Personality Disorder Impaired thought process: difficult thinking and

PERSONALITY - The aggregate of the physical and mental concentrating, impaired memory, unable to regulate incoming
qualities of the individual as these interact in characteristic sensory stimulus, poor attention span, agitated.
fashion with his environment. It includes perceptions,
attitudes, and emotions. Types of Personality Disorder
PERSONALITY TRAIT - Those characteristics of an individual CLUSTER DISORDERS DESCRIPTION
which make him unique and form the basis for the way he Cluster A: Odd Paranoid Clients are
perceives the world and how he relates to others. and Eccentric Schizoid withdrawn and
PERSONALITY DISORDER - Personality disturbances that come Schizotypal engage in odd
together to create a pervasive pattern of behavior and inner behavior.
experience that is quite different from the norms of the Cluster B: Erratic, Antisocial Attention seeker
culture. Dramatic and Borderline
 They have disturbances in self- image. Emotional Histrionic
 Decreased ability to have successful relationships. Narcissistic
 Inflexible maladaptive behavior pattern or traits that may Cluster C: Avoidant Client seeks to
impair social, intellectual functioning and relationships. Avoidant, Anxious Dependent avoid or minimize
 A spectrum of maladaptive traits that produces or and Fearful Obsessive- experience
influences considerable psychological and emotional Compulsive anxiety
disturbances and impair relationships. Not Specified Passive - Clients are
Aggressive covertly
Characteristics of Personality Disorder aggressive
 Maladaptive traits often prevent a person’s interpersonal
relationships and they increase the level of anxiety or PREVALENCE OF PD
internal stress.  13.4% prevalence rate
 MALADAPTIVE BEHAVIOR PATTERNS are the hallmark of  Most common of which are the avoidant, schizoid and
personality disorders. paranoid personality disorders.
 Maladaptive traits are often rigid and inflexible that exist ETIOLOGIES OF PD
in attitudes and behavior of the person,
 Once a person’s trait is established, it is extremely  There is no clear- cut single cause for PD, largely
resistant but not impossible to change. unknown.
 Multi- causation, genetic and environmental factors may
Features of Personality Disorder all apply roles.
 The onset begins during adolescence and young  Temperament may also play a role.
adulthood.
 Poor impulse control, rigid and inflexible CLUSTER A
 Mood characteristics SCHIZOID PERSONALITY DISORDERS
 Impaired judgment DESCRIPTION: Characterized by a pervasive pattern of
 Impaired reality testing detachment from social relationships and a restricted range of
 Impaired object relations emotional expression in interpersonal settings.
 Impaired though process  People with schizoid personality disorder avoid
 Impaired self- perception treatment as much as they avoid other relationships
 Impaired stimulus barrier unless their life circumstances change significantly.
 Acting out to manage internal pain. ASSESSMENT:
 Forms of acting out includes physical and verbal  Social detachment and lack of close relationships
attacks, manipulation, substance abuse,  Interest in solitary activities
promiscuous sexual behavior, and suicide attempts.  Aloof and indifferent to praise and criticism
 Restricted expression of emotions
Mood Characteristics: experiences abandonment and  Lack of interest in others.
depression  Indecisive and lacking future goals.
 Moods include rage, guilt, fear, and emptiness.  They may succeed in vocational areas (computers or
Impaired judgment: has difficulty with problem solving. electronics) if they have little contact with others.
 Unable to perceive the consequences of behavior.
Impaired reality testing: distorts reality and often projects NURSING MANAGEMENT
own feelings onto others.  Improve client’s functioning in the community.
Impaired object relations: rigid reality and inflexible and has  Provide facilities that will promote socialization through
difficulty in intimate relationships. group activities.
Impaired self- perception: Distorted self- perception and  Help client to identify the family members as his/ her
experiences self- hate or self- idealization. primary relationship.
 CLUSTER B
ANTISOCIAL PERSONALITY DISORDER
SCHIZOTYPAL PERSONALITY DISORDER DESCRIPTION: characterized by a pervasive pattern of
Description: characterized by a pervasive pattern of social and disregard for and violation of the rights of others—and with
interpersonal deficits marked by acute discomfort with and the central characteristics of deceit and manipulation.
reduced capacity for close relationships as well as by cognitive  Onset is in childhood or adolescence, although formal
or perceptual distortions and behavioral eccentricities. diagnosis is not made until the client is 18 years of age.
ASSESSMENT: ASSESSMENT:
 Magical Thinking  Clients are skillful at deceiving others.
 Odd thinking and ideas of reference  Exhibit signs of mild or moderate anxiety
 Relationship Deficit  Often display false emotions chosen to suit the occasion
 They frequently use words incorrectly, which makes their or to work to their advantage.
speech sound bizarre.  Cannot empathize with the feelings of others.
 Lack the ability to experience and to express a full range  Clients are oriented, have no sensory–perceptual
of emotions such as anger, happiness, and pleasure. alterations, and have average or above-average IQs.
 Flat affect  Poor judgment
 Experience great anxiety around other people especially  Self- centered, easily bored.
those who are unfamiliar.  No shame or guilt

NURSING MANAGEMENT NURSING MANAGEMENT

 Developed self- care and social skills and improved  Limit setting
functioning in the community.  Teach client to solve problems effectively and manage
 Encourage the client about the daily routine for hygiene emotions of anger or frustrations.
and grooming.
 The nurse can role play interactions that have with each BORDERLINE PERSONALITY DISORDER
of the people.  Characterized by a pervasive pattern of unstable
 Clients may be able to make written requests or to use interpersonal relationships, self-image, and affect as well
the telephone for business. as marked impulsivity.
 Social skills training helps the client to talk clearly with ASSESSMENT:
others.  The pervasive mood is dysphoric, involving unhappiness,
restlessness, and malaise.
PARANOID PERSONALITY DISORDER  Splitting: Thinking about self and others is often extreme
DESCRIPTION: characterized by pervasive mistrust and  Clients may experience dissociative episodes (periods of
suspiciousness of others. Clients with this disorder interpret wakefulness when they are unaware of their actions).
others’ actions as potentially harmful. During periods of  Many clients also report flashbacks of previous abuse or
stress, they may develop transient psychotic symptoms. trauma.
ASSESSMENT:  They make decisions impulsively based on emotions
 Clients appear aloof and withdrawn and may remain a rather than facts.
considerable physical distance from the nurse.  Self- destructive behavior and unable to tolerate anxiety.
 Clients also may appear guarded or hypervigilant.  These clients have extreme fears of abandonment and
 Restricted affect difficulty believing a relationship still exists once the
 Mood may be labile, quickly changing from quietly person is away from them.
suspicious to angry or hostile.
 Responses may become sarcastic for no apparent reason. NURSING MANAGEMENT
 May feel suspicion and mistrust to people and  Promote safety.
environment.  Help client to cope and control emotions.
 Defense Mechanism: Projection (used to blame others)  Cognitive restructuring techniques
 Conflict with authority figures on the job is common.  Teach client socialization skills.

NURSING MANAGEMENT HISTRIONIC PERSONALITY DISORDER

 Serious, straight forward approach  Characterized by a pervasive pattern of excessive
 Teach client to validate ideas before taking actions. emotionality and attention seeking.
 Involve them in formulating a plan of care.  The client is lively dramatic and enjoys being the center
of attention.
ASSESSMENT:
 Attention seeker.
 Needs to be the center of attention.
 Sexually seductive and provocative
 Self- dramatizing and theatrical
 Overly concerned with appearance  Cannot tolerate being alone and must always have a close
 Has romantic fantasies and control partners. relationship.
 Bores easily  Needs others to assume responsibility and make
 Displays dependency. decisions.

NURSING MANAGEMENT NURSING MANAGEMENT

 Teach client social skills.  Foster client’s self- reliance and autonomy
 Provide factual feedback about behavior.  Teach problem- solving and decision-making skills.
 Cognitive restructuring techniques
NARCISSISTIC PERSONALITY DISORDER
 Characterized by a pervasive pattern of grandiosity (in OBESSIVE- COMPULSIVE PERSONALITY DISPORDER
fantasy or behavior), need for admiration, and lack of  Characterized by a pervasive pattern of preoccupation
empathy. with perfectionism, mental and interpersonal control,
 Has increase sense of self- importance. and orderliness at the expense of flexibility, openness,
ASSESSMENT and efficiency.
 They lack the ability to recognize or to empathize with ASSESSMENT
the feelings of others.  Orderliness and Perfectionism
 They may express their grandiosity overtly, or they  Overly conscientious
quietly may expect to be recognized for their perceived  Inflexible ad preoccupied with details and rules.
greatness.  Devoted to work and lacks leisure.
 Preoccupied with fantasies of unlimited success, power,  Miserly and stubborn
brilliance, beauty, or ideal love.  Hoards worthless objects
 Overestimates abilities and underestimates contribution
of others. NURSING MANAGEMENT
 They expect special treatment from others and often are  Encourage negotiation with others.
puzzled or even angry when they do not receive it.  Assist client to make timely decisions and complete work.
 Cognitive restructuring techniques.
NURSING MANAGEMENT
 Matter of Fact approach (straightforward and NOT SPECIFIED
unemotional) PASSIVE- AGGRESSIVE PERSONALITY DISORDER
 Gain cooperation with needed treatment  Characterized by a negative attitude and a pervasive
 Teach client any needed self- care skills. pattern of passive resistance to demands for adequate
social and occupational performance.
CLUSTER C ASSESSMENT
AVOIDANT PERSONALITY DISORDER  They may alternate between hostile self-assertion such
 Characterized by a pervasive pattern of social discomfort as stubbornness or fault finding and excessive
and reticence, low self-esteem, and hypersensitivity to dependence, expressing contrition and guilt.
negative evaluation.  Mood may be sad or upset.
ASSESSMENT  The affects may be sad or angry.
 Feelings of inadequacy  Impaired judgment and decision making
 Social inhibition  Clients complain they are misunderstood and
 Lack of support system unappreciated by others.
 Hypersensitive to reactions of others and reacts poorly to  They express such resistance through procrastination,
criticism. forgetfulness, stubbornness, and intentional inefficiency,
 Have low self- esteem. especially in response to tasks assigned by authority
 Fearful of rejection, criticism figures.

NURSING MANAGEMENT NURSING MANAGEMENT

 Support and reassurance  Help client to identify feelings and express them directly.
 Cognitive restructuring techniques  Assist client to examine own feelings and behavior
 Promote self- esteem. realistically.
THERAPY: Provide Behavioral therapy
DEPENDENT PERSONALITY DISORDER  Consistency in approach
 Characterized by a pervasive and excessive need to be  Maintain a safe environment.
taken care of, which leads to submissive and clinging  Establish therapeutic relationship.
behavior and fears of separation.  Set limits to behavior.
ASSESSMENT  Help the client to learn ways to reduce anxiety.
 Difficulty making decisions.  Limit setting
 Lack autonomy.  Develop a written contract.
 Encourage to keep journal. involved in predisposition to schizophrenia. Other factors
 Recognize and deal with manipulative behavior. like prenatal infections, perinatal complications, and
 Maintain safety against self- destructive behaviors. environmental stressors are also being studied. The
 Allows the client to discuss feelings rather than act them manner of transmission of genetic predisposition is not
out. clearly understood.
 Provide consistency in response to client’s acting out  Biochemical factors. Involves dopamine (focus of most
behavior. studies), serotonin, norepinephrine, and epinephrine.
 Discuss expectations and responsibilities with the client. Excessive dopamine activity is linked to hallucinations,
 Discuss the consequences that will follow certain agitation, and delusion. High norepinephrine is linked to
behaviors. positive symptoms of schizophrenia.
 Inform the client that harm to self, others and property is  Other factors include structural brain abnormalities (e.g.,
unacceptable. enlarged ventricles), developmental (e.g., faulty neuronal
 Identify splitting behavior. connections), and other possible causes (e.g., maternal
 Assist the client to deal directly with anger. influenza during second trimester of pregnancy, epilepsy
 Encourage clients to participate in group activities and of the temporal lobe, head injury, etc.)
praise non- manipulative behavior.
 Set and maintain limits to decrease manipulative
behaviors. SIGNS AND SYMPTOMS
 Remove clients from group situations in which attention POSTIVE OR HARD SYMPTOMS
seeking behaviors occur.  "Positive" doesn't mean "good." Positive symptoms are
 Provide realistic praise for positive behavior in social things "added" or "new" to your personality or how you
situations. experience life because of schizophrenia.
Ways to handle manipulative behavior.  Positive symptoms are associated with temporal lobe
 Set clear realistic limits. abnormalities.
 Confront the client about manipulative behavior.  Ambivalence: Holding seemingly contradictory beliefs or
 Clearly and consistently communicate care plans and feelings about the same person, event, or situation
client behaviors to other nurses.  Associative looseness: Fragmented or poorly related
 Accepts no gift or flattery. thoughts and ideas.
 Form therapeutic nurse- patient relationship.  Delusions: Fixed false beliefs that have no basis of reality.
 Echopraxia: Imitation of the movements and gestures of
another person whom the client is observing.
 Flight of ideas: Continuous flow of verbalization in which
Nursing Care Management of Client with Schizophrenia the person jumps rapidly from one topic to another.
Schizophrenia refers to a group of severe, disabling  Hallucinations: False sensory perceptions or perceptual
psychiatric disorders marked by withdrawal from reality, experiences that do not exist of reality.
illogical thinking, possible delusions, and hallucinations, and  Ideas of reference: False impressions that external events
emotional, behavioral, or intellectual disturbance. have special meaning for the person.
 These disturbances last for at least for six (6) months. The  Perseveration: Persistent adherence to a single idea or
level of functioning in work, interpersonal relationship, topic; verbal repetition of a sentence, word, or phrase;
and self-care are markedly below the level since the resisting attempts to change the topic.
onset of symptoms.
 Have difficulty distinguishing reality from fantasy. Their TYPES OF HALLUCINATION
speech and behavior may frighten or mystify those OLFACTORY HALLUCINATION:
around them. Involve smells or odors. They may be a specific scent such as
 Schizophrenia causes bizarre thoughts, perceptions, urine or feces or a more general scent such as a rotten or
emotions, movements, and behavior. rancid odor. In addition to clients with schizophrenia, this type
 Schizophrenia usually is diagnosed in late adolescence or of hallucination often occurs with dementia, seizures, or
early adulthood. Rarely does it manifest in childhood. The cerebrovascular accidents.
peak incidence of onset is 15 to 25 years of age for men
and 25 to 35 years of age for women. VISUAL HALLUCINATIONS:
 The prevalence of schizophrenia is estimated at about Involve seeing images that do not exist at all, such as lights or
1% of the total population. a dead person, or distortions such as seeing a frightening
monster instead of the nurse. They are the second most
CAUSES common type of hallucination.
 Precise cause is unknown.
 There is currently no way to predict who will develop the TACTILE HALLUCINATIONS:
disease. Refer to sensations such as electricity running through the
 Genetic factors. It is believed that multiple genes body or bugs crawling on the skin. Tactile hallucinations are
(strongest evidence points to chromosomes 13 and 6) are
found most often in clients undergoing alcohol withdrawal; PERSECUTORY/PARANOID DELUSIONS involve the client’s
they rarely occur in clients with schizophrenia. belief that “others” are planning to harm the client or are
spying, following, ridiculing, or belittling the client in some
GUSTATORY HALLUCINATIONS: way. Sometimes the client cannot define who these “others”
Involve a taste lingering in the mouth or the sense that food are.
tastes like something else. The taste may be metallic or bitter Examples: The client may think that food has been poisoned
or may be represented as a specific taste. or that rooms are bugged with listening devices. Sometimes
the “persecutor” is the government, FBI, or other powerful
VISCERAL HALLUCINATIONS: Are unpleasant sensations that organization. Occasionally, specific individuals, even family
appears to arise from internal organs and can occur in both members, may be named as the “persecutor.”
psychiatric and neurological disorders. DELUSION OF OBSERVATION:
The belief where a person thinks he is being watched.
VISCERAL HALLUCINATIONS: Example: "Joe was under a delusion of observation when he thought he was
being watched.
 Involve the client’s report that he or she feels bodily DELUSION OF GRANDEUR:
functions that are usually undetectable. Are characterized by the client’s claim to association with famous people or
 Example: would be the sensation of urine forming or or the client’s belief that he or she is famous or capable of great
celebrities,
impulses being transmitted through the brain.
The client may claim to be engaged to a famous movie star or related
to some public figure, such as claiming to be the daughter of the president of the
NEGATIVE OR SOFT SYMPTOMS United States, or he or she may claim to have found a cure for cancer.
 Negative symptoms are associated with frontal cortex DELUSION OF GUILT:
and ventricular abnormalities.  This is a false feeling of remorse or guilt of delusional
 "Negative" doesn't mean "bad." Negative symptoms are intensity. A
"lost" from your personality or how you experience life.  Example, believe that he or she has committed some
 HALLUCINATION: False sensory perceptions or perceptual horrible crime and should be punished severely.
experiences that do not really exist.  Another example is a person who is convinced that he or
she is responsible for some disaster (such as fire, flood, or
 Alogia: Tendency to speak very little or to convey little
earthquake) with which there can be no possible
substance of meaning (poverty of content).
connection.
 Anhedonia: Feeling no joy or pleasure from life or any
HYPOCHONDRIACAL DELUSION:
activities or relationships.
 These are fixed beliefs about a poor state of health
 Apathy: Feelings of indifference toward people, activities,
despite convincing medical evidence to the contrary.
and events.
 Example: Marina believed she is suffering from serious
 Blunted affect: Restricted range of emotional feeling,
illness although the physician said that she is okay.
tone, or mood.
DELUSION OF BEING LOVED:
 Is a type of delusional disorder where the affected person
THINKING DISORDERS
believes that another person is in love with him or her.
THINKING: The process of using one's mind to consider or
 This belief is usually applied to someone with higher
reason about something
status or a famous person but can also be applied to a
THINKING DISORDERS:
complete stranger.
 A failure to be able to "think straight." Thoughts may
DELUSION OF JEALOUSY:
come and go rapidly.
 False belief that a spouse or lover is having an affair, with
 The person may not be able to concentrate on one
no proof to back up their claim.
thought for very long and may be easily distracted,
DELUSION OF INFLUENCE:
unable to focus attention.
 The patient has a pathological belief that his thoughts,
 The person may be unable to connect thoughts into
acts and emotions are caused by external influence
logical sequences, with thoughts becoming disorganized
(magic, hypnosis).
and fragmented.
 At delusion of influence there is feeling of thoughts,
experiences, and actions imposition.
SIGNS AND SYMPTOMS OF THINKING DISORDERS
 Person says that his own will is replaced with foreign will
DELUSION:
or force. It seems to the patient that his internal
Fixed, false beliefs with no basis in reality in the psychotic
thoughts, feelings, and actions are known to strangers.
phase of the illness. A common characteristic of schizophrenic
delusions is the direct, immediate, and total certainty with
SIGNS AND SYMPTOMS
which the client holds these beliefs. Because the client
NEGATIVE OR SOFT SYMPTOMS
believes the delusion, he or she therefore acts accordingly.
 Catatonia: Psychologically induced immobility
TYPES OF DELUSION
occasionally marked by periods of agitation or
excitement; the client seems motionless, as if in a trance.
 Flat affect: Absence of any facial expression that would Example: “I will take a pill if I go up the hill but not if my
indicate emotions or mood. name is Jill, I don’t want to kill.”
 Lack of volition: Absence of will, ambition, or drive to  Verbigeration is the stereotyped repetition of words or
take action or accomplish tasks. phrases that may or may not have meaning to the
listener. Example: “I want to go home, go home, go
ASSESSMENT OF SYMPTOMS home, go home.”
NEGATIVE POSITIVE  Word salad is a combination of jumbled words and
Hypoactive Hyperactive phrases that are disconnected or incoherent and make no
Withdrawn Sociable sense to the listener. Example: “Corn, potatoes, jump up,
Thought Blocking Flight of Ideas play games, grass, cupboard

ASSESSMENT OF SYMPTOMS PHASES OF SCHIZOPHRENIA

ASSESS FOR CONTENT OF THOUGHT: Prodromal Phase
NURSING DIAGNOSIS: Disturbed thought Process  Occurs before hospitalization or within the year.
PLANNING/ IMPLEMENTATION:  Characterized by clear decline from his previous level of
 Present Reality functioning.
 Provide Safety  May withdraw from friends and families and hobbies and
EVALUATION: interests, exhibit peculiar behavior, and deterioration in
Improved thought Process work and school performance.
Active Phase
 Commonly triggered by a stressful event
ASSESS FOR HALLUCINATION/ ILLUSIONS
 Characterized by presence of acute psychotic symptoms
NURSING DIAGNOSIS: Disturbed Sensory Perception
(e.g., hallucinations, delusions, incoherence, and
PLANNING/ IMPLEMENTATION:
catatonic behaviors).
 Present Reality
 Prognosis worsens with each acute episode.
 Provide Safety
Residual Phase
EVALUATION:
 This is at this point in which illness pattern is established,
Improved Sensory Perception
disability level may be stabilized, and late improvements
may occur.
ASSESS FOR SUSPICIOUS
Paranoid Type
NURSING DIAGNOSIS: Risk for other directed violence
 Characterized by persecutory (feeling victimized or spied
PLANNING/ IMPLEMENTATION: on) or grandiose delusions,
 Present Reality  Hallucinations: Experience frequent auditory
 Provide Safety hallucinations and, occasionally, excessive religiosity
EVALUATION: (delusional religious focus) or hostile and aggressive
Eliminate/ minimize risk for other directed violence behavior.

ASSESS FOR SUICIDAL TYPES OF SCHIZOPHRENIA

NURSING DIAGNOSIS: Risk for self-directed violence Disorganized Shizophrenia
PLANNING/ IMPLEMENTATION:  Characterized by grossly inappropriate or flat affect,
 Present Reality incoherence, loose associations, and extremely
 Provide Safety disorganized behavior.
EVALUATION:  Usually includes extreme social impairment.
Eliminate/ minimize risk for other directed violence  Sad but smiles (inappropriate affect)
 No reaction (flat affect)
COGNITIVE SYMPTOMS  Flight of ideas (disorganized speech)
 Reflect the patient’s abnormal thinking, poor decision-  Combination of positive and negative signs and
making skills, poor problem-solving skills, and ability to symptoms
communicate and his strange behavior.
 Thought disorder is characterized by confused thinking Catatonic type Schizophrenia
and speech (e.g., incoherent ramblings, loose association,  Characterized by marked psychomotor disturbance,
word salad, wandering). either motionless or excessive motor activity.
 Bizarre behavior includes childlike silliness, laughing or  Motor immobility may be manifested by catalepsy (waxy
giggling, agitation, inappropriate appearance, hygiene, flexibility) or stupor.
and conduct.  Ambivalence
 Favorite word is “No”
UNSUAL SPEECH PATTERN  Negativism (client do not follow what you tell them to do)
 Clang associations are ideas that are related to one NURSING MANAGEMENT: Meet Needs
another based on sound or rhyming rather than meaning.
PARANOID SCHIZOPHRENIA  The basis for diagnosing schizophrenia is formed by
 Suspicious mental status examination, psychiatry history, and
 Mistrust careful clinical observation.
 Scared  Diagnostic test results. No definitive diagnostic tool for
 Withdrawn schizophrenia but certain tests like CT scan and MRI may
NURSING MANAGEMENT be ordered to rule out disorders than can cause psychosis
 Gain trust by 1 to 1 short interaction but frequent (e.g. vitamin deficiencies and enlarged ventricles).
 Foods should be in a sealed container.  Ventricular-brain ratio may find elevated VBR in
 Medications should be in tamper resistant foil. schizophrenic patients.
If Violent:  Brain scans reveal functional cerebral asymmetries in a
 Keep door open. reverse pattern.
 Position near door
 Don’t touch client. MEDICAL MANAGEMENT
 Call for reinforcement Drug Therapy. Schizophrenia is mainly treated by
 One arm’s length away from the client. antipsychotics (neuroleptic) drugs.
 These prevent relapse of acute symptoms.
Undifferentiated Type:  Psychotic symptoms must be present 12 to 24 months
 Characterized by mixed schizophrenic symptoms (of before patients receive their first medical treatment.
other types) along with disturbances of thought, affect,  Examples of these drugs include the typical or
and behavior such as delusions and hallucinations. conventional typical antipsychotic chlorpromazine
Residual Type: (Thorazine) and the atypical
 Characterized by at least one previous, though not a
current, episode; social withdrawal; flat affect; and NURSING MANAGEMENT
looseness of associations. NURSING ASSESSMENT:
 Recognize schizophrenia. Note characteristic signs and
SCHIZOPHRENIFORM DISORDER symptoms of schizophrenia (e.g., speech abnormalities,
Schizophreniform disorder: thought distortions, poor social interactions).
 The client exhibits the symptoms of schizophrenia but for  Establish trust and rapport. Don’t tease or joke with
less than the 6 months necessary to meet the diagnostic patients. Expect that patient is going to put you through
criteria for schizophrenia. rigorous testing periods. Introduce yourself and explain
 Social or occupational functioning may or may not be your purpose.
impaired.  Maximize level of functioning. Assess patient’s ability to
carry out activities of daily living (ADLs).
DELUSIONAL DISORDER  Assess positive and negative symptoms.
Delusional disorder:  Assess medical history. Assess if the client is on
 The client has one or more non-bizarre delusions—that medications, what these are, and adherence to therapy.
is, the focus of the delusion is believable.  Assess support system. Determine whether the family is
 Psychosocial functioning is not markedly impaired, and well informed about the disease.
behavior is not obviously odd or bizarre.
NURSING DIAGNOSIS:
BRIEF PSYCHOTIC DISORDER Impaired Physical Mobility: related to depressive mood state
Brief Psychotic Disorder: and reluctance to initiate movement.
 The client experiences the sudden onset of at least one Impaired Social Interaction: related to problems in thought
psychotic symptom, such as delusions, hallucinations, or patterns and speech.
disorganized speech or behavior, which lasts from 1 day Decreased Cardiac Output: related to orthostatic hypotensive
to 1 month. drug effects.
 The episode may or may not have an identifiable stressor Risk for Suicide: related to impulsiveness and marked
or may follow childbirth. changes in behavior.
Risk for Injury: related to hallucinations and delusions.
Risk for Imbalanced Nutrition: less than body requirements
related to self-neglect and refusal for self-care.
NURSING INTRVENTIONS/ IMPLEMENTATIONS:
SHARED PSYCHOTIC DISORDER  Establish trust and rapport. Don’t touch client without
Shared psychotic disorder (folie à deux): telling him first what you are going to do. Use an
 Two people share a similar delusion. The person with this accepting, consistent approach; short, repeated contacts
diagnosis develops this delusion in the context of a close are best until trust has been established. Language
relationship with someone who has psychotic delusions. should be clear and unambiguous. Maintain a sense of
hope for possible improvement and convey this to the
DIAGNOSIS patient.
 Maximize level of functioning. Avoid promoting  Accompanying self-doubt, guilt, and anger alter life
dependence by doing only what the patient can’t do for activities, especially those that involve self-esteem,
himself. Reward positive behavior and work with him to occupation, and relationships.
increase his personal sense of responsibility in improving
functioning. GENETIC:
 Promote social skills. Provide support in assisting him to  First-degree relatives of people with bipolar disorder
learn social skills. have a 3% to 8% risk for developing bipolar disorder.
 Ensure safety. Maintain a safe environment with minimal NEUROCHEMICAL:
stimulation.  Neurochemical influences of neurotransmitters (chemical
 Ensure adequate nutrition. Monitor patient’s nutritional messengers) focus on serotonin and norepinephrine as
status and if the patient thinks his food is poisoned, let the two major biogenic amines implicated in mood
him fix his own food if possible or offer him foods in disorders.
closed containers that he can open. Institute suicide NEUROENDOCRINE:
and/or homicide precautions as appropriate.  Elevated glucocorticoid activity is associated with the
 Keep it real. Engage patient in reality-oriented activities stress response, and evidence of increased cortisol
that involve human contact (e.g., workshops, inpatient secretion is apparent in about 40% of clients with
social skills training). depression, with the highest rates found among older
 Deal with hallucinations by presenting reality. Explore the clients.
content of hallucinations. Avoid arguing about the  Major depressive disorder often in women aged 40 years
hallucinations. Tell them you do not see, hear, smell, or old, for bipolar age 30 years old.
feel it but explain that you know that these hallucinations
are real to him. CATEGORIES OF MOOD DISORDERS
 Promote compliance and monitor drug therapy. MAJOR DEPRESSIVE EPISODE:
Administer prescribed drugs and encourage the patient  Lasts at least 2 weeks, during which the person
to comply. Ensure that patient is really taking the drug. experiences a depressed mood or loss of pleasure in
 Encourage family involvement. Involve family in patient nearly all activities.
treatment and teaching.  Symptoms must be present every day for 2 weeks and
result in significant distress or impair social, occupational,
NURSING MANAGEMENT FOR PARANOID TYPE or other important areas of functioning.
At least five (5) of the following symptoms are present:
 Focus on altered thought process, perception and sleep 1. Depressed mood; diminished interest or pleasure
disturbance. 2. changes in appetite or weight loss,
 Establish nurse- client relationship. 3. sleep, or psychomotor activity.
 Providing safe environment and do not argue with them. 4. decreased energy; feelings of worthlessness or guilt.
 Promote good sleeping techniques. 5. difficulty thinking, concentrating, or making decisions.
6. recurrent thoughts of death or suicidal ideation, plans, or
NURSING MANAGEMENT FOR CATATONIC TYPE attempts.
 Focus on client with stupor or over excitement. BIPOLAR I- MANIC EPISODE
 Provide good dietary intake.  Bipolar disorder is diagnosed when a person’s mood
 Avoid infection, malnutrition, and disturbance of cycles between extremes of mania and depression (as
metabolism. described previously).
 Provide appropriate environment.  Mania is a distinct period during which mood is
 Avoid violent behaviors such as attacking or committing abnormally and persistently elevated, expansive, or
suicide. irritable. Typically, this period lasts about 1 week (unless
 Promote safety o client. the person is hospitalized and treated sooner),
At least three (3) of the following symptoms are present:
 Grandiosity
 Decreased need for sleep
 More talkativeness
 Flight of ideas
 Distractibility
 Increased of goal directed activity.
Nursing Care Management of Client with Mood Disorders  Excessive involvement in pleasurable activities
 Mood disorders, also called affective disorders, are BIPOLAR II- HYPOMANIA
pervasive alterations in emotions that are manifested by
depression, mania, or both.  Hypomania is a period of abnormally and persistently
 They interfere with a person’s life, plaguing him or her elevated, expansive, or irritable mood lasting 4 days.
with drastic and long-term sadness, agitation, or elation.  The difference is that hypomanic episodes do not impair
the person’s ability to function (in fact, he or she may be
 quite productive), and there are no psychotic features  Postpartum psychosis is a psychotic episode developing
(delusions and hallucinations). within 3 weeks of delivery and beginning with fatigue,
 A mixed episode is diagnosed when the person sadness, emotional lability, poor memory, and confusion
experiences both mania and depression nearly every day and progressing to delusions, hallucinations, poor insight
for at least 1 week. and judgment, and loss of contact with reality. This
 Bipolar I Disorder—one or more manic or mixed medical emergency requires immediate treatment.
episodes usually accompanied by major depressive
episodes. MAJOR DEPRESSIVE PSYCHOPHARMACOLOGY
 Bipolar II Disorder—one or more major depressive MAJOR DEPRESSIVE DISORDER:
episodes accompanied by at least one hypomanic  ANTIDEPRESSANT MEDICATIONS
episode.  Tricyclic Antidepressant
 Selective Serotonin Reuptake Inhibitor
RELATED DISORDERS  Monoamine Oxidase Inhibitors
DYSTHYMIC DISORDER MEDICAL MANAGEMENT:
 Dysthymic disorder is characterized by at least 2 years of  ELECTROCONVULSIVE THERAPY
depressed mood for more days than not with some
additional, less severe symptoms that do not meet the SELECTIVE SEROTONIN ANTIDEPRESSANT:
criteria for a major depressive episode.  Their action is specific to serotonin reuptake inhibition.
SYMPTOMS:  Insomnia decreases in 3 to 4 days.
 Depressed mood for more days than not, for at least 2  Appetite returns to a more normal state in 5 to 7 days
years or more.  Energy returns in 4 to 7 days.
 Poor appetite or overeating  In 7 to 10 days, mood, concentration, and interest in life
 Insomnia or hypersomnia improve.
 Low energy or fatigue
 Low self- esteem
 Poor concentration or difficulty making decisions.
 Feeling of hopelessness

CYCLOTHYMIC DISORDER
 Cyclothymic disorder is characterized by 2 years of
numerous periods of both hypomanic symptoms that do
not meet the criteria for bipolar disorder.
 A mild form of bipolar disorder II disorder characterized
by episodes of hypomania and episodes of mild
depression. TRICYCLIC ANTIDEPRESSANTS:
 They relieve symptoms of hopelessness, helplessness,
OTHER DISORDER anhedonia (lack of pleasure), inappropriate guilt, suicidal
 Seasonal affective disorder (SAD) has two subtypes. ideation, and daily mood variations.
 In one, most commonly called winter depression or fall  Tricyclic and heterocyclic antidepressants have a lag
onset SAD, people experience increased sleep, appetite, period of 10 to 14 days before reaching a serum level that
and carbohydrate cravings; weight gain; interpersonal begins to alter symptoms.
conflict; irritability; and heaviness in the extremities  they take 6 weeks to reach full effect.
beginning in late autumn and abating in spring and
summer.
 The other subtype, called spring-onset SAD, is less
common, with symptoms of insomnia, weight loss, and
poor appetite lasting from late spring or early summer
until early fall. SAD is often treated with light therapy.

 Postpartum or “maternity” blues are a frequent normal

experience after delivery of a baby. They are
characterized by labile mood and affect, crying spells,
sadness, insomnia, and anxiety. Symptoms begin
approximately 1 day after delivery, usually peak in 3 to 7 MONOAMINE OXIDASE INHIBITORS:
days, and subside rapidly with no medical treatment.  2-4 week before it reaches the full therapeutic effects
 Monitor for hypertensive crisis.
 Postpartum depression meets all the criteria for a major  Instruct client to avoid tyramine rich foods.
depressive episode, with onset within 4 weeks of
delivery.
  A cognitive disorder is a disruption or impairment in
these higher-level functions of the brain.
 Cognitive disorders can have devastating effects on the
ability to function in daily life.
 They can cause people to forget the names of immediate
family members, to be unable to perform daily household
tasks, and to neglect personal hygiene.

ORGANIC MENTAL DISORDER

 Organic mental disorders are disturbances that may be
caused by injury or disease affecting brain tissues as well
BIPOLAR/ MANIC as by chemical or hormonal abnormalities.
 Exposure to toxic materials, neurological impairment, or
Lithium: undergo first kidney test and check for blood levels abnormal changes associated with aging can also cause
• Level: .6 – 1.2 meq/L these disorders.
• Increase urination  Is a form of decreased mental function due to a medical
• Tremors, fine hand or physical disease, rather than a psychiatric illness.
• Hydration of 3L/day
• Increase DELERIUM
• Uu (diarrhea)  Delirium is a syndrome that involves a disturbance of
• Mouth dry consciousness accompanied by a change in cognition.
 Delirium usually develops over a short period, sometimes
Signs of Lithium toxicity a matter of hours, and fluctuates, or changes, throughout
• Nausea, vomiting, diarrhea the course of the day.
• Increase sodium  Clients with delirium have difficulty paying attention, are
* Wait for 2 – 4 weeks before lithium therapy takes effects. easily distracted and disoriented, and may have sensory
disturbances such as illusions, misinterpretations, or
NURSING MANAGEMENT hallucinations.
 Cognitive- Behavioral Therapy COMMON CAUSES OF DELIRIUM
 Provide safety of the client
 Promote therapeutic relationship.  Physiologic or metabolic: Hypoxemia, electrolyte
 Promote activities of daily living and physical care disturbances, renal or hepatic failure, hypoglycemia or
 Manage medications. hyperglycemia, dehydration, sleep deprivation, thyroid or
glucocorticoid disturbances.
BIPOLAR PSYCHOPHARMACOLOGY  Infection Systemic: sepsis, urinary tract infection,
BIPOLAR DISORDER: pneumonia Cerebral: meningitis
 Lithium  Drug Intoxication: Lithium, alcohol, sedatives
 Anticonvulsant Drugs
 Antipsychotic drugs: If a client in the acute stage of mania SIGNS AND SYMPTOMS
or depression exhibits psychosis (disordered thinking as  Difficulty with attention
seen with delusions, hallucinations, and illusions  Easily distractible
NURSING MANAGEMENT  Disoriented
 May have sensory disturbances such as illusions,
 Cognitive- Behavioral Therapy misinterpretations, or hallucinations.
 Provide safety to client.  Can have sleep–wake cycle disturbances.
 Meet psychologic needs.  Changes in psychomotor activity
 Provide therapeutic communication.  May experience anxiety, fear, irritability, euphoria, or
 Promote appropriate behavior. apathy.
 Manage medications.
APPLICATION OF THE NURSING PROCESS
Nursing Care of the Client with Cognitive Disorders ASSESSMENT
 COGNITION IS THE BRAIN’S ability to process, retain, and  Obtain history of drug and alcohol abuse from client.
use information.  Assess for client’s ability to provide accurate data.
 Cognitive abilities include reasoning, judgment, GENERAL APPEARANCE and MOTOR BEHAVIOR
perception, attention, comprehension, and memory.  Restless and hyperactive
 These cognitive abilities are essential for many important  Less coherent, and difficulty understanding.
tasks, including making decisions, solving problems,  Client scream especially at night
interpreting the environment, and learning new MOOD and AFFECT
information.  Anxiety, fear, irritability and anger
 Euphoria and apathy  Dementia is a chronic or progressive syndrome which
THOUGHT PROCESS AND CONTENT result from cerebral disease. It affects the functions
 Inability to sustain attention, illogical speech, including memory, thinking, orientation comprehension,
disorganized thought process. calculations, learning capacity, language, and judgement.
SENSORIUM and INTELLECTUAL PROCESS  Impairment of cognitive function are commonly
 Usually oriented to person but disoriented to time and accompanied by deterioration in emotional control, social
place. behavior, or motivation.
 Impaired recent and immediate memory  This syndrome occurs in Alzheimer's disease,
 Hallucinations and illusions Cerebrovascular disease, and others affecting the brain.
JUDGEMENT and INSIGHT
 Clients often cannot perceive potentially harmful COMPARISON OF DELIRIUM and DEMENTIA
situations or act in their own best interests.
ROLES and RELATIONSHIPS INDICATOR DELIRIUM DEMENTIA
 Clients are unlikely to fulfill their roles during the course Onset Rapid Gradual and Insidious
of delirium. Brief (Hours – Progressive
Duration
SELF- CONCEPT Day) Deterioration
 Client feels frightened and threatened. Impaired. Not Affective
Duration
Fluctuates
PSYCHOPHARMACOLOGY
Memory Short – term Short – term then
 Antipsychotic medication, such as Haloperidol (Haldol), memory impaired eventually destroyed
may be used in doses of 0.5 to 1 mg to decrease
Speech Slurred, rambling, Normal in early stage,
agitation.
pressure, progressive aphasia in
 Sedatives and Benzodiazepines are avoided because they
irrelevant later stage
may worsen delirium.
Thought Temporarily Impaired thinking,
process disorganized eventual loss of
NURSING INTERVENTIONS
thinking abilities
Promoting client’s safety:
Perception Visual or tactile Often absent but can
 Teach client to request assistance for activities (getting
hallucinations have paranoia,
out of bed, going to bathroom).
and delusions hallucinations, and
 Provide close supervision to ensure safety during these
delusions
activities.
Mood Anxious, fearful if Depressed and
 Promptly respond to client’s call for assistance
hallucinating, anxious in early stage,
Managing client’s confusion
weeping, irritable restless pacing, angry
 Speak to client in a calm manner in a clear low voice; use
outbursts in later
simple sentences.
stage
 Allow adequate time for client to comprehend and
respond.
 Allow client to make decisions as much as able. DEMENTIA
 Provide orienting verbal cues when talking with client. Aphasia, which is deterioration of language function
Controlling environment to reduce sensory overload.  Receptive aphasia, also known as Wernicke's aphasia, is
 Keep environmental noise to minimum (television, radio). a type of aphasia in which an individual is unable to
 Monitor client’s response to visitors; explain to family understand language in its written or spoken form.
and friends that client may need to visit quietly one on  Expressive aphasia, also known as Broca's aphasia, is
one. characterized by partial loss of the ability to produce
 Validate client’s anxiety and fears, but do not reinforce language (spoken or written), although comprehension
misperceptions. generally remains intact.
Promoting sleep and proper nutrition  Apraxia: which is impaired ability to execute motor
 Monitor sleep and elimination patterns. functions despite intact motor abilities.
 Monitor food and fluid intake; provide prompts or
 Agnosia: which is inability to recognize or name objects
assistance to eat and drink adequate amounts of food
despite intact sensory abilities.
and fluids.
 Provide periodic assistance to bathroom if client does not  Disturbance in executive functioning: which is the ability
make requests. to think abstractly and to plan, initiate, sequence,
 Discourage daytime napping to help sleep at night. monitor, and stop complex behavior.
 Encourage some exercise during day like sitting in a chair,
walking in hall, or other activities client can manage.
ALZHEIMER’S DISEASE
DEMENTIA
 Alzheimer's disease is a physical disease which attacks  Unable to hold head erect.
the brain resulting in impaired memory, thinking and  Will ultimately sleep into stupor or coma.
behavior.
 A primary degenerative cerebral disease with unknown DIAGNOSTIC PROCEDURES
etiology and is manifested by neuropathological and Diagnosis is made by exclusion; tests are performed to rule
neurochemical signs. Usually insidious in onset and out other diseases.
develops slowly but steadily over a period of several Positive diagnosis is made on autopsy.
years.  Positron emission tomography (PET) shows metabolic
 Affects woman more often than men. activity of the cerebral cortex.
 Computed Tomography Scan (CT scan) reveals excessive
TWO TYPES OF ALZHEIMER’S DISEASE and progressive brain atrophy.
Sporadic Alzheimer's disease  Magnetic Resonance Imaging (MRI) rules out intracranial
 The disease can affect adults at any age, but usually lesions
occurs after age 65.
 Sporadic Alzheimer's disease is by far the most common MEDICAL MANAGEMENT
form of Alzheimer's disease. Donepezil (Aricept)
 It affects people who may or may not have a family Dosage: 5–10 mg orally per day
history of the disease. Nursing Consideration: Monitor for nausea, diarrhea, and
Familial Alzheimer's disease insomnia. Test stools periodically for GI bleeding.
 The disease runs in a few families and is very rare. Rivastigmine (Exelon)
 If a parent has a mutated gene, each child has a50% Dosage: 3–12 mg orally per day divided into two doses
chance of inheriting it. Nursing Consideration: Monitor for nausea, vomiting,
 The presence of the gene means that the person will abdominal pain, and loss of appetite.
eventually develop Alzheimer's disease, usually in their Galantamine (Reminyl)
40's or 50's Dosage: 16–32 mg orally per day divided into two doses
 Familial Alzheimer's disease affects a very small number Nursing Consideration: Monitor for nausea, vomiting, loss of
of people. appetite, dizziness, and syncope.
Memantine (Namenda)
CLINICAL MANIFESTATIONS Dosage: 10–20 mg per day divided into two doses
Stage 1: Mild (Early confusion) Nursing Consideration: Monitor for hypertension, pain,
 Early cognitive decline in one or more areas headache, vomiting, constipation, and fatigue
 Memory loss
 Decrease ability to function in work. NURSING MANAGEMENT
 Name finding deficit.  Provide the patient with the safe environment; this may
 Decrease in social functioning. involve admission to a facility outside of the home.
 Recall difficulties and anxiety  Assist the patient with exercise, as ordered, to help
Stage 2: Moderate maintain mobility.
 Unable to perform complex tasks (e.g., managing  Maintain and established daily routine to decreased
personal finances, planning a dinner party, unable to confusion and disorientation.
concentrate, no knowledge of current events).  Use obvious signs in the patient’s room and place
Stage 3. Moderately severe (Early Dementia) familiar belongings at the bed.
 Usually needs assistance for survival.  Display clock with big hands for time orientation.
 Needs reminders to bath, selecting clothes and other  Calendar clearly marked with dates also for orientation.
daily functions.  Encourage client to read papers and listen to the radio
 Maybe disoriented to time or recent events although this and TV to make them interested in the new events.
can fluctuate.  Let them to choose topics of conversation and make face
 May become tearful. to face contact with them.
Stage 4. Severe (Dementia)  Speak slowly and use words that are easy to understand.
 Needs assistance with dressing, bathing and toilet  Ensure adequate nutrition by basing food choices on the
functions. patient’s current abilities, including the ability to chew
 May forget spouse, and other family members names. and swallow or use utensils.
 Generally unaware of his surroundings  Intervene with an agitated or fearful patient by helping
 Increase in CNS disturbances (e.g., agitation, delusions, him focus on another activity.
paranoia, obsessive anxiety, increase potential for violent  Refer the patient and his family to appropriate
behavior and tendency to wonder. community resources and support services.
Stage 5. Very severe (late dementia)  Establish an effective communication system with the
 Unable to speak. patient and his family to help them adjust to the patient’s
 May scream or make other sounds. altered abilities.
 Unable to ambulate, sit up, smile or feed self.  Offer emotional support to the patient and his family.
 • Accounts for half of all complaints at sexuality clinics
• 22% of women and 5% of men suffer from this disorder.
Problem: Inability to dress/groom self • Sexual Aversion Disorder
Nursing diagnosis: Self-care deficit: Dressing/grooming • Little interest in sex
related to psychologic impairment secondary to depression. • Extreme fear, panic, or disgust related to physical or
Problem: Suppressed feelings sexual contact.
Nursing Diagnosis: In effected coping related to situational • 10% of males report panic attacks during attempted
crisis. sexual activity.
Problem: Immobility
Nursing Diagnosis: Impaired physical mobility related to Sexual Arousal Disorders:
generalized weakness and fatigue. • Male Erectile Disorder
Problem: Disturbed Thought Process • Difficulty achieving and maintaining an erection.
Nursing Diagnosis: Disturbed thought process related to • Female Sexual Arousal Disorder
psychological changes: Neurochemical • Difficulty achieving and maintaining adequate
(deficiencies of neurotransmitters acetylcholine, lubrication.
somatostatin, and norepinephrine). • Associated Features of Sexual Arousal Disorders
• Problem is arousal, not desire.
• Problem affects about 5% of males, 14% of females.
Sexual and Gender Identity Disorders • Males are more troubled by the problem than females.
The Nature of Gender Identity Disorder • Erectile problems are the main reason males seek help.
• Clinical Overview
• Person feels trapped in the body of the wrong sex. Orgasm Disorders:
• Assume the identity of the desired sex, but the goal • Premature Ejaculation
is not sexual. • Ejaculation occurring before the man or partner wishes
• Causes are Unclear. it to
• Gender identity develops between 18 months and 3 • 21% of all adult males meeting criteria for premature
years of age. ejaculation
• Sex-Reassignment as a Treatment of Gender Identity • Most prevalent sexual dysfunction in adult males
Disorder • Most common in younger, inexperienced males, but
• Who is a candidate? – Some basic prerequisites declines with age.
before surgery
• 75% report satisfaction with new identity Sexual Pain Disorders:
• Female-to-male conversions adjust better than • Defining Feature: Marked Pain During Intercourse
male-to-female. • Dyspareunia
• Extreme pain during intercourse
PHASES OF SEXUAL DYSFUNCTION • Adequate sexual desire, and ability to attain arousal and
DESIRE PHASE PLATEAU PHASE orgasm.
Sexual urges occur in response to Brief period of time • Must rule out medical reasons for pain.
sexual cues or fantasies. before orgasm • Affects 1% to 5% of men and about 10% to 15% of
women.
AROUSAL PHASE ORGASM PHASE • Vaginismus
A subjective sense of sexual pleasure In male: Feelings of • Limited to females
and physiological signs of sexual inevitability of • Outer third of the vagina undergoes involuntary
arousal. ejaculation. spasms.
In female: contraction • Complaints include feeling of ripping, burning, or
In male: Penile Tumescence- an of the walls of the tearing.
increase blood flow into the penis. vagina. • Affects over 5% of women seeking treatment.
• Prevalence rates are higher in more conservative
In female: Vasocongestion- blood RESOLUTION PHASE countries and subgroups.
poos in the pelvic area leading to Decrease arousal after
vaginal lubrication and nipple orgasm. Assessing Sexual Behavior and Sexual Dysfunction
erection. • Comprehensive Interview
• Include a detailed history of sexual behavior, lifestyle,
Sexual Desire Disorders: An Overview and associated factors.
• Hypoactive Sexual Desire Disorder • Medical Examination
• Little or no interest in any type of sexual activity • Must rule out potential medical causes of sexual
• Masturbation, sexual fantasies, and intercourse are rare dysfunction.
in this disorder. • Psychophysiological Evaluation
• Exposure to erotic material
 • Determine extent and pattern of physiological and • Sexual sadism and masochism
subjective sexual arousal. • Pedophilia
• Males – Penile strain gauge Fetishism and Transvestic Fetishism
• Females – Vaginal photoplethysmograh. • Fetishism
• Sexual attraction to nonliving objects (i.e., inanimate
Causes of Sexual Dysfunctions and/or tactile)
• Biological Contributions • Numerous targets of fetishistic arousal, fantasy, urges,
• Physical disease and medical illness and desires.
• Prescription medications • Transvestic Fetishism
• Use and abuse of alcohol and other drugs. • Sexual arousal with the act of cross-dressing
• Psychological Contributions • Males may show highly masculinized compensatory
• The role of “anxiety” vs. “distraction” behaviors.
• The nature and components of performance anxiety • Most do not show compensatory behaviors.
• Psychological profiles associated with sexual • Many are married and the behavior is known to spouse.
dysfunction.
• Social and Cultural Contributions: Negative Scripts About Voyeurism and Exhibitionism
Sexuality • Voyeurism
• Erotophobia – Learned negative attitudes about • Practice of observing an unsuspecting individual
sexuality. undressing or naked
• Negative or traumatic sexual experiences • Risk associated with “peeping” is necessary for sexual
• Deterioration of interpersonal relationships, lack of arousal.
communication. • Exhibitionism
• Exposure of genitals to unsuspecting strangers
Psychosocial Treatment of Sexual Dysfunction • Element of thrill and risk is necessary for sexual
• Education alone arousal.
• Surprisingly effective
• Master’s and Johnson’s Psychosocial Intervention Sexual Sadism and Sexual Masochism
• Education • Sexual Sadism
• Eliminate performance anxiety – Sensate focus and • Inflicting pain or humiliation to attain sexual
nondemand pleasuring. gratification.
• Additional Psychosocial Procedures • Sexual Masochism
• Squeeze technique – Premature ejaculation • Suffer pain or humiliation to attain sexual
• Masturbatory training – Female orgasm disorder gratification.
• Use of dilators – Vaginismus • Relation Between Sadism and Rape
• Exposure to erotic material – Low sexual desire • Some rapists are sadists, but most do not show
problems paraphilic patterns of arousal.
• Rapists show sexual arousal to violent sexual and non-
Medical Treatment of Sexual Dysfunction sexual material.
• Erectile Dysfunction
• Viagra Pedophilia
• Injection of vasodilating drugs into the penis • Overview
• Penile prosthesis or implants • Pedophiles – Sexual attraction to young children
• Vascular surgery • Incest – Sexual attraction to one’s own children.
• Vacuum device therapy • Both may involve male and/or female children or very
• Few Medical Procedures Exist for Female Sexual young adolescents.
Dysfunction • Pedophilia is rare, but not unheard of, in females.
• Associated Features
Paraphilias: • Most pedophiles and incest perpetrators are male.
• Nature of Paraphilias • Incestuous males may be aroused to adult women,
• Sexual attraction and arousal to inappropriate people, not true for pedophiles.
or objects • Most rationalize the behavior and engage in other
• Often multiple paraphilic patterns of arousal moral compensatory behavior.
• High comorbidity with anxiety, mood, and substance
abuse disorders Pedophilia: Causes and Assessment
• Main Types of Paraphilias • Causes of Pedophilia
• Fetishism • Pedophilia is associated with sexual and social
• Voyeurism problems and deficits.
• Exhibitionism • Patterns of inappropriate arousal and fantasy may be
• Transvestic fetishism learned early in life.
 • The role of high sex drive, coupled with suppression
of urges.
• Psychophysiological Assessment of Pedophilia
• Assess extent of deviant patterns of sexual arousal Nursing Management for Client with Eating Disorders
• Assess extent of desired sexual arousal to adult ANOREXIA NERVOSA
content Anorexia: Refers to loss of appetite
• Assess social skills and the ability to form Nervosa: Indicates that the loss is due to emotional reasons.
relationships. Anorexia Nervosa is a life-threatening eating disorder
characterized by the client’s refusal or inability to maintain a
Pedophilia: Psychosocial Treatment minimally normal body weight, intense fear of gaining weight
• Psychosocial Interventions or becoming fat, significantly disturbed perception of the
• Most are behavioral and target deviant and shape or size of the body.
inappropriate sexual associations. Incidence and Characteristics:
• Covert sensitization – Imaginal procedure involving  Affects 3.7% of women.
aversive consequences.  Less common than bulimia
• Orgasmic reconditioning – Associate masturbation  6 to 20% die as a result of the illness
with appropriate stimuli  Higher death rate than any other psychiatric disorder
• Family/marital therapy – Address interpersonal  Females, 90% (Male numbers are growing)
problems.  Onset: Adolescence to early adulthood (14 and 18 years
• Coping and relapse prevention – Teaches self-control old)
and coping with risk.  Age of onset is decreasing.
 Often insidious
Pedophilia: Medical Treatment  Occurs during important life transitions.
• Medications: The Equivalent of Chemical Castration  No loss of appetite
• Often used for dangerous sexual offenders  Deliberate Weight loss
• Types of Available Medications  Refusal to maintain normal weight.
• Cyproterone acetate – Anti-androgen, reduces  Intense fear of gaining weight, even if underweight
testosterone, sexual urges and fantasy.  Body image disturbances
• Medroxyprogesterone acetate – Depo-provera, also  In female adults or adolescents, absence of at least 3
reduces testosterone. consecutive menstrual cycles
• Triptoretin – A newer and more effective drug that  Types are: Restricting and Binge/Purging
inhibits gonadtropin secretion.
• Efficacy of Medication Treatments TYPES OF ANOREXIA NERVOSA
• Drugs work to greatly reduce sexual desire, fantasy,  RESTRICTING TYPE: Clients with the restricting subtype
arousal. lose weight primarily through dieting, fasting, or
• Relapse rates are high with medication excessive exercising. Those with the binge eating and
discontinuation. purging subtype engage regularly in binge eating followed
by purging.
Summary of Sexual and Gender Identity Disorders  Binge Eating: means consuming a large amount of food in
• Gender Identity and Gender Identity Disorder a discrete period of usually 2 hours or less.
• Problem is not sexual; the problem is feeling trapped  Purging involves compensatory behaviors designed to
in body of wrong sex. eliminate food by means of self-induced vomiting or
• Sexual Dysfunctions are Common in Men and Women misuse of laxatives, enemas, and diuretics.
• Problems with desire, arousal, and/or orgasm  Some clients with anorexia do not binge but still engage
• Require comprehensive assessment and treatment in purging behaviors after ingesting small amounts of
approaches. food.
• Paraphilias Represent Inappropriate Sexual Attraction
• Desire, arousal, and orgasm gone awry. WARNING SIGNS
• Require comprehensive assessment and treatment  Pretending to have eaten previously as an excuse to avoid
approaches. a meal.
• Available Psychosocial and Medical Treatment Options  Avoiding eating with the family
are Generally Efficacious  Hiding food or disposal of food that has been pretended
to be eaten.
 Using time restriction often as an excuse for skipping
breakfast
 Insisting on walking somewhere if offered a lift /
excessive activity.
 Avoiding situations where there is food.
 Avoiding eating in front of others
 Becoming unusually agitated if forced into a situation  Nutrition less than body requirements related to refusal
where there is food. to eat; excessive exercise.
 Cutting food into tiny pieces and eating extremely slowly  Risk for falls related to hypotension.
FOOD RELATED BEHAVIORS IN ANOREXIA NERVOSA  Fluid volume deficit related to laxative overuse.
 Constipation related to altered gastric motility.
 Restricting intake, fasting  Imbalanced fluid volume related to fluid shifts.
 Hoarding food  Impaired cardiac or peripheral tissue perfusion related to
 Highly avoidant of certain foods decreased cardiac output.
 Preoccupation with calories, meals, recipes, etc.
 Preparing/serving elaborate meals for others COLLABORATIVE MANAGEMENT
 Rituals before and during eating  Weight Restoration
 become compulsions.  Rehydration
 Nutritional Rehabilitation
PURGING BEHAVIOR IN ANOREXIA NERVOSA  Correction of electrolytes
 Eat normally in a social situation.  May require total parenteral nutrition (TPN) for severe
 Amount of food eaten is not excessive. malnourished client.
 Purge if no success with severe restricting  Weight gain and adequate food intake are most often the
criteria for determining the effectiveness of treatment.
METABOLIC CONSEQUENCES
PSYCHOPHARMACOLOGY
 Amitriptyline (Elavil) and the antihistamine
cyproheptadine (Periactin) in high doses (up to 28
mg/day) can promote weight gain in inpatients with
anorexia nervosa.
 Olanzapine (Zyprexa) has been used with success
because of its antipsychotic effect (on bizarre body image
distortions) and associated weight gain.
 Fluoxetine (Prozac) has some effectiveness in preventing
relapse in clients whose weight has been partially or
completely restored.

PSYCHOTHERAPY
CLINICAL MANIFESTATIONS  Family Therapy: is useful to help members to be effective
 Decreased peristalsis is exacerbated by overuse of participants in the client’s treatment.
laxatives or enemas.  Individual Therapy: Therapy that focuses on the client’s
 Delayed gastric emptying. particular issues and circumstances, such as coping skills,
 Feel full much longer. self-esteem, self-acceptance, interpersonal relationships,
 Dehydration assertiveness, can improve overall functioning and life
 Amenorrhea, decreased development of secondary sex satisfaction.
characteristics
 Osteopenia or Osteoporosis BULIMIA
 Bone mass loss may be irreversible.  Means to have an insatiable appetitive.
 Weakness and fatigue  Begins in late adolescence or early adulthood: 18 or 19
 But will persist in excessive exercising to burn years old.
calories.  Primarily in women
 Heart failure, life threatening arrhythmias  4% of young adults
 Cardiac ventricular dilation  Symptom overlap with Anorexia, making diagnosis
 Decreased thickness of the ventricular wall difficult.
 Decrease oxygenation of the cardiac muscle
 Renal failure CHARACTERISTICS
 Hide their eating-disordered behaviors.
COMPLICATIONS  Lack of weight loss
 Hypokalemia  Coexisting mental disorders:
 Hypocalcemia  Purging develops as a way to compensate for massive
 Metabolic Acidosis amounts of food eaten.
 Metabolic Alkalosis  Restrictive eating…. then purging…. cycle

NURSING DIAGNOSIS BINGE EATING

 Feelings of lack of control
 Often done in secret  Warm nurturing environment
 High calorie-High carbohydrate  Convey an understanding of their fears.
 Consumed in less than 2 hours.  Close observation
 Addicted to the high experienced when eating.  Do we let these patients go to the rest room alone?
 Should we let them go to their room right after a
PURGING meal?
 Compensatory Behavior for Binge Eating  Nonjudgmental confrontation
 May use manual stimulation, laxatives, and/or emetics.  CONSISTENCY
 Over time, self-induced vomiting occurs with minimal  Encourage the patient to talk to staff when they feel the
stimulation. need to purge.
 Post-purging: sense of relief, calm  Weighing
 Family Therapy
COMPLICATIONS  Group Therapy
 Electrolyte imbalances  Dietitian
 Metabolic Acidosis  Follow-up Therapy (outpatient)
 Metabolic Alkalosis
 Cardiomyopathy Management of Eating Disorders
 Enlarged salivary glands. • Anorexia
 Erosion of dental enamel • Increase weight to 90% of average body weight.
 Russell’s sign • Increase self-esteem.
 Pancreatitis • Decrease needs for perfection (provided by
thinness)
MANAGEMENT • Bulimia
 Stabilize weight without purging. • Stabilize weight without purging.
 Inpatient treatment for medical stabilization and dietary
management • Both Anorexia and Bulimia:
 Long-term outpatient tx. addresses psychosocial issues. • Inpatient treatment for medical stabilization and
 More likely to want help: break the cycle. dietary management
 More likely to enter treatment of them on volition. • Long-term outpatient tx. addresses psychosocial
 Tendency to manipulate. issues.
 Hide the degree of the problem.
MEDICATIONS: Management: Starvation Phase of Anorexia
 SSRI for Bulimia • Assess labs:
 Equally effective for depressed and non-depressed • Monitor intake/output.
patients • Assess for cardiovascular, neurological and complications.
 Desipramine (Norpramin) • Refeed slowly, careful dietary supervision.
 Imipramine (Tofranil) • Intravenous lines and feeding tubes if client refuse food.
 Emitryptyline (Elavil)
 Nortriptyline (Pamelor) Nurse Patient Relationship
 Phenelzine (Nardil) • Anorexia Nervosa
 Fouxetine (Prozac) • Usually forced into tx.
• Tx means loss of control overeating.
NURSE PATIENT RELATIONSHIP FOR EATING DISORDERS • Nurses are the enemy.
 Do not confront denial but encourage feelings • Bulimia Nervosa
identification. • More likely to want help: break the cycle.
 Honesty • More likely to enter treatment of their on volition.
 Collaborate • Tendency to manipulate.
 TEACH patient about their disorder. • Hide the degree of the problem.
 Assist to identify positive qualities.
 Eat with the client. Nurse Patient Relationship:
 Set appropriate limits. Some Interventions for Eating Disorders
 Encourage decision making concerning issues other than • Do not confront denial but encourage feelings
food. identification.
 Behavior modification: • Honesty
 Patient input • Collaborate
 Reward for weight gain • TEACH patient about their disorder.
• Assist to identify positive qualities.
MILIEU MANAGEMENT • Eat with the client.
 Orientation • Set appropriate limits.
• Encourage decision making concerning issues other than  The substance use is continued despite knowledge of
food. having a persistent or recurrent physical or psychological
• Behavior modification: problem that is likely to have been caused or exacerbated
• Patient input by the substance.
• Reward for weight gain
ETIOLOGY
Nursing Management for Patients on Substance Abuse  Children of alcoholic parents are at higher risk for
 Psychoactive Substances are substances that, when developing alcoholism and drug dependence.
taken in or administered into one's system, affect mental  Inconsistency in the parent’s behavior, poor role
processes, e.g. cognition or affect. modeling, and lack of nurturing pave the way for the
 Substance Abuse is a maladaptive pattern of substance child to adopt a similar style of maladaptive coping,
use manifested by recurrent and significant adverse stormy relationships, and substance abuse.
consequences related to repeated use of the substance;  Some people use alcohol as a coping mechanism or to
any use of substances that poses significant hazards to relieve stress and tension, increase feelings of power, and
health; leads to clinically significant impairment or decrease psychologic pain.
distress occurring within a 12-month period.  Social and environmental factors: availability of the
 Tolerance: The need for increased amount of a substance substances
to produce the same effect.
 Intoxication is use of a substance that results in TYPES OF SUBSTANCES
maladaptive behavior.  ALCOHOL
 Dependence: a compulsive or chronic requirement; a  OPIATES
need so strong as to generate physical or psychological  MARIJUANA
distress if left unfulfilled.  HYPNOTIC
 Physical dependence is evidenced by a cluster of  STIMULANTS
cognitive, behavioral, and physiological symptoms
indicating continued use of the substance despite ALCOHOL
significant substance-related problems.  Alcohol is a central nervous system depressant that is
 Psychological dependence is indicated by an absorbed rapidly into the bloodstream.
overwhelming desire to repeat the use of a particular  Initially, the effects are relaxation and loss of inhibitions.
drug to produce pleasure or avoid discomfort.  Most commonly abused drug.
 Withdrawal syndrome refers to the negative psychologic  Physically addicting
and physical reactions that occur when use of a  alcohol becomes integrated into physiologic
substance ceases or dramatically decreases. processes at the cellular level.
 Detoxification is the process of safely withdrawing from a
substance. The treatment of other substance-induced ALCOHOL INTOXICATION
disorders such as psychosis and mood disorders are  Slurred speech
discussed in depth in separate chapters.  Unsteady gait, lack of coordination
 Impaired attention, concentration, memory, and
DIAGNOSTIC CRITERIA FOR SUBSTANCE ABUSE judgment.
 Recurrent substance use resulting in a failure to fulfill  Aggressiveness or display inappropriate sexual behavior.
major role obligations at work, school, or home.  Experiences Blackout.
 Recurrent substance uses in situations in which it is  BLACKOUT: which is an episode during which the
physically hazardous. person continues to function but has no conscious
 Recurrent substance-related legal problems. awareness of his or her behavior at the time or any
 Continued substance uses despite having persistent or later memory of the behavior.
recurrent social or interpersonal problems caused or
exacerbated by the effects of the substance. ALCOHOL WITHDRAWAL:
 Begins 4 to 12 hours after cessation or marked reduction
CRITERIA FOR SUBSTANCE DEPENDENCE of alcohol intake.
 The substance is often taken in larger amounts or over a  Peaks on the second day and is over in about 5 days.
longer period than was intended.  coarse tremor of hands, tongue, or eyelids
 There is a persistent desire or unsuccessful efforts to cut  nausea or vomiting
down or control substance use.  malaise or weakness
 A great deal of time is spent in activities necessary to  tachycardia, sweating, elevated blood pressure
obtain the substance, use the substance, or recover from  transient hallucinations or illusions
its effects.  progression to alcohol withdrawal delirium
 Important social, occupation, or recreational activities are
given up or reduced because of substance use. Related physiological effects.
 Wernicke’s encephalopathy
  Severe thiamine (Vit. B-1) deficiency psychosis, including hallucinations (usually visual) and
 Paralysis of the ocular muscles depersonalization. Hallucinogens distort reality.
 Ataxia Examples of hallucinogens are mescaline, psilocybin, lysergic
 Somnolence, stupor, or death acid diethylamide, and “designer drugs” such as Ecstasy.

Korsakoff’s psychosis HALLUCINOGEN INTOXICATIONS:

 Confusion, Loss of recent memory.  Anxiety, depression, paranoid ideation, ideas of
 Confabulation- reference, fear of losing one’s mind, and potentially
 Often occurs in conjunction with Wernicke’s dangerous behavior such as jumping out of a window.
encephalopathy (“Wernicke-Korsakoff syndrome”)  Physiologic symptoms include sweating, tachycardia,
palpitations, blurred vision, tremors, and lack of
FOUR PHASES OF PROGRESSION OF ALCOHOL coordination.
Phase I: The Pre-alcoholic Phase.
 Use of alcohol to relieve everyday stress and tension. HYPNOTICS
Phase II: The Early Alcoholic Phase  Induces varying degrees of CNS depression.
 Characterized by blackouts.  Categories include barbiturates, nonbarbiturate
 Alcohol becomes requirement as opposed to source of hypnotics, and antianxiety agents.
pleasure or relief.  Physiologically and psychologically addicting.
Phase III: The Crucial Phase  May generate “psychic drive” for continued use to
 Loss of control over drinking achieve maximum level of functioning or feeling of well-
 Interference with social and/or occupational function being.
Phase IV: The Chronic Phase
 Emotional and physical disintegration. HYPNOTIC INTOXICATION
 Life-threatening physical manifestations of both use and • slurred speech
withdrawal symptomology present. • incoordination/unsteady gait
• nystagmus
OPIOID • impaired memory; stupor/coma
 Opioids are popular drugs of abuse because they
desensitize the user to both physiologic and psychologic HYPNOTICS WITHDRAWAL:
pain and induce a sense of euphoria and well-being.  Diaphoresis
 Opioid compounds include both potent prescription  nausea/vomiting
analgesics such as morphine, meperidine (Demerol),  increased heart rate
codeine, hydromorphone, oxycodone, methadone,  psychomotor agitation; hand tremors; seizures
oxymorphone, hydrocodone, and propoxyphene as well  Insomnia
as illegal substances such as heroin and normethadone.  hallucinations/illusions

OPIOIDS INTOXICATION: CANNABIS (MARIJUANA)

 apathy, lethargy,  Cannabis sativa is the hemp plant that is widely
 impaired judgment, psychomotor retardation or agitation cultivated for its fiber used to make rope and cloth and
 constricted pupils, drowsiness, slurred speech, and for oil from its seeds.
impaired attention and memory.  It has become widely known for its psychoactive resin.
 Severe intoxication or opioid overdose can lead to coma,  This resin contains more than 60 substances, called
respiratory depression, pupillary constriction, cannabinoids, of which 8-9tetrahydrocannabinol is
unconsciousness, and death. thought to be responsible for most of the psychoactive
effects.
OPIOIDS WITHDRAWAL:  Marijuana refers to the upper leaves, flowering tops, and
 Develops when drug intake ceases or decreases or may stems of the plant; hashish is the dried resinous exudate
be due to administration of opioid antagonist. from the leaves of the female plant.
 Withdrawal symptoms: 6 to 24 hours, peak in 2 to 3 days,  Cannabis is most often smoked in cigarettes (joints).
subside in to 7 days.  Research has shown that cannabis has short term effects
 Anxiety, restlessness, aching back and legs, and cravings of lowering intraocular pressure, but it is not approved
for more opioids. for the treatment of glaucoma.
 Nausea, vomiting, dysphoria, lacrimation, rhinorrhea,  It also has been studied for its effectiveness in relieving
sweating, diarrhea, fever an insomnia. the nausea and vomiting associated with cancer
chemotherapy and the anorexia and weight loss of AIDS.
HALLUCINOGENS  Currently, two cannabinoids, dronabinol (Marinol) and
Hallucinogens are substances that distort the user’s nabilone (Cesamet), have been approved for treating
perception of reality and produce symptoms similar to nausea and vomiting from cancer chemotherapy.
MARIJUANA INTOXICATION:  Widely used stimulant (readily available)
 Cannabis begins to act less than 1 minute after  Increases alertness.
inhalation. Peak effects usually occur in 20 to 30 minutes  Withdrawal symptoms include depression, irritability,
and last at least 2 to 3 hours. insomnia, difficulty concentrating, increased appetite.
 impaired motor coordination, inappropriate laughter,
impaired judgment and short-term memory, and NURSING INTERVENTIONS
distortions of time and perception. Anxiety, dysphoria,  Health teaching for the client and family
and social withdrawal  Dispel myths surrounding substance abuse.
 Physiologic effects: increased appetite, include  Decrease codependent behaviors among family
conjunctival injection (bloodshot eyes), dry mouth, members.
hypotension, and tachycardia.  Make appropriate referrals for family members.
 delirium or, rarely, cannabis-induced psychotic disorder,  Promote coping skills.
 Role-play potentially difficult situations
MARIJUANA WITHDRAWAL:  Focus on the here-and-now with clients.
 Although some people have reported withdrawal  Set realistic goals such as staying sober today.
symptoms of muscle aches, sweating, anxiety, and
tremors. Medications used in the treatment of Substance Abuse
 No clinically significant withdrawal syndrome is identified. DOWNERS

SUBSTANCES CLINICAL MANIFESTATIONS

STIMULANTS Alcohol Bradycardia
Stimulants are drugs that stimulate or excite the central Barbiturate Bradypnea
nervous system. Opiates Moist Mouth
CATEGORIES: Narcotics Pupil Constrictions
AMPHETAMINES: Marijuana Urinary Retention
 Pleasurable euphoria followed by profound Morphine Constipation
depression/exhaustion; other intoxication effects are Codeine Hypotension
hyperactivity/irritability, combativeness, paranoia, and Heroine Coma
affective blunting. Weight Gain
AMPHETAMINES:
 Toxic psychosis occurs in most chronic users; may be UPPERS
irreversible.
 Withdrawal symptoms include dysphoria, psychomotor SUBSTANCES CLINICAL MANIFESTATIONS
retardation, fatigue, insomnia or hypersomnia, vivid Cocaine Tachycardia
unpleasant dreams, and increased appetite. Hallucinogens Awake
Amphetamines Tachypnea
COCAINE: Dry Mouth
 Highly addictive due to intense feelings of euphoria (only Pupils Dilate
lasts about 30-60 minutes) Hypertension
 Chronic inhalation results in runny nose/sniffles, frequent Seizure
colds, weight loss, and hyperactivity Weight Loss
 Potentially fatal stroke/seizure/heart attack possible
(even with first-time use) Disulfiram (Antabuse)
 Inhibits metabolism of alcohol in the body, producing an
COCAINE: uncomfortable, potentially life-threatening reaction to
 Withdrawal symptoms include “crashing” (intense, alcohol exposure.
unpleasant feelings of sadness), fatigue, insomnia or  Taken daily and lasts in the body for up to two weeks.
hypersomnia, increased appetite, agitation, psychomotor  Maintain abstinence from alcohol.
retardation, and possible suicidal ideation.
Acamprosate (Campral)
CAFFEINE:  Maintenance of abstinence from alcohol
 Most widely used stimulant (readily available)  Ineffective in clients who have not undergone
 Relieves fatigue and increases alertness detoxification and not achieved alcohol abstinence prior
 Withdrawal symptoms include headache, muscle to initiation.
pain/stiffness, fatigue, anxiety, irritability, depression,  Concomitant use with psychosocial therapy
impaired psychomotor function.  Monitor for diarrhea, vomiting, flatulence and pruritus.

Nicotine
Clonidine (Catapres)  Alcohol and other drug abuse
 Assists heroin abuser through detox.  Intergenerational transmission process: violence is
 Non-opiate antihypertensive that partially blocks transmitted from one family generation to the next.
withdrawal symptoms but does not completely remove
unpleasant feelings associated with withdrawal. INTIMATE PARTNER VIOLENCE
 Monitor blood pressure before each dose, do not give if Intimate partner violence is the mistreatment or misuse of
client is hypotensive. one person by another in the context of an emotionally
intimate relationship. The relationship may be spousal,
Naltrexone (ReVia) between partners, boyfriend, girlfriend, or an estranged
 Does not produce “narcotic high.” relationship.
 Non-habit forming Psychological Abuse or emotional abuse includes yelling,
“Replaces” heroin or other opiates by binding to the same making threats, belittling.
receptors in the brain that produce feelings of pleasure. Physical abuse: severe battering, physical damages
Take medication with food or milk, drug may cause headache, Sexual abuse: sexual nipples, rape, slapping and hitting the
restlessness and irritability. partner.

Methadone (Dolophine) CLINICAL FEATURE OF AN HUSBAND HUSBAND

 Synthetic opioid used for treatment of heroin addiction.  Treats wife like a material property
 Given orally and absorbed slowly so that it does not  Has feeling of inadequacy.
produce “rush” associated with IV heroin use.  Emotionally immature, irrationally jealous
 Alleviates opioid cravings for a short time.  Physically punishing the family
 Dose gradually reduced during detoxification, and client  Dependent
is not told how much of the drug they are being given.
 Use is highly controversial due to “trading one addiction
for another.”
 May cause nausea and vomiting.

Narcan
 Opioid antagonist
 Counteracts dangerous respiratory depressant effects of
heroin or another opiate overdose.
 When given to client under the influence of an opiate,
the individual may experience acute withdrawal
symptoms.
Thiamine (Vitamin B1)
 Prevents or treats Wernicke- Korsakoff syndrome in
alcoholism.
 Instruct the client about the proper nutrition intake.

Abuse and Violence

Abuse is defined as any action that intentionally harms or
injures another person.
Violence is aggression, usually physical aggression that causes
harm.

Family Violence
 Family violence encompasses spouse battering.
 Neglect and physical, emotional, or sexual abuse of
children
 elder abuse; and marital rape.
 The home may be the most dangerous place for the
victims. CHILD ABUSE
 Child abuse or maltreatment generally is defined as the
Characteristics of violent families: intentional injury of a child.
 Social isolation: Family members do not tell others what  It can include physical abuse or injuries, neglect or failure
is happening. to prevent harm, failure to provide adequate physical or
 Abuse of power and control: Holds the physical,
economic and social control in the family.
 emotional care or supervision, abandonment, sexual • Helplessness
assault. Hesitance to talk openly Anger or agitation.
TYPES OF CHILD ABUSE Withdrawal or depression
MATERIAL ABUSE INDICATORS
 Sexual Abuse: rape, oral-genital contact, sexual • Unpaid bills Standard of living below elder's means
molestations like rubbing of organs to a child’s body, and Sudden sale or disposal of elder's property/possessions
exposing adult genitals. Unusual or inappropriate activity in bank accounts Signatures
 Neglect: includes refusal to seek health care or delay on checks that differ from the elders.
doing so; abandonment; inadequate supervision; reckless • Recent changes in will or power of attorney when elder is
disregard for the child’s safety, abusive emotional not capable of making those decisions
treatment; spousal abuse in the child’s presence; or Missing valuable belongings that are not just misplaced.
failing to enroll the child in school. • Lack of television, clothes, or personal items that are eas- ily
 Psychological abuse: blaming, screaming, name-calling, affordable
and using sarcasm; fighting, yelling, and chaos; and • Unusual concern by the caregiver over the expense of the
emotional deprivation or withholding of affection, elder's treatment when it is not the caregiver's money being
nurturing, and normal experience. spent

ASSESSMENT OF ABUSED OR NEGLECTED CHILD NEGLECT INDICATORS

 Serious injuries such as fractures, burns, or lacerations Poor personal hygiene
with no reported history of trauma. • Lack of needed medications or therapies
 Delay in seeking treatment for a significant injury. • Dirt, fecal or urine smell, or other health hazards in the
 Child or parent giving a history inconsistent with severity elder's living environment
of injury, such as a baby with contrecoup injuries to the Rashes, sores, or lice on the elder
brain (shaken baby syndrome) that the parents claim Elder has an untreated medical condition or is malnour- ished
happened when the infant rolled off the sofa. or dehydrated not related to a known illness.
 Inconsistencies or changes in the child’s history during • Inadequate material items, such as clothing, blankets,
the evaluation by either the child or the adult furniture, and television
 Unusual injuries for the child’s age and level of
development, such as a fractured femur in a 2-month-old INDICATORS OF SELF-NEGLECT
or a dislocated shoulder in a 2-year-old • Inability to manage personal finances, such as hoarding,
 High incidence of urinary tract infections; bruised, red, or squandering, or giving away money while not paying bills
swollen genitalia; tears or bruising of rectum or vagina. • Inability to manage activities of daily living, such as per-
 Evidence of old injuries not reported, such as scars, sonal care, shopping, or housework
fractures not treated, and multiple bruises that • Wandering, refusing needed medical attention, isolation,
parent/caregiver cannot explain adequately. and substance use
Failure to keep needed medical appointments Confusion,
ELDER ABUSE memory loss, and unresponsiveness.
 Elder abuse is the maltreatment of older adults by family • Lack of toilet facilities, or living quarters infested with
members or caregivers. animals or vermin
 It may include physical and sexual abuse, psychological
abuse, neglect, self-neglect, financial exploitation, and WARNING INDICATORS FROM CAREGIVER
denial of adequate medical treatment. Elder is not given opportunity to speak for self, to have
visitors, or to see anyone without the presence of the
ASSESSMENT OF ELDERLY ABUSE caregiver
PHYSICAL ABUSE INDICATORS • Attitudes of indifference or anger toward the elder
• Frequent, unexplained injuries accompanied by a habit of •
seeking medical assistance from various locations Blaming the elder for his or her illness or limitations
• Reluctance to seek medical treatment for injuries or de- nial Defensiveness
of their existence • Conflicting accounts of elder's abilities, problems, and so
• Disorientation or grogginess indicating misuse of forth
medications • Previous history of abuse or problems with alcohol or drugs
• Fear or edginess in the presence of family member or
caregiver RAPE and SEXUAL ASSAULT
 Rape is a crime of violence and humiliation of the victim
PSYCHOSOCIAL ABUSE INDICATORS expressed through sexual means.
• Change in elder's general mood or usual behavior  Rape is the perpetration of an act of sexual intercourse
• Isolated from previous friends or family with a female against her will and without her consent,
• Sudden lack of contact from other people outside the whether her will is overcome by force, fear of force,
elder's home drugs, or intoxicants.
 make a list of activities and keep materials on hand to
engage client when client's feelings are intense.

DYNAMICS OF RAPE Help Promote Client's Self-Esteem

 Recent research has categorized male rapists into four - Refer to client as "survivor" rather than "victim."
categories: - Establish social support system in community.
 Sexual sadists who are aroused by the pain of their victims. - Make a list of people and activities in the community
 Exploitive predators who impulsively use their victims as for client to contact when he or she needs help.
objects for gratification
 Inadequate men who believe that no woman would CHILDREN AND ADOLESCENT WITH MENTAL DISORDERS
voluntarily have sexual relations with them and who are Children and adolescents experience some of the same
obsessed with fantasies about sex. mental health problems as adults, such as mood and anxiety
 Men for whom rape is a displaced expression of anger and disorders, and are diagnosed with these disorders using the
rage. same criteria as for adults.

APPLICATION OF THE NURSING PROCESS MENTAL RETARDATION

 Assess for history of trauma or abuse.  The essential feature of mental retardation is below-
 General Appearance: uncomfortable when the client is average intellectual functioning (intelligence quotient [IQ]
too close. less than 70),
 Anxious, agitated, difficulty sitting still, moving around  Accompanied by significant limitations in areas of
the room. adaptive functioning such as communication skills, self-
 Mood and Affect: look scared, may cry, scream when care, home living, social or interpersonal skills, use of
remember the flashbacks, speaks in different tone of community resources, self-direction, academic skills,
voice, unable to identify feelings or emotions. work, leisure, and health and safety.
 Thoughts and processes: hallucination, self-destructive  It is defined by the American Association of Mental
thoughts, suicidal ideation Deficiency as significantly sub-average general intellectual
 Sensorium and intellectual processes: memory gaps, functioning existing concurrently with deficits in adaptive
ideas of self-harm, decrease attention, oriented to reality behavior and manifested during the developmental
except when there is a flashback. period (18 years of age).
 Assess for history of trauma or abuse.
 Judgement and Insight: Impaired decision-making and  Prenatal Infection and intoxication
problem- solving skills.  Trauma or physical agent (e.g., lack of oxygen)
 Self-concept: has low self-esteem, may see themselves as  Metabolic Disturbance
helpless, hopeless and worthless.  Inadequate Prenatal Nutrition
 Roles and relationships: Close relationships are difficult  Chromosomal abnormalities
or impossible because the client’s ability to trust others is  Prematurity
severely compromised. Often the client has quit work or  Low birth weight
has been fired, and he or she may be estranged from  Autism
family members.  Environmental deprivation

NURSING INTERVENTIONS CLASIFICATIONS MENTAL RETARDATION

Promote Client's Safety Classificatio Manifestations
- Discuss self-harm thoughts. n
- Help client develop plan for going to safe place when Pre- School-Age Adult
having destructive thoughts or impulses. School
Help Client Cope with Stress and Emotions Mild The child The child can The adult
- Use grounding techniques to help client who is Retardation often is acquire can usually
dissociating or experiencing flashbacks. (IQ: not noted practical skills achieve
- Validate client's feelings of fear but try to increase 50-70) as and learn to social and
contact with reality. retarded, read and do vocational
- During dissociative experience or flashback, help client but is arithmetic to skills.
change body position but do not grab or force client to slow to sixth grade Occasional
stand up or move. walk, talk level with guidance
- Use supportive touch if client responds well to it. Teach and feed special may be
deep breathing and relaxation techniques. Use self. education needed. The
distraction techniques such as participating in physical classes. The adult may
exercise, listening to music, talking with others, or child achieves a handle
engaging in a hobby or other enjoyable activity. Help to mental age of 8 marriage,
 to 12 years but not elementary respond to and
child self-help, habit supervision
rearing. such as training and in a
feeding. has the protective
Classificatio Manifestations mental age environmen
n of a toddler. t.
Pre- School-Age Adult
School Classification Manifestations
Moderate Noticeabl The child can The adult Pre-School School-Age Adult
Retardation e delays, learn simple can perform Profound Gross There are The adult
(IQ: 35-50) especially communication simple tasks Retardation retardation is obvious may walk
in speech , health, and under (IQ: evident. delays in all but needs
are safety habits, sheltered BEOW 20) There is a areas. The complete
evident. and simple conditions capacity for child shows custodial
manual skills. A and can function in basic care. The
mental age of 3 travel alone sensorimoto emotional adult will
to 7 years is to familiar r areas, but response and have
achieved. places. Help the child may respond primitive
with self- needs total to skillful speech.
maintenanc care. training in Regular
e is usually the use of physical
needed. legs, hands activity is
and jaws. beneficial.
Classificatio Manifestations The child
n needs close
Pre-School School-Age Adult supervision
Severe The child The child The adult and has the
Retardation exhibits usually walks can mental age
(IQ: marked with conform to of a young
20- 35) motor delay disability. daily infant.
and had little Some routines
to no understandi and NURSING MANAGEMENT
communicati ng of speech repetitive  Assess all children for signs of developmental delays.
on skills. The and activities,  Administer prescribed medications for associated
child may response is but needs problems such as anticonvulsants for seizure disorders,
respond to evident. The constant and methylphenidate (Ritalin) for attention deficit
training in child can direction hyperactivity disorder.
elementary respond to and  Support the family at the time of initial diagnosis by
self-help, habit supervision actively listening to their feelings and concerns and
such as training and in a assessing their composite strengths.
feeding. has the protective  Facilitate the child’s self-care abilities by encouraging the
mental age environmen parents to enroll the child in an early stimulation
of a toddler. t. program, establishing a self-feeding program, initiating
independent toileting, and establishing an independent
Classificatio Manifestations grooming program (all developmentally appropriate).
n  Promote optimal development by encouraging self-care
Pre-School School-Age Adult goals and emphasize the universal needs of children, such
Severe The child The child The adult as play, social interaction and parental limit setting.
Retardation exhibits usually walks can  Promote anticipatory guidance and problem solving by
(IQ: marked with conform to encouraging discussions regarding physical maturation
20- 35) motor delay disability. daily and sexual behaviors.
and has little Some routines  Assist the family in planning for the child’s future needs
to no understandi and (e.g., Alternative to home care, especially as the parents
communicati ng of speech repetitive near old age); refer them to community agencies.
on skills. The and activities,  Guarantee child’s physical and mental safety.
child may response is but needs
respond to evident. The constant Provide child and family teaching
training in child can direction
 Identify normal developmental milestones and  Also includes stereotyped behaviors, interests, and
appropriate stimulating activities including play and activities.
socialization.
 Discuss the need for patience with the child’s slow
attainment of developmental milestones.
 Inform parents about stimulation, safety and motivation. ASPERGER’S DISORDER
 Supply information regarding normal speech  Is a pervasive developmental disorder characterized by
development and how to accentual nonverbal cues, such the same impairments of social interaction and restricted
as facial expression and body language, to help cue stereotyped behaviors seen in autistic disorder.
speech development.  There are no language or cognitive delays.
 This rare disorder occurs more often in boys than in girls,
AUTISM and the effects are generally lifelong.

RETT’S DISORDER
 Is a pervasive developmental disorder characterized by
the development of multiple deficits after a period of
normal functioning.
 It occurs exclusively in girls, is rare, and persists
throughout life. Rett’s disorder develops between birth
and 5 months of age.
 The child loses motor skills and begins showing
stereotyped movements instead.
 She loses interest in the social environment, and severe
impairment of expressive and receptive language
becomes evident as she grows older.

CLINICAL MANIFESTATIONS
 Display little eye contact.
 Make few facial expressions.
 Use limited gestures to communicate.
 Limited capacity to relate to peers or parents.
 Lack spontaneous enjoyment, express no moods or
“THE WORLD FROM A DIFFERENT PERSPECTIVE” emotional affect, and cannot engage in play or make-
believe with toys.
Autistic disorder, the best known of the pervasive  There is little intelligible speech. These children engage in
developmental disorders, is more prevalent in boys than in stereotyped motor behaviors such as hand flapping, body
girls, and it is identified usually by 18 months and no later twisting, or head banging.
than 3 years of age.  Resistance to change in routine.
 Auto” – children are “locked within themselves.”
 Autism impacts normal development of the brain in areas CHARACTERISTICS
of social interaction and communication skills. 1. Communication/
 Difficult to communicate with others and relate to the Language
outside world. 2. Social Interaction
 Occasionally, aggressive and/or self-injurious behavior 3. Behaviors
may be present. 4. Sensory and movement
 Unresponsive and does not want to be touched. disorders
 Autistic Savant: high intelligence and has a ratio of 1:100. 5. Resistance to change
(predictability)
Assessment: 5. Intellectual functioning
 Appearance – flat affect and loves constancy and
ritualistic. COMMUNICATION/ LANGUAGE
 Behavior – withdrawn. Broad range of abilities, from no verbal communication to
 Communication – echolalia quite complex skills
Two common impairments:
TYPES OF AUTISM A. Delayed language
AUTISTIC DISORDER B. Echolalia- meaningless repetition of another person's
 Impairments in social interaction, communication, and spoken words.
imaginative play.
 Apparent before age 3. SENSORY AND MOVEMENT DISORDERS
 Very common ATTENTION DEFICIT
 Over- or under-sensitive to sensory stimuli  7 years and below onset
 Abnormal posture and movements of the face, head,  Duration: 6 months and above
trunk, and limbs.  Settings: house and school
 Abnormal eye movements
 Repeated gestures and mannerisms CLINICAL MANIFESTATIONS
 Movement disorders can be detected very early – • Inattention Symptoms (at least 6 symptoms required)
perhaps at birth. • Fails to give close attention to details or makes
careless mistakes in schoolwork, work, etc.
PREDICTABILITY • Difficulty sustaining attention.
 Change in routine is very stressful. • Does not seem to listen when spoken to directly.
 May insist on particular furniture arrangement, food at • Does not follow through on instructions and fails to
meals, TV shows. finish schoolwork, chores, etc.
 Symmetry is often important. • Difficulty organizing tasks and activities.
 Interventions need to focus on preparing students for • Avoids tasks requiring sustained mental effort.
change if possible. • Loses things necessary for tasks or activities.
• Easily distracted by extraneous stimuli
INTELLECTUAL FUNCTIONING • Forgetful in daily activities
 Autism occurs in children of all levels of intelligence, from
those who are gifted to those who have mental • Hyperactivity-Impulsivity Symptoms (at least 6
retardation. symptoms required)
 In general, majority of individuals with autism are also • Difficulty playing or engaging in activities quietly
identified as having mental retardation – 75% below 70. • Always "on the go" or acts as if "driven by a motor”
 Verbal and reasoning skills are difficult. • Talks excessively
• Blurts out answers
NURSING MANAGEMENT • Difficulty waiting in lines or awaiting turn
 Increase the child’s interest by reciprocal interacting and • Interrupts or intrudes on others
foster the development of social skills. • Runs about or climbs inappropriately
 Facilitate verbalization of appropriate emotional • Fidgets with hands or feet or squirms in seat
responses and foster development of communication, • Leaves seat in classroom or in other situations in
especially language skills. which remaining seated is expected
 Facilitate the development of psychomotor skills in play
and activities of daily living and focus on the  Mood may be labile, even to the point of verbal outbursts
development of cognitive skills. or temper tantrums. Anxiety, frustration, and agitation
 Promote positive behavior support. are common.
 Ability to pay attention or to concentrate is markedly
NURSING DIAGNOSIS impaired. The child’s attention span may be as little as 2
 Impaired verbal communication or 3 seconds with severe ADHD or 2 or 3 minutes in
 Impaired social interaction milder forms of the disorder.
 Self-mutilation  Exhibit poor judgment and often do not think before
 Risk for injury acting.
 They generally feel out of place and bad about
MEDICAL MANAGEMENT themselves.
 Pharmacologic treatment with antipsychotics, such as  The child is usually unsuccessful academically and socially
haloperidol (Haldol) or risperidone (Risperdal) at school.
 may be effective for specific target symptoms such  He is frequently disruptive and intrusive at home, which
as temper tantrums, aggressiveness, self-injury, causes friction with siblings and parents.
hyperactivity, and stereotyped behaviors.
NURSING DIAGNOSIS
ATTENTION DEFICIT  Risk for Injury
 Attention deficit hyperactivity disorder (ADHD) is  Ineffective Role Performance
characterized by inattentiveness, overactivity, and  Impaired Social Interaction
impulsiveness.  Compromised Family Coping
 ADHD is a common disorder, especially in boys.
 The essential feature of ADHD is a persistent pattern of NURSING MANAGEMENT
inattention and/or hyperactivity and impulsivity more  Provide an environment as free from distractions as
common than generally observed in children of the same possible. Institute interventions on a one-to-one basis.
age. Gradually increase the amount of environmental stimuli.
 Engage the client’s attention before giving instructions
(i.e., call the client’s name and establish eye contact).
 Give instructions slowly, using simple language and • Teachers see these students as:
concrete directions. Uninterested
–
 Ask the client to repeat instructions before beginning Unenthusiastic
–
tasks. Careless
–
 Separate complex tasks into small steps. • Students with Conduct Disorder have:
 Provide positive feedback for completion of each step. – Poor interpersonal relations
 Allow breaks, during which the client can move around. – Rejected by their peers.
 State expectations for task completion clearly. – Poor social skills
 Initially, assist the client to complete tasks. • Students with Conduct Disorder are most likely to be:
 Assist the client to verbalize by asking sequencing – Left behind in grades.
questions to keep on the topic (“Then what happens?” – Show lower achievement levels.
and “What happens next?”). – End school sooner than same-age peers

NURSING MANAGEMENT • Is often comorbid with other disorders.

 Include parents in planning and providing care • Is one of the most prevalent psychopathological
 Focus on child’s strengths as well as problems disorders.
 Teach accurate administration of medication and • Affects:
possible side effects • 6 – 16% of males
 Inform parents that child is eligible for special school • 2 – 9% of females
services • 1.3 to 3.8 million children have conduct disorder.
 Assist parents to identify behavioral approaches to be
used at home • Males exhibit:
 Help parents achieve a balance of praising child and – Fighting
correcting child’s behavior – Stealing
 Emphasize the need for structure and consistency in – Vandalism
child’s daily routine and behavioral expectations. • Overly aggressive
• Females exhibit:
 Medications often are effective in decreasing – Lying
hyperactivity and impulsiveness and improving attention; – Truancy
this enables the child to participate in school and family – Running away
life. – Substance abuse
 Methylphenidate (Ritalin): effective in 70% to 80% – Prostitution
of children with ADHD; it reduces hyperactivity,
impulsivity, and mood lability and helps the child to CLASSIFICATIONS
pay attention more appropriately. Mild: resulting in only minor harm to others
 Transdermal Patch (Daytrana): Wear patch for 9 • Examples include lying, truancy, and staying out late
hours—drug effects last 3 hours after removal. without permission.
Moderate: Increase in amount of harm to others
MEDICAL MANAGEMENT • Examples include vandalism and theft.
 Amphetamine compound (Adderall) Severe: causing considerable harm to others
Available in a sustained-release form taken once daily; this • Examples include forced sex, cruelty to animals, use
eliminates the need for additional doses when the child is of a weapon, burglary, and robbery.
at school.
SUB TYPES
CONDUCT DISORDER Overt Aggression: overt aggression involves outward or open
Conduct disorder is characterized by persistent antisocial confrontational acts of aggression, such as physical fighting,
behavior in children and adolescents that significantly impairs verbal threats and bullying.
their ability to function in social, academic, or occupational Covert Antisocial: Antisocial behaviors are disruptive acts
areas. characterized by covert and overt hostility and intentional
 The rights of others aggression toward others.
 Age-appropriate social norms
 Includes: NURSING MANAGEMENT
 Aggression to people and animals  Role model appropriate conversation and social skills for
 Destruction of property the client.
 Deceitfulness and theft  Specify and describe the skills you are demonstrating.
 Violation of rules  Practice social skills with the client on a one-to-one basis.
 Gradually introduce other clients into the interactions
and discussions.
 Assist the client to focus on age- and situation
appropriate topics.
 Encourage the client to give and receive feedback with
others in his or her age group. Facilitate expression of
feelings among clients in supervised group situations
 Encourage the client to discuss his or her thoughts and
feelings. Give positive feedback for appropriate
discussions.
 Tell the client that he or she is accepted as a person,
although a particular behavior may not be acceptable.
 Give the client positive attention when behavior is not
problematic.
 Teach the client about limit setting and the need for
limits. Include time for discussion.
 Teach the client the problem-solving process as an
alternative to acting out