freud, the Father of Psychoanalysis
· Founded the personality components; Id, Ego, and Superego
o Id: The part of ones nature that reflects basic or innate desires
such a pleasure seeking behavior, aggression, and sexual
impulses. The id seeks instant gratification, causes impulsive
thinking behavior, and has no rules or regard for social
o Superego: The part of ones nature that reflects moral and ethical
concepts, values, parental and social expectations; therefore, it
is the directional opposite to the id.
o Ego: The balancing or mediating force between the id and the
superego. The ego represents mature and adaptive behavior that
allows a person to function successfully.
· Psychosexual development
o Oral (birth to 18 months)
o Anal (18 to 36 months)
o Phallic/Oedipal (3 to 5 years)
o Latency (5 to 11 or 13 years)
o Genital (11 or 13 years)
· Transference and Countertranference
o Transference occurs when the client onto the therapist/nurse
attitudes and feelings that the client previously felt in other
o Countertranference occurs when the therapist/nurse displaces
onto the client attitudes or feelings from his or her past.
Developmental Theorists; Erikson and Piaget
· Erikson focused on personality development across the life span while
focusing on social and psychological development in life stages.
o Trust vs. Mistrust (infant)
o Autonomy vs. Shame and Doubt (toddler)
o Initiative vs. guilt (preschool)
o Industry vs. Inferiority (school age)
o Identity vs. Role confusion (adolescence)
o Intimacy vs. isolation (young adult)
o Generativity vs. stagnation (middle adult)
o Ego integrity vs. despair (maturity)
· Erikson believed that psychosocial growth occurs in sequential stages,
and each stage is dependent on the completion of the previous
· Piaget explored how intelligence and cognitive functioning develop in
o Sensorimotor (birth to 2 years): The child develops a sense of
self as separate from the environment and the concept of object
permanence. Begins to form mental images.
o Preoperational (2-6 years): Child begins to express himself with
language, understands the meaning of symbolic gestures, and
begins to classify objects.
o Concrete operations (6-12 years): Child begins to apply logical
thinking, understands reversibility, is increasingly social and
able to apply rules; however, thinking is still concrete.
o Formal operations (12 to 15 years and beyond): Child learns to
think and reason in abstract terms, further develops logical
thinking and reasoning, and achieves cognitive maturity.
Harry Stacks Sullivan: Interpersonal Relationships and Milieu therapy
· The importance and significance of interpersonal relationships in
one’s life was Sullivan’s greatest contribution to the field of mental
· Sullivan developed the first therapeutic community or milieu with
young men with schizophrenia in 1929. He found that within the
milieu, the interactions among clients were beneficial, and then the
treatment should emphasize on the roles of the client-client
o Milieu therapy is used in the acute care setting; one of the
nurses’ primary roles is to provide safety and protection while
promoting social interaction.
Hildegard Peplau: Therapeutic nurse-patient relationship (The bomb-diggity
· Developed the concept of the therapeutic nurse-patient relationship,
which includes 4 phases: orientation, identification, exploitation, and
o The orientation phase is directed by the nurse and involves
engaging the client in treatment, providing explanations and
information, and answering questions. During this time the
nurse would orient the patient to the rules and expectations (if
in an acute setting).
o The identification phase begins when the client works
interdependently with the nurse, expresses feelings, and begins
to feel stronger. This phase can begin either within a few hours
to a few days; the patient can identify the nurse and
environment on his own. They “come together”. Kinky.
o In the exploitation phase, the client makes full use of the
services offered. He moves toward independence.
o In the resolution phase, the client no longer needs professional
services and gives up dependent behavior.
o Keep in mind that after the resolution phase, the client can
regress and move back into the above mentioned phases.
· Paplau defined anxiety as the initial response to a psychic threat,
describing 4 levels of anxiety: acute, moderate, severe, and panic.
o Acute anxiety is a positive state of heightened awareness and
sharpened senses, allowing the person to learn new behaviors
and solve problems. The person can take in all available stimuli
o Moderate anxiety involved a decreased perceptual field (focus
on immediate task only); the person can learn new behavior or
solve problems only with assistance. Another person can
redirect the person to the task. Remember, this is the ideal
anxiety state for teaching a client regarding health concerns
such as diabetes, as Cathy says so.
o Severe anxiety involves feelings of dread or terror. The person
CANNOT be redirected to a task; he focuses only on scattered
details and has physiologic symptoms such as tachycardia,
diaphoresis, and chest pain. The client may go to the ER
thinking he is having a heart attack. In lecture, Cathy stated that
this person can still be “talked down”. The first priority is to
move the person away from all stimuli, and then attempt to talk
with them to calm down.
o Panic anxiety can involve loss of rational thought, delusions,
hallucinations, and complete physical immobility and muteness.
The person my bolt and run aimlessly, often exposing himself
and others to injury.
Humanistic Theories; Maslow’s Hierarchy of needs.
· Everyone should know this one. It is outlined on page 56 in your
· He used a pyramid to arrange and illustrate the basic drives or needs
to motivate people.
o The most basic needs, physiologic needs, need to be met first.
This includes food, water, shelter, sleep, sexual expression, and
freedom of pain. These MUST be met first.
o The second level involves safety and security needs, which
involve protection, security, freedom from harm or threatened
o The third level is love and belonging needs, which include
enduring intimacy, friendship, and acceptance.
o The fourth level involves esteem needs, which includes the
need for self-respect and esteem from others.
o The highest level is self-actualization, the need for beauty, truth,
and justice. Few people actually become self-actualized.
o Remember, traumatic life experiences or compromised health
can cause a person to regress to a lower level of motivation.
Pavlov: Classic conditioning (Behavior theory)
· Pavlov believed that behavior can be changed through conditioning
with external or environmental conditions or stimuli.
· Maturational crises, sometimes called developmental crises, are
predictable events in the normal course of a life, such as leaving home
for the first time, getting married, having children, etc.
· Situational crises are unanticipated or sudden events that threaten an
individuals integrity; such as a death of a loved one and loss of a job.
· Adventitious crises, sometimes called social crises, include natural
disasters like floods, earthquakes, or hurricanes; war, terrorist attacks;
riots; and violent crimes such as rape or murder.
Non-violent crisis intervention
The heart of crisis intervention is:
· Safety (#1!)
People in crisis need care and welfare.
Staff responses should be safety and security.
· Increase or change in behavior. Can be anything
different from usual behavior (excitement, pacing).
· Nursing interventions:
o Ask “What’s going on?”
o Give supportive care and let the patient know that
· Loss of rationality.
· Nursing interventions:
o Direct approach to setting limits.
o Take away privileges.
o Give the patient some control and choices.
Acting out person:
· Loss of rational control.
· Nursing interventions:
o Everything Cathy showed us on non-violent
physical crisis intervention
· Subsiding of energy.
· Nursing interventions:
o Establish therapeutic rapport
o Prime time to talk and teach about preventions of
What if the patient simply refuses?
· Set limits!
· Make the limits reasonable and enforceable.
Releasing… Venting… Mad as heck!
· Allow the patient to do this!
· Just stay calm as a nurse
· While they’re venting, they’re also releasing. This is a
· This is NOT A GOOD THING.
· What if the patient tells you…?
o I know what car you drive.
o I know your last name.
o I know you have 2 dogs and I’m going to kill them.
· Nursing interventions:
o Get a witness! Do not be by yourself with this
Non-verbal behavior that affect proxemics
· Factors that affect:
o Size, gender, disability, environment, agitation,
history, and speed.
· 18-36” is personal space (usually how wide ones arm
· Always be the closest to the door.
Kinesics (Body language)
· Facial expressions, stance, posture, breathing, hand
· When approaching a client, stand at 45 degree angle
· Stand with hands to side (especially when with a
· Move when the patient moves.
· Be as calm as possible.
· 55% nonverbal
· 7% verbal
· 38% paraverbal it’s not what you say; it’s how you
· TVC (total voice control)
Always remember not to lose eye contact.
If you’re being grabbed…
· Gain physiologic advantage
o Know where the weak point of grab is
o Leverage- use what you have!
o Momentum—it comes in handy
· Gain psychological advantage
o Stay calm
o Have a plan
o Don’t forget the element of surprise
Non-Violent physical control and restraint should be
used as a LAST RESORT.
Categories of Mood disorders
o Major depression
o Period of normalcy
Unipolar: Major depression
· Sad mood or lack of interest in life for 2 or more weeks
· Another 4 symptoms must also be present
o Change in appetite (increase or decrease)
o Change in sleep patterns (too much or too little)
o Unable to concentrate and make decisions
o Loss of self-esteem (guilt- how you were raised;
how worthy a person perceives themselves).
· Those at risk:
o Suffering from anxiety and irritability
o PP depression
o Chronic illness (dialysis)
o Grief and loss
· Can be observed by others, or the depression is just in
· Major depression occurs at least twice as often in
· Single and divorced people have the highest rates of
· Psychotherapy (groups, counselor)
· Psychopharmacology (Meds)
· The biggest concern is memory loss.
· Patient is pre-medicated, much like a pre-op patient
· Elders are treated for depression with ECT more
frequently than younger persons.
o Elder persons have increased intolerance of side
effects of antidepressants
o ECT produces a more rapid response
· Safety is primary concern
· Watch for overt cues of suicide (Obvious) active
· Covert cues are more subtle—passive
· People who suddenly are happier are of great concern;
may have made the suicidal plan are content with their
· People whose meds are finally working—have enough
energy to carry out the act
· Compare verbal with non-verbal behaviors—do they
· Asocia l: Withdrawal from family and friends
· Anhedonic : Lose sense of pleasure
· When confronting these client’s about their behavior,
use “I” statements
o “I really wish you’d join the group”
· Feel overwhelmed with normal activities
· Difficulty with task completion
· Always exhausted
· Ruminate : Worry to excess.
· Lack energy for normal activities (always tired)
· Assess safety for client (PRIORITY!)
· Perform suicide lethality assessment
· Orient client to new surroundings (they need structure)
· Offer explanations of unit routine (again, need
· Start to promote a therapeutic relationship; schedule
short interaction times.
Patient and Family teaching
· Stress importance of follow-up care—keep it structured;
make appointment for them.
· Stress importance of continuing medications; assess if
they can afford them
· Make phone number lists of how to get help if they
· Condition with cyclic mood changes
· Person has manic episodes, periods of profound
depression, and times of normal behavior in-between
· Occurs equally in men and women; often seen in highly
Clinical course of mania
· Episode of unusual, grandiose, or agitated mood lasting
at least one week with three or more of the following
o Exaggerated self-esteem
o Pressured speech
o Flight of ideas
o Reduced ability to filter out stimuli
o More activities with increased energy
o Lithium is not metabolized; rather, it is reabsorbed
by the proximal tubule and excreted in the urine.
o Thought to work in the synapse to increase
destruction of dopamine and norepinephrine;
decreases sensitivity to postsynaptic receptors
(Basically- when a person is in a manic phase, they
are synapsing super fast. Lithium helps slow this
o Onset of action is 5-14 days; other drugs must be
used during the acute phases to reduce symptoms
of mania or depression.
o Maintenance lithium level is 0.5-1.0 mEq/L.
3 is toxic! Duh.
o Lithium is a salt contained in the human body. It
not only competes for salt receptor sites but also
affects calcium, potassium, and magnesium ions
as well as glucose metabolism.
MUST complete an electrolyte blood panel
(focus on Chloride).
o Having too much salt in the diet can cause the
lithium level to be too low.
o Not having enough dietary salt can cause the
lithium levels to be too high.
o Persistent thirst and diluted urine can indicate the
need to call the MD; lithium dosage may need to
· Anticonvulsant drugs: mechanism is unclear, but they
raise the brains threshold for dealing with stimulation;
this prevents the person from being bombarded with
external and internal stimuli.
Huge concern about agranulocytosis (a
decrease in WBC).
Need serum levels monitored 12 hours after
Need to monitor serum level, CBC with
platelets, liver function including ammonia
level (ammonia is a by-product of liver
Anticonvulsant and benzodiazepine
Drug dependence can occur
Monitor CBC, liver function
Withdrawal drug slowly to prevent GI issues
Cannot be used alone to manage bipolar;
must be used in conjunction with lithium or
another mood stabilizer.
Helpful hints to care for bipolar clients
· You can’t teach a manic client
· Safety is a huge issue because their judgment is poor.
· Only spend short periods of time with patient
· Must be flexible in taking intake assessment; may need
to obtain data in several short sessions as well as
talking to family members.
· Ask the client to explain any coded speech
· Assist the client to meet socially accepting behaviors.
“Kathy, you are too close to my face. Please stand back
· Feed them finger foods high in calories while in a manic
phase; provide nutritional support!
· Use simple sentences when communicating. It is also
helpful to ask client to repeat brief messages to ensure
they have heard and incorporated them.
o “Please speak more slowly. I’m having trouble
· Avoid becoming involved in power struggles over who
will dominate the conversation.
· 4 out of 5 who actually commit suicide have made at
least one prior attempt
· In a majority of cases, there are clear indicators hat the
person was very troubled.
· Few than 15% of suicide victims leave suicide notes
· The suicide risk is greatest in the 90 days following a
major depressive episode.
· “survivor guilt” happens when 1 or more family
members feel guilty that they are still living
· “Separation anxiety” may cause they surviving to “join
the beloved deceased”
· Make the patient sign a “contract for life”
· Crisis intervention—may need 1:1 care. The client is no
more than 2-3 feet away from a staff member at any
time, including going to the bathroom.
Anxiety disorders & Substance abuse
· Most common emotional disorder in the U.S.
· Prevalent in women; age <45
· Flight or fight responses
· Sympathetic fibers increase the vital signs
· Adrenal glands release adrenalin which causes the body
o Take in more oxygen
o Dilate the pupils (brings more light into eyes;
o Increase the arterial blood pressure and heart rate
o Constrict peripheral vessels (makes skin cool and
o Increase glycogenolysis to free glucose for fuel
(glycogen is being broken down in the liver)
o Shunt blood from GI and reproductive organs
· Difficulty with logical thought
· Increased agitation with motor activity
· Increased vital signs
· Client will try to change the feelings of discomfort by:
o Changing behavior by adaptation
o Changing behavior with defense mechanisms
· Panic disorder
· Phobic disorder
· Generalized anxiety
· Anxiety related to medical conditions
· Substance-induced anxiety disorder
Development of Anxiety Disorders
· Predisposing factors
o Onset: Acute or insidious (builds up)
o Precipitating event
o Chronic stressors
o Unusual behavior
o Fears disproportionate to reality
Levels of anxiety
o Psychological: Wide perceptional field, sharpened
senses, increased motivation, effective problem
solving, increased learning ability, irritability.
o Physiologic: Restlessness, fidgeting, “butterflies”,
difficulty sleeping, hypersensitivity to noise.
o Psychological: perceptual field narrowed to
immediate task, selectively attentive, cannot
connect thoughts or events independently,
increased use of automatisms
o Physiologic: Muscle tension, diaphoresis, pounding
pulse, HA, dry mouth, high voice pitch, faster rate
of speech, GI upset, frequent urination
o Psychological: Perceptual field narrowed to one
detail or scattered details; cannot complete tasks;
cannot solve problems or learn effectively;
behavior geared toward anxiety relief and is
usually ineffective; doesn’t respond to redirection;
feels awe, dread, or horror; cries; ritualistic
o Physiologic: Severe HA, N/V, diarrhea, rigid stance,
vertigo, pale, tachycardia, chest pain.
o Psychological: Perceptual field reduced to focus on
self; cannot process any environmental stimuli;
distorted perceptions; loss of rational thought;
doesn’t recognize potential danger; can’t
communicate verbally; possible delusions or
hallucinations; may be suicidal.
o Physiologic: May bolt and run OR totally immobile
and mute; dilated pupils, increased blood pressure
and pulse; flight, fright, or freeze.
Seyle Response to stress
· Alarm reaction
o Physiologic response
o Body prepares to defend itself
· Resistance stage
o Body will defend by flight or fight
o If the stress is gone; body relaxes
· Exhaustion stage
o Negative response to anxiety and stress
o Body stores are depleted
· An episode lasting 15-30 minutes in which a client
experiences rapid, intense, escalating anxiety; great
emotional discomfort; and physiologic discomfort.
· Defined as recurrent, unexpected panic attacks
followed by a month of persistent concern or worry
about having another attack.
· 75% with panic disorder have spontaneous attacks with
· Others have attacks stimulated by phobias or chemical
changes within the body.
o Positive reframing
o Assertiveness training
· An illogical, intense, persistent fear of a specific object
or social situation that causes extreme distress and
interferes with having a normal life.
· Treatment for phobias:
“Flooding” Getting rid of fear all at one
Obsessive-Compulsive Disorder (OCD)
· Obsessions: Recurrent thoughts, ideas, visualizations,
or inappropriate impulses that disturb a person’s life;
has no control over them.
· Compulsions: Behaviors or rituals continuously carried
out to get rid of the obsessive thoughts and reduce
· Higher incidence with groups in higher economic status
and with more education
· Nursing interventions:
o Remember, a lot of the time people feel guilty
about their thoughts and behaviors.
o Do not try to stop the act unless the act is harmful
o Talk to them! Use “I” statements
o If they are too down on themselves—limit your
time with them. For instance, “I hate myself. No
one cares about me. I’m fat and ugly.” The nurse
would then say, “I am going to come back in 30
minutes. In that time frame, I want you to think of
your good qualities.”
o Do not argue with OCD person.
o Inject reality. If a teenager thinks she is pregnant
despite a negative pregnancy test, tell her the
TEST IS NEGATIVE. Take them back into reality.
o If they repetitively do an act over and over again;
help them set a goal. For instance, “Let’s try to
only wash your hands once every ten minutes.”
Post Traumatic Stress disorder
· Three clusters if symptoms are present
o Reliving the event
Memories, dreams, or flashbacks
o Avoiding reminders of the event
Staying away from any stimuli that could be
associated with the trauma.
o Being on guard (hyper-arousal)
Less responsive to stimuli
Insomnia, irritability, or angry outbursts
· At risk people include:
o Combat veterans
o Victims of violence
o Abused victims
o Children in traffic accident (and the parents)
Only 46% of parents sought help for their
children. KIDS NEED HELP.
· Symptoms of PTSD occur 3 months or more after the
· Some more signs of PTSD:
o Have issues with authority figures
o Their first emotions are anger, rage, and guilt
o Their guilt comes out as anger (violent behavior)
o Isolate themselves
o Don’t want to talk about it
o Drug and alcohol abuse
o Manifests in physiological symptoms (HA, GI
· Nursing interventions:
o Have specific staff members assigned to client to
facilitate building trust
o Consistency is the key
o Be non-judgmental; encourage client to talk
o Help them acknowledge where grief is coming
o Involve family
o Give positive feedback
· Goals for PTSD:
o Short term : Safety, decrease insomnia, identify
o Long term : Accept the fact that the experience
happened and live healthy.
· I’m not going to go much into these notes; there wasn’t
much information in the lecture that is not in the
· Overdose of alcohol:
o Alcohol is a depressant; decreased respirations
and blood pressure, vomiting may cause
· Overdose of benzodiazepines require a gastric lavage
including instillation of activated charcoal.
o Cocaine, amphetamines, and Ritalin
o Increases HR and BP; decreases cardiac output
o Cocaine specifically causes MI’s
· Two purposes:
o Safe withdrawal with medication
Suppress symptoms of abstinence
Around the clock schedule and PRN
Never, ever go cold turkey.
o Prevent relapse
May need to go to AA for rest of life.
· Disturbance of consciousness accompanied by change
in cognition; disoriented
o Alert and oriented to person only
o Typically have problems recalling on memory and
· Develops over a short period of time
· Easily distracted
· Difficulty concentrating
· Illusions, hallucinations
· Onset is rapid
· Brief duration
· Level of consciousness is impaired
· Slurred speech
· Anxious mood
Causes of Delirium
· Low sodium
o Normal is 135-145 mEq/L
o Always check electrolytes!
· Drug related
o Or, withdrawal from drugs and alcohol
o Sedatives and benzodiazepines cause confusion
· Effects of anesthesia
The nursing process: Assessment
· Interview with simple questions and explanations
· Frequent breaks
· History of onset; not reliable from client
o Interview family members; ask: “Is the how your
mom typically acts?”
o Frequently assess moods; moods change quickly
· Thought process/content
o Many have visual hallucinations
o Very restless; hard to keep in bed.
Nursing process: Goals
· Free from injury
o Fall precautions
· Demonstrate increased orientation
o Use reality orientation and validate feelings
· Adequate balance of activity and rest
o Help the patient keep days and nights straight
· Adequate nutrition
o Often forget to eat; needs nutritional supplements
· Return to optimal level of functioning
· A goal needs a timeline to make it measurable!
Nursing process: Intervention
· Patient safety
· Managing confusion
o Often frightened at night.
· Promote comfort and rest
· Adequate fluids and nutrition
o Always offer little sips of water!
Nursing process: Evaluation
· Successful treatment of underlying causes for delirium
returns client to former level of functioning
· Client and family education about avoidance of
· Monitor chronic health problems
· Careful use of medications
· No alcohol or other non-prescribed drugs
· More progressive, gradual, and permanent
· Involves multiple cognitive deficits
o Primarily memory impairment
· Involves at least one of the following:
o Asphasia (deterioration of language function)
o Apraxia (impaired ability to execute motor
o Agnosia (inability to name or recognize objects)
o Disturbance in executive functioning (ability to
think abstractly and to plan, initiate, sequence,
monitor, and stop complex behavior)
· May also present:
o Echolalia (echoing what is heard)
o Palilalia (repeating words or sounds over and over)
Clinical course of Dementia
o Difficulty finding words
o Frequently loses objects and experiences anxiety
about these losses.
o Occupational and social settings are less
enjoyable, and the person may avoid them.
o Confusion is present along with memory loss
o The person cannot complete complex tasks but
remains oriented to person and place.
o Still recognizes familiar people.
o Some assistance with care
o Executive functioning suffers (especially with
o Personality and emotional changes occur
o May be delusional, wander at night, forget the
names of spouse and children and require
assistance in ADLs.
o Most live in ECF.
Causes of Dementia
· Decreased metabolic activity
· Genetic component
· Alzheimer’s disease (#1)
· Creutzfeld-Jacob disease (CNS disorder; develops at 40-
60 years. Causes by infectious particle that is resistant
· Parkinson’s disease
· Huntington’s disease (inherited gene; brain atrophy,
demyelination, and enlargement of the brain ventricles.
Begins in late 30’s)
· Vascular Dementia (#2)
o Symptoms similar to Alzheimer’s, but more abrupt,
followed by rapid changes in functioning; a
plateau; more abrupt changes, another plateau,
and so on.
o Caused by decreased blood supply to the brain.
· Native Americans and Eastern countries hold elders in a
position of authority, respect, power, and decision
making for family; this does not change despite
memory loss or confusion.
· May feel they are being disrespectful and reluctant to
make decisions or plans for elders with dementia.
Treatment for Dementia
· Underlying cause
o Example: Vascular dementia can be helped by
diet, exercise, control of hypertension or diabetes.
o Cognex and Aricept are cholinesterase inhibitors
and have shown therapeutic effects; slow the
progress of dementia. They do not reverse
damage already done.
Must have liver function tests done with
Flu-like symptoms, diarrhea, sleep
disturbances are common.
o Tegretol and Depakote help stabilize mood and
diminish aggressive outbursts.
These doses are often ½-2/3 less lower than
prescribed for seizures, therefore, does not
need to be in the “therapeutic level” for
o Benzodiazepines may cause delirium and can
worsen already compromised cognitive abilities.
Nursing process: Assessment
o Remember, interview family
· Motor behavior and general appearance
o Display aphasia
o Conversation repetitive
o Apraxia (such as combing hair)
o Gait disturbance
o Uninhibited behavior; never have displayed these
· Mood and Affect
o Grieve at first
o Emotional outbursts are common
o Pattern of withdrawal; lethargic, apathetic, look
dazed and listless.
· Thought process and content
o Executive functioning impaired
o Have to stop working
o Client may accuse others of stealing lost objects
· Sensorium and Intellectual Processes
o First affects recent and immediate memory,
eventually impairs the ability to recognize family
members and oneself.
o Confabulation : clients make up answers to fill in
memory gaps; often inappropriate words or
fabricated ideas (SCREW YOU, ASSHOLE).
o Visual hallucinations are common.
· Judgment and insight
o Underestimate risk
· Self concept
o Initially grieve, and then slowly lose sense of self.
· Roles and Relationships
· Physiologic and self-care considerations
o Altered sleep-wake cycle
o Some clients ignore internal cues such as hunger
o Neglect bathing and grooming; become
Read the Nursing Diagnoses and Nursing Goals on
your own. Too damn lazy to type out.
Nursing Process: Interventions
· Demonstrate caring attitude
· Keep clients involved; relate to environment
· Validate client’s feelings of dignity
· Offer limited choices
· Reframing (offering alternate points of view to explain
· See page 487—there’s a good table there about
o Physical and Chemical restraint should be the last
Nursing process: Evaluation
· Goals change as disease progresses
· Reassessment is vital!
· Client always needs assessed, goals and interventions
· Evaluation is a continuing process.
· Remember… short term goals; all goals need a
Types of schizophrenia
· Paranoid schizophrenia
o Auditory hallucinations
o Anxiety and anger
o Persecutory schemes
· Disorganized schizophrenia
o Extreme social withdrawal
o Disorganized speech or behavior
o Flat or inappropriate affect
o Silliness unrelated to speech
o Stereotyped behaviors
o Grimacing mannerisms
o Inability to perform activities of daily living
· Catatonic schizophrenia
o Significant psychomotor disturbances
o Waxy flexibility
o Excessive purposeless motor activity
o Automatic obedience
o Stereotyped or repetitive behavior
· Undifferentiated schizophrenia
o Undifferentiated schizophrenia does not meet the
criteria for paranoid, disorganized, or catatonic
o Delusions and hallucinations
o Disorganized speech
o Disorganized or catatonic behavior
o Flat affect
o Social withdrawal
· Residual schizophrenia
o Diagnosed as schizophrenic in the past
o Time limited between attacks but may last for
o The client exhibits considerable social isolation
and withdrawal and impaired role functioning
· Assess the client’s physical needs
· Set limits on the client’s behaviors when it interferes
with others and becomes disruptive
· Maintain a safe environment
· Initiate one-on-one interaction and progress to small
groups as tolerated
o Although, reintegrating the client into the milieu as
soon as possible is essential
· Spend time with the client even if client is unable to
· Monitor for altered thought processes
· Maintain ego boundaries and avoid touching the client
o Touching others without warning or invitation
o Intruding in others’ living spaces
o Talking to or caressing inanimate objects
o Undressing, masturbating, or urinating in public
· Limit the time of interaction with the client
o Initially, the client may only tolerate 5-10 minutes
of contact at one time.
· Avoid an overly-warm approach; a neutral approach is
· Do not make promises to the client that cannot be kept
· Establish daily routines
· Assist the client to improve grooming and to accept
responsibility for self-care
· Sit with the client in silence if necessary
· Provide short, brief and frequent contact with the client
· Tell the client when you are leaving
· Tell the client when you do not understand
· Do not “go along” with the clients delusions or
· Provide simple concrete activities such as puzzles or
· Reorient the client as necessary
· Help the client establish what is real and unreal
· Stay with the client if he is frightened
· Speak to the client in a simple direct and concise
· Reassure the client that the environment is safe
· Remove the client from group situations if the client’s
behavior is too bizarre, disturbing, or dangerous to
o Reassure others that the client’s inappropriate
behaviors or comments are not his fault (without
· Set realistic goals
· Initially do not offer choices to the client, and gradually
assist the client in making own decisions
· Use canned or packaged food, especially with the
paranoid schizophrenic client
· Provide a radio or tape player at night for insomnia
· Explain to the client everything that is being done
· Set limits on the client behavior if the client is unable to
· Decrease excessive stimuli in the environment
· Monitor for suicide risk
· Assist the client to use alternative means to express
feelings through must or art therapy or writing.
Nursing interventions for the client experiencing
· Ask the client to describe the delusion
· Be open and honest in interactions to reduce
· Focus the conversation on reality based topics rather
than the delusion
· Encourage the client to express feelings and focus on
the feelings that the delusions generate
· If the client obsesses on the delusion, set firm limits on
the amount of time for talking about the delusion
· Do not dispute with the client or try to convince the
client that the delusions are false
· Validate if part of the delusion is real
· Recognize accomplishments and provide positive
feedback for successes
Nursing interventions for the client experiencing
· Monitor for hallucination cues
o See blue box on page 296
· Elicit description of hallucination to protect the client
o The nurses understanding of the hallucination
helps the nurse know how to calm or reassure the
· Intervene with one on one contact
· Decrease stimuli or move the client to another area
· Avoid conveying to the client that others are also
experiencing the hallucination
· Respond verbally to anything real the client talks about
· Avoid touching the client
· Encourage the client to express feelings
· During a hallucination, attempt to engage the client’s
attention through a concrete activity
o Teaching the client to talk back to the voices
forcefully also may help him or her manage
· Accept and do not judge or joke about the client’s
· Provide easy activities and a structured environment
with routine activities of daily living
· Monitor for signs or increasing fear, anxiety, or
· Provide seclusion if necessary
· Administer medications as prescribed
Language and communication disturbances
· Clang association : Repetition of words or phrases that
are similar in sound but in no other way.
· Echolalia : Repetition of words or phrases heard from
· Mutism : Absence of verbal speech
· Neologism : A new word devised that has a special
meaning to the client
· Word salad : Form of speech in which words or phrases
are connected meaninglessly
· Latency of response : hesitation before the client
responds to questions. This latency or hesitation may
last 30-45 seconds and usually indicates the client’s
difficulty with cognition or thought processes.
· Thought broadcasting : believe that others can hear
· Thought withdrawa l: believe others are taking their
· Thought insertion : others are placing thoughts in their
mind against their will
Abnormal motor behaviors
· Akathisia : Displaying motor restlessness and muscular
quivering; the client is unable to sit or lie quietly
· Echopraxia : Repeating the movements of another
· Waxy flexibility : having one’s arms or legs placed in a
certain position and holding that same position for
· Dyskinesia : Impairment of the power of voluntary
Child and adolescent disorders
Psychiatric disorders are not diagnosed as easily in children
as they are in adults.
· Children lack the abstract cognitive abilities and verbal
skills to describe what is happening.
· Mild retardations: IQ 50-70
· Moderate retardation: IQ 35-50
· Severe retardation: IQ 20-35
· Profound retardation: IQ less than 20.
· Some issues are due to background and family issues
· Transition into adulthood often very difficult
· Depression is almost always due to a combination of
· Boys are more successful in committing suicide; more
violent in attempts
o Acetaminophen affects liver
o Ibuprophen affects kidneys
· Presents as “classic” symptoms in girls
· In boys, depression is more likely to be “acted out” with
aggressive behavior such as risk taking, substance
abuse, confrontations with authority.
o Drinking in teenage years (ages 15-17) stops
emotional growth. Kids that grow into adults are
stuck in this stage (Identity vs. Role confusion).
They learn that drinking is the way to cope. This is
· First major episode are during adolescent years; often
between the ages of 15-19
· Manic depression
o Teens may be sad and gloomy one day and excited
and elevated the next
o Mood stabilizers are important in decreasing mood
Lithium (check blood levels!)
· In depression, one of the first cues is a large drop in
· Other symptoms disguised:
o Drug/alcohol abuse
o Lack of concentration
o Restlessness or hyperactivity
o Anti-social behavior (conduct disorder)
· Extreme fatigue, sleep all the time but are not rested
· Suicide warning signs…
o Constant insomnia; may be on computer at all
hours of the night
o Changes in behavior
o Dropping grades—again, school is a huge issue
· Interventions for suicide
o High risk teens make their decisions after a
“disaster” has occurred: break-ups, academic
failure, fight with parents, or run-in with authority
o Alcohol is involved in ½ of all suicides; seriously
· Suicide is not chosen; it happens when pain exceeds
resources for pain
· Talk to your kids!
o The best place is in the car when they’re trapped,
Start with the basics; “How are you doing?”
Then get down and dirty to the real subject
· Group of disorders of thought processes characterized
by gradual disintegration of mental function
· Occurs in adolescents or as young adults
· Suicide is the #1 cause of death in young people with
· Treatment and prognosis
o Lifetime of therapy and family support
o Struggle for family to stay involved
Often rejected or just can’t take anymore
disruption in their lives.
· Symptoms often begin slowly and gradually during their
childhood or teenage years and increase in severity as
time goes on.
· Though a chronic disease, there will be periods of
reduced symptoms followed by “flare-ups”, often
stressful times in person’s life.
· Relief is only temporary; usually both obsessions and
compulsions occur together
· Recognize thoughts or behaviors are irrational; but are
compelled to continue them “against their will”.
o Exposure and response prevention
o SSRIs help reduce symptoms of OCD—monitor for
o Washing, cleaning, constant checking, mental
o Touching, ordering, rearranging
o Asking for reassurance or confessing
o Masturbation—especially seen in children who
haven’t yet discovered this is socially
· Most prevalent in boys; identified no later than 3-years
· Child has little eye contact, few facial expression,
doesn’t use gestures to communicate
· Does not relate to parents or peers, lacks spontaneous
enjoyment, apparent absence of mood and emotional
affect, can not be engaged in play or make believe
· Repetitive motor behaviors such as hand-flapping, body
twisting, or head banging
· May improve as child acquires language skills
· Short term impatient therapy is used when behaviors
such as head banging or tantrums are out of control
o Haldol or Risperadol may be effective (prn, of
· Goals of treatment:
o Reduce behavioral symptoms
o Promotes learning and development
o Language skills development
Attention deficit disorder
· Characterized by patterns of inattention, hyperactivity,
· Account for most mental health referrals
· Needs to be physically seen for a renewal of ADHD
· Often diagnosed when a child starts school
· Distinguishing bipolar disorder from ADHD can be
difficult but is crucial because treatment is so different
for each disorder
· Signs and symptoms
o Inattentive behaviors
o Hyperactive/impulsive behaviors
Often leaves seat
Can’t play quietly
Cannot wait turn
o The most effective treatment combines
pharmacotherapy with behavioral, psychosocial,
and educational interventions
o Methylphenidate (Ritalin)
o Amphetamine compound (Adderall)
The most common side effects of these drugs
are insomnia, loss of appetite, and weight
loss or failure to gain weight.
Giving stimulants during daytime hours
usually combats insomnia.
Give the child breakfast and snacks to gain
o Atomoxetine (Strattera)
Non-stimulant drug; is an antidepressant—
selective norepinephrine reuptake inhibitor.
Most common side effects were decreased
appetite, N/V, tiredness, and upset stomach.
Can cause liver damage, must have liver
function tests periodically.
· Strategies for Home and School
o Behavioral strategies are necessary to help the
child master appropriate behaviors.
o Effective approaches:
Provide consistent rewards
Consequences for behavior
Offer consistent praise
Use time out
Give verbal reprimands
Use daily report cards for behavior
Point system for positive and negative
Therapeutic play; use play to understand
thoughts and feelings and helps with
· Cultural considerations
o Parents from different cultures have a different
threshold for tolerating specific types of behavior.
· General appearance and Motor behavior
o Speech is unimpaired, but the child cannot carry
on a conversation; he interrupts, blurts out
answers before the question is finished, and fails
to pay attention to what is said.
· Mood and affect
o Mood may be labile, even to the point of verbal
outbursts or temper tantrums.
o Anxiety, frustration, and agitation are common
· Judgment and insight
o May fail to perceive harm or danger and engage in
impulsive acts such as running into the street and
jumping off of high objects.
· Physiologic and Self-care considerations
o Children with ADHD may be thin if they do not
take time to eat properly or cannot sit through
o May be a history of physical injuries due to risk-taking
· Nursing diagnoses
o Risk for injury
Child will remain free from injury
If the child is engaged in a potentially
dangerous activity, the first step is to
stop the behavior.
This may require physical intervention if
the child is running into a street or
jumping off of a high place.
Attempting to talk or reason to a child
engaged in a dangerous activity is
unlikely to succeed because of their
inability to pay attention and to listen.
When the incidence is over and the child
is safe, talk to the child about the
o Ineffective role performance
Will not violate others boundaries
Give positive feedback for meeting
State acceptable behavior clearly
o Impaired social interactions
Demonstrate age-appropriate social skills
Supervise the child closely while he is
It is often necessary to act first to stop
the harmful behavior by separating the
child from the friend
o Improved role performance
Simplify instructions and directions—give one
step of a process at a time
Give the child positive feedback and sense of
Manage the environment
Minimal noise and distraction
Face the teacher in the front row and
away from window or door
o Ineffective family coping
Will complete tasks
Face the child on his level and use good
Give the child frequent breaks
Routines are important; child with ADHD
do not adjust to changes readily
o Parental support
Listen to parent’s feelings
Because these children often are not
diagnosed until the 2nd or 3rd grade, they may
have missed much basic learning for reading
and math. Parents should know that it takes
time for them to catch up to other children
the same age.
Medications are often in decreasing
hyperactivity and impulsivity relatively
Improved sociability, peer relations, and
academic achievement happen more slowly.
· Characterized by persistent antisocial behavior in
children and adolescents that significantly impair their
ability to function in social, academic, or occupational
o Symptoms are clustered into 4 areas
Aggression to people and animals
Destruction to property
Deceitfulness and theft
Serious violation of rules and the law
o More symptoms
Poor frustration tolerance
Tempter often out of control
Early onset of sexual behavior, alcohol and
substance abuse, smoking, risky behavior
See more in the red box on page 457
· Types of conduct disorder
o Classified by age of onset
Adolescent-onset type is defined by no
behaviors of conduct disorder until after 10
years of age.
Least likely to be aggressive
Have more normal peer relationships
Less likely to have persistent conduct
disorder or antisocial personality
disorder as adults
Childhood-onset type involves symptoms
before 10 years of age
Disturbed peer relationships
More likely to have persistent conduct
disorder and to develop antisocial
personality disorder as adults
o Can be classified as:
Mild : few conduct problems causing minor
harm to others
Lying, truancy, staying out late without
Moderate : Number of conduct problems
increase as does the amount of harm to
Vandalism and theft
Severe : Many conduct problems that cause
considerable harm to others.
Forced sex, cruelty to animals, weapons,
· Treatment of conduct disorder
o MUST BE GEARED TOWARD DEVELOPMENTAL AGE
o School aged:
Child, family, and school environment are the
focus of treatment
Family therapy is essential
Rely less on their parents, so treatment is
based on individual therapy.
Conflict resolution, anger management, social
Try to keep the adolescent in his environment
o Medications have little effect
Antipsychotics for clients who present a clear
danger to others
Mood stabilizers for clients with labile moods
· Cultural considerations
o Be careful of diagnosis of Conduct disorder, must
know history and circumstances of each child.
High areas of crime rates
Could be a matter of survival
· Nursing process
o Risk for Other-directed violence
The client will not hurt others or damage
Inform the client of the rule or limit
Explain the consequences if broken
State expected behavior
Time out; not a punishment—a place to
regain self control
Give client a schedule of daily activities
The client will participate in treatment
More likely to participate in treatment
and daily routines if they have input
concerning the schedule
o Ineffective coping
The client will learn effective problem-solving
and coping skills
Help identify the problem and to solve
o Impaired social interaction
The client will use age-appropriate and
acceptable behaviors when interacting with
Teach social skills
Discuss the news, sports, or other topics as
the client may not know how to have a
o Chronic low self-esteem
The client will verbalize positive, age-appropriate
statements about self
Oppositional Defiant disorder
· Consists of an enduring pattern of uncooperative,
defiant, and hostile behavior toward authority figures
without major antisocial violations.
· A certain level of oppositional behavior is common in
children in adolescence.
· Oppositional defiant disorder is diagnosed only when
behaviors are more frequent and intense than
unaffected peers and cause dysfunction in social,
academic, or work situations.
· Sudden, rapid, recurrent, non-rhythmic motor
movement or vocalization
· Stress and fatigue exacerbates tics
· Treatment: Risperadol and Zyprexia
· Complex vocal tics
o Coprolalia : Use of socially unacceptable words,
o Palilalia : Repeating own sounds or words
o Echolalia : Repeating the last heard sound, word, or
· Multiple motor tics and one or more vocal tics
· May occur many times a day for over a year
· Usually identified by 7 years of age
· Encopresis : repeated passage of feces into
inappropriate places such as clothing or floor by a child
who is at least 4 years of age either chronically or
developmentally. Often involuntary, but can be
intentional (oppositional defiant disorder or conduct
disorder). Associated with constipation that occurs for
psychological, not medical reasons.
· Enuresis : Repeated voiding of urine during the day or
night into clothing or bed by a child at least 5 years of
· Treated with imipramine (Tofranil), an antidepressant
with a side effect of urinary retention.
o Was once treated with vasopressin which
decreases circulatory volume.
The distinguishing factor of anorexia includes an earlier age
of onset and below-normal body weight; the person fails to
recognize the eating behavior as a problem. Clients with
bulimia have a latter age at onset and a near-normal body
weight. They usually are ashamed and embarrassed by the
Eating disorders appear to be equally common among
Hispanic and white women and less common among African
American and Asian women.
· A life-threatening eating disorder characterized by the
client’s refusal or inability to maintain a minimally
normal body weight, intense fear of gaining weight or
becoming fat, significantly disturbed perception of the
shape or size of the body, and steadfast inability or
refusal to acknowledge the seriousness of the problem
or even that one exists.
· Has experienced amenorrhea for at least 3 consecutive
· Complaints of constipations and abdominal pain
· Cold intolerance
· Hypotension, hypothermia, bradycardia
o Intravascular volume is decreased; less blood to
pump through heart, also due to excessive
· Elevated BUN
o Normal levels: 10-20 mg/dl
o Urea is formed in the liver and is the end product
of protein metabolism.
o In anorexia, the body has already used fat for
energy; it is now breaking down muscles for
energy—the reason for the elevated BUN
· Decreased albumin
o Normal levels: 3.5-5 g/dl
o Measures amount of protein in the body; albumin
is a protein formed in the liver.
o Albumin tests are a great indicator of nutritional
· Leukopenia and mild anemia
o Not enough food and nutrients to replenish cells
· Has a preoccupation with food and food-related
· Can be divided into 2 subgroups:
o Restricting subtype : lose weight primarily through
dieting, fasting, or excessively exercising.
o Binge eating and purging subtype : engage
regularly in binge eating followed by purging.
· Engage in unusual or ritualistic food behaviors
o Refusing to eat around others
o Cutting food into minute pieces
o Not allowing the food they eat to touch their lips
· Excessive exercise is common
· Diagnosed between 14 and 18 years of age
· Pleased with their ability to control their weight and
may express this.
· As the illness progresses, depression and lability in
mood become more apparent
· Isolate themselves
· Believe peers are jealous of their weight loss and
believe family and health care professionals are trying
to make them “fat and ugly”.
· Clients who use laxatives are at a greater risk for
· Autonomy may be difficult in families that are
overprotective or in with enmeshment (lack of clear
boundaries) exists. By losing weight, these clients have
some control in their lives.
· Have body image disturbance (page 409)
· Can be very difficult to treat because they are often
resistant, appear uninterested, and deny their
o Focusing on weight restoration
o Nutritional rehabilitation
o Correction of electrolyte imbalances
o Severely malnourished individuals may require
TPN, tube feedings, or hyperalimentation to
receive adequate nutritional intake.
o Access to the bathroom is supervised to prevent
purging as clients begin to eat more food.
o Weight gain and adequate food intake are most
often the criteria for determining the effectiveness
o Amitriptyline (Elavil) and the antihistamine
cyproheptadine (Periactin) in high doses (up to
28mg/d) can promote weight gain in inpatients.
o Olanzapine (Zyprexa) has been used with success
because of both its antipsychotic effect (on bizarre
body image distortions) and associated weight
o Fluoxetine (Prozac) has shown some effectiveness
in preventing relapse in clients whose weight has
been partially or completely restored; close
monitoring is needed because weight loss can be a
· Family members often describe clients with anorexia as
perfectionists with above average intelligence,
dependable, eager to please, and seeking approval
before their condition began.
· Clients with anorexia appear slow, lethargic, and
fatigued; they may appear emaciated, depending on
the amount of weight loss. May be slow to respond and
have difficulty deciding what to say.
· Reluctant to answer questions fully because they do not
want to acknowledge any problem.
· Often wear loose clothing in layers
· Seldom smile, laugh, or enjoy any attempts at humor
· Characterized by recurrent episodes (at least twice a
week for 3 months) of binge eating followed by
inappropriate measures to avoid weight gain such as
purging (vomiting, laxatives, diuretics, enemas, or
emetics), fasting, or excessively exercising.
· Engaging in binge eating secretly
· Binging or purging episodes are often precipitated by
strong emotions and followed by guilt, remorse, shame,
· Recurrent vomiting destroys tooth enamel, has dental
caries and ragged or chipped teeth. Dentists are often
the first health care professionals to recognize this.
· Bulimia is typically diagnosed at 18 or 19.
· Clients with bulimia are aware that their eating
behavior is pathologic and go great lengths to hide it
· Clients with a co-morbid personality disorder tend to
have poorer outcomes than those without.
· Most are treated on an outpatient basis
· Antidepressants are more effective than the placebos in
reducing binge eating
· Clients are often focused on pleasing others and have a
history of impulsive behavior such as substance abuse
and shoplifting as well as anxiety, depression, and
· May be underweight, overweight, but are generally
close to expected body weight for age and size
· Appear open and willing to talk; initially pleasant and
cheerful as though nothing is wrong
Imbalanced Nutrition: Less than/More than body
· The client will establish adequate nutritional eating
o Implement and supervise the regimen for
o A diet of 1200-1500 calories is ordered, with
gradual increases in calories until clients are
ingesting adequate amounts for height, activity
level, and growth needs.
Start slowly—will have massive diarrhea
o The client with anorexia may be critically
TPN through central line
o A liquid protein supplement is given to replace any
food not eaten to ensure consumption to ensure
total number of calories prescribed
o Must monitor meals and snacks and will sit at the
table during eating away from the other clients
A major goal is to first get them to the table
o Diet beverages and food substitutions may be
o Specified time may be set for consuming each
meal and snack
o Discourage clients from performing food rituals
such as cutting food into tiny pieces or mixing
foods in unusual combinations
o Be alert for any attempts by client to hide or
o Must remain in view of staff for 1-2 hours to
ensure they do not vomit; access to bathrooms is
o Client is weighed daily on awakening and after
they have emptied their bladder. Have the client
wear a hospital gown each time they are weighed;
they may attempt to place objects in their clothing
to give the appearance of weight gain.
o In bulimia, the clients should sit at a table in a
kitchen or dining room.
o Write out a grocery list, it is easier to follow a
nutritious eating plan
· The client will eliminate use of compensatory behaviors
such as excessive exercise and use of laxatives and
· The client will demonstrate coping mechanisms not
related to food
· The client will verbalize feelings of guilt, anger, anxiety,
or an excessive need for control
o Help the client recognize emotions such as anxiety
or guilt by asking them to describe what they are
feeling; allow adequate time for response. Do not
ask “are you anxious? Sad?” because the client
may quickly agree rather than struggle for an
o Encourage self-monitoring (page 414); a behavior-cognitive
Disturbed body image
· The client will verbalize acceptance of body image with
stable body weight
o Help clients identify areas of personal strength
that are not food-related broadens clients’
perceptions of themselves.
Somatization: The transference of mental experiences and
states into bodily symptoms.
Somatoform disorders: Characterized as the presence of
physical symptoms that suggest a medical condition without
demonstrable organic basis to account fully for them. The
three central features of somatoform disorders are as
· Physical complaints suggest major medical illness but
have no demonstrable organic basis.
· Psychological factors and conflicts seem important in
initiating, exacerbating, and maintaining the symptoms.
· Symptoms or magnified health concerns are not under
the client’s conscious control.
The five specific somatoform disorders are as followed:
· Somatization disorder : Characterized by multiple
physical symptoms. It begins by 30 years of age,
extends over several years, and includes a combination
of pain and GI, sexual, and pseudoneurologic
o Client’s jump from one physician to the next, or
may see several providers at once in an effort to
obtain relief of symptoms.
o They tend to be pessimistic about the medical
establishment and often believe their disease
could be diagnosed of the providers were more
· Conversion disorder : Involves unexplained, usually
sudden deficits in sensory or motor function (blindness,
paralysis). These deficits suggest a neurological
disorder but are associated with psychological factors.
An attitude of la belle indifference, a seemingly lack
of concern or distress, is the key feature.
· Pain disorder : Pain is the primary physical symptom
which is generally unrelieved by analgesics and greatly
affected by psychological factors in terms of onset,
severity, exacerbation, and maintenance.
· Hypochondriasis : Preoccupation with the fear that one
has a serious disease (disease conviction) or will get a
serious disease (disease phobia). It is thought that
clients with this disorder misinterpret bodily sensations
· Body dysmorphic disorder : Preoccupation with an
imagined or exaggerated defect in personal appearance
such as thinking one’s nose is too large or teeth are
crooked and unattractive.
Symptoms of a somatization disorder
· Pain symptoms : complaints of headache, pain in the
abdomen, head, joints, back, chest, rectum; pain during
urination, menstruation, or sexual intercourse.
· GI symptoms : nausea, bloating, vomiting (other than
pregnancy), diarrhea, or intolerance of several foods.
· Sexual symptoms : Sexual indifference (don’t care to do
the dirty), erectile or ejaculatory dysfunction, irregular
menses, excessive menstrual bleeding.
· Pseudoneurologic symptoms : Impaired coordination or
balance, paralysis or localized weakness, difficulty
swallowing or lump in throat, aphonia (loss of speech
sounds), urinary retention, swollen tongue,
hallucinations, double vision, blindness, deafness,
seizures; disassociative symptoms such as amnesia; or
loss of consciousness other than fainting.
· Malingering : The intentional production of false or
grossly exaggerated physical or psychological
symptoms; it is motivated by external incentives such
as avoiding work, evading criminal prosecution,
obtaining financial compensation, or obtaining drugs.
Their purpose is some external incentive or outcome
that they view as important and results directly from
their illness. People who malinger can stop the physical
symptoms as soon as they have gained what they
· Factitious disorder : This is also known as Munchausen
syndrome. Occurs when a person intentionally produces
or feigns physical or psychological symptoms solely to
o Munchausen syndrome by proxy occurs when a
person inflicts illness or injury to someone else to
gain the attention of emergency medical
personnel or to be a “hero” for saving the victim.
This occurs most often in people who are in or
familiar with medical professions, such as nurses,
physicians, medical technicians, or hospital
· Primary gain : Direct external benefits that being sick
provides, such as relief of anxiety, conflict, or distress.
· Secondary gains : Internal or personal benefits received
from others because one is sick, such as attention from
family members and comfort measures (being brought
tea, receiving a back rub).
· Treatment focuses on managing symptoms and
improving quality of life.
· A trusting relationship helps to ensure that client’s stay
with and receive care from one provider instead of
· SSRIs are commonly used for depression that may
accompany somatoform disorders.
· The nurse must investigate physical health status
thoroughly to ensure there is no underlying pathology
requiring treatment. It is important not to dismiss all
future complaints because at any time the client could
develop a physical condition that would require medical
· In many cases, the client’s appearance brightens and
they look much better as the assessment interview
begins because they have the nurse’s undivided
· Client’s often have sleep pattern disturbances, lack
basic nutrition, and get no exercise.
· Ineffective coping
o The client will identify the relationship between
stress and physical symptoms.
Emotion-focused coping strategies help the
clients relax and reduce feelings of stress.
This includes progressive relaxation, deep
breathing, guided imagery, and distractions
such as music.
Problem-focused coping strategies help to
resolve or change a client’s behavior or
situation or to manage life stressors. This
includes learning problem solving methods.
The nurse should help the client role play the
· Ineffective denial
o The client will verbally express emotional feelings
The nurse should not attempt to confront
clients about somatic symptoms or attempt
to tell them that these symptoms are not
Encourage the client to write in a daily
Limiting the time that clients can focus on
physical complaints alone may be necessary.
The nurse may have to explain to the family
about primary and secondary gains; this will
encourage relatives to stop reinforcing the
· Impaired social interactions
o The client will follow an established daily routine
The nurse must help the client to establish
this that includes improved health behaviors.
The challenge for the nurse is to validate the
client’s feelings while encouraging him to
participate in activities.
The nurse should help the client plan social
contact with others, what to talk about (other
than the client’s complaints), and can
improve the client’s confidence in making
o The client will demonstrate alternative ways to
deal with stress, anxiety, and other feelings
· Disturbed sleep pattern
o The client will demonstrate healthier behaviors
regarding rest, activity, and nutritional intake.
The nurse explains that inactivity and poor
eating habits perpetuate discomfort and that
often it is necessary to engage in behaviors
even though one doesn’t feel like it.