Chapter Content

A. Care of clients with

maladaptive patterns of
behavior across the
lifespan

Maladaptive
Patterns
Care of Clients with maladaptive patterns of behavior across the
lifespan (childhood, adolescent, adulthood)

I. Anxiety Disorders
Definition
✓ A group of disorders in which anxiety is a predominant symptom
✓ The degrees range from mild anxiety to severe (panic attack)
LEVELS OF ANXIETY

MILD MODERATE SEVERE PANIC

-the client has -the client experiences -the ability to perceive is - complete disruption of
increased narrowing of the ability to further reduced and the the ability to perceive
alertness, ability concentrate (selective focus is on small and takes place. The client is
to learn and attention). Pacing, scattered details. Learning unable to function
experiences a tremors, increased rate of cannot occur. Physiologic normally and unable to
motivational force speech, physiologic responses also occur as the focus on reality.
changes and verbalization individual experiences a
about expected danger sense of impending doom.
occur. Focus is on the
immediate concerns.

ETIOLOGY ASSESSMENT/FINDINGS DIAGNOSIS

• Found equally in men and • Fear, dread, or apprehension • Anxiety
women • Feeling powerless • Panic
• Hereditary predisposition • Crying • Fear
• Biochemical factors: • Irritability • Ineffective individual coping
neurotransmitters may • Scattered thoughts, inability to • Powerlessness
play a role (GABA and concentrate or solve problems • Social isolation
norepinephrine) • Preoccupation with self
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 • Psychologic and • Rapid speech,
interpersonal factors hyperventilation, tachycardia
• Early psychic trauma, • Palpitations, chest pains, jittery
• Pathogenic parent-child behavior
relationship, • Diaphoresis
• Pathogenic family • Insomnia
patterns • Diarrhea and/or urinary
• Loss of social supports urgency and frequency

Management/Treatment
✓ Pharmacologic: Anxiolytics (anti-anxiety drugs) such as alprazolam (Xanax) and
diazepam (Valium).
✓ It generally takes 2-3 weeks for the anti-anxiety effects to be apparent and 4-6
weeks or longer for the drug to be fully effective.
✓ Psychotherapy
✓ Occupational therapy
✓ Recreational therapy
ANTI-ANXIETY DRUGS
1. Benzodiazepines Examples: -lam/-pam
-most commonly used Alprazolam (Xanax), Diazepam (Valium), Clonazepam (Klonopin). Lorazepam
Ativan), Flurazepam (Dalmane)
2. Non benzodiazepines -new class of drugs used for the short treatment of insomnia and anxiety
Examples: Zolpidem and Zaleplon
3. Serotonin and Dopamine -Examples: Buspirone (Buspar)
agonist
4. Barbiturates Examples: Phenobarbital, Pentobarbital, Secobarbital

Nursing Management
✓ Provide a non-demanding environment; stay with client if indicated
✓ Acknowledge client's feelings of fear, worry, helplessness
✓ Do not force contact with feared item or situation
✓ If client demonstrates compulsive behavior, allow the compulsion but set
reasonable limits
✓ Provide distracting activities
✓ Allow temporary dependence
✓ Speak calmly, slowly and clearly
✓ Assist client in ADL as indicated
✓ Encourage relaxation techniques and regular physical exercise
✓ Administer medications as ordered
✓ Limit caffeine intake
✓ Teach client
✓ Medications and side effects
✓ Relaxation techniques

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TYPES /SPECIFIC DISORDERS

Generalized Anxiety Disorder (GAD)

✓ It is characterized by unrealistic or excessive anxiety and worry occurring more days
than not in 6-month period
✓ The continued high level of anxiety causes symptoms such as restlessness, irritability,
fatigue, depression, difficulty concentrating, muscle tension, sleep disturbance and
feeling of helplessness
✓ Symptoms interfere with daily normal activities
Phobic Disorders
✓ Individuals with phobic disorders recognize that their phobias (fear of specific objects,
activities and situations) are irrational
✓ They manage their anxiety by avoiding the feared stimuli.
✓ The three types of phobias include: agoraphobia (fear of being alone in public places),
social phobia (fear of embarrassment and humiliation in public settings) and specific
phobia (involves an unrealistic fear of a specific object orsituation)

COMMON PHOBIAS
1. Acrophobia -fear of heights
2. Agoraphobia -fear of open places
3. Androphobia -fear of men
4. Autophobia -fear of being alone
5. Claustrophobia -fear of enclosed spaces
6. Entomophobia -fear of insects
7. Hematophobia -fear of blood
8. Necrophobia -fear of dead bodies
9. Nyctophobia -fear of the night
10. Pyrophobia -fear of fire

Panic Disorder
✓ Individuals who have panic disorders have recurrent panic attacks.
✓ The onset of panic attack is sudden and the source of anxiety may not be identifiable.
✓ The symptoms include a desire to escape, chest pains, chills, dizziness, nausea,
palpitations, shortness of breath, sweating, trembling and fear of loss of control
Obsessive-Compulsive Disorder (OCD)
✓ Characterized by recurrent obsessions (a persistent painful, obtrusive though,
emotion or urge that one cannot suppress or ignore and compulsions (the
performance of a repetitious, uncontrollable but purposeful act to prevent some
future event or situation) or a combination of both that interferes with normal life
✓ Anxiety will increase if obsessive thoughts and compulsive behaviors are interrupted.
✓ Nurses should assist the clients to allow the client to complete the ritual but limits
should be applied gradually and should mutually agree with the limitation of the
rituals

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Post-Traumatic Stress Disorder (PTSD)
✓ Associated with exposure to an extremely, traumatic event such as military
combat/wars, rape, assault, kidnapping, torture, disasters and life-threatening
illnesses
✓ The symptoms include a blunted affect, lack of responsiveness, social withdrawal,
hopelessness, restlessness, depression, nightmares, flashbacks and outbursts of anger
✓ They use denial and repression to cope with anxiety

II. Somatoform Disorders

Definition
✓ Somatoform disorders are reflected in disorders of physiological complaints or
symptoms, are not under voluntary control and do not demonstrate organic findings
ETIOLOGY ASSESSMENT/FINDINGS DIAGNOSIS

• Physical symptoms have no • The onset is variable • Ineffective individual

organic basis • Done to achieve primary gain coping
• Biologic and genetic factors (illness allows reprieve from • Altered family process
play a role responsibilities) and secondary • Denial
• A person learns to produce gain (sick role allows fro • Body image disturbance
somatization to achieve dependency needs to be met) • Self-care deficit
attention or reward • May be depressed, anxious or • Chronic pain
• Characterized by multiple unaffected, usually preoccupied
complaints in different body with symptoms,
systems and are more
prevalent in women than in
men

Management/Treatment
✓ There is no specific psychotropic medication for somatoform disorders although there
is some evidence for use of antidepressants with pain and somatization disorders
Nursing Management
✓ Establish a trusting and therapeutic relationship. Recall that the client does not create
the symptoms consciously or on purpose.
✓ Teach client methods to reduce physiological arousal including relaxation techniques,
visual imagery, self-talk and physical exercise.
✓ Encourage verbalization of feelings

Types/Specific Disorders
Somatization Disorder
✓ It is a chronic and severe disorder in which the client expresses emotional conflict
through physical complaints usually with a loss of alteration of physical functioning.

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 ✓ Such a loss or alteration is not under voluntary control and it differs from other
somatoform disorders because of the multiple complaints reported and the multiple
organ systems affected. This disorder is often familial

Conversion Disorder
✓ A disorder in which motor, sensory or visceral function is lost and about which the
client is usually indifferent (la belle indifference)
✓ The symptoms are often symbolically reted to primary gain

Pain Disorder
✓ It is a somatoform disorder characterized by pain as the dominant physical symptom
✓ The client seeks medical attention for severe and prolonged pain with no organic basis
for pain or the pain intensity
Hypochondriasis
✓ It is a somatoform disorder in which a client presents with an unrealistic or
exaggerated physical complaint
✓ Minor physical symptoms are of great concern to the client and often result in an
impairment of social or occupational functioning
✓ Such persons usually shop for doctors because they don’t feel that they get the proper
medical attention
✓ They usually have a history of multiple visits to multiple health care practitioners.
Their concern persists in spite of having negative findings

Body Dysmorphic Disorder

✓ Individuals with body dysmorphic disorder have a pervasive feeling of ugliness and are
pre-occupied with an imagined defect in physical appearance or vastly exaggerated
concert about a minimal defect
✓ The person believes that he/she is unattractive or even repulsive
✓ The disorder is persistent, client has repeated surgeries, dental work or dermatological
treatment for the defects

III. Dissociative Disorders

Definition
✓ Individuals with dissociative disorder exhibit the separation of an idea or mental
thoughts from conscious awareness or from emotional significance and affect.
ETIOLOGY ASSESSMENT/FINDINGS DIAGNOSIS

• Traumatic experience • Recounts of trauma and/or • Anxiety related to the

(commonly accidents, severe stress traumatic experience
natural disasters and • Symptoms appear in adulthood • Ineffective individual
assault) after stressful events coping
• May be induced if using • May report symptoms of • Personal identity
psychoactive drugs depression and anxiety disturbance
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 • Severe childhood • Headaches are common • Sensory-perceptual
physical, sexual or • There may be feelings of alteration
emotional abuse detachment from the self or • Altered thought
environment process
• Insight may be impaired and • Powerlessness
client unaware of memory • High risk for self
impairment mutilation

Management/Treatment
✓ Anti-anxiety drugs are used for short term symptomatic treatment
✓ Antidepressants for depression and anti-psychotics for extreme agitation (if
those symptoms are present)

Nursing Management
✓ Create a self and calm environment
✓ Mutually develop a plan of care and prevent stressors than can elicit
disscoation
✓ Teach stress management and coping techniques such as progressive muscle
relaxation and grounding (focus on the external environment)
✓ Discuss traumatic event and its meaning
✓ Educate about the specific dissociative disorder
✓ Refer to support groups
Types/Specific Disorders
Dissociative Amnesia
✓ Formerly known as psychogenic amnesia and is characterized by the inability to recall
an extensive amount of personal information because of physical or psychological
trauma
✓ Clinical features include perplexity, disorientation and purposeless wandering
▪ Localized amnesia: short term period (hours) after a disturbing event
▪ Selective amnesia: amnesia for some events only
▪ Generalized amnesia: amnesia for whole lifetime of experiences
▪ Continuous amnesia: forgets successive events as they occur

Dissociative Fugue
✓ A disorder characterized by suddenly wandering away or taking a trip away from
one’s home, accompanied by amnesia for some or all of past events
✓ Theperson usually travels from the usual environment, unable to recall important
aspects of identity (old and new identities do not alternate), usually lasts from hours
to days and rarely months
✓ Once the client has returned to the pre-fugue state, he/she has no memory of events
during the fugue

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Dissociative Identity Disorder (DID)
✓ This was formerly known as multiple personality disorder in which a person is
dominated by two or more personalities that alternately takes over the person’s
behavior
✓ Emergence of various personalities or alters occurs suddenly and is often associated
with psychosocial stress and conflict
✓ An alter is a personality state or identity that recurrently takes over the behavior of a
person with DID. It may represent different ages and genders
✓ Switching occurs by dissociating from one alter to another
✓ Associated with severe physical or sexual abuse during childhood

Depersonalization disorder
✓ The client with this disorder experiences an uncomfortable and distorted perception
of self, body and one’s life that is associated with a sense of unreality
✓ The client describes himself/herself as “detached from the body”
▪ Depersonalization: feeling of detachment or separation from one’s self as if
in a dream-like state
▪ Derealization: a feeling that the external world is unreal or strange.

IV. Mood Disorders

Definition
✓ Characterized by changes in mood that ranges from depression to elation and involves
pathological mood and other related disturbances
✓ Mood is defined as a prolonged emotional state that affects a person’s life and
personality
✓ The affect is how the individual present feeling of mood
✓ The DSM-IV divides mood disorders into 2 major categories: depressive disorders and
bipolar disorders
ETIOLOGY ASSESSMENT/FINDINGS DIAGNOSIS
• Psychosocial theories of • Clients do not have enough • High risk for violence,
depression: energy to talk for long self-directed
• Freud: anger internalized periods of time • High risk for violence,
and directed against ego
• They are not able to focus directed at others
• Seligman: depression
their attention for long • Ineffective individual
results from learned
helplessness: individual periods of time coping
who fails over time learns • Withdrawal from others and • Nutrition, altered
to expect poor outcomes decreasing interest in life • Sleep pattern
and eventually gives up activities disturbance
• Beck: cognitive theory: • The person may not take • Spiritual distress
over time, cognition is care of his/her basic needs
altered, resulting in • Clients with manic disorders
negative attitudes; events
may become more talkative,
can trigger depression
cannot sit still, and more
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 • Biological cycles affect gregarious.
mood (via Circadian • The traits typical of mood
rhythm) disorders: Impaired job
• light affects mood by functioning, Impaired social
increasing melatonin
activities, Impaired
• melatonin is a mood
modulator which
relationships, Necessitates
decreases in depression hospitalization (in most
• Genetic predisposition cases), No time longer than
• Biochemical theories of two weeks has client had
mood disorders: delusions or hallucinations
Mania without the mood
• probably a genetic factor disturbance, Findings are not
• biochemical influences superimposed on
• possible deficiency of schizophrenia, delusional
neurotransmitter GABA disorder and psychotic
(gamma aminobutyric
disorder and Findings are not
acid)
caused by organic disease
• possible excess of
norepinephrine and
• possible increase in
electrolytes: sodium and
calcium
Depression
• possible deficit of
serotonin, dopamine,
norepinephrine
• possible deficit of TSH
(thyroid-stimulating
hormone) and/or other
neuroendocrine
disturbances
• depression is more
common in viral infections
(AIDS, mononucleosis,
hepatitis)
• possible deficit in vitamin
intake or metabolism:
(vitamin B complex, folic
acid)
• genetics may be involved

Management/Treatment
✓ Electroconvulsive therapy (ECT) is used for the treatment of depression
✓ Psychotherapy
✓ Occupational therapy
✓ Recreational therapy
✓ Cognitive therapy
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 ANTI-MANIC DRUGS
Lithium carbonate - is the drug of choice for controlling manic episodes in clients with bipolar
(Lithane) disorder. Full effect does usually occur for 2-3 weeks
- the nurse should instruct the client o maintain a constant sodium intake. Sodium
depletion can lead to lithium toxicity
- the nurse should monitor serum lithium level. Toxic level is 1.5 mEq/L and
above. Adverse effects include fine hand tremors, GI upset, thirst and muscle
weakness while toxic effects include persistent GI upset, confusion, sedation, ECG
changes, hyper irritability of muscles
Carbamazapine -were originally developed an marketed for treatment of seizure disorders
(Carbatrol), valproic acid -recently these drugs have been used with success to treat bipolar disorders and
(Depakene) usually given to clients who have not responded to lithium

Antipsychotics: Examples: Chlorpromazine (Thorazine), Haloperidol (Haldol)

ANTI-DEPRESSANTS
1. Tricyclic -Prevent nerve endings from taking up norepinephrine and serotonin. Increase the
antidepressants (TCA) action of norepinephrine and serotonin in nerve cells. Initial response is said to
take about 2-3 weeks
Side-effects: Hypotension, sedation, anti-cholinergic side-effects
Examples: -ine
Amitriptyline (Elavil), Imipramine (Tofranil), Nortriptyline (Pamelor)
2. MAO Inhibitors -Lower the production of monoamine oxidase in the liver. Thus the central nervous
(Monoamine oxidase system stores more endogenous epinephrine, norepinephrine, serotonin, and
inhibitors) dopamine.
Contraindications: convulsive disorders, prostatic hypertrophy, severe renal,
cardiac or hepatic disease
Adverse effect: Can cause hypertensive crisis when clients ingest tyramine-rich
foods (aged cheese, wine, aged/cured meats, soy sauce, yeast, salami etc.)
Examples: -ine
Phenelzine (Nardil), Tranylcypromine (Parnate)

3. Selective Serotonin -Blocks the reuptake of serotonin

Reuptake Inhibitors SSRI’s Has fewer side-effects that TCA’s or MAOI’s.
(SSRI) Side-effects: Nausea, insomnia and sexual dysfunction
-Examples: Fluoxetine (Prozac), Sertraline (Zoloft)

Nursing Management
For Mania / Bipolar disorder:
✓ Protect client and others from harm
✓ Provide quiet environment with few stimuli
✓ Give medications as ordered; be sure client swallows medications
✓ Establish trusting relationship
✓ Do not argue with client or provoke hostility
✓ Redirect client to task at hand
✓ Set firm, consistent limits; explain them simply
✓ Allow client to express anger in positive ways
✓ Offer finger foods
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 ✓ Increase client's fluid intake to at least 1000cc/day
✓ Allow client to pace
✓ Teach client :
▪ Acceptable ways to release anger
▪ Medications and side effects
▪ Importance of taking medication
For Depression:
✓ Provide a safe environment for the client
✓ Monitor suicidal thoughts
✓ Take suicide precautions as indicated
✓ Observe the client closely
✓ Encourage the client to focus on strengths rather than weaknesses
✓ Assist the client to learn strategies that will affect more positive thinking
✓ Encourage the client to express feelings and needs
Types/Specific Disorders
Bipolar disorders
✓ Mood disorders that include one or more manic or hypomanic episodes and usually
one or more depressive episodes
✓ Bipolar disorders :onset usually before age 30
▪ Bipolar disorder, mixed: both manic and depressive episodes present
▪ Bipolar I: consists of one or more periods of major depression plus one or
more periods of clear-cut; no marked drop in social and job functioning;
manic episode requires hospitalization
▪ Bipolar II: consists of one or more periods of major depression plus periods
of hypomania ; includes all symptoms in definition of mood disorder and
does not require hospitalization
▪ Cyclothymic mood disorder: many milder findings of mania and depression
periods of normal mood are short usually does not require hospitalization

Mania
✓ DSM IV criteria for mania; period of abnormally/persistently elevated mood or
irritability and at least three of these signs and signs
▪ Grandiosity
▪ Decreased sleep
▪ Hypertalkative, with pressured speech and flight of ideas or racing thoughts
▪ Highly goal-directed activity (sexual, work)
▪ Highly distractible
▪ Pursues pleasure, but overestimates own skill and luck

Major Depression
✓ It is characterized by loss of interest in life and a depressed mood which moves from
mild to severe
✓ It includes all 7 typical traits of mood disorders

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 ✓ Specific criteria for depression include: melancholia, crying, absence of pleasure;
slumped posture, apathy; loss of desire for food and/or sex , slower reactions, low
self-confidence; inhibition, introversion, ruminating, decreased communication, social
isolation, fatigue and/or insomnia, decreased concentration, poor hygiene,
hopelessness, pessimism and self-destructiveness

V. Suicide
Definition
✓ Suicide is a self-harming act intended to produce death

Degrees
▪ Completed suicide: life ends
▪ Attempted suicide: failed self-destructive act
▪ Suicide ideation: thoughts of ending one's life
ETIOLOGY ASSESSMENT/FINDINGS DIAGNOSIS
/EPIDEMIOLOGY
Epidemiology • Ask the client about any • Risk for self-directed
• Women attempt more than thoughts and feelings related violence
men to harming oneself, • Ineffective individual
• Men are more often determining suicidal coping
successful ideations, how the client has • Hopelessness
• Second leading cause of sought help, what kind of
• Powerlessness
death in adolescence plan the client has, mental
status of the client, client’s • Chronic low self-esteem
Etiology
• Depression available support systems • Altered thought process
• Delusions/hallucinations in • Statements about suicide • Social isolation
psychotic clients • Anger, sadness, hopelessness, • Defensive coping
• Hopelessness negative view of future
• Environmental factors: work • Recent loss of job, loved one
or school performance, loss • Perceived lack of support
of job, death of loved one, system
unsatisfying interpersonal • Self-mutilation
relationships

Management/Treatment
For Suicidal Ideation
✓ Objective: to treat the condition that underlies the suicidal thoughts
✓ Medications: amitriptyline (Elavil), chlorpromazine (Thorazine)
✓ Nursing Management
▪ Administer medications as ordered
▪ Institute suicide precautions
▪ Encourage relaxation strategies
✓ Suicide precautions
▪ Place the client on q15 minute checks
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 ▪ Maintain an awareness of the clients whereabouts constantly
▪ Remove personal belongings and items that can be used by the client to
▪ harm himself/herself
▪ Keep the room and unit free of objects that can be used by the client to
▪ harm himself/herself
▪ Work with the client to develop a safety plan and assess the client
▪ frequently

VI. Eating Disorders

Definition
✓ This is a subcategory of disorders that includes multiple types of eating behavior
disturbances
ETIOLOGY ASSESSMENT/FINDINGS DIAGNOSIS
Psychoanalytic theory • Personal relationships • Imbalanced
• Conflicts stem from oral become superficial and nutrition less than
phase of development distant body requirements
• Clients often have anxious, • Social contact avoided • Anxiety related to
compulsive mothers especially if food is involved inadequate coping
• Obsessive-compulsive • Preoccupation with food, mechanisms
control of body and life, via meal planning, caloric • Disturbed body
food intake and methods to image
• Controlling bodily functions avoid eating • Constipation
is critical to client's attempt • Eats in private • Diarrhea
at self-control • Mood irritable and defiant • Fatigue related to
Interpersonal theory • Exercises excessively excessive exercise
• Results from dysfunctional • Physical findings • Deficient fluid
family relationships • weight falls below 85% of volume
• Parents avoid their own normal • Impaired social
conflicts by controlling child • bradycardia interaction
• Child's self-identity becomes • anemia • Compromised
blurred • amenorrhea family coping
• During adolescence parents • decreased renal function • Risk for impaired
become over controlling and • dental problems skin integrity
demanding • fluid and electrolyte • Chronic low self-
• Demands thwart client's imbalances esteem
attempts at autonomy
• Adolescent attempts to
control self through
controlling food intake.
Cognitive theory
• Eating-disorder behaviors
are learned
• Society glorifies thinness
• For the adolescent or young
adult, thinness equates with
self-worth.
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Management/Treatment
✓ Objective: to correct underlying cause and prevent complications of weight loss
▪ Client may require hospital care
▪ Nutritional planning
▪ Psychotherapy: individual and/or family
▪ Group therapy
▪ Occupational therapy
▪ Recreational therapy
▪ If there is an underlying depression, treat with antidepressants
✓ Nursing Management
▪ Monitor weight as prescribed
▪ Monitor client's eating/record intake and output
▪ Administer nasogastric feedings if ordered
▪ Encourage oral hygiene
▪ Set limits on eating including time allotted for meals
▪ Stay with client during meals
▪ Accompany client to bathroom after meals to prevent self-induced vomiting
▪ Encourage client to express feelings
▪ Encourage socialization
▪ Monitor for findings of electrolyte imbalance or dehydration
▪ Assist client to identify strengths
▪ Teach client
• Relaxation techniques
• Alternative coping methods
• Assertiveness skills

TYPES/SPECIFIC DISORDERS
Anorexia Nervosa
✓ Weight loss through restriction of food intake leading to emaciation
✓ May involve purging behaviors
✓ Tend to reject mature-appearing body
✓ Tendency to asceticism

Bulimia Nervosa
✓ Eating binges alternate with dieting or purging
✓ Purging behaviors may include self-induced vomiting, misuse of emetics and cathartics
or laxatives
✓ More likely than those with anorexia to show impulsive or chaotic behavior
✓ Usually near normal weight
✓ Tend to be outgoing and sensitive to others
✓ Major issue: control self/environment through eating behaviors
✓ Drive for thinness
✓ Population at risk: Adolescents and young adults , In industrialized countries, Models,
dancers and gymnasts at higher risk

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 VII. Personality Disorders
Definition
✓ This is diagnosed when personality patterns or traits are inflexible, enduring,
pervasive, maladaptive and cause significant functional impairment or distress
✓ They are organized into three diagnostic clusters:
▪ Cluster A – individuals with these disorders appear odd and eccentric
(example: paranoid personality, schizoid personality and schizotypal
personality)
▪ Cluster B – individuals with these disorders appear dramatic and erratic
(example: borderline personality, antisocial personality, histrionic personality
and narcissistic personality)
▪ Cluster C - individuals with these disorders appear anxious and fearful
(example: avoidant personality, dependent personality and obsessive-
compulsive personality)
ETIOLOGY ASSESSMENT/FINDINGS DIAGNOSIS
• Limbic system -assess level of function in the areas Cluster A
dysregulation and CNS of affect, cognition, behavior and - Ineffective individual
irritability interpersonal relationships coping
• Decreased levels of Cluster A
- Fear
serotonin - Secretive
- Social isolation
• Elevated levels of - Suspicious
norepinephrine - Spiritual distress
• Abnormal levels of
- Argumentative Cluster B
dopamine - Indifferent - Impaired social
• Genetic factors may - Poverty of thought interaction
play a role - Paranoid ideation - High risk for violence,
• Hostility toward the Cluster B self-directed
self may be projected
- Superficial expression of - High risk for violence,
towards others
emotion directed at others
• They may try to live up
to perfectionist - Lack of remorse or guilt - Fear
standards imposed on - Egocentric or grandiose - Personal identity
them by their parents - Unpredictable and self- disturbance
or others destructive Cluster C
• Underdeveloped - Attention-seeking - Ineffective individual
superego Cluster C coping
• Anxiety -
• Social oppression
- Lack of self-confidence Fear

• Inability to manage - Fear of being abandoned

conflict - High need for routine, rigid,
• A chaotic and abusive stubborn and emotionally
environment constricted

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Treatment
✓ Antipsychotic agents may be prescribed on a short-term basis to alleviate psychotic
symptoms
✓ SSRI’s may be prescribed to diminish the rapid mood swings and obsessive rumination
associated with certain personality disorders
✓ Self-help groups to increase the client’s self-awareness
✓ Individual and group therapies
✓ Impulse control training
✓ Limit setting
✓ Problem solving exercises and assertiveness training

Nursing Management
Cluster A
✓ Approach people in a gentle, interested and non-obtrusive manner
✓ Respect client’s needs for distance and privacy
✓ Gradually encourage interaction with others if appropriate
Cluster B
✓ Provide a consistent and structured environment to avoid manipulation and
power struggles
✓ Safety is always the first priority of care
✓ Set limits as necessary
✓ Engage in frequent staff conferences to counteract client’s ability to play one
staff member against the other
✓ Encourage direct communication to minimize attention seeking through the
use of dramatic and seductive behavior
✓ Help clients who display a sense of entitlement to acknowledge the needs of
others
Cluster C
✓ Encourage expression of feelings
✓ Help clients recognize impairment or distress related to their need for
perfection and control
✓ Help client acknowledge and discuss their sense of inadequacy and fear of
rejection
TYPES/SPECIFIC DISORDERS

TYPE CHARACTERISTICS
Cluster A
1. Paranoid Pattern of distrust and suspiciousness such that the behavior and motives
personality disorder of others are suspected as malevolent. Person is secretive, hyper alert to
danger and argumentative to maintain a safe distance between
themselves and others.
Cluster A Pattern of detachment from social relationships and restricted range of
2. Schizoid personality emotions. The person has little interest in activities, affect is bland,
disorder blunted or flat, appear to have poverty of thought, expressed thoughts
are vague, indifferent, aloof, desire no close friends.
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 Cluster A Pattern of acute discomfort in close relationships, cognitive or perceptual
3. Schizotypal distortions and eccentricities of behavior. This is characterized by
personality disorder tangential or vague speech, display transient psychotic symptoms,
inappropriate affect, paranoid ideation, illusions and magical thinking may
be present.
Cluster B
1. Borderline - Personal relationships are unstable; lonely; emotions shallow
personality disorder - Images of self and others are primarily bad; feels inadequate
- Anger, hostility
- Projection of hostility onto others
- Acts out and denies responsibility for actions
- Poor judgment
- Impaired problem solving
- Very "black or white" thinking
- Regression
- Marked mood swings
- Demanding
- Sarcastic
- Manipulative
- Behaves self-destructively
- Splitting
Cluster B Pattern of disregard for and violation of the rights of others. This is
2. Antisocial characterized by manifestations such as lying, stealing, vandalism, fighting
personality disorder and running away from home, consistent irresponsibility, impulsive and
reckless, lack of guilt or remorse, irritable and aggressive.
Cluster B Pattern of excessive attention-seeking behavior. This is characterized by
3. Histrionic displaying seductive and attention-seeking behavior, conversation is
personality disorder superficial, overly dramatic and shallow expression of emotions.
Cluster B Pattern of grandiosity, need for admiration and lack of empathy. This is
4. Narcissistic characterized by being preoccupied with fantasies of power and success,
personality disorder seeks constant admiration and entitlement, extremely grandiose and
exploits others to achieve personal goals, arrogant, egoistical, lacks
empathy
Cluster C
1. Avoidant Pattern of social inhibition, feelings of inadequacy and hypersensitivity to
personality disorder negative evaluation. This is characterized by lack of self-confidence and
extremely sensitive to rejections, fearful, shy, hurt by criticism and views
self as inadequate and inferior.
Cluster C Pattern of submissive and clinging behavior related to a need to be taken
2. Dependent cared of. This is characterized by desiring help with everyday decisions,
personality disorder difficulty in disagreeing with others, anxious when left alone, lacks self-
confidence and preoccupied with fear of being abandoned.
Cluster C
3. Obsessive- Pattern of preoccupation with orderliness, perfectionism and control. This
compulsive is characterized by a high need for routine, difficulty with task completion
personality disorder related to a need for perfection, inflexibility, rigid, stubborn and
emotionally constricted

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 VIII. Schizophrenia
Definition
✓ A multifaceted psychosis with early onset; criteria from DSM IV are as follows:
▪ When disease is in active phase, the client shows psychotic behaviors.
(Psychosis is severe ego dysfunction. Psychosis is also part of other DSM-IV
diagnoses of dysfunctions of thought and sensorium.)
▪ Findings involve many psychological processes
▪ Previously, client had functioned at a higher level
▪ Schizophrenia normally sets in before 30 years of age
▪ Findings last six months or more
▪ Not caused by affective or organic mental disorder
▪ Involves hallucinations and/or delusions
General Characteristics
✓ Self-care often fails
✓ Social adjustment is impaired
✓ Orientation to the environment is lost
✓ Boundaries between self/others dissolve
✓ External/internal stimuli are confused (delusions/hallucinations)
✓ Reality testing fails

ETIOLOGY ASSESSMENT/FINDINGS DIAGNOSIS

• Biogenetic (possible Positive symptoms • Impaired thought
hereditary factor) • Hallucinations-false sensory process
Biochemical perception • Anxiety
• Dopamine hydrochloride • Delusions – false beliefs
• Individual
- too much • Looseness of associations
ineffective coping
neurotransmitter for • Agitated or bizarre behaviors
neural activity Alterations in thinking • Social isolation
• Research has suggested 1. Types of delusions • Risk for violence,
abnormalities of • Ideas of reference self-directed
neurotransmitters • Ideas of Persecution • Sensory-
norepinephrine, • Ideas of Grandeur perceptual
serotonin, acetylcholine • Somatic delusions alterations
and GABA (gamma • Jealousy • Impaired verbal
aminobutyric acid). • Control/being controlled
Contributing factors communication
• Thought-broadcasting- belief
• Poor relationships with • Self-care deficit
that others can hear his thoughts
primary caretaker • Thought insertion- belief that
• Sleep pattern
• Dysfunctional family others have the ability to put disturbance
systems thoughts into a person’s mind • Chronic low self-
• Stressful life events • Thought withdrawal esteem
• Decreased socio- 2. Associative looseness
economic status (SES) 3. Neologisms- inventing new

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 words
4. Concrete thinking
5. Echolalia- repeating the words
6. Echopraxia- repeating the actions
7. Clang association- rhyming words
8. Word salad- combining words in
a sentence that makes no sense
Alterations in perception
1. Hallucinations
• Auditory
• Visual
• Olfactory
• Gustatory
• Tactile
Alterations in behavior
• Bizarre behavior
• Extreme motor agitation
• Stereotyped behaviors
• Automatic obedience
• Waxy flexibility
• Stupor
• Negativism
• Agitated behavior
Negative symptoms
• Apathy
• Anhedonia – diminished ability to
experience pleasure
• Alogia – poverty of speech
• Anergia – lack of energy
• Avolition – lack of motivation
• Ambivalence – conflicting
emotions
Associated findings
• Depression/suicide
• Water intoxication
• Substance abuse
• Violent behavior
Interferes with person's ability to:
• Initiate and maintain
relationships
• Initiate and maintain
conversations
• Hold a job
• Make decisions
• Maintain adequate hygiene and
grooming

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 Management/Treatment
Psychopharmacology
✓ Antipsychotic agents and neuroleptics
▪ Decrease psychotic symptoms
▪ Decrease agitation
▪ Less effective with negative symptoms
▪ Decrease dopamine - dependent neural activity in the brain and
▪ other parts of the body (causing extrapyramidal symptoms)
▪ Antiparkinsonian agents: used to counteract these extrapyramidal
symptoms
ANTIPSYCHOTIC/NEUROLEPTIC DRUGS
Typical -Traditional ( initially introduced in the 1950’s)
anti-psychotics -Effective in treating the positive symptoms of schizophrenia
-Most common side-effects are the extrapyramidal side-effects
-Examples: Chlorpromazine (Thorazine), Haloperidol (Haldol), Thioridazine (Mellaril)
and Fluphenazine (Prolixin)
Atypical - Effective in treating the positive and negative symptoms of schizophrenia
anti-psychotics -Minimal to no risk of developing extrapyramidal side-effects
- Decreased risk for the development of tardive dyskinesia
-Examples: Clozapine (Clozaril), Risperidone (Risperdal) and Olazapine (Zyprexa)
Antiparkiso- - Increases the dopamine levels and is used to prevent or manage the extrapyramidal
nism drugs side-effects of anti-psychotic medications.
-Examples: Benztropine (Cogentin), Biperiden (Akineton) and Diphenhydramine
(Benadryl)

EXTRA-PYRAMIDAL SIDE-EFFECTS
1. Akathisia – restlessness, inability to remain still
2. Akinesia – absence of movement or difficulty with movement
3. Dystonia- muscle spasms, spastic movements of the neck and back, wryneck, oculogyric
crisis
4. Tardive Dyskinesia- involuntary and abnormal movements of the tongue, involuntary
movements of extremities and trunk
5. Neuroleptic malignant syndrome- potentially lethal side-effect characterized by elevated
white blood cell count, muscle rigidity, hyperthermia, tremors and altered consciousness

Individual psychotherapy
✓ Long-term therapy
✓ Difficult because schizophrenia impairs interpersonal functioning
✓ Focused, supportive problem-solving is most useful
Group therapy in schizophrenia
✓ Oriented toward providing support, an environment in which the client can
develop social skills, and a format that allows friendships to begin
✓ Some success with long-term work
✓ Less success if client actively delusional and/or psychotic
Social skills training
✓ Role play to simulate anticipated interactions
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 ✓ Teach eye contact, interpersonal skills, voice, posture
✓ Vocational/rehabilitation often succeeds
✓ Long-term treatment
✓ Includes job training
✓ Promotes semi-independent daily activities
✓ Raises self esteem
Family therapy
✓ To help families cope with psychotic and residual symptoms of
schizophrenia
✓ To help reduce relapse rate
Nursing Management
✓ Protect client and others from harm, including suicide precautions as
indicated
✓ Administer medications as ordered
✓ Monitor for extrapyramidal symptoms
✓ Establish trust, decrease anxiety
✓ Encourage or reinforce:
▪ Client's sense of control
▪ Reality orientation
▪ Self-care
✓ Help client set realistic goals
✓ Provide safe and successful experiences
✓ Assist with hygiene and/or feeding as indicated
✓ Teach client:
▪ Importance of medication compliance
▪ Medications and side effects
TYPES/SPECIFIC DISORDERS

TYPES
1. Paranoid type Preoccupation with one or more delusions or frequent auditory
hallucinations
None of the following is prominent: disorganized speech, disorganized
or catatonic behavior or flat or inappropriate affect
2. Catatonic type Psychomotor disturbances such as stupor, waxy flexibility, rigidity,
excitement or posturing are the prominent features.
3. Residual type It is a subtype used to describe clients experiencing negative symptoms
following one acute episode of schizophrenia. Clinical symptoms may
persist over time or the client may experience a complete remission
4.Disorganized type This is considered the most severe. The client experiences a
disintegration of the personality and is withdrawn. Speech may be
incoherent. Behavior is uninhibited along with a lack of attention to
personal hygiene and grooming. Prognosis is poor.
5. Undifferentiated Is usually characterized by atypical symptoms that do not meet the
type criteria for the subtypes of the paranoid, catatonic or disorganized
schizophrenia. The client may both exhibit positive and negative
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 symptoms. Odd behavior, delusions, hallucinations and incoherence
may occur.

IX. Substance-Related Disorders

Definition
✓ Maladaptive behaviors resulting from the regular intake of large amounts of
addictive chemicals
✓ Addictive chemicals include alcohol, stimulants, depressants, hallucinogens,
narcotics
✓ The DSM-IV clinical syndromes include: intoxication, withdrawal, abuse and
dependence
Levels of Substance Abuse
▪ Abuse is pathologic use of mood-altering chemicals that continues for at least 1
month, which impairs social or occupational functioning
▪ Dependence is a more severe level of abuse that involves impaired ability to
control use of substance and results in withdrawal (adverse consequences) when
substance is discontinued or reduced
▪ Chemical dependence is a chronic and progressive disease that can be fatal if left
untreated
Types of Dependence
▪ Psychologic dependence: pleasure that intensifies craving for substance; often
begins in teens and twenties
▪ Physiologic dependence: after repeated use, physiology changes; and after
substance is reduced or removed, withdrawal symptoms appear
▪ Tolerance: drug dosage must keep increasing to achieve same effect
SUBSTANCE/ ASSESSMENT/ TREATMENT/
ETIOLOGY FINDINGS MANAGEMENT
1. Alcohol Physiological effects of long-term Treatment of alcohol dependence
-This is a CNS depressant alcohol abuse: • Antianxiety agents:
that is absorbed rapidly • Anemia chlordiazepoxide (Librium)
into the bloodstream. • Hypertension • Vitamin and nutritional
Although alcohol is a legal • Tachycardia therapy
substance, problem • Hepatomegaly • Disulfiram (Antabuse) - alcohol
drinking has detrimental • Ascites abuse deterrent
physiologic and social • Cirrhosis • Support groups (Alcoholics
effects. • Gastritis Anonymous)
Dependence • Esophagitis • Thiamine-to prevent or treat
- Daily intake of large • Malabsorption syndrome Korsakoff’s psychosis
quantities, or • Fatigue Nursing care in alcohol dependence
- Excessive drinking • Depression 1. During withdrawal
limited to weekends; • Impaired judgment; cognitive • Stay with client
or impairment • Provide quiet environment
• Tremors • Administer medications as
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 - Periods of abstinence • Wernicke-korsakoff ordered
with binges lasting for syndrome • Protect the client from harm
weeks or longer -Symptoms of withdrawal usually • Institute seizure precautions as
Etiology begin 4-12 hours after cessation or indicated
• Unknown marked reduction of alcohol intake • Maintain adequate fluid intake
• Stress has been Withdrawal symptoms: 2. During abstinence
• Hand tremors
implicated • Provide emotional support
• Some research • Sweating
• Provide nutritious diet
suggests a familial • Elevated pulse and blood
pressure • Encourage the development of
tendency
• Insomnia new coping skills
• Nausea and vomiting • Provide relaxation exercises
• Severe untreated withdrawal • Inform client about support
may progress to delirium groups and rehab programs
tremens
2. Stimulants Intoxication effects: • If discontinued, withdrawal
-include cocaine, crack, • Euphoric feeling follows
amphetamines • Psychomotor agitation • Stimulant withdrawal is not
-they are drugs that • Mood swings treated pharmacologically
stimulates or excites the • Tachycardia • Overdose may cause lethal
CNS • Hypertension cardiac or respiratory arrest
• Dilated pupils • Emergency care of overdose
• Perspiration and chills on stimulants:
• Insomnia cardiopulmonary support
• Impaired cognitive function
• Seizures
Withdrawal symptoms:
• Marked dysphoria
• Fatigue
• Increased appetite
• Altered sleeping patterns
• Agitation
• Panic attacks
3. Depressants Intoxification symptoms: • Overdose can lead to
- include barbiturates, • Slurred speech respiratory depression, coma
tranquilizers, sedatives and • Impaired cognitive function; • Emergency care of overdose
hypnotics confusion • Respiratory support
• Emotional lability • Keep client awake and moving
• Lack of coordination
• Cold and clammy skin
Withdrawal symptoms:
• Autonomic hyperactivity –
opposite effect of the drug
• Insomnia
• Anxiety
• Psychomotor agitation
4. Narcotics Intoxification symptoms: • Overdose threatens life:
-include: heroin, morphine, • Euphoria depresses respiratory function
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 meperidine, codeine • Tranquility and alters level of
- induces a sense of • Drowsiness consciousness
euphoria and well-being • Constricted pupils • Emergency care includes
• Clouded sensorium cardiopulmonary support
Withdrawal symptoms: • Methadone, a potent synthetic
• Watery eyes opiate, is used as a substitute
• Yawning for heroin in some
• Sneezing maintenance programs. It can
• Diaphoresis be used as a replacement for
the opioid and the dosage is
then decreased over 2 weeks.
5. Hallucinogens Intoxification symptoms: • Overdose threatens life:
- include: LSD, PCP, • Tachycardia depresses respiratory function
mescaline, psilocybin • Hypertension and alters level of
-are the substances that • Hallucinations consciousness
distort the user’s • Nausea • Treatment: drug rehabilitation
perception of reality and • Impaired attention and
produces symptoms similar judgment
to psychosis • Aggressive behavior
• Impulsivity
• Potentially life threatening
• Potentially psychotic long-
term effects
No withdrawal symptoms has
been identified for hallucinogens
although some people have
reported a craving for the drug
6. Marijuana • Impaired motor coordination •
• Inappropriate laughter
• Impaired judgment
• Bloodshot eyes
• Dry mouth
• Hypotension
• Tachycardia
No clinically significant withdrawal
symptom of marijuana is identified

Nursing Management
✓ Protect the client and others from harm
✓ Help client through drug rehabilitation as indicated
✓ Provide emotional support
✓ Help the client develop a support system
✓ Provide emergency care for overdose

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 X. Abuse and Violence
Definition
✓ The term abuse is used in the psychiatric mental health nursing to describe behaviors
in which an individual misuses, attacks or injures another individual
✓ Abuse may be physical, sexual or emotional
✓ Neglect is also a form of abuse
✓ The term violence is used to describe behaviors in which an individual displays an
intensive destructive or uncontrolled force to injure a person
✓ Have three elements for abuse to occur: the abuse, the victim and a crisis
✓ The abuser is the person who inflicts the abuse and the victim is the recipient of the
abuse or violence. Victims are powerless to stop the abuse
✓ May be directed toward a child, a spouse or the elderly
✓ Rape is a violent sexual abuse

Abusers
✓ Often blame victim
✓ Demonstrate poor impulse control
✓ Have frequently been victims of abuse themselves

Etiology
✓ There is no single theory about the cause of abuse. Biologists believe that aggression is
inherent and humans and is regulated by the hormone testosterone and related to the
imbalance of serotonin
✓ The social perspective say that abuse and violence is a learned behavior, poor
parenting skills contribute to it and violence is part of the socialization process
✓ The are also other theories that say the abusers have low self-esteem and fear of
abandonment and abuse is about gender and power
✓ Societal issues also promote abuse such as poverty, unemployment, crime and teen
pregnancy
TYPES
Spouse or Partner Abuse
✓ It is mistreatment or misuse of one person by another in the context of an intimate
relationship
✓ The abuse can be emotional, psychological, physical, sexual or a combination. Ninety
to Ninety five percent of domestic victims are women
✓ Women have difficulty leaving abusive relationships because of financial and
emotional dependence on the abuser and the risk of suffering increased violence or
death
✓ Dependency is the trait most commonly found in abused wives who stay with their
husbands

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 CYCLE OF ABUSE AND VIOLENCE

Child Abuse
✓ It is defined as the intentional injury of a child
✓ It can include physical abuse or injuries, neglect or failure to prevent harm,
failure to provide adequate physical or emotional care or supervision,
abandonment, sexual assault and torture
✓ Parents who abuse their children often have minimal parenting knowledge
and skills and parents who abuse their children are often emotionally
immature, needy and incapable of meeting their own needs much less those
of a child
✓ This tendency for adults to raise their children the same way they were raised
perpetuates the cycle of family violence
✓ Adults who were victims of abuse as children frequently abuse their own
children
Elder Abuse
✓ It is the maltreatment of older adults by family members or caretakers
✓ It may include physical or sexual abuse, neglect, self-neglect, financial
exploitation and denial of adequate medical treatment
✓ The victim may have bruises or fractures, may lack the needed glasses or
hearing aids, may be denied food, fluids or medications or may be restrained
in a bed or chair

Rape and Sexual Assault

✓ It is a crime of violence and humiliation of the victim expressed through
sexual means
✓ Rape is the perpetration of an act of sexual intercourse with a female against
her will and without her consent, whether her will is overcome by force, fears
of force, drugs or intoxicants
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 ✓ It is also considered rape if the woman is incapable of exercising rational
judgment because of mental deficiency or if she is below the age of consent
FINDINGS TREATMENT NURSING
MANAGEMENT
Physical abuse • In general, cases of • Provide emotional
• Broken bones and/or dislocations abuse must be reported support
• Welts, and/or bruises Removal of victim from • Document all signs of
Sexual abuse source of abuse abuse
• Bruising or bleeding in genital or • Protective services • File appropriate reports
anal area, • Directing abuser to help • Assist in placement for
• Pain or itching in genital area, or therapy protection
• Rape, evidence of sexual • Assist abuser in
intercourse, obtaining appropriate
• Genitourinary infections counseling
General neglect
• Malnutrition
• Habitual behaviors: rocking, head
banging
• Learning disorders
• Social isolation
• Aggressive behavior

XI. Cognitive Impairment Disorders

Cognitive impairment disorders
✓ A group of disorders characterized by deficits in cognition (the manner in which the
brain processes information), memory that represents a significant change from
mental the client’s previous functioning
Fundamental Principles when Caring for Clients with Cognitive Disorders
✓ Provide a safe, familiar environment; provide direct supervision as necessary; provide a
consistent caregiver to foster trust
✓ Reorient the client to time, place, and person; excessive use may cause anxiety
✓ Keep client involved in reality and in the home situation as long as possible
✓ Allow client to assume as much responsibility for self-care as possible
✓ Provide a quiet environment; reduce stimuli; help client maintain relationships
✓ Plan care so that the staff approaches these clients when they appear receptive
✓ Attempt to follow familiar routines; keep the schedule of activities flexible to make use
of the client’s lability of mood and easy distractibility
✓ Encourage adequate nutritional intake; monitor intake and output
✓ Provide diversional activities including exercises that the client enjoys and can handle
✓ Observe for changing physiologic and neurologic symptoms
✓ Prevent physical harm related to confusion, aggression, or fluid and electrolyte
imbalance
✓ Support family caregivers; maintain non-judgmental attitude
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 DELIRIUM
Definition
✓ Delirium is characterized by a disturbed consciousness and change in cognitive
function that develops over a short period of time; onset is acute and symptoms
develop rapidly

ETIOLOGY ASSESSMENT/FINDINGS
• Delirium is complex and usually • Impaired consciousness and attention,
multifactored. disorientation
• The following risk factors are • Disorganized thinking and rambling speech
associated with delirium: • Disturbance in the sleep-wake cycle, such as
• Advanced age daytime sleepiness and nighttime agitation
• Preexisting illness • Psychomotor changes (hyperactivity and agitation,
• Infection and/or or hypoactivity and somnolence)
electrolyte and metabolic • Misinterpretation of situations and reality illusions,
imbalance and hallucinations
• Bone fractures • Labile mood (rapid, unpredictable shifts from one
• Brain damage or emotional state to another).
dementia.

Management/Treatment
- Reduction of causative agent such as fever or toxins
- Prevention of further damage
- Provision of diet high in calories, protein, and vitamins; elimination of caffeine
- Prescription of mild sedatives if necessary
- Provision of a safe, quiet environment
- Reorientation to time, place, and person

Nursing Management
- Refer to Fundamental Principles When Caring for Clients with Cognitive
Disorders
- Implement measures as ordered to reduce causative factors
- Reassure family members that symptoms associated with the delirium may
subside if this is realistic with treatment
- Provide one-to-one caregiver assignment during restless or agitated periods

Types/Specific Disorders
1. In delirium due to a general medical condition, multiple medical conditions
can be associated with delirium; acute or chronic illnesses, hormonal and
nutritional factors, sensory impairments, and various medications as well as
surgical. procedures can all contribute.

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 2. In substance-induced delirium and substance withdrawal delirium, the
client’s history, physical examination, and diagnostic study findings indicate
the delirium is associated with substance use.
3. In delirium due to multiple etiologies, several medical conditions or a
combination of substance use and medical conditions is evident,
4. Delirium not otherwise specified is the DSM-TVTR classification applied
when insufficient evidence exists to establish a definitive etiology

• DEMENTIA
Definition. Dementia is characterized by multiple cognitive deficits that include memory
Impairment and at least one of the following cognitive disturbances: aphasia. apraxia.
agnosia, or a disturbance in executive functioning.

ETIOLOGY ASSESSMENT/FINDINGS
• Dementia can develop as a result of • Aphasia: the loss of language ability; speech is
chronic delirium caused by an often impoverished, and the client may have
untreated or untreatable acute difficulty “finding” the right words
condition. • Apraxia: an impaired ability to carry out
• Vascular disease may occur with such motor activities despite intact sensory
disorders as hypertension, function
arteriosclerosis, and atherosclerosis, • Confabulation: filling in memory gaps with
resulting in cerebrovascular accident detailed fantasy believed by the affected
and ensuing dementia, (Note: Treating individual
hypertension can decrease the client’s • Sundown syndrome: increased disorientation
risk of developing dementia of the and confusion at night a. Perseveration
Alzheimer’s type.) phenomenon: repetitive behaviors, including
• About 40% of those with Parkinson’s pacing and echo-1 ing others’ words
disease develop dementia. • Memory losses (initially, loss of recent
• Certain genetic disorders, including memory; eventually, remote memory
Huntington’s chorea and Pick’s impairment)
disease, cause dementia, • Disorientation to time, place, and person
• HIV infection can affect the central • Decreased ability to concentrate or to learn
nervous system, causing HIV new material
encephalopathy or AIDS dementia • Difficulty making decisions
complex. • Poor judgment (for example, the client may
• Structural disorders of brain tissue, not be aware of environmental
such as normal pressure considerations of safety and security).
hydrocephalus and injury resulting
from a head trauma, can lead to
dementia,

Management/Treatment
a. Treatment of this progressive, degenerative disorder is directed toward a lo1l
term outcome and maintaining the client’s quality of life.
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 b. A multidisciplinary team approach that includes the collaborative efforts of
nurses, doctors, dietitians, psychiatrists and psychologists, social workers,
pharmacists, and rehabilitative specialists (occupational, physical, and activity
therapists) is commonly used.
c. Statistics indicate that 7 out of 10 people with Alzheimer’s disease live at
home, and family and friends care for 75% of them; thus, a family focus on
treatment and management is vital.
d. Community-focused management varies, depending on the client’s needs and
level of functioning.
- Community nurses provide home health visits.
- Adult day-care services provide therapeutic activities, rehabilitative
services, recreation, and respite services for caregivers.
- Residential (personal care) facilities provide assisted living for some
clients.
- About half of all skilled nursing facility residents reportedly have
.Alzheimer’s disease.
- The Alzheimer’s Association is a national organization that provides
family and caregiver support groups, educates the community, funds
research, and lobbies for legislative action.
e. Pharmacologic intervention may include the use of commonly prescribed
medications or experimental therapies.
- Certain medications may be used to slow the client’s rate of decline (by
increasing acetylcholine levels and helping to maintain neuronal
functioning) or to manage the client’s behavior and distressing
symptoms.
1. Anticholinesterase
1. Donepezil
2. Galantamine
3. Rivastigmine tartate
2. Antioxidants (vitamin E)
3. N-methyl-D-aspartate (NMDA)receptor antagonists (memantine)
- Experimental therapies include the use of nonsteroidal anti-
inflammatory drugs (NSAIDs) to reduce the risk of Alzheimer’s disease
and antioxidant (vitamin E) therapy to protect neurons.

Nursing Management
- Refer to Fundamental Principles When Caring for Clients with Cognitive
Disorders
- Toilet client frequently
- Feed the client who is not able to feed self
- Protect client from self and environment
- Support client’s attempts at independence
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 - Support family’s decisions regarding present and future care of client;
encourage completion of advance directives
- Assess effectiveness of medication to delay progression of cognitive
symptoms (e.g., donepezil [Aricept], rivastigmine [Exalon])
- Support caregivers as necessary (e.g., respite care, home health aides, long-
term residence for client with dementia)

Types/Specific Disorders
1. Dementia of the Alzheimer’s type, the most common of all dementias,
accounts for about two-thirds of all dementias involving those over age 65.
The most common form of dementia affecting elderly dents, dementia of the
Alzheimer’s type may be categorized according to its stage and related
symptoms, Although clients do not necessarily pass through the specific
sequence of deterioration as outlined below, the stages are helpful in
determining the client’s cement cognitive state,

Stage Behavior Affect Cognitive behavior

Mild • Difficulty completing tasks • Anxious • Recent memory losses
• Decline in goal-directed • Depressed (targets appointments
activity • Frustrated and conversation
Lack of attention to personal • Suspicious • Time disorientation
appearance and activities of • Fearful • Decreased ability to
daily living concentrate
• Withdrawal from usual social • Difficulty making
activities decisions
• Frequent searching for • Poor judgment
misplaced objects; may accuse
others of stealing
Moderate • Socially inappropriate • Labile mood • Recent and remote
behavior • Flat, apathetic memory losses
• Self-care deficits (bathing, • Catastrophic agitation (amnesia)
toileting, • Paranoia • Confabulation
dressing, grooming) • Disorientation to time,
• Wandering and pacing place, and person
• Hoarding objects • Some degree of
• Hyperorality agnosla, apraxla, and
• Disturbance in sleep-wake aphasia
cycle
Severe • Decreased ability to ambulate • Flat, apathetic • Progression of
or engage in other motor • Occasional cognitive changes, with
activities catastrophic reactions increased severity of
• Decreased swallowing ability may continue amnesia, agnosla,
• Complete self -care deficits apraxia, and aphasia
(requires
constant care)
• Inability to recognize caregiver

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 2. Vascular (multi-infarct) dementia, the second-leading cause of dementia in
elderly clients, occurs when blood clots block small blood vessels in the brain
and destroy brain tissue.
3. Other types of dementia are associated with general medical conditions,
such as Parkinson’s disease, Pick’s disease, Huntington’s chorea, Creutzfeldt-
Jakob disease, and HIV

• AMNESTIC DISORDERS
Definition: Amnestic disorders are characterized by a disturbance in memory that is due
to either the direct physiologic effects of a general medical condition or the persisting
effects of a substance (drug of abuse. medication, or toxin exposure)

Onset may be acute (such as from a traumatic brain injury, stroke, or other
cerebrovascular event) or insidious and slow (such as from prolonged substance at
chronic neurotoxic exposure, or sustained nutritional deficiency).

ETIOLOGY ASSESSMENT/FINDINGS
• Common causes of • Impaired ability to learn new information or an inability to recall
amnestic disorder include learned information or past events
head trauma, hypoxia, and • Confabulation (making up information to fill memory gaps)
CNS infections, • Profound amnesia resulting in disorientation to place and time
• Chronic thiamine deficiency • Apathy, lack of initiative, and emotional blandness
associated with alcoholism • Lack of insight into memory deficits
(Korsakoff’s syndrome also • Disorientation to self (rarely occurs; more common in dementia).
causes this disorder.

Management/treatment
- Treatment is similar to that of delirium if the amnestic disorder is an acute
problem.
- When the disorder is chronic, treatment is similar to that of dementia.

Nursing Management
- Refer to Fundamental Principles When Caring for Clients with Cognitive
Disorders
- Maintain the client in a safe environment
- Support the client’s attempts at independence
- Assist with health care team’s efforts to identify causative agent
- Support client and family regarding present and future care decisions

Types/Specific Disorders
• In amnestic disorder due to a general medical condition, the client’s condition stems
from a specific medical disorder (such as a cerebrovascular accident, traumatic brain
injury or encephalitis).
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 • Substance-induced persisting amnestic disorder is characterized by impaired learning
that directly results from the use of a substance (such as alcohol, sedatives, hypnotics,
or opiates) as evidenced by the clients history, physical ex nation, and laboratory
findings.
• The label amnestic disorder not otherwise specified may be applied when other cause
has been identified.

XII. Cognitive Disorders

Definition. A cognitive disorder is a disruption or impairment of the higher level functions
of the brain (reasoning, judgment, perception, attention, comprehension and memory).
Cognitive disorders can have devastating effects on the ability to function in daily life. The
primary categories of cognitive disorders are delirium, dementia and amnesic disorders.

Types
a. Delirium
- an acute irreversible disorder characterized by the clouding of
consciousness and a reduced ability to focus and maintain attention.

b. Dementia
- is a chronic, irreversible brain disorder characterized by impairments in
memory, abstract thinking and judgment as well as changes in personality. It
is manifested by memory impairment and one or more of the following
cognitive disturbances.
i. Aphasia- loss of the ability to understand or use language
ii. Apraxia- an inability to carry out skilled and purposeful movements
iii. Agnosia- inability to recognize familiar situations, people or stimuli

Levels
Mild- Forgetfulness is the hallmark of mild, beginning dementia. The person
has difficulty of finding words, frequently loses objects and begins to
experience anxiety about these loses.
Moderate- confusion is apparent along with progressive memory loss. The
person no longer can perform complex tasks but remains oriented to the
person or place.
Severe-Personality and mental changes occur. The person may be delusional,
wander at night, forget the names of his/her spouse and children and require
assistance in activities of daily living.

c. Amnesic disorders
- development of memory impairment characterized by inability to learn new
information or inability to recall previously learned information.

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 DELIRIUM DEMENTIA
Onset Rapid Gradual and insidious
Duration Brief Progressive deterioration
Level of Impaired, fluctuates Not affected
consciousness
Memory Impaired short term memory Short then long term memory impaired then
destroyed eventually
Thought Temporarily disorganized Impaired thinking, eventual loss of thinking
process abilities
Etiology General medical conditions cause an interference of blood supply and the necessary
nutrients to the brain that can result in cognitive disorders such as brain hypoxia, vitamin
deficiency, infections, endocrine and metabolic disorders, hepatic and renal failure, trauma
and tumors. It can also be caused by the ingestion of substances such as alcohol, cannabis,
hallucinogens or opioids.
Assessment/ Fluctuating levels of consciousness Difficulty performing complex tasks
Signs and Alternating patterns of hyperactivity Decreased concentration
symptoms Hypoactive behaviors Forgetfulness
Cognitive changes (disorganized thinking, Wandering or aggressive behavior
easily distracted, disorientation to place Aphasia, hyperorality, Perserveration,
and time, impairment in recent and confabulation, agraphia ang Agnosia
remote memory and sleep pattern Progressive deterioration in motor ability
disturbances) Severe decline in cognitive function

Diagnosis • Acute confusion • Acute confusion

• Anxiety • Altered thought process
• Altered thought process • Self care deficit
• Self care deficit • Impaired verbal communication
• Impaired verbal communication • Risk for injury
• Risk for injury • Ineffective family coping
• Risk for trauma • Risk for care giver role strain
• Self-esteem disturbance
• Visual/auditory/tactile/
sensory/perceptual alterations
Treatment Psychopharmacology
Cholinesterase inhibitors – slows progression of mild to moderate dementia. Example:
Tacrine (Cognex) and Donepezil (Aricept).
Management of anxiety – Example: Lorazepam (Ativan), Buspirone (Buspar)
Management of depression – Example: SSRI’s
Management of psychotic features: Example: Atypical antipsychotics like Olanzapine
(Zyprexa) and Risperidone (Risperdal)
Behavior modification (Reality orientation)
Group and individual therapies (Reminiscence therapy, validation therapy)
Milieu therapy
Nursing Maintain nutrition and fluid balance Not usually life threatening
Management Restrain only when necessary since it Give individualized attention, consistent social
increases agitation and fear interaction, group activities, exercise,
Safety is a priority stimulation of the senses
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 One on one observation Place client in a lighted room, give clear and
Repetitive orientation simple instructions, find out the source of
Lighted room anxiety, try to alleviate coping mechanisms to
Don’t reinforce hallucinations defend self become emphasized during anxiety

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