Nursing Diagnoses in Psyciatric PDF

2506_FM_i-xxxvi.
indd ii 10/4/10 3:53:18 PM

Impaired communication, verbal, 1819, 2324, 119120
Impulsive behavior, 259, 262, 283, 297, 299
Inability to meet basic needs, 17, 64, 121, 140141, 169, 187, 620t
Inappropriate/exaggerated behaviors, 34, 118, 252, 273, 307, 337
Inattention, 26
Ineffective coping, 114115, 169170, 181183, 243245, 325328
Injury risk, 367369
Insomnia, 39,122123, 128, 143, 158159, 165, 166, 242, 326, 424, 619t
La belle indifference, 179, 185

Loose associations or ight of ideas, 620t
Loss of a valued entity, recently experienced, 620t
Low self-esteem, 32, 35, 3738, 4749, 6768, 92, 94, 9799, 133135, 216217,
229231, 249251, 269270, 292294, 303305
Manic behavior, 125, 145, 620t

Manipulative behavior, 36, 37, 47, 94, 148, 238, 250, 282, 620t
Memory loss, 194195, 374t, 581582, 618
Multiple personalities/gender identity disturbance, 194, 197, 620t
Noncompliance, 32, 4042, 189, 266, 364, 619t
Orgasmic problems, 204, 205, 208, 620t

Overeating, compulsive, 219, 226, 620t
Pain, 176177, 180181, 204, 205, 206, 321323

Paraphilic behaviors, 201203, 207, 606
Personal identity disturbance, 2425, 196198, 213214, 620t
Phobias, 165, 314, 620
Physical symptoms as coping behavior, 51, 52, 267, 271, 272, 620t
Powerlessness, 170172, 315317, 619t
Projection of blame, 38, 157, 250, 301, 364, 620t
Regression/regressive behaviors, 110, 131, 141

Religiosity, 110
Repression, 360
Ritualistic behaviors, 169, 620t
Seductive remarks/inappropriate sexual behaviors, 28, 313, 620t

Self-image, 290
Self-mutilative behavior, 2122, 4445, 260261, 282284
Sensory perception alterations, 6567, 116117, 155157, 185186
Sexual abuse/assault, 310, 317, 356, 357
Sexual behaviors, 203, 206207, 210, 331, 621t
Social interaction, impaired, 1923, 3435, 4647, 5253, 135137, 157158, 214216,
251253, 289290, 305307
Social isolation, 4647, 5253, 112114, 135137, 157158, 172173, 214216, 238,
289290, 305307
Spiritual distress (risk for), 404405
Stealing, 28, 257
Stress from caring for chronically ill person, 69, 356, 621t
Stress from locating to new environment, 253255, 621t
Substance abuse behaviors, 7886, 87t89t, 94, 129, 297, 314, 343, 360, 621t
Suicide, 2122, 3032, 6062, 129131, 150152, 238241, 282284, 314, 326, 621t
Suspiciousness, 60, 110, 154, 276, 621t
Thought processes, disturbed, 6264, 117119, 139140, 154155, 157
Verbal communication, impaired, 1819, 2324, 119120

Vomiting, excessive, self-induced, 219, 621t
Withdrawn behavior, 20, 21, 23, 97, 113, 253, 277, 355, 621t
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2506_FM_i-xxxvi.indd ii 10/4/10 3:53:18 PM
Nursing
Diagnoses in
Psychiatric
Nursing:
Care Plans and Psychotropic Medications
EIGHTH EDITION
Mary C. Townsend, DSN, PMHCNS-BC

Clinical Specialist/Nurse Consultant
Adult Psychiatric Mental Health Nursing
Former Assistant Professor and

Coordinator, Mental Health Nursing
Kramer School of Nursing
Oklahoma City University
Oklahoma City, OK
2506_FM_i-xxxvi.indd iii 10/4/10 3:53:18 PM

F. A. Davis Company
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Copyright 2011 by F. A. Davis Company
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for changes and new information regarding dose and contraindications before admin-
istering any drug. Caution is especially urged when using new or infrequently ordered
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Library of Congress Cataloging-in-Publication Data
Townsend, Mary C., 1941-

Nursing diagnoses in psychiatric nursing : care plans and
psychotropic medications / Mary C. Townsend. 8th ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-8036-2506-8 (alk. paper)
1. Psychiatric nursingDiagnosisHandbooks, manuals, etc.
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tional Reporting Service is: 8036-1169-2/04 0 + $.25.
2506_FM_i-xxxvi.indd iv 10/4/10 3:53:19 PM

This Book Is Dedicated:
To my husband, Jim, who encourages and supports me throughout
all my writing projects, and whose love continues to nurture and
sustain me, even after 49 years.
To my daughters, Kerry and Tina, my grandchildren, Meghan

and Matthew, and my sons-in-law, Ryan and Jonathan. You are
the joys of my life.
To my faithful and beloved companions, Chiro, Angel, and Max,

who make me laugh and bring pure pleasure into my life each
and every day.
And nally, to the memory of my father and mother, Francis and

Camalla Welsh, who reared my sister Francie and me without
knowledge of psychology or developmental theories but with
the kind of unconditional love I have come to believe is so vital
to the achievement and maintenance of emotional wellness.
MCT
2506_FM_i-xxxvi.indd v 10/4/10 3:53:19 PM

2506_FM_i-xxxvi.indd vi 10/4/10 3:53:19 PM
Consultants
Maude H. Alston, RN, PhD

Assistant Professor of Nursing
University of North Carolina at Greensboro
Greensboro, North Carolina
Betty J. Carmack, RN, EdD

Assistant Professor
University of San Francisco
School of Nursing
San Francisco, California
Doris K. DeVincenzo, PhD

Professor
Lienhard School of Nursing
Pace University
Pleasantville, New York
Mary Jo Gorney-Fadiman, RN, PhD

Assistant Professor
San Jose State University
School of Nursing
San Jose, California
Mary E. Martucci, RN, PhD

Associate Professor and Chairman
Saint Marys College
Notre Dame, Indiana
Sheridan V. McCabe, BA, BSN, MSN, PhD

Assistant Professor of Nursing
University of Virginia
School of Nursing
Charlottesville, Virginia
Elizabeth Anne Rankin, PhD

Psychotherapist and Consultant
University of Maryland
School of Nursing
Baltimore, Maryland
vii
2506_FM_i-xxxvi.indd vii 10/4/10 3:53:19 PM

viii CONSULTANTS
Judith M. Saunders, DNS, FAAN

Postdoctoral Research Fellow
University of Washington
School of Nursing
Seattle, Washington
Gail Stuart, RN, CS, PhD

Associate Professor
Medical University of South Carolina
College of Nursing
Charleston, South Carolina
2506_FM_i-xxxvi.indd viii 10/4/10 3:53:20 PM

Reviewers
Susan Atwood
Faculty
Antelope Valley College
Lancaster, California
Jaynee R. Boucher MS, RN

St. Josephs College of Nursing
Syracuse, New York
Sherry Campbell
Allegany College of Maryland
Cumberland, Maryland
Lorraine Chiappetta
Professor
Washtenaw Community College
Ann Arbor, Michigan
Ileen Craven
Instructor
Roxborough Memorial Hospital
Philadelphia, Pennsylvania
Marcy Echternacht
College of St. Mary
Omaha, Nebraska
Susan Feinstein
Instructor Psychiatric Nursing
Cochran School of Nursing
Yonkers, New York
Mavonne Gansen
Northeast lowa Community College
Peosta, lowa
ix
2506_FM_i-xxxvi.indd ix 10/4/10 3:53:20 PM

x REVIEWERS
Diane Gardner
Assistant Professor
University of West Florida
Pensacola, Florida
Jo Anne C. Jackson, EdD, RN

Middle Georgia College
Cochran, Georgia
Elizbeth Kawecki
South University
Royal Palm Beach, Florida
Florence Keane DNSc, MSN, BSN

Assistant Professor
Florida International University
Miami, Florida
Gayle Massie MSN, RN

Professor
Shawne, State University
Portsmouth, Ohio
Mary McClay
Walla Walla University
Portland, Oregon
Judith Nolen
Clinical Assistant Professor
University of Arizona
Tucson, Arizona
Pamela Parlocha
California State University - East Bay
Hayward, California
Joyce Rittenhouse
Burlington County College
Pemberton, New Jersey
Phyllis Rowe, DNP, RN, ANP

Riverside Community College
Riverside, California
Georgia Seward
Baptist Health Schools Little Rock
Little Rock, Arkansas
2506_FM_i-xxxvi.indd x 10/4/10 3:53:21 PM

REVIEWERS xi
Anna Shanks
Shoreline Community College
Seattle, Washington
Rhonda Snow
Stillman College
Tuscaloosa, Alabama
Karen Tarnow, RN, PhD

Clinical Associate Professor
University of Kansas Medical Center
Kansas City, Kansas
Shirley Weiglein
South University
Tampa, Florida
Tammie Willis
Penn Valley Community College
Kansas City, Missouri
2506_FM_i-xxxvi.indd xi 10/4/10 3:53:21 PM

2506_FM_i-xxxvi.indd xii 10/4/10 3:53:21 PM
Acknowledgments
My special thanks and appreciation:

To Bob Martone, who patiently provides assistance and
guidance for all my writing projects.
To the editorial and production staffs of the F.A. Davis
Company, who are always willing to provide assistance when
requested and whose consistent excellence in publishing makes
me proud to be associated with them.
To the gracious individuals who read and critiqued the origi-
nal manuscript, providing valuable input into the nal product.
And nally, a special acknowledgement to the nurses who
staff the psychiatric units of the clinical agencies where nurs-
ing students go to learn about psychiatric nursing. To those of
you who willingly share your knowledge and expertise with, and
act as role models for, these nursing students. If this book pro-
vides you with even a small amount of nursing assistance, please
acknowledge it as my way of saying, thanks.
MCT
xiii
2506_FM_i-xxxvi.indd xiii 10/4/10 3:53:21 PM

xiv CONTENTS
Contents
How to Use This Book xxvii
Index of DSM-IV-TR Psychiatric Diagnoses xix
UNIT ONE
THE FOUNDATION FOR PLANNING

PSYCHIATRIC NURSING CARE
CHAPTER 1
Nursing Process: One Step to
Professionalism 1
UNIT TWO
ALTERATIONS IN PSYCHOSOCIAL
ADAPTATION
CHAPTER 2
Disorders Usually First Diagnosed
in Infancy, Childhood, or Adolescence 14
CHAPTER 3
Delirium, Dementia, and Amnestic
Disorders 54
CHAPTER 4
Substance-Related Disorders 71
CHAPTER 5
Schizophrenia and Other Psychotic
Disorders 105
CHAPTER 6
Mood Disorders: Depression 125
xiv
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CONTENTS xv
CHAPTER 7
Mood Disorders: Bipolar Disorders 145
CHAPTER 8
Anxiety Disorders 161
CHAPTER 9
Somatoform Disorders 176
CHAPTER 10
Dissociative Disorders 191
CHAPTER 11
Sexual and Gender Identity Disorders 201
CHAPTER 12
Eating Disorders 218
CHAPTER 13
Adjustment Disorder 236
CHAPTER 14
Impulse Control Disorders 256
CHAPTER15
Psychological Factors Affecting Medical
Condition 264
CHAPTER 16
Personality Disorders 275
UNIT THREE
SPECIAL TOPICS IN PSYCHIATRIC/

MENTAL HEALTH NURSING
CHAPTER 17
Problems Related to Abuse or Neglect 310
CHAPTER 18
Premenstrual Dysphoric Disorder 320
CHAPTER 19
HIV Disease 329
2506_FM_i-xxxvi.indd xv 10/4/10 3:53:22 PM

xvi CONTENTS
CHAPTER 20
Homelessness 341
CHAPTER 21
Psychiatric Home Nursing Care 348
CHAPTER 22
Forensic Nursing 358
CHAPTER 23
Complementary Therapies 370
CHAPTER 24
Loss and Bereavement 390
UNIT FOUR
PSYCHOTROPIC MEDICATIONS
CHAPTER 25
Antianxiety Agents 406
CHAPTER 26
Antidepressants 417
CHAPTER 27
Mood-Stabilizing Drugs 447
CHAPTER 28
Antipsychotic Agents 472
CHAPTER 29
Antiparkinsonian Agents 502
CHAPTER 30
Sedative-Hypnotics 511
CHAPTER 31
Agents Used to Treat Attention-Decit/
Hyperactivity Disorder 522
APPENDIX A
Comparison of Development Theories 538
APPENDIX B
Ego Defense Mechanisms 545
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CONTENTS xvii
APPENDIX C
Levels of Anxiety 548
APPENDIX D
Stages of Grief 552
APPENDIX E
Relationship Development and Therapeutic
Communication 557
APPENDIX F
Psychosocial Therapies 570
APPENDIX G
Electroconvulsive Therapy 580
APPENDIX H
Medication Assessment Tool 583
APPENDIX I
Cultural Assessment Tool 588
APPENDIX J
The DSM-IV-TR Multiaxial Evaluation
System 590
APPENDIX K
Global Assessment of Functioning (GAF)
Scale 592
APPENDIX L
DSM-IV-TR Classication: Axes I and II
Categories and Codes 595
APPENDIX M
Mental Status Assessment 610
APPENDIX N
Assigning Nursing Diagnoses to Client
Behaviors 618
APPENDIX O
Brief Mental Status Evaluation 622
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xviii CONTENTS
APPENDIX P
U.S. Food and Drug Administration (FDA)
Pregnancy Categories 624
APPENDIX Q
U.S. Drug Enforcement Agency (DEA)
Controlled Substances Schedules 626
APPENDIX R
Abnormal Involuntary Movement Scale
(AIMS) 628
Bibliography 631
Subject Index 639
Drug Index 683
Nursing Diagnoses Index 691
2506_FM_i-xxxvi.indd xviii 10/4/10 3:53:23 PM

Index of DSM-IV-TR
Psychiatric Diagnoses
Classication: Axes I and II Categories and Codes
Academic problem, 609

Acculturation problem, 609
Acute stress disorder, 162, 604
Adjustment disorder, 607
with anxiety, 236, 607
with depressed mood, 236, 607
with disturbance of conduct, 236, 607
with mixed anxiety and depressed mood, 236, 607
with mixed disturbance of emotions and conduct, 236, 607
Adult antisocial behavior, 609
Adverse effects of medication, 608
Age-related cognitive decline, 609
Agoraphobia with history of panic disorder, 604
Agoraphobia without history of panic disorder, 161
Alcohol abuse, 598
Alcohol dependence, 598
Alcohol-induced anxiety disorder, 598
Alcohol-induced mood disorder, 598
Alcohol-induced persisting amnestic disorder, 598
Alcohol-induced persisting dementia, 598
Alcohol-induced psychotic disorder, 598
Alcohol-induced sexual dysfunction, 598
Alcohol-induced sleep disorder, 598
Alcohol intoxication, 598
Alcohol intoxication delirium, 598
Alcohol withdrawal, 598
Alcohol withdrawal delirium, 598
Amnestic disorder due to general medical condition, 57, 598
Amnestic disorders, 54, 598
Amphetamine abuse, 598
Amphetamine dependence, 598
Amphetamine-induced anxiety disorder, 599
Amphetamine-induced mood disorder, 599
Amphetamine-induced psychotic disorder, 599
xix
2506_FM_i-xxxvi.indd xix 10/4/10 3:53:23 PM

xx INDEX OF DSM-IV-TR PSYCHIATRIC DIAGNOSES
Amphetamine-induced sexual dysfunction, 599

Amphetamine-induced sleep disorder, 599
Amphetamine intoxication, 599
Amphetamine intoxication delirium, 599
Amphetamine withdrawal, 599
Anorexia nervosa, 218, 606
Antisocial personality disorder, 276, 607
Anxiety disorder, 604
Anxiety disorder due to general medical condition, 163, 604
Aspergers disorder, 596
Attention-decit and disruptive behavior disorder, 596
Attention-decit/hyperactivity disorder, 26, 596
Autistic disorder, 596
Avoidant personality disorder, 277, 607
Bereavement, 609
Bipolar disorder, 145, 603
Body dysmorphic disorder, 177, 604
Borderline intellectual functioning, 609
Borderline personality disorder, 276, 607
Breathing-related sleep disorder, 606
Brief psychotic disorder, 106, 603
Bulimia nervosa, 219, 606
Caffeine-induced anxiety disorder, 599

Caffeine-induced sleep disorder, 599
Caffeine intoxication, 599
Cannabis abuse, 599
Cannabis dependence, 599
Cannabis-induced anxiety disorder, 599
Cannabis-induced psychotic disorder, 599
Cannabis intoxication, 599
Cannabis intoxication delirium, 599
Catatonic disorder due to general medical condition, 598
Childhood disintegrative disorder, 596
Childhood or adolescent antisocial behavior, 609
Chronic motor or vocal tic disorder, 596
Circadian rhythm sleep disorder, 606
Cocaine abuse, 599
Cocaine dependence, 599
Cocaine-induced anxiety disorder, 600
Cocaine-induced mood disorder, 599
Cocaine-induced psychotic disorder, 599
Cocaine-induced sexual dysfunction, 600
Cocaine-induced sleep disorder, 600
Cocaine intoxication, 599
2506_FM_i-xxxvi.indd xx 10/4/10 3:53:23 PM

INDEX OF DSM-IV-TR PSYCHIATRIC DIAGNOSES xxi
Cocaine intoxication delirium, 599

Cognitive disorder, 598
Communication disorders, 596
Conduct disorder, 27, 596
Conversion disorder, 177, 604
Cyclothymic disorder, 146, 604
Delirium, 54, 597

Delirium due to general medical condition, 54, 597
Delirium due to multiple etiologies, 55, 597
Delirium due to substance intoxication, 55, 597
Delirium due to substance withdrawal, 55, 597
Delusional disorder, 106, 603
Dementia, 5557, 597
Dementia due to Creutzfeldt-Jakob disease, 56, 597
Dementia due to general medical condition, 57, 597
Dementia due to head trauma, 56, 597
Dementia due to HIV disease, 56, 597
Dementia due to Huntingtons disease, 56, 597
Dementia due to multiple etiologies, 597
Dementia due to Parkinsons disease, 56, 597
Dementia due to Picks disease, 56, 597
Dementia due to substance, 57, 597
Dementia of Alzheimers type, 5556, 597
Dependent personality disorder, 277, 607
Depersonalization disorder, 192, 605
Depressive disorders, 603
Developmental coordination disorder, 595
Diagnosis deferred on Axis II, 609
Diagnosis or condition deferred on Axis I, 609
Disorder of written expression, 595
Disruptive behavior disorder, 26, 596
Dissociative amnesia, 191, 605
Dissociative disorders, 191192, 605
Dissociative fugue, 191, 605
Dissociative identity disorder, 192, 605
Dyspareunia, 204, 605
Dyssomnia, 606
Dysthymic disorder, 126, 603
Eating disorder, 606

Elimination disorders, 596
Encopresis, 596
Enuresis, 596
Exhibitionism, 201, 606
Expressive language disorder, 596
2506_FM_i-xxxvi.indd xxi 10/4/10 3:53:24 PM

xxii INDEX OF DSM-IV-TR PSYCHIATRIC DIAGNOSES
Factitious disorder, 604

Feeding and eating disorders of infancy or early childhood,
596
Female dyspareunia due to general medical condition,
Female hypoactive sexual desire disorder due to general medical
condition, 605
Female orgasmic disorder, 204, 605
Female sexual arousal disorder, 204, 605
Fetishism, 201202, 606
Frotteurism, 202, 606
Gender identity disorder, 211, 605

Generalized anxiety disorder, 162, 604
Hallucinogen abuse, 600

Hallucinogen dependence, 600
Hallucinogen-induced anxiety disorder, 600
Hallucinogen-induced mood disorder, 600
Hallucinogen-induced psychotic disorder, 600
Hallucinogen intoxication, 600
Hallucinogen intoxication delirium, 600
Hallucinogen persisting perception disorder, 600
Histrionic personality disorder, 276277, 607
Hypersomnia, 606
Hypersomnia due to general medical condition, 607
Hypersomnia related to another mental disorder, 606
Hypoactive sexual desire disorder, 204, 605
Hypochondriasis, 177, 604
Identity problem, 609

Impulse control disorder, 607
Inhalant abuse, 600
Inhalant dependence, 600
Inhalant-induced anxiety disorder, 600
Inhalant-induced mood disorder, 600
Inhalant-induced persisting dementia, 600
Inhalant-induced psychotic disorder, 600
Inhalant intoxication, 600
Inhalant intoxication delirium, 600
Insomnia, 606
Insomnia due to general medical condition, 607
Insomnia related to another mental disorder, 606
Intermittent explosive disorder, 256, 607
Kleptomania, 257, 607
Learning disorders, 595
2506_FM_i-xxxvi.indd xxii 10/4/10 3:53:24 PM

INDEX OF DSM-IV-TR PSYCHIATRIC DIAGNOSES xxiii
Major depressive disorder, 603

Male dyspareunia due to general medical condition, 605
Male erectile disorder, 204, 605
Male erectile disorder due to general medical condition, 605
Male hypoactive sexual desire disorder due to general medical
condition, 605
Male orgasmic disorder, 204, 605
Malingering, 609
Mathematics disorder, 595
Medication-induced movement disorder, 608
Medication-induced postural tremor, 608
Mental disorder NOS due to general medical condition, 598
Mental retardation, 15, 595
Mixed receptive-expressive language disorder, 596
Mood disorder due to general medical condition, 126, 604
Mood disorders, 125126, 603604
Motor skills disorder, 595
Narcissistic personality disorder, 277, 607

Narcolepsy, 606
Neglect of child, 311, 608
Neuroleptic-induced acute akathisia, 608
Neuroleptic-induced dystonia, 608
Neuroleptic-induced parkinsonism, 608
Neuroleptic-induced tardive dyskinesia, 608
Neuroleptic malignant syndrome, 608
Nicotine dependence, 600
Nicotine withdrawal, 600
Nightmare disorder, 606
No diagnosis on Axis II, 609
No diagnosis or condition on Axis I, 609
Noncompliance with treatment, 4042, 609
Obsessive-compulsive disorder, 162, 604

Obsessive-compulsive personality disorder, 277, 607
Occupational problem, 609
Opioid abuse, 601
Opioid dependence, 601
Opioid-induced mood disorder, 601
Opioid-induced psychotic disorder, 601
Opioid-induced sexual dysfunction, 601
Opioid-induced sleep disorder, 601
Opioid intoxication delirium, 601
Oppositional deant disorder, 29, 596
Orgasmic disorders, 204, 605
Other female sexual dysfunction due to general medical
condition, 605
2506_FM_i-xxxvi.indd xxiii 10/4/10 3:53:24 PM

xxiv INDEX OF DSM-IV-TR PSYCHIATRIC DIAGNOSES
Other male sexual dysfunction due to general medical condition,

605
Other (or unknown) substance abuse, 602
Other (or unknown) substance dependence, 602
Other (or unknown) substance-induced disorders, 602
Other (or unknown) substance intoxication, 602
Other (or unknown) substance withdrawal, 602
Pain disorder, 604

Panic disorder, 176177
Panic disorder with agoraphobia, 161, 604
Panic disorder without agoraphobia, 161, 604
Paranoid personality disorder, 276, 607
Paraphilia, 201203, 606
Parasomnia, 606
Parasomnia due to general medical condition, 607
Parent-child relational problem, 608
Passive-aggressive personality disorder, 277
Pathological gambling, 257, 607
Pedophilia, 202, 606
Personality change due to general medical condition, 598
Personality disorder, 607
Pervasive developmental disorders, 596
Phase of life problem, 609
Phencyclidine abuse, 601
Phencyclidine dependence, 601
Phencyclidine-induced anxiety disorder, 601
Phencyclidine-induced mood disorder, 601
Phencyclidine-induced psychotic disorder, 601
Phencyclidine intoxication, 601
Phencyclidine intoxication delirium, 601
Phobia
agoraphobia, 161, 604
social, 161162, 604
specic, 162, 604
Phonological disorder, 596
Physical abuse
of adult, 311, 608
of child, 310, 608
Pica, 596
Polysubstance dependence, 602
Posttraumatic stress disorder, 162, 604
Premature ejaculation, 204, 605
Primary hypersomnia, 606
Primary insomnia, 606
Psychological factors affecting medical condition, 608
2506_FM_i-xxxvi.indd xxiv 10/4/10 3:53:24 PM

INDEX OF DSM-IV-TR PSYCHIATRIC DIAGNOSES xxv
Psychotic disorder, 105107, 603

Psychotic disorder due to general medical condition, 107, 603
Pyromania, 257, 607
Reactive attachment disorder of infancy or early childhood, 597

Reading disorder, 595
Relational problem, 608
Relational problem related to mental disorder or general medical
condition, 608
Religious or spiritual problem, 609
Retts disorder, 596
Rumination disorder, 596
Schizoaffective disorder, 106, 603

Schizoid personality disorder, 276, 607
Schizophrenia, 105106, 603
Schizophreniform disorder, 106, 603
Schizotypal personality disorder, 276, 607
Sedative, hypnotic, or anxiolytic intoxication, 601
Sedative, hypnotic, or anxiolytic intoxication delirium, 601
Sedative, hypnotic, or anxiolytic withdrawal, 601
Sedative, hypnotic, or anxiolytic withdrawal delirium, 602
Sedative-, hypnotic-, or anxiolytic-induced disorders, 601602
Selective mutism, 597
Separation anxiety disorder, 4849, 597
Sexual abuse
of adult, 311, 608
of child, 310311, 608
Sexual aversion disorder, 204, 605
Sexual dysfunction, 605
Sexual dysfunction due to general medical condition, 605
Sexual masochism, 202, 606
Sexual sadism, 202, 606
Shared psychotic disorder, 106, 603
Sibling relational problem, 608
Sleep disorder due to general medical condition, 607
Sleep terror disorder, 606
Sleepwalking disorder, 606
Social phobia, 161162, 604
Somatization disorder, 176, 604
Somatoform disorders, 604
Specic phobia, 162, 604
Stereotypic movement disorder, 597
Stuttering, 596
Substance-related disorders, 71104, 598603. See also at
specic substances
2506_FM_i-xxxvi.indd xxv 10/4/10 3:53:25 PM

xxvi INDEX OF DSM-IV-TR PSYCHIATRIC DIAGNOSES
Tic disorders, 596

Tourettes disorder, 4244, 596
Transient tic disorder, 596
Transvestic fetishism, 606
Trichotillomania, 257258, 607
Undifferentiated somatoform disorder, 604

Unspecied mental disorder (nonpsychotic), 609
Vaginismus, 204, 605

Vascular dementia, 597
Voyeurism, 202203, 606
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INTRODUCTION xxvii
Introduction
HOW TO USE THIS BOOK

NANDA International (NANDA-I) describes its purpose as
follows:
NANDA International exists to develop, re ne and promote ter-
minology that accurately reects nurses clinical judgments. This
unique, evidence-based perspective includes social, psychological
and spiritual dimensions of care (NANDA-I, 2009).
Standardization of nursing actions and common terminol-
ogy is important in the provision of consistent care over time,
among nurses, across shifts, and even between different health-
care agencies. This text incorporates the nomenclature of
Taxonomy II that has been adopted by NANDA-I.
There are those individuals who believe that NANDAs list
is incomplete. My intent is not to judge the completeness of this
list but rather to suggest the need for clinical testing of what is
available. NANDA encourages nurses to submit new diagnoses
for consideration, after testing and research of that diagnosis has
been conducted in the clinical setting.
There are three essential components in a nursing diagnosis,
which comprise the PES format. The P identies the prob-
lem (or human issue of concern), the E represents the etiol-
ogy (or cause) of the problem, and the S describes a cluster of
signs and symptoms, or what has come to be known as de ning
characteristics. These three parts are combined into one state-
ment by the use of connecting words. The diagnosis would
then be written in this manner: Problem (or issue of concern)
related to etiology evidenced by signs and symptoms (de n-
ing characteristics).
The problem can be identied as the human response to
actual or potential health problems as assessed by the nurse. The
etiology may be represented by past experiences of the individ-
ual, genetic inuences, current environmental factors, or patho-
physiological changes. The de ning characteristics describe
what the client says and what the nurse observes that indicate
the existence of a particular problem.
Nursing diagnoses, then, become the basis for the care plan.
This book may be used as a guide in the construction of care
plans for various psychiatric clients. The concepts are presented
xxvii
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xxviii INTRODUCTION
in such a manner that they may be applied to various types of

health care settings: inpatient hospitalization, outpatient clinic,
home health, partial hospitalization, and private practice, to
name a few. Major divisions in the book are identied by psychi-
atric diagnostic categories, according to the order in which they
appear in the Diagnostic and Statistical Manual of Mental Disor-
ders, Fourth Edition, Text Revision (DSM-IV-TR, APA, 2000).
The use of this format is not to imply that nursing diagnoses are
based on, or ow from, medical diagnoses; it is meant only to
enhance the usability of the book. In addition, I am not suggest-
ing that those nursing diagnoses presented with each psychiatric
category are all-inclusive.
It is valid, however, to state that certain nursing diagnoses
are indeed common to individuals with specic psychiatric dis-
orders. The diagnoses presented in this book are intended to be
used as guidelines for construction of care plans that must be
individualized for each client, based on the nursing assessment.
The interventions can also be used in areas in which interdisci-
plinary treatment plans take the place of the nursing care plan.
Each chapter in Unit II begins with an overview of informa-
tion related to the medical diagnostic category, which may be
useful to the nurse as background assessment data. This section
includes:
1. The Disorder: A de nition and common types or categories
that have been identied.
2. Predisposing Factors: Information regarding theories of
etiology, which the nurse may use in formulating the re-
lated to portion of the nursing diagnosis, as it applies to the
client.
3. Symptomatology: Subjective and objective data identifying
behaviors common to the disorder. These behaviors, as they
apply to the individual client, may be pertinent to the evi-
denced by portion of the nursing diagnosis.
Information presented with each nursing diagnosis includes
the following:
1. Defi nition: The approved NANDA de nition is included
for each of the accepted NANDA nursing diagnoses. Any
additions or alterations made by the author to the NANDA
de nition are identied by brackets [ ].
2. Possible Etiologies (related to): This section suggests
possible causes for the problem identied. Those not ap-
proved by NANDA are identied by brackets [ ]. Related/
Risk Factors are given for diagnoses for which the client
is at risk. Note: Defi ning characteristics are replaced by
related/risk factors for the Risk for diagnoses.
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INTRODUCTION xxix
3. Defining Characteristics (evidenced by): This section in-

cludes signs and symptoms that may be evident to indicate that
the problem exists. Again, as with denitions and etiologies,
those not approved by NANDA are identied by brackets [ ].
4. Goals/Objectives: These statements are made in client behav-
ioral objective terminology. They are measurable, short- and
long-term goals, to be used in evaluating the effectiveness of
the nursing interventions in alleviating the identied problem.
There may be more than one short-term goal, and they may
be considered stepping stones to fulllment of the long-term
goal. For purposes of this book, long-term, in most instances,
is designated as by discharge from treatment, whether the
client is in an inpatient or outpatient setting.
5. Interventions with Selected Rationales: Only those inter-
ventions that are appropriate to a particular nursing diagno-
sis within the context of the psychiatric setting are presented.
Rationales for selected interventions are included to provide
clarication beyond fundamental nursing knowledge, and to
assist in the selection of appropriate interventions for indi-
vidual clients. Important interventions related to communi-
cation may be identied with the icon.
6. Outcome Criteria: These are behavioral changes that can
be used as criteria to determine the extent to which the nurs-
ing diagnosis has been resolved.
To use this book in the preparation of psychiatric nursing
care plans, nd the section in the text applicable to the clients
psychiatric diagnosis. Review background data pertinent to the
diagnosis, if needed. Complete a biopsychosocial history and as-
sessment on the client. Select and prioritize nursing diagnoses
appropriate to the client. Using the list of NANDA-approved
nursing diagnoses, be sure to include those that are client-
specic, and not just those that have been identied as common
to a particular medical diagnosis. Select nursing interventions
and outcome criteria appropriate to the client for each nursing
diagnosis identied. Include all of this information on the care
plan, along with a date for evaluating the status of each problem.
On the evaluation date, document success of the nursing inter-
ventions in achieving the goals of care, using the desired client
outcomes as criteria. Modify the plan as required.
Unit III deals with client populations with special psychiatric
nursing needs. These include victims of abuse or neglect, clients
with premenstrual dysphoric disorder or HIV disease, clients
who are homeless, and clients who are experiencing bereave-
ment. Topics related to forensic nursing, psychiatric home nurs-
ing care, and complementary therapies are also included.
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xxx INTRODUCTION
Unit IV, Psychotropic Medications, has been updated to in-

clude new medications that have been approved by the U.S. Food
and Drug Administration (FDA) since the last edition. This
information should facilitate use of the book for nurses adminis-
tering psychotropic medications and also for nurse practitioners
with prescriptive authority. The major categories of psychotropic
medications are identied by chemical class. Information is pre-
sented related to indications, actions, contraindications and pre-
cautions, interactions, route and dosage, and adverse reactions
and side effects. Examples of medications in each chemical class
are presented by generic and trade name, along with information
about half-life, controlled and pregnancy categories, and avail-
able forms of the medication. Therapeutic plasma level ranges
are provided, where appropriate. Nursing diagnoses related to
each category, along with nursing interventions, and client and
family education are included in each chapter.
Another helpful feature of this text is the table in Appendix N,
which lists some client behaviors commonly observed in the
psychiatric setting and the most appropriate nursing diagnosis
for each. It is hoped that this information will broaden the un-
derstanding of the need to use a variety of nursing diagnoses in
preparing the client treatment plan.
This book helps to familiarize the nurse with the current
NANDA-approved nursing diagnoses and provides suggestions
for their use within the psychiatric setting. The book is de-
signed to be used as a quick reference in the preparation of care
plans, with the expectation that additional information will be
required for each nursing diagnosis as the nurse individualizes
care for psychiatric clients.
MCT
NANDA-I NURSING DIAGNOSES

TAXONOMY II (20092011)
Domain 1: Health Promotion
Ineffective health maintenance
Ineffective self health management
Impaired home maintenance
Readiness for enhanced immunization status
Self neglect
Readiness for enhanced nutrition
Ineffective family therapeutic regimen management
Readiness for enhanced self health management
Domain 2: Nutrition
Ineffective infant feeding pattern
Impaired swallowing
Imbalanced nutrition: Less than body requirements
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INTRODUCTION xxxi
Imbalanced nutrition: More than body requirements

Risk for imbalanced nutrition: More than body requirements
Risk for unstable blood glucose level
Neonatal jaundice
Risk for impaired liver function
Risk for electrolyte imbalance
Decient fluid volume
Risk for decient fluid volume
Excess fluid volume
Risk for imbalanced fluid volume
Readiness for enhanced fluid balance
Domain 3: Elimination and Exchange

Impaired urinary elimination
Urinary retention
Functional urinary incontinence
Stress urinary incontinence
Urge urinary incontinence
Reex urinary incontinence
Risk for urge urinary incontinence
Readiness for enhanced urinary elimination
Overow urinary incontinence
Bowel incontinence
Diarrhea
Constipation
Risk for constipation
Perceived constipation
Dysfunctional gastrointestinal motility
Risk for dysfunctional gastrointestinal motility
Impaired gas exchange
Domain 4: Activity/Rest
Insomnia
Disturbed sleep pattern
Sleep deprivation
Readiness for enhanced sleep
Risk for disuse syndrome
Impaired physical mobility
Impaired bed mobility
Impaired wheelchair mobility
Impaired transfer ability
Impaired walking
Decient diversional activity
Delayed surgical recovery
Sedentary lifestyle
Disturbed energy eld
Fatigue
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xxxii INTRODUCTION
Decreased cardiac output

Ineffective breathing pattern
Activity intolerance
Risk for activity intolerance
Risk for bleeding
Impaired spontaneous ventilation
Dysfunctional ventilatory weaning response
Ineffective peripheral tissue perfusion
Risk for decreased cardiac tissue perfusion
Risk for ineffective cerebral tissue perfusion
Risk for ineffective gastrointestinal perfusion
Risk for ineffective renal perfusion
Risk for shock
Readiness for enhanced self-care
Dressing self-care decit
Bathing self-care decit
Feeding self-care decit
Toileting self-care decit
Domain 5: Perception/Cognition
Unilateral neglect
Impaired environmental interpretation syndrome
Wandering
Disturbed sensory perception (specify: visual, auditory,
kinesthetic, gustatory, tactile, olfactory)
Decient knowledge (specify)
Readiness for enhanced knowledge (specify)
Acute confusion
Chronic confusion
Impaired memory
Risk for acute confusion
Readiness for enhanced decision-making
Ineffective activity planning
Impaired verbal communication
Readiness for enhanced communication
Domain 6: Self-Perception
Disturbed personal identity
Powerlessness
Risk for powerlessness
Readiness for enhanced power
Hopelessness
Readiness for enhanced hope
Risk for loneliness
Readiness for enhanced self-concept
Chronic low self-esteem
Situational low self-esteem
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INTRODUCTION xxxiii
Risk for situational low self-esteem

Risk for compromised human dignity
Disturbed body image
Domain 7: Role Relationships

Caregiver role strain
Risk for caregiver role strain
Impaired parenting
Risk for impaired parenting
Readiness for enhanced parenting
Interrupted family processes
Readiness for enhanced family processes
Dysfunctional family processes
Risk for impaired attachment
Effective breastfeeding
Ineffective breastfeeding
Interrupted breastfeeding
Ineffective role performance
Parental role confl ict
Impaired social interaction
Readiness for enhanced relationship
Domain 8: Sexuality
Sexual dysfunction
Ineffective sexuality pattern
Readiness for enhanced childbearing process
Risk for disturbed maternal/fetal dyad
Domain 9: Coping/Stress Tolerance

Relocation stress syndrome
Risk for relocation stress syndrome
Rape-trauma syndrome
Post-trauma syndrome
Risk for post-trauma syndrome
Fear
Anxiety
Death anxiety
Chronic sorrow
Ineffective denial
Grieving
Complicated grieving
Risk for complicated grieving
Impaired individual resilience
Readiness for enhanced resilience
Risk for compromised resilience
Risk-prone health behavior
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xxxiv INTRODUCTION
Ineffective coping
Stress overload
Disabled family coping
Compromised family coping
Defensive coping
Ineffective community coping
Readiness for enhanced coping
Readiness for enhanced family coping
Readiness for enhanced community coping
Autonomic dysreexia
Risk for autonomic dysreexia
Disorganized infant behavior
Risk for disorganized infant behavior
Readiness for enhanced organized infant behavior
Decreased intracranial adaptive capacity
Domain 10: Life Principles

Readiness for enhanced spiritual well-being
Readiness for enhanced hope
Spiritual distress
Risk for spiritual distress
Decisional confl ict
Noncompliance
Risk for impaired religiosity
Impaired religiosity
Readiness for enhanced religiosity
Moral distress
Domain 11: Safety/Protection

Risk for infection
Impaired oral mucous membrane
Risk for injury
Risk for perioperative positioning injury
Risk for falls
Risk for trauma
Risk for vascular trauma
Impaired skin integrity
Risk for impaired skin integrity
Impaired tissue integrity
Impaired dentition
Risk for suffocation
Risk for aspiration
Ineffective airway clearance
Risk for peripheral neurovascular dysfunction
Ineffective protection
Risk for sudden infant death syndrome
Risk for self-mutilation
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INTRODUCTION xxxv
Self-mutilation
Risk for other-directed violence
Risk for self-directed violence
Risk for suicide
Risk for poisoning
Latex allergy response
Risk for latex allergy response
Risk for imbalanced body temperature
Ineffective thermoregulation
Hypothermia
Hyperthermia
Readiness for enhanced immunization status
Risk for contamination
Contamination
Domain 12: Comfort

Acute pain
Chronic pain
Nausea
Impaired comfort
Readiness for enhanced comfort
Social isolation
Domain 13: Growth/Development

Delayed growth and development
Risk for disproportionate growth
Adult failure to thrive
Risk for delayed development
Source: NANDA International nursing diagnoses: De nitions and clas-

si cation 2009-2011. (2009). Hoboken, NJ: Wiley-Blackwell. With
permission.
INTERNET REFERENCES
http://www.apna.org
http://www.nanda.org
http://www.nursecominc.com
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2506_FM_i-xxxvi.indd xxxvi 10/4/10 3:53:30 PM
UNIT ONE
THE FOUNDATION FOR

PLANNING PSYCHIATRIC
NURSING CARE
C H A P T E R
1
Nursing Process: One
Step to Professionalism
Nursing has struggled for many years to achieve recognition as a
profession. Out of this struggle has emerged an awareness of the
need to do the following:
1. De ne the boundaries of nursing (What is nursing?).
2. Identify a scientic method for delivering nursing care.
In its statement on social policy, the American Nurses
Association (ANA) presented the following de nition:
Nursing is the protection, promotion, and optimization of health
and abilities, prevention of illness and injury, alleviation of suffer-
ing through the diagnosis and treatment of human response, and
advocacy in the care of individuals, families, communities, and
populations (ANA, 2010, p. 10).
The nursing process has been identied as nursings scien-
tic methodology for the delivery of nursing care. The curricula
of most nursing schools include nursing process as a component
of their conceptual frameworks. The National Council of State
Boards of Nursing (NCSBN) has integrated the nursing proc-
ess throughout the test plan for the National Council Licensure
Examination for Registered Nurses (NCSBN, 2010). Questions
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2 THE FOUNDATION FOR PLANNING PSYCHIATRIC NURSING CARE
that relate to nursing behaviors in a variety of client situations

are presented according to the steps of the nursing process:
1. Assessment: Establishing a database on a client
2. Diagnosis: Identifying the clients health care needs and
selecting goals of care
3. Outcome identification: Establishing criteria for measuring
achievement of desired outcomes
4. Planning: Designing a strategy to achieve the goals established
for client care
5. Implementation: Initiating and completing actions necessary
to accomplish the goals
6. Evaluation: Determining the extent to which the goals of
care have been achieved
By following these six steps, the nurse has a systematic frame-
work for decision-making and problem-solving in the delivery of
nursing care. The nursing process is dynamic, not static. It is an
ongoing process that continues for as long as the nurse and client
have interactions directed toward change in the clients physical
or behavioral responses. Figure 1-1 presents a schematic of the
ongoing nursing process.
Diagnosis is an integral part of the nursing process. In this
step, the nurse identies the human responses to actual or
potential health problems. In some states, diagnosing is identi-
ed within the Nurse Practice Acts as a legal responsibility of
(Re)Assessment
Evaluation
Diagnosis
Implementation
Outcome Identification
Planning
Figure 1-1: The ongoing nursing process.
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Nursing Process: One Step to Professionalism 3
the professional nurse. Nursing diagnosis provides the basis

for prescribing the specic interventions for which the nurse
is accountable.
As an inherent part of the nursing process, nursing diagno-
sis is included in the ANA Standards of Practice. These stand-
ards provide one broad basis for evaluating practice and reect
recognition of the rights of the person receiving nursing care
(ANA, 2010).
CONCEPT MAPPING
Concept mapping is a diagrammatic teaching and learning strat-
egy that allows students and faculty to visualize interrelation-
ships between medical diagnoses, nursing diagnoses, assessment
data, and treatments. The concept map care plan is an innovative
approach to planning and organizing nursing care. Basically, it
is a diagram of client problems and interventions. Compared
to the commonly used column-format care plans, concept map
care plans are more succinct. They are practical, realistic, and
time-saving, and they serve to enhance critical-thinking skills
and clinical reasoning ability.
The nursing process is foundational to developing and us-
ing the concept map care plan, just as it is with all types of
nursing care plans. Client data are collected and analyzed,
nursing diagnoses are formulated, outcome criteria are identi-
ed, nursing actions are planned and implemented, and the
success of the interventions in meeting the outcome criteria
is evaluated.
The concept map care plan may be presented in its entirety
on one page, or the assessment data and nursing diagnoses may
appear in diagram format on one page, with outcomes, inter-
ventions, and evaluation written on a second page. Additionally,
the diagram may appear in circular format, with nursing diag-
noses and interventions branching off the client in the center
of the diagram. Or, it may begin with the client at the top
of the diagram, with branches emanating in a linear fashion
downward.
As stated previously, the concept map care plan is based
on the components of the nursing process. Accordingly, the
diagram is assembled in the nursing process stepwise fashion,
beginning with the client and his or her reason for needing
care, nursing diagnoses with subjective and objective clinical
evidence for each, nursing interventions, and outcome criteria
for evaluation.
Various colors may be used in the diagram to designate vari-
ous components of the care plan. Lines are drawn to connect
the various components to indicate any relationships that exist.
For example, there may be a relationship between two nursing
2506_Ch01_001-013.indd 3 10/1/10 9:32:57 AM

diagnoses (e.g., there may be a relationship between the nursing

diagnoses of pain or anxiety and disturbed sleep pattern). A line
between these nursing diagnoses should be drawn to show the
relationship.
Concept map care plans allow for a great deal of creativity on
the part of the user, and they permit viewing the whole picture
without generating a great deal of paperwork. Because they re-
ect the steps of the nursing process, concept map care plans
also are valuable guides for the documentation of client care.
Doenges, Moorhouse, and Murr (2008) state,
As students, you are asked to develop plans of care that often con-
tain more detail than what you see in the hospital plans of care.
This is to help you learn how to apply the nursing process and
create individualized client care plans. However, even though
much time and energy may be spent focusing on lling the col-
umns of traditional clinical care plan forms, some students never
develop a holistic view of their clients and fail to visualize how
each client need interacts with other identied needs. A new tech-
nique or learning tool [concept mapping] has been developed to
assist you in visualizing the linkages, enhance your critical think-
ing skills, and to facilitate the creative process of planning client
care (p. 35).
An example of one format for a concept map care plan is
presented in Figure 1-2.
The purpose of this book is to assist students and staff nurses
as they endeavor to provide high-quality nursing care to their
psychiatric clients. The following is an example of a nursing his-
tory and assessment tool that may be used to gather informa-
tion about the client during the assessment phase of the nursing
process.
NURSING HISTORY AND ASSESSMENT TOOL

I. General Information
Client name: Allergies:
Room number: Diet:
Doctor: Height/weight:
Age: Vital signs: TPR/BP
Sex: Name and phone no. of
signicant other:
Race:
Dominant language: City of residence:
Marital status: Diagnosis (admitting
& current):
Chief complaint:
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Medical Diagnosis
Signs and Signs and

Symptoms Symptoms
Nursing Nursing
Diagnosis Diagnosis
Nursing Actions Nursing Actions
Medication
Outcomes Outcomes
Figure 1-2: Example of a format for a concept map care plan.
2506_Ch01_001-013.indd 5 10/1/10 9:32:58 AM

II. Conditions of admission

Date: Time:
Accompanied by:
Route of admission (wheelchair; ambulatory; cart):
Admitted from:
III. Predisposing Factors

A. Genetic Inuences
1. Family conguration (use genograms):
Family of origin: Present family:
Family dynamics (describe signicant
relationships between family members):
2. Medical/psychiatric history:
a. Client:
b. Family member
3. Other genetic inuences affecting present

adaptation. This might include effects specic to
gender, race, appearance, such as genetic physical
defects, or any other factor related to genetics that
is affecting the clients adaptation that has not been
mentioned elsewhere in this assessment.
B. Past Experiences
1. Cultural and social history:
a. Environmental factors (family living arrange-
ments, type of neighborhood, special working
conditions):
b. Health beliefs and practices (personal responsibility

for health; special self-care practices):
2506_Ch01_001-013.indd 6 10/1/10 9:32:58 AM

c. Religious beliefs and practices:
d. Educational background:
e. Signicant losses/changes (include dates):
f. Peer/friendship relationships:
g. Occupational history:
h. Previous pattern of coping with stress:
i. Other lifestyle factors contributing to present

adaptation:
C. Existing Conditions
1. Stage of development (Erikson):
a. Theoretically:
b. Behaviorally:
c. Rationale:
2. Support systems:
3. Economic security:
4. Avenues of productivity/contribution:
a. Current job status:
b. Role contributions and responsibility for others:
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IV. Precipitating Event

Describe the situation or events that precipitated this illness/
hospitalization:
V. Clients Perception of the Stressor

Clients or family members understanding or description of
stressor/illness and expectations of hospitalization:
VI. Adaptation Responses

A. Psychosocial
1. Anxiety level (circle level, and check the
behaviors that apply):
Mild Moderate Severe Panic
Calm Friendly Passive
Alert Perceives environment correctly
Cooperative Impaired attention
Jittery Unable to concentrate
Hypervigilant Tremors Rapid speech
Withdrawn Confused
Disoriented Fearful Hyperventilating
Misinterpreting the environment
(hallucinations or delusions)
Depersonalization Obsessions
Compulsions Somatic complaints
Excessive hyperactivity Other
2. Mood/affect (circle as many as apply):
Happiness Sadness Dejection Despair
Elation Euphoria Suspiciousness
Apathy (little emotional tone) Anger/hostility
3. Ego defense mechanisms (describe how used
by client):
Projection
Suppression
Undoing
Displacement
Intellectualization
Rationalization
Denial
Repression
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Isolation
Regression
Reaction formation
Splitting
Religiosity
Sublimation
Compensation
4. Level of self-esteem (circle one):
low moderate high
Things client likes about self
Things client would like to change about self
Nurses objective assessment of self-esteem:

Eye contact
General appearance
Personal hygiene
Participation in group activities and interactions
with others
5. Stage and manifestations of grief (circle one):

Denial Anger Bargaining Depression
Acceptance
Describe the clients behaviors that are associated
with this stage of grieving in response to loss or
change.
6. Thought processes (circle as many as apply):

Clear Logical Easy to follow Relevant
Confused Blocking Delusional Rapid ow
of thoughts
Slowness in thought association Suspicious
Recent memory: Loss Intact
Remote memory: Loss Intact
Other:
7. Communication patterns (circle as many as

apply):
Clear Coherent Slurred Incoherent
speech
Neologisms Loose Flight of
associations ideas
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Aphasic Perseveration Rumination

Tangential Loquaciousness
speech
Slow, impoverished speech
Speech impediment (describe)
Other
8. Interaction patterns (describe clients pattern of

interpersonal interactions with staff and peers on
the unit, e.g., manipulative, withdrawn, isolated,
verbally or physically hostile, argumentative, passive,
assertive, aggressive, passive-aggressive, other):
9. Reality orientation (check those that apply):

Oriented to: Time Person
Place Situation
10. Ideas of destruction to self/others? Yes No
If yes, consider plan; available means
B. Physiological
1. Psychosomatic manifestations (describe any somatic
complaints that may be stress-related):
2. Drug history and assessment:

Use of prescribed drugs:
PRESCRIBED
NAME DOSAGE FOR RESULTS
Use of over-the-counter drugs:

NAME DOSAGE USED FOR RESULTS
2506_Ch01_001-013.indd 10 10/1/10 9:32:59 AM

Use of street drugs or alcohol:

HOW WHEN
AMOUNT OFTEN LAST EFFECTS
NAME USED USED USED PRODUCED
3. Pertinent physical assessments:

a. Respirations: Normal Labored
Rate Rhythm
b. Skin: Warm Dry Moist
Cool Clammy Pink
Cyanotic Poor turgor Edematous
Evidence of: Rash Bruising
Needle tracks Hirsutism Loss of hair
Other
c. Musculoskeletal status: Weakness
Tremors
Degree of range of motion (describe limitations)
Pain (describe)
Skeletal deformities (describe)
Coordination (describe limitations)
d. Neurological status:
History of (check all that apply):
Seizures (describe method of control)
Headaches (describe location and frequency)

Fainting spells Dizziness
Tingling/numbness (describe location)
e. Cardiovascular: B/P Pulse
History of (check all that apply):
Hypertension Palpitations
Heart murmur Chest pain
Shortness of breath Pain in legs
Phlebitis Ankle/leg edema
Numbness/tingling in extremities
Varicose veins
f. Gastrointestinal:
Usual diet pattern:
Food allergies:
Dentures? Upper Lower
Any problems with chewing or
swallowing?
Any recent change in weight?
2506_Ch01_001-013.indd 11 10/1/10 9:33:00 AM

Any problems with:

Indigestion/heartburn?
Relieved by
Nausea/vomiting?
Relieved by
History of ulcers?
Usual bowel pattern
Constipation? Diarrhea?
Type of self-care assistance provided for either of
the above problems
g. Genitourinary/Reproductive:
Usual voiding pattern
Urinary hesitancy?
Frequency?
Nocturia? Pain/burning?
Incontinence?
Any genital lesions?
Discharge? Odor?
History of sexually transmitted disease?
If yes, please explain:
Any concerns about sexuality/sexual activity?
Method of birth control used

Females:
Date of last menstrual cycle
Length of cycle
Problems associated with menstruation?
Breasts: Pain/tenderness?
Swelling? Discharge?
Lumps? Dimpling?
Practice breast self-examination?
Frequency?
Males:
Penile discharge?
Prostate problems?
h. Eyes:
Yes No Explain
Glasses?
Contacts?
Swelling?
Discharge?
Itching?
Blurring?
Double vision?
2506_Ch01_001-013.indd 12 10/1/10 9:33:00 AM

i. Ears:
Yes No Explain
Pain?
Drainage?
Difculty
hearing?
Hearing aid?
Tinnitus?
j. Medication side effects:
What symptoms is the client experiencing that
may be attributed to current medication usage?
k. Altered lab values and possible signicance:
l. Activity/rest patterns:
Exercise (amount, type, frequency)
Leisure time activities:
Patterns of sleep: Number of hours per night

Use of sleep aids?
Pattern of awakening during the night?
Feel rested upon awakening?
m. Personal hygiene/activities of daily living:
Patterns of self-care: Independent
Requires assistance with:
Mobility
Hygiene
Toileting
Feeding
Dressing
Other
Statement describing personal hygiene and
general appearance
n. Other pertinent physical assessments:
VII. Summary of Initial Psychosocial/

Physical Assessment:
Knowledge Decits Identied:
Nursing Diagnoses Indicated:
2506_Ch01_001-013.indd 13 10/1/10 9:33:01 AM

UNIT TWO
ALTERATIONS IN
PSYCHOSOCIAL
ADAPTATION
C H A P T E R
2
Disorders Usually
First Diagnosed in
Infancy, Childhood, or
Adolescence
BACKGROUND ASSESSMENT DATA
Several common psychiatric disorders may arise or become
evident during infancy, childhood, or adolescence. Essential fea-
tures of many disorders are identical, regardless of the age of the
individual. Examples include the following:
Cognitive disorders Personality disorders
Schizophrenia Substance-related disorders
Schizophreniform disorder Mood disorders
Adjustment disorder Somatoform disorders
Sexual disorders Psychological factors affect-
ing medical condition
There are, however, several disorders that appear during the
early developmental years and are identied according to the
childs ability or inability to perform age-appropriate tasks or
intellectual functions. Selected disorders are presented here. It
14
2506_Ch02_014-053.indd Sec1:14 10/1/10 9:33:15 AM

Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence 15
is essential that the nurse working with these clients understand

normal behavior patterns characteristic of the infant, childhood,
and adolescent years.
MENTAL RETARDATION
Dened
Mental retardation is dened by decits in general intellectual
functioning and adaptive functioning and measured by an indi-
viduals performance on intelligence quotient (IQ) tests (American
Psychiatric Association [APA], 2000). Mental retardation is cod-
ed on Axis II in the APA (2000) Diagnostic and Statistical Manual
of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR)
Classication (see Appendix L). Mental retardation is further
categorized (by IQ level) as follows:
Mild (IQ of 5070)
Moderate (IQ of 3549)
Severe (IQ of 2034)
Profound (IQ below 20)
Predisposing Factors
1. Physiological
a. About 5% of cases of mental retardation are caused by
hereditary factors, such as Tay-Sachs disease, phenylke-
tonuria, and hyperglycinemia. Chromosomal disorders,
such as Down syndrome and Klinefelter syndrome, have
also been implicated.
b. Events that occur during the prenatal period (e.g., fetal
malnutrition, viral and other infections, maternal ingestion
of alcohol or other drugs, and uncontrolled diabetes) and
the perinatal period (e.g., birth trauma or premature sepa-
ration of the placenta) can result in mental retardation.
c. Mental retardation can occur as an outcome of childhood
illnesses, such as encephalitis or meningitis, or be the
result of poisoning or physical trauma in childhood.
2. Psychosocial
a. From 15% to 20% of cases of mental retardation are attrib-
uted to deprivation of nurturance and social, linguistic, and
other stimulation and to severe mental disorders, such as
autistic disorder (APA, 2000).
Symptomatology (Subjective and Objective Data)

1. At the mild level (IQ of 5070), the individual can live in-
dependently but with some assistance. He or she is capable
of sixth-gradelevel work and can learn a vocational skill.
Social skills are possible, but the individual functions best in
2506_Ch02_014-053.indd Sec1:15 10/1/10 9:33:15 AM

16 ALTERATIONS IN PSYCHOSOCIAL ADAPTATION
a structured, sheltered setting. Coordination may be slightly

affected.
2. At the moderate level (IQ of 3549), the individual can per-
form some activities independently but requires supervision.
Academic skill can be achieved to about the second-grade
level. The individual may experience some limitation in
speech communication and in interactions with others.
Motor development may be limited to gross motor ability.
3. The severe level of mental retardation (IQ of 2034) is charac-
terized by the need for complete supervision. Systematic habit
training may be accomplished, but the individual does not
have the ability for academic or vocational training. Verbal
skills are minimal and psychomotor development is poor.
4. The profoundly mentally retarded individual (IQ of less than
20) has no capacity for independent living. Constant aid and
supervision are required. No ability exists for academic or vo-
cational training. There is a lack of ability for speech develop-
ment, socialization skills, or ne or gross motor movements.
The individual requires constant supervision and care.
Common Nursing Diagnoses and

Interventions for the Client with Mental
Retardation
(Interventions are applicable to various health care settings, such as
inpatient and partial hospitalization, community outpatient clinic,
home health, and private practice.)
RISK FOR INJURY

Denition: At risk of injury as a result of environmental
conditions interacting with the individuals adaptive and
defensive resources
Related/Risk Factors (related to)

Altered physical mobility
[Aggressive behavior]
Goals/Objectives
Short-/Long-term Goal
Client will not experience injury.
Interventions with Selected Rationales

1. To ensure client safety:
a. Create a safe environment for client. Remove small items
from the area where client will be ambulating and move
sharp items out of his or her reach.
2506_Ch02_014-053.indd Sec1:16 10/1/10 9:33:16 AM

b. Store items that client uses frequently within easy reach.

c. Pad side rails and headboard of client with history of
seizures.
d. Prevent physical aggression and acting out behaviors
by learning to recognize signs that client is becoming
agitated.
Outcome Criteria
1. Client has experienced no physical harm.
2. Client responds to attempts to inhibit agitated behavior.
SELF-CARE DEFICIT
De nition: Impaired ability to perform or complete [activities of
daily living] for self
Possible Etiologies (related to)

Musculoskeletal impairment
Cognitive impairment
De ning Characteristics (evidenced by)
Inability to wash body
Inability to put on clothing
Inability to bring food from receptacle to mouth
[Inability to toilet self without assistance]
Goals/Objectives
Short-term Goal
Client will be able to participate in aspects of self-care.
Long-term Goal
Client will have all self-care needs met.
1. Identify aspects of self-care that may be within clients
capabilities. Work on one aspect of self-care at a time.
Provide simple, concrete explanations. Because clients
capabilities vary so widely, it is important to know each
client individually and to ensure that no client is set up
to fail.
2. Offer positive feedback for efforts at assisting with own
self-care. Positive reinforcement enhances self-esteem and
encourages repetition of desirable behaviors.
3. When one aspect of self-care has been mastered to the
best of clients ability, move on to another. Encourage inde-
pendence but intervene when client is unable to perform. Cli-
ent comfort and safety are nursing priorities.
2506_Ch02_014-053.indd Sec1:17 10/1/10 9:33:16 AM

Outcome Criteria
1. Client assists with self-care activities to the best of his or her
ability.
2. Clients self-care needs are being met.
IMPAIRED VERBAL COMMUNICATION

De nition: Decreased, delayed, or absent ability to receive, pro-
cess, transmit, and use a system of symbols [to communicate]

[Developmental alteration]

Speaks or verbalizes with difculty
Difculty forming words or sentences
Difculty expressing thought verbally
Inappropriate verbalization
Does not or cannot speak
Goals/Objectives
Short-term Goal
Client will establish trust with caregiver and a means of com-
municating needs.
Long-term Goals
1. Clients needs are being met through established means of
communication.
2. If client cannot speak or communicate by other means, needs
are met by caregivers anticipation of clients needs.

1. Maintain consistency of staff assignment over time. This
facilitates trust and the ability to understand clients ac-
tions and communication.
2. Anticipate and fulll clients needs until satisfactory com-
munication patterns are established. Learn (from family,
if possible) special words client uses that are different from
the norm.
3. Identify nonverbal gestures or signals that client may use
to convey needs if verbal communication is absent. Practice
these communication skills repeatedly. Some children with
mental retardation, particularly at the severe level, can
only learn by systematic habit training.
2506_Ch02_014-053.indd Sec1:18 10/1/10 9:33:16 AM

Outcome Criteria
1. Client is able to communicate with consistent caregiver.
2. (For client who is unable to communicate): Clients needs, as
anticipated by caregiver, are being met.
IMPAIRED SOCIAL INTERACTION

De nition: Insufficient or excessive quantity or ineffective qual-
ity of social exchange

[Speech deciencies]
[Difculty adhering to conventional social behavior (because of
delayed maturational development)]
Use of unsuccessful social interaction behaviors
Dysfunctional interaction with others
[Observed] discomfort in social situations
Goals/Objectives
Short-term Goal
Client will attempt to interact with others in the presence of
trusted caregiver.
Long-term Goal
Client will be able to interact with others using behaviors that
are socially acceptable and appropriate to developmental level.
1. Remain with client during initial interactions with others.
The presence of a trusted individual provides a feeling of
security.
2. Explain to other clients the meaning of some of clients
nonverbal gestures and signals. Others may be more accepting
of clients differentness if they have a better understanding of
his or her behavior.
3. Use simple language to explain to client which behaviors
are acceptable and which are not. Establish a procedure for
behavior modication that offers rewards for appropriate be-
haviors and renders an aversive reinforcement in response to
the use of inappropriate behaviors. Positive, negative, and
aversive reinforcements can contribute to desired changes in
behavior. The privileges and penalties are individually deter-
mined as caregiver learns the likes and dislikes of client.
2506_Ch02_014-053.indd Sec1:19 10/1/10 9:33:17 AM

Outcome Criterion
1. Client interacts with others in a socially appropriate manner.
AUTISTIC DISORDER
Dened
Autistic disorder is characterized by a withdrawal of the child
into the self and into a fantasy world of his or her own creation.
Activities and interests are restricted and may be considered
somewhat bizarre. In 2009, the Centers for Disease Control
and Prevention reported that in the United States 1.1% of chil-
dren aged 3 to 17 years had an autism spectrum disorder (ASD).
ASD includes several disorders with similar symptoms based
on level of severity. These include autistic disorder, Retts disor-
der, childhood disintegrative disorder, pervasive developmen-
tal disorder not otherwise specied, and Aspergers disorder.
Autistic disorder occurs about four times more often in boys than
in girls. Onset of the disorder occurs before age 3, and in most cases
it runs a chronic course, with symptoms persisting into adulthood.
1. Physiological
a. Genetics. An increased risk of autistic disorder exists
among siblings of individuals with the disorder (APA,
2000). Studies with both monozygotic and dizygotic twins
have also provided evidence of a genetic involvement.
b. Neurological Factors. Abnormalities in brain structures
or functions have been correlated with autistic disorder
(National Institute of Mental Health [NIMH], 2009).
Certain developmental problems, such as postnatal neu-
rological infections, congenital rubella, phenylketonuria,
and fragile X syndrome, also have been implicated.
Symptomatology (Subjective and Objective
Data)
1. Failure to form interpersonal relationships, characterized by
unresponsiveness to people; lack of eye contact and facial re-
sponsiveness; indifference or aversion to affection and physical
contact. In early childhood, there is a failure to develop coop-
erative play and friendships.
2. Impairment in communication (verbal and nonverbal) char-
acterized by absence of language or, if developed, often an
immature grammatical structure, incorrect use of words,
echolalia, or inability to use abstract terms. Accompanying
nonverbal expressions may be inappropriate or absent.
3. Bizarre responses to the environment, characterized by resis-
tance or extreme behavioral reactions to minor occurrences;
abnormal, obsessive attachment to peculiar objects; ritualis-
tic behaviors.
2506_Ch02_014-053.indd Sec1:20 10/1/10 9:33:17 AM

4. Extreme fascination for objects that move (e.g., fans, trains).

Special interest in music, playing with water, buttons, or
parts of the body.
5. Unreasonable insistence on following routines in precise
detail (e.g., insisting that exactly the same route always be
followed when shopping).
6. Marked distress over changes in trivial aspects of environ-
ment (e.g., when a vase is moved from its usual position).
7. Stereotyped body movements (e.g., hand icking or
twisting, spinning, head banging, complex whole-body
movements).

Interventions for the Client with
Autistic Disorder
(Interventions are applicable to various health care settings, such as in-
patient and partial hospitalization, community outpatient clinic, home
health, and private practice.)
RISK FOR SELF-MUTILATION

De nition: At risk for deliberate self-injurious behavior causing
tissue damage with the intent of causing nonfatal injury to attain
relief of tension

[Neurological alterations]
[History of self-mutilative behaviors in response to increasing
anxiety]
[Obvious indifference to environment or hysterical reactions to
changes in the environment]
Goals/Objectives
Short-term Goal
Client will demonstrate alternative behavior (e.g., initiating in-
teraction between self and nurse) in response to anxiety within
specied time. (Length of time required for this objective will
depend on severity and chronicity of the disorder.)
Long-term Goal
Client will not in ict harm on self.

1. Intervene to protect child when self-mutilative behaviors,
such as head banging or other hysterical behaviors, become
evident. The nurse is responsible for ensuring client safety.
2506_Ch02_014-053.indd Sec1:21 10/1/10 9:33:17 AM

2. A helmet may be used to protect against head banging,

hand mitts to prevent hair pulling, and appropriate pad-
ding to protect extremities from injury during hysterical
movements.
3. Try to determine if self-mutilative behaviors occur in response
to increasing anxiety and, if so, to what the anxiety may be
attributed. Mutilative behaviors may be averted if the cause
can be determined.
4. Work on one-to-one basis with child to establish trust.
5. Offer self to child during times of increasing anxiety, in or-
der to decrease need for self-mutilative behaviors and provide
feelings of security.
Outcome Criteria
1. Anxiety is maintained at a level at which client feels no need
for self-mutilation.
2. When feeling anxious, client initiates interaction between
self and nurse.

De nition: Insufficient or excessive quantity or ineffective
quality of social exchange

Self-concept disturbance
Absence of [available] signicant others
[Unfullled tasks of trust versus mistrust]

[Lack of responsiveness to, or interest in, people]
[Failure to cuddle]
[Lack of eye contact and facial responsiveness]
[Indifference or aversion to affection and physical contact]
[Failure to develop cooperative play and peer friendships]
Goals/Objectives
Short-term Goal
Client will demonstrate trust in one caregiver (as evidenced
by facial responsiveness and eye contact) within specied time
(depending on severity and chronicity of disorder).
2506_Ch02_014-053.indd Sec1:22 10/1/10 9:33:17 AM

Long-term Goal
Client will initiate social interactions (physical, verbal, nonver-
bal) with caregiver by discharge from treatment.

1. Function in a one-to-one relationship with child. Consisten-
cy of staffclient interaction enhances the establishment of
trust.
2. Provide child with familiar objects (favorite toys, blanket).
These items will offer security during times when child feels
distressed.
3. Convey a manner of warmth, acceptance, and availability as cli-
ent attempts to fulll basic needs. These characteristics enhance
establishment and maintenance of a trusting relationship.
4. Go slowly. Do not force interactions. Begin with positive
reinforcement for eye contact. Gradually introduce touch,
smiling, hugging. The autistic client may feel threatened by
an onslaught of stimuli to which he or she is unaccustomed.
5. Support client with your presence as he or she endeavors
to relate to others in the environment. The presence of
an individual with whom a trusting relationship has been
established provides a feeling of security.
Outcome Criteria
1. Client initiates interactions between self and others.
2. Client uses eye contact, facial responsiveness, and other
nonverbal behaviors in interactions with others.
3. Client does not withdraw from physical contact.
IMPAIRED VERBAL
COMMUNICATION
De nition: Decreased, delayed, or absent ability to receive, pro-
cess, transmit, and use a system of symbols [to communicate]

[Inability to trust]
[Withdrawal into the self]

Does not or cannot speak.
[Immature grammatical structure]
2506_Ch02_014-053.indd Sec1:23 10/1/10 9:33:18 AM

[Echolalia]
[Pronoun reversal]
[Inability to name objects]
[Inability to use abstract terms]
[Absence of nonverbal expression (e.g., eye contact, facial
responsiveness, gestures)]
Goals/Objectives
Short-term Goal
Client will establish trust with one caregiver (as evidenced by
facial responsiveness and eye contact) by specied time (depend-
ing on severity and chronicity of disorder).
Long-term Goal
Client will have established a means for communicating (verbally
or nonverbally) needs and desires to staff by time of discharge
from treatment.

1. Maintain consistency in assignment of caregivers. Consistency
facilitates trust and enhances caregivers ability to under-
stand childs attempts to communicate.
2. Anticipate and ful ll clients needs until satisfactory com-
munication patterns are established. Anticipating needs
helps to minimize frustration while child is learning com-
munication skills.
3. Use the techniques of consensual validation and seeking
clari cation to decode communication patterns. (Examples:
I think you must have meant... or Did you mean to say
that...?) (see Appendix E). These techniques work to verify
the accuracy of the message received, or to clarify any hid-
den meanings within the message. Take caution not to put
words into clients mouth.
4. Use en face approach (face-to-face, eye-to-eye) to convey cor-
rect nonverbal expressions by example. Eye contact expresses
genuine interest in, and respect for, the individual.
Outcome Criteria
1. Client is able to communicate in a manner that is understood
by others.
2. Clients nonverbal messages are congruent with verbalizations.
3. Client initiates verbal and nonverbal interaction with others.
DISTURBED PERSONAL IDENTITY

De nition: Inability to maintain an integrated and complete
perception of self
2506_Ch02_014-053.indd Sec1:24 10/1/10 9:33:18 AM


[Unfullled tasks of trust versus mistrust]
[Inadequate sensory stimulation]

[Inability to separate own physiological and emotional needs
from those of others]
[Increased levels of anxiety resulting from contact with others]
[Inability to differentiate own body boundaries from those of
others]
[Repeating words he or she hears others say or mimicking move-
ments of others]
Goals/Objectives
Short-term Goal
Client will name own body parts and body parts of caregiver within
specied time (depending on severity and chronicity of disorder).
Long-term Goal
Client will develop ego identity (evidenced by ability to recog-
nize physical and emotional self as separate from others) by time
of discharge from treatment.

1. Function in a one-to-one relationship with child. Consisten-
cy of staffclient interaction enhances the establishment of
trust.
2. Assist child to recognize separateness during self-care activi-
ties, such as dressing and feeding. These activities increase
childs awareness of self as separate from others.
3. Point out and assist child in naming own body parts. This
activity may increase childs awareness of self as separate
from others.
4. Gradually increase amount of physical contact, using touch
to point out differences between client and nurse. Be cautious
with touch until trust is established, because this gesture may
be interpreted by client as threatening.
5. Use mirrors and drawings or pictures of child to reinforce
childs learning of body parts and boundaries.
Outcome Criteria
1. Client is able to differentiate own body parts from those of
others.
2. Client communicates ability to separate self from environ-
ment by discontinuing use of echolalia (repeating words
heard) and echopraxia (imitating movements seen).
2506_Ch02_014-053.indd Sec1:25 10/1/10 9:33:18 AM

DISRUPTIVE BEHAVIOR DISORDERS

Attention-Decit/Hyperactivity Disorder
De ned
Attention-decit/hyperactivity disorder (ADHD) is character-
ized by a persistent pattern of inattention and/or hyperactivity-
impulsivity that is more frequent and severe than is typically
observed in individuals at a comparable level of development
(APA, 2000). The disorder is frequently not diagnosed until
the child begins school because, prior to that time, childhood
behavior is much more variable than that of older children.
ADHD is 4 to 9 times more common in boys than in girls and may
occur in as many as 3% to 7% of school-age children. The course
can be chronic, persisting into adulthood. The DSM-IV-TR
further categorizes the disorder into the following subtypes: com-
bined type, predominantly inattentive type, and predominantly
hyperactive-impulsive type.
1. Physiological
a. Genetics. A number of studies have indicated that heredi-
tary factors may be implicated in the predisposition to
ADHD. Siblings of hyperactive children are more likely
than normal children to have the disorder.
b. Biochemical. Abnormal levels of the neurotransmitters
dopamine, norepinephrine, and possibly serotonin have
been suggested as a causative factor.
c. Prenatal, Perinatal, and Postnatal Factors. Maternal
smoking during pregnancy has been linked to ADHD in
offspring (Linnet et al., 2005). Intrauterine exposure to
toxic substances, including alcohol, can produce effects on
behavior. Premature birth, fetal distress, precipitated or
prolonged labor, and perinatal asphyxia have also been im-
plicated. Postnatal factors include cerebral palsy, epilepsy,
and other central nervous system abnormalities resulting
from trauma, infections, or other neurological disorders.
2. Psychosocial
a. Environmental Influences. Disorganized or chaotic en-
vironments or a disruption in family equilibrium may
predispose some individuals to ADHD. A high degree of
psychosocial stress, maternal mental disorder, paternal
criminality, low socioeconomic status, poverty, growing up
in an institution, and unstable foster care are factors that
have been implicated (Dopheide, 2001; Voeller, 2004).
1. Difculties in performing age-appropriate tasks.
2. Highly distractible.
2506_Ch02_014-053.indd Sec1:26 10/1/10 9:33:19 AM

3. Extremely limited attention span.

4. Shifts from one uncompleted activity to another.
5. Impulsivity, or decit in inhibitory control, is common.
6. Difculty forming satisfactory interpersonal relationships.
7. Disruptive and intrusive behaviors inhibit acceptable social
interaction.
8. Difculty complying with social norms.
9. Some children with ADHD are very aggressive or op-
positional. Others exhibit more regressive and immature
behaviors.
10. Low frustration tolerance and outbursts of temper are
common.
11. Boundless energy, exhibiting excessive levels of activity,
restlessness, and dgeting
12. Often described as perpetual motion machines, continu-
ously running, jumping, wiggling, or squirming
13. They experience a greater than average number of
accidents, from minor mishaps to more serious incidents
that may lead to physical injury or the destruction of
property.
Conduct Disorder
De ned
The DSM-IV-TR describes the essential feature of this disor-
der as a repetitive and persistent pattern of conduct in which
the basic rights of others or major age-appropriate societal
norms or rules are violated (APA, 2000). The conduct is more
serious than the ordinary mischief and pranks of children and
adolescents. The disorder is more common in boys than in
girls, and the behaviors may continue into adulthood, often
meeting the criteria for antisocial personality disorder. Con-
duct disorder is divided into two subtypes based on the age at
onset: childhood-onset type (onset of symptoms before age 10
years) and adolescent-onset type (absence of symptoms before
age 10 years).
1. Physiological
a. Birth Temperament. The term temperament refers to
personality traits that become evident very early in
life and may be present at birth. Evidence suggests a
genetic component in temperament and an association
between temperament and behavioral problems later
in life.
b. Genetics. Twin studies have revealed a signicantly higher
number of conduct disorders among those who have family
members with the disorder.
2506_Ch02_014-053.indd Sec1:27 10/1/10 9:33:19 AM

2. Psychosocial
a. Peer Relationships. Social groups have a signicant im-
pact on a childs development. Peers play an essential
role in the socialization of interpersonal competence,
and skills acquired in this manner affect the childs long-
term adjustment. Studies have shown that poor peer re-
lations during childhood were consistently implicated in
the etiology of later deviance (Ladd, 1999). Aggression
was found to be the principal cause of peer rejection, thus
contributing to a cycle of maladaptive behavior.
b. Theory of Family Dynamics. The following factors related
to family dynamics have been implicated as contributors
in the predisposition to this disorder (Foley et al., 2004;
Popper et al., 2003; Sadock & Sadock, 2007):
Parental rejection
Inconsistent management with harsh discipline
Early institutional living
Frequent shifting of parental gures
Large family size
Absent father
Parents with antisocial personality disorder and/or
alcohol dependence
Association with a delinquent subgroup
Marital con ict and divorce
Inadequate communication patterns
Parental permissiveness

1. Uses physical aggression in the violation of the rights of
others.
2. The behavior pattern manifests itself in virtually all areas of
the childs life (home, school, with peers, and in the commu-
nity).
3. Stealing, ghting, lying, and truancy are common prob-
lems.
4. There is an absence of feelings of guilt or remorse.
5. The use of tobacco, liquor, or nonprescribed drugs, as well
as the participation in sexual activities, occurs earlier than
the peer groups expected age.
6. Projection is a common defense mechanism.
7. Low self-esteem is manifested by a tough guy image.
Often threatens and intimidates others.
8. Characteristics include poor frustration tolerance, irritabil-
ity, and frequent temper outbursts.
9. Symptoms of anxiety and depression are not uncommon.
10. Level of academic achievement may be low in relation to age
and IQ.
2506_Ch02_014-053.indd Sec1:28 10/1/10 9:33:19 AM

11. Manifestations associated with ADHD (e.g., attention dif-

culties, impulsiveness, and hyperactivity) are very common
in children with conduct disorder.
Oppositional Deant Disorder
De ned
The DSM-IV-TR denes this disorder as a pattern of negativistic,
deant, disobedient, and hostile behavior toward authority gures
that occurs more frequently than is typically observed in individu-
als of comparable age and developmental level (APA, 2000). The
disorder typically begins by 8 years of age and usually not later
than early adolescence. The disorder is more prevalent in boys
than in girls and is often a developmental antecedent to conduct
disorder.
1. Physiological
a. Refer to this section under Conduct Disorder.
2. Psychosocial
a. Theory of Family Dynamics. It is thought that some par-
ents interpret average or increased levels of developmen-
tal oppositionalism as hostility and a deliberate effort on
the part of the child to be in control. If power and con-
trol are issues for parents, or if they exercise authority
for their own needs, a power struggle can be established
between the parents and the child that sets the stage for
the development of oppositional deant disorder.
1. Characterized by passive-aggressive behaviors such as stub-
bornness, procrastination, disobedience, carelessness, nega-
tivism, testing of limits, resistance to directions, deliberately
ignoring the communication of others, and unwillingness to
compromise.
2. Other symptoms that may be evident are running away, school
avoidance, school underachievement, temper tantrums, ght-
ing, and argumentativeness.
3. In severe cases, there may be elective mutism, enuresis, en-
copresis, or eating and sleeping problems.
4. Blames others for mistakes and misbehavior.
5. Has poor peer relationships.
Interventions for Clients with Disruptive
Behavior Disorders
2506_Ch02_014-053.indd Sec1:29 10/1/10 9:33:20 AM

RISK FOR SELF-DIRECTED OR

OTHER-DIRECTED VIOLENCE
De nition: At risk for behaviors in which an individual demon-
strates that he or she can be physically, emotionally, and/or sexu-
ally harmful [either to self or to others]

[Unsatisfactory parentchild relationship]
[Neurological alteration related to premature birth, fetal
distress, precipitated or prolonged labor]
[Dysfunctional family system]
[Disorganized or chaotic environments]
[Child abuse or neglect]
[Birth temperament]
Body language (e.g., rigid posture, clenching of sts and jaw,
hyperactivity, pacing, breathlessness, threatening stances)
[History or threats of violence toward self or others or of
destruction to the property of others]
Impulsivity
[History of] cruelty to animals
Suicidal ideation, plan [available means]
Goals/Objectives
Short-term Goals
1. Client will seek out staff at any time if thoughts of harming
self or others should occur.
2. Client will not harm self or others.
Long-term Goal
Client will not harm self or others.

1. Observe clients behavior frequently. Do this through rou-
tine activities and interactions to avoid appearing watchful
and suspicious. Clients at high risk for violence require
close observation to prevent harm to self or others.
2. Observe for suicidal behaviors: verbal statements, such as
Im going to kill myself or Very soon my mother wont
have to worry herself about me any longer, or nonverbal be-
haviors, such as giving away cherished items or mood swings.
Most clients who attempt suicide have communicated their
intent, either verbally or nonverbally.
3. Determine suicidal intent and available means. Ask, Do
you plan to kill yourself? and How do you plan to do it?
2506_Ch02_014-053.indd Sec1:30 10/1/10 9:33:20 AM

Direct, closed-ended questions are appropriate in this in-

stance. The client who has a usable plan is at higher risk
than one who does not.
4. Obtain verbal or written contract from client agreeing not to
harm self and agreeing to seek out staff in the event that such
ideation occurs. Discussion of suicidal feelings with a trusted
individual provides a degree of relief to client. A contract
gets the subject out in the open and places some of the re-
sponsibility for his or her safety with client. An attitude of
acceptance of client as a worthwhile individual is conveyed.
5. Help client to recognize when anger occurs and to accept those
feelings as his or her own. Have client keep an anger note-
book, in which a record of anger experienced on a 24-hour
basis is kept. Information regarding source of anger, behav-
ioral response, and clients perception of the situation should
also be noted. Discuss entries with client, suggesting alterna-
tive behavioral responses for those identied as maladaptive.
6. Act as a role model for appropriate expression of angry feel-
ings, and give positive reinforcement to client for attempting
to conform. It is vital that client express angry feelings, be-
cause suicide and other self-destructive behaviors are often
viewed as a result of anger turned inward on the self.
7. Remove all dangerous objects from clients environment.
Clients physical safety is a nursing priority.
8. Try to redirect violent behavior with physical outlets for
clients anxiety (e.g., punching bag, jogging, volleyball).
Anxiety and tension can be relieved safely and with benefit
to client in this manner.
9. Be available to stay with client as anxiety level and tensions
begin to rise. The presence of a trusted individual provides
a feeling of security.
10. Staff should maintain and convey a calm attitude to client.
Anxiety is contagious and can be communicated from staff
to client and vice versa. A calm attitude conveys a sense of
control and a feeling of security to client.
11. Have sufcient staff available to indicate a show of strength
to client if it becomes necessary. This conveys to client an
evidence of control over the situation and provides some
physical security for staff.
12. Administer tranquilizing medications as ordered by physi-
cian, or obtain an order if necessary. Monitor medication
for effectiveness and for adverse side effects. Short-term use
of antianxiety medications (e.g., chlordiazepoxide, alpra-
zolam, lorazepam) provides relief from the immobilizing
effects of anxiety and facilitates clients cooperation with
therapy.
2506_Ch02_014-053.indd Sec1:31 10/1/10 9:33:21 AM

13. Mechanical restraints or isolation room may be required

if less restrictive interventions are unsuccessful. It is
clients right to expect the use of techniques that ensure
the safety of client and others by the least restrictive
means.
Outcome Criteria
for aggression.
2. Client seeks out staff to discuss true feelings.
3. Client recognizes, verbalizes, and accepts possible conse-
quences of own maladaptive behaviors.
4. Client does not harm self or others.
DEFENSIVE COPING
De nition: Repeated projection of falsely positive self-evaluation
based on a self-protective pattern that defends against underlying
perceived threats to positive self-regard

[Low self-esteem]
[Negative role models]
[Lack of positive feedback]
[Repeated negative feedback, resulting in feelings of
diminished self-worth]

Denial of obvious problems or weaknesses
Projection of blame or responsibility
Rationalization of failures
Hypersensitivity to criticism
Grandiosity
Superior attitude toward others
Difculty establishing or maintaining relationships
Hostile laughter or ridicule of others
Difculty in perception of reality testing
Lack of follow-through or participation in treatment or therapy
2506_Ch02_014-053.indd Sec1:32 10/1/10 9:33:21 AM

Goals/Objectives
Short-term Goal
Client will verbalize personal responsibility for difculties
experienced in interpersonal relationships.
Long-term Goal
Client will demonstrate ability to interact with others with-
out becoming defensive, rationalizing behaviors, or expressing
grandiose ideas.

1. Recognize and support basic ego strengths. Focusing on
positive aspects of the personality may help to improve self-
concept.
2. Encourage client to recognize and verbalize feelings of
inadequacy and need for acceptance from others and to
recognize how these feelings provoke defensive behaviors,
such as blaming others for own behaviors. Recognition of
the problem is the first step in the change process toward
resolution.
3. Provide immediate, matter-of-fact, nonthreatening feed-
back for unacceptable behaviors. Client may lack knowledge
about how he or she is being perceived by others. Providing
this information in a nonthreatening manner may help to
eliminate these undesirable behaviors.
CLINICAL PEARL Say to the client, When you say those things to people,
they dont like it, and they dont want to be around you. Try to think how you would
feel if someone said those things to you.
4. Help client identify situations that provoke defensiveness

and practice through role-play more appropriate responses.
Role-playing provides confi dence to deal with diffi cult situ-
ations when they actually occur.
5. Provide immediate positive feedback for acceptable behav-
iors. Positive feedback enhances self-esteem and encourages
repetition of desirable behaviors.
6. Help client set realistic, concrete goals and determine
appropriate actions to meet those goals. Success increases
self-esteem.
7. With client, evaluate the effectiveness of the new behaviors
and discuss any modications for improvement. Because of
limited problem-solving ability, assistance may be required
to reassess and develop new strategies in the event that some
new coping methods prove ineffective.
2506_Ch02_014-053.indd Sec1:33 10/1/10 9:33:21 AM

Outcome Criteria
1. Client verbalizes and accepts responsibility for own behavior.
2. Client verbalizes correlation between feelings of inadequacy

and the need to defend the ego through rationalization and
grandiosity.
3. Client does not ridicule or criticize others.
4. Client interacts with others in group situations without
taking a defensive stance.


[Neurological alterations related to premature birth, fetal dis-
tress, precipitated or prolonged labor]
[Verbalized or observed] discomfort in social situations
[Verbalized or observed] inability to receive or communicate
a satisfying sense of belonging, caring, interest, or shared
history
[Observed] use of unsuccessful social interaction behaviors
[Behavior unacceptable for appropriate age by dominant
cultural group]
Goals/Objectives
Short-term Goal
Client will interact in age-appropriate manner with nurse in
one-to-one relationship within 1 week.
Long-term Goal
Client will be able to interact with staff and peers, by the time of
discharge from treatment, with no indication of discomfort.
1. Develop trusting relationship with client. Be honest; keep
all promises; convey acceptance of the person, separate from
2506_Ch02_014-053.indd Sec1:34 10/1/10 9:33:22 AM

unacceptable behaviors (It is not you, but your behavior, that

is unacceptable.) Acceptance of client increases his or her
feelings of self-worth.
2. Offer to remain with client during initial interactions with
others. Presence of a trusted individual provides a feeling of
security.
3. Provide constructive criticism and positive reinforcement for
clients efforts. Positive feedback enhances self-esteem and
4. Confront client and withdraw attention when interactions
with others are manipulative or exploitative. Attention to the
unacceptable behavior may reinforce it.
5. Act as a role model for client through appropriate interac-
tions with other clients and staff members.
6. Provide group situations for client. It is through these group
interactions that client will learn socially acceptable behavior,
with positive and negative feedback from his or her peers.
Outcome Criteria
1. Client seeks out staff member for social, as well as therapeutic,
interaction.
2. Client has formed and satisfactorily maintained one inter-
personal relationship with another client.
3. Client willingly and appropriately participates in group
activities.
4. Client verbalizes reasons for past inability to form close
interpersonal relationships.
INEFFECTIVE COPING
De nition: Inability to form a valid appraisal of the stressors, in-
adequate choices of practiced responses, and/or inability to use
available resources

Situational crisis
Maturational crisis
[Inadequate support systems]
[Inadequate coping strategies]
[Low self-esteem]
2506_Ch02_014-053.indd Sec1:35 10/1/10 9:33:22 AM


Inability to meet [age-appropriate] role expectations
Inadequate problem solving
Poor concentration
Risk taking
[Manipulation of others in the environment for purposes of ful-
lling own desires]
[Verbal hostility toward staff and peers]
[Hyperactivity, evidenced by excessive motor activity, easily dis-
tracted, short attention span]
[Unable to delay gratication]
[Oppositional and deant responses to adult requests or rules]
Goals/Objectives
Short-term Goal
Within 7 days, client will demonstrate ability and willingness to
follow rules of the treatment setting.
Long-term Goal
By discharge from treatment, client will develop, and use, age-
appropriate, socially acceptable coping skills.
1. If client is hyperactive, make environment safe for continuous
large-muscle movement. Rearrange furniture and other objects
to prevent injury. Client physical safety is a nursing priority.
2. Provide large motor activities in which client may partici-
pate. Nurse may join in some of these activities to facilitate
relationship development. Tension is released safely and
with benefit to client through physical activities.
3. Provide frequent, nutritious snacks that client may eat on
the run, to ensure adequate calories to offset clients exces-
sive use of energy.
CLINICAL PEARL Set limits on manipulative behavior.

Say, I understand why you are saying these things (or doing these things)
and I will not tolerate these behaviors from you. Take caution not to reinforce
manipulative behaviors by providing desired attention.
4. Identify for client the consequences of manipulative behavior.

All staff must follow through and be consistent. Client may
try to play one staff member against another, so consistency
is vital if intervention is to be successful. Aversive reinforce-
ment may work to decrease unacceptable behaviors.
5. Do not debate, argue, rationalize, or bargain with client.
Ignoring these attempts may work to decrease manipulative
behaviors.
2506_Ch02_014-053.indd Sec1:36 10/1/10 9:33:22 AM

6. Caution should be taken to avoid reinforcing manipulative

behaviors by providing desired attention. Attention provides
positive reinforcement and encourages repetition of the
undesirable behavior.
7. Confront clients use of manipulative behaviors and explore
their damaging effects on interpersonal relationships. Manip-
ulative clients often deny responsibility for their behaviors.
8. Encourage discussion of angry feelings. Help client identify
the true object of the hostility. Dealing with the feelings
honestly and directly will discourage displacement of the
anger onto others.
9. Explore with client alternative ways of handling frustration
that would be most suited to his or her lifestyle. Provide sup-
port and positive feedback to client as new coping strategies
are tried. Positive feedback encourages use of the acceptable
behaviors.
Outcome Criteria
1. Client is able to delay gratication, without resorting to ma-
nipulation of others.
2. Client is able to express anger in a socially acceptable manner.
3. Client is able to verbalize alternative, socially acceptable, and
lifestyle-appropriate coping skills he or she plans to use in
response to frustration.
LOW SELF-ESTEEM
De nition: Negative self-evaluating/feelings about self or self-
capabilities

Lack of approval
Repeated negative reinforcement

Lack of eye contact
Exaggerates negative feedback about self
Expressions of shame or guilt
Evaluation of self as unable to deal with events
Rejects positive feedback about self
2506_Ch02_014-053.indd Sec1:37 10/1/10 9:33:22 AM

Hesitant to try new things or situations

[Denial of problems obvious to others]
[Projection of blame or responsibility for problems]
[Rationalization of personal failures]
[Hypersensitivity to criticism]
[Grandiosity]
Goals/Objectives
Short-term Goal
Client will independently direct own care and activities of daily
living within 1 week.
Long-term Goal
By time of discharge from treatment, client will exhibit increased
feelings of self-worth as evidenced by verbal expression of positive
aspects about self, past accomplishments, and future prospects.

1. Ensure that goals are realistic. It is important for client to
achieve something, so plan for activities in which the pos-
sibility for success is likely. Success enhances self-esteem.
2. Convey unconditional positive regard for client. Commu-
nication of your acceptance of him or her as a worthwhile
human being increases self-esteem.
3. Spend time with client, both on a one-to-one basis and in
group activities. This conveys to client that you feel he or she
is worth your time.
4. Assist client in identifying positive aspects of self and in
developing plans for changing the characteristics he or she
views as negative.
5. Help client decrease use of denial as a defense mechanism.
Give positive reinforcement for problem identication and
development of more adaptive coping behaviors. Positive
reinforcement enhances self-esteem and increases clients
use of acceptable behaviors.
6. Encourage and support client in confronting the fear of fail-
ure by having client attend therapy activities and undertake
new tasks. Offer recognition of successful endeavors and
positive reinforcement for attempts made. Recognition and
positive reinforcement enhance self-esteem.
Outcome Criteria
1. Client verbalizes positive perception of self.
2. Client participates in new activities without exhibiting
extreme fear of failure.
2506_Ch02_014-053.indd Sec1:38 10/1/10 9:33:23 AM

ANXIETY (MODERATE TO SEVERE)

De nition: Vague uneasy feeling of discomfort or dread accom-
panied by an autonomic response (the source often nonspecific
or unknown to the individual); a feeling of apprehension caused
by anticipation of danger. It is an alerting signal that warns of im-
pending danger and enables the individual to take measures to
deal with threat.

Situational and maturational crises
Threat to self-concept [perceived or real]
Threat of death
Unmet needs
[Fear of failure]
[Innately, easily agitated temperament since birth]

Overexcited
Fearful
Feelings of inadequacy
Fear of unspecied consequences
Restlessness
Insomnia
Poor eye contact
Focus on self
[Continuous attention-seeking behaviors]
Difculty concentrating
Impaired attention
Increased respiration and pulse
Goals/Objectives
Short-term Goals
1. Within 7 days, client will be able to verbalize behaviors that
become evident as anxiety starts to rise.
2. Within 7 days, client will be able to verbalize strategies to
interrupt escalation of anxiety.
Long-term Goal
By time of discharge from treatment, client will be able to main-
tain anxiety below the moderate level as evidenced by absence of
disabling behaviors in response to stress.
2506_Ch02_014-053.indd Sec1:39 10/1/10 9:33:23 AM


1. Establish a trusting relationship with client. Be honest, con-
sistent in responses, and available. Show genuine positive
regard. Honesty, availability, and acceptance promote trust
in the nurseclient relationship.
2. Provide activities geared toward reduction of tension and
decreasing anxiety (walking or jogging, volleyball, musical
exercises, housekeeping chores, group games). Tension and
anxiety are released safely and with benefit to client through
physical activities.
3. Encourage client to identify true feelings, and to acknowl-
edge ownership of those feelings. Anxious clients often deny
a relationship between emotional problems and their anxi-
ety. Use of the defense mechanisms of projection and dis-
placement is exaggerated.
4. Nurse must maintain an atmosphere of calmness; anxiety
is easily transmitted from one person to another.
5. Offer support during times of elevated anxiety. Reassure
client of physical and psychological safety. Client safety is a
nursing priority.
6. Use of touch is comforting to some clients. However, nurse
must be cautious with its use, because anxiety may foster
suspicion in some individuals who might misinterpret touch
as aggression.
7. As anxiety diminishes, assist client to recognize specic
events that preceded its onset. Work on alternative responses
to future occurrences. A plan of action provides client with
a feeling of security for handling a difficult situation more
successfully, should it recur.
8. Help client recognize signs of escalating anxiety, and explore
ways client may intervene before behaviors become disabling.
9. Administer tranquilizing medication, as ordered. Assess for
effectiveness, and instruct client regarding possible adverse
side effects. Short-term use of antianxiety medications (e.g.,
lorazepam, chlordiazepoxide, alprazolam) provides relief
from the immobilizing effects of anxiety and facilitates
clients cooperation with therapy.
Outcome Criteria
1. Client is able to verbalize behaviors that become evident
when anxiety starts to rise, and takes appropriate action to
interrupt progression of the condition.
2. Client is able to maintain anxiety at a manageable level.
NONCOMPLIANCE
De nition: Behavior of person and/or caregiver that fails to
coincide with a health-promoting or therapeutic plan agreed on
2506_Ch02_014-053.indd Sec1:40 10/1/10 9:33:23 AM

by the person [or caregiver] and health care professional. In the

presence of an agreed-on, health-promoting or therapeutic plan,
persons or caregivers behavior is fully or partially nonadher-
ent and may lead to clinically ineffective or partially ineffective
outcomes.

[Biochemical alteration]
[Negative temperament]
[Retarded ego development]
[Low frustration tolerance and short attention span]
[Denial of problems]

Behavior indicative of failure to adhere [to treatment regimen]
[Inability to sit still long enough to complete a task]
[Expression of opposition to requests for participation]
[Refusal to follow directions or suggestions of treatment team]
Goals/Objectives
Short-term Goal
Client will participate in and cooperate during therapeutic
activities.
Long-term Goal
Client will complete assigned tasks willingly and independently
or with a minimum of assistance.

For the client with inattention and hyperactivity:
1. Provide an environment for task efforts that is as free of dis-
tractions as possible. Client is highly distractible and is unable
to perform in the presence of even minimal stimulation.
2. Provide assistance on a one-to-one basis, beginning with
simple, concrete instructions. Client lacks the ability to
assimilate information that is complicated or has abstract
meaning.
3. Ask that instructions be repeated to determine clients level
of comprehension.
4. Establish goals that allow client to complete a part of the task,
rewarding completion of each step with a break for physical
activity. Short-term goals are not so overwhelming to client
with such a short attention span. The positive reinforcement
2506_Ch02_014-053.indd Sec1:41 10/1/10 9:33:24 AM

(physical activity) increases self-esteem and provides incen-

tive for client to pursue the task to completion.
5. Gradually decrease the amount of assistance given to task
performance, while assuring client that assistance is still
available if deemed necessary. This encourages client to per-
form independently while providing a feeling of security
with the presence of a trusted individual.
For the client with oppositional tendencies:
6. Set forth a structured plan of therapeutic activities. Start
with minimum expectations and increase as client begins
to manifest evidence of compliance. Structure provides
security, and one or two activities may not seem as over-
whelming as the whole schedule of activities presented at
one time.
7. Establish a system of rewards for compliance with therapy
and consequences for noncompliance. Ensure that the re-
wards and consequences are concepts of value to client. Posi-
tive and negative reinforcements can contribute to desired
changes in behavior.
8. Convey acceptance of client separate from the undesirable
behaviors being exhibited. (It is not you, but your behavior,
that is unacceptable.) Unconditional acceptance enhances
self-worth and may contribute to a decrease in the need for
passive-aggressive behavior toward others.
Outcome Criteria
1. Client cooperates with staff in an effort to complete assigned
tasks.
2. Client complies with treatment by participating in therapies
without negativism.
3. Client takes direction from staff without becoming defensive.
TOURETTES DISORDER
Dened
Tourettes disorder is characterized by the presence of multiple
motor tics and one or more vocal tics that may appear simulta-
neously or at different periods during the illness (APA, 2000).
Onset of the disorder can be as early as 2 years, but it occurs
most commonly during childhood (around age 6 to 7 years).
Tourettes disorder is more common in boys than in girls. The
duration of the disorder may be lifelong, although there may
be periods of remission that last from weeks to years (APA,
2000). The symptoms usually diminish during adolescence and
adulthood and, in some cases, disappear altogether by early
adulthood.
2506_Ch02_014-053.indd Sec1:42 10/1/10 9:33:24 AM

1. Physiological
a. Genetics. Family studies have shown that Tourettes dis-
order is more common in relatives of individuals with
the disorder than in the general population. It may
be transmitted in an autosomal pattern intermediate
between dominant and recessive (Sadock & Sadock,
2007).
b. Brain Alterations. Altered levels of neurotransmitters
and dysfunction in the area of the basal ganglia have been
implicated in the etiology of Tourettes disorder.
c. Biochemical Factors. Abnormalities in levels of dopa-
mine, serotonin, dynorphin, gamma-aminobutyric acid
(GABA), acetylcholine, and norepinephrine have been
associated with Tourettes disorder (Popper et al., 2003).
2. Psychosocial
a. The genetic predisposition to Tourettes disorder may
be reinforced by certain factors in the environ-
ment, such as complications of pregnancy (e.g., severe
nausea and vomiting or excessive stress), low birth
weight, head trauma, carbon monoxide poisoning, and
encephalitis.

Data)
Signs and symptoms of Tourettes disorder are as follows (APA,
2000; Popper et al., 2003):
1. The disorder may begin with a single motor tic, such as eye
blinking, neck jerking, shoulder shrugging, facial grimacing,
or coughing.
2. Complex motor tics may follow and include touching, squat-
ting, hopping, skipping, deep knee bends, retracing steps,
and twirling when walking.
3. Vocal tics include various words or sounds such as clicks,
grunts, yelps, barks, sniffs, snorts, coughs; in about 10% of
cases, a complex vocal tic involves uttering obscenities.
4. Vocal tics may include repeating certain words or phrases out
of context, repeating ones own sounds or words (palilalia), or
repeating what others say (echolalia).
5. The movements and vocalizations are experienced as compul-
sive and irresistible, but they can be suppressed for varying
lengths of time.
6. Tics are exacerbated by stress and attenuated during periods in
which the individual becomes totally absorbed by an activity.
7. Tics are markedly diminished during sleep.
2506_Ch02_014-053.indd Sec1:43 10/1/10 9:33:24 AM

Common Nursing Diagnoses and Interventions

for the Client with Tourettes Disorder

Denition: At risk for behaviors in which an individual demon-
strates that he or she can be physically, emotionally, and/or sexually
harmful [either to self or to others]

[Low tolerance for frustration]
[Abnormalities in brain neurotransmitters]
Body language (e.g., rigid posture, clenching of sts and jaw, hy-
peractivity, pacing, breathlessness, and threatening stances)
Impulsivity
Suicidal ideation, plan, [available means]
Goals/Objectives
Short-term Goals
1. Client will seek out staff or support person at any time if
thoughts of harming self or others should occur.
Long-term Goal
1. Observe clients behavior frequently through routine activities
and interactions. Become aware of behaviors that indicate a rise
in agitation. Stress commonly increases tic behaviors. Recog-
nition of behaviors that precede the onset of aggression may
provide the opportunity to intervene before violence occurs.
2. Monitor for self-destructive behavior and impulses. A
staff member may need to stay with client to prevent self-
mutilation. Client safety is a nursing priority.
3. Provide hand coverings and other restraints that prevent
client from self-mutilative behaviors. Provide immediate ex-
ternal controls against self-aggressive behaviors.
4. Redirect violent behavior with physical outlets for frustra-
tion. Excess energy is released through physical activities
and a feeling of relaxation is induced.
2506_Ch02_014-053.indd Sec1:44 10/1/10 9:33:25 AM

5. Administer medication as ordered by physician. Several

medications have been used to treat Tourettes disorder. The
most common ones include the following:
a. Haloperidol (Haldol). Haloperidol has been the drug of
choice for Tourettes disorder. Children on this medica-
tion must be monitored for adverse effects associated with
most antipsychotic medications (see Chapter 28). Because
of the potential for adverse effects, haloperidol should
be reserved for children with severe symptoms or with
symptoms that interfere with their ability to function.
Usual dosage for children 3 to 12 years of age is 0.05 to
0.075 mg/kg/day in two or three divided doses.
b. Pimozide (Orap). The response rate and side effect pro-
le of pimozide are similar to those of haloperidol. It is
used in the management of severe motor or vocal tics that
have failed to respond to more conventional treatment.
It is not recommended for children younger than age
12 years. Dosage is initiated at 0.05 mg/kg at bedtime;
dosage may be increased every third day to a maximum of
0.2 mg/kg, not to exceed 10 mg/day.
c. Clonidine (Catapres). Clonidine is an antihyperten-
sive medication, the efcacy of which in the treatment of
Tourettes disorder has been mixed. Some physicians like
it and use it as a drug of rst choice because of its rela-
tive safety and few side effects. Recommended dosage is
150 to 200 mcg/day.
d. Atypical Antipsychotics. Atypical antipsychotics are
less likely to cause extrapyramidal side effects than are
the older antipsychotics (e.g., haloperidol and pimo-
zide). Risperidone, the most studied atypical antipsy-
chotic in Tourettes disorder, has been shown to re-
duce symptoms by 21% to 61% compared with placebo
(results that are similar to those of pimozide and cloni-
dine) (Dion et al., 2002). Both olanzapine and ziprasi-
done have demonstrated effectiveness in decreasing tic
symptoms of Tourettes disorder. However, weight gain
and abnormal glucose tolerance may be troublesome
side effects, and ziprasidone has been associated with
increased risk of QTc interval prolongation (Zinner,
2004).
Outcome Criteria
for aggression.
2. Client seeks out staff or support person for expression of true
feelings.
3. Client has not harmed self or others.
2506_Ch02_014-053.indd Sec1:45 10/1/10 9:33:25 AM



[Low tolerance for frustration]
[Impulsiveness]
[Oppositional behavior]

history
Goals/Objectives
Short-term Goal
Client will develop a one-to-one relationship with nurse or sup-
port person within 1 week.
Long-term Goal
Client will be able to interact with staff and peers using age-
appropriate, acceptable behaviors.

1. Develop a trusting relationship with client. Conveyac-
ceptance of the person separate from the unacceptable
behavior. Unconditional acceptance increases feelings of
self-worth.
2. Discuss with client which behaviors are and are not accept-
able. Describe in matter-of-fact manner the consequences of
unacceptable behavior. Follow through. Aversive reinforce-
ment can alter undesirable behaviors.
3. Provide group situations for client. Appropriate social behav-
ior is often learned from the positive and negative feedback of
peers.
tions with others. Role modeling of a respected individual is
one of the strongest forms of learning.
2506_Ch02_014-053.indd Sec1:46 10/1/10 9:33:25 AM

Outcome Criteria
1. Client seeks out staff or support person for social, as well as
for therapeutic, interaction.
2. Client verbalizes reasons for past inability to form close
interpersonal relationships.
3. Client interacts with others using age-appropriate, acceptable
behaviors.
LOW SELF-ESTEEM
capabilities

[Shame associated with tic behaviors]

Lack of eye contact
Self-negating verbalizations
Hesitant to try new things or situations
[Manipulation of others]
Goals/Objectives
Short-term Goal
Client will verbalize positive aspects about self not associated
with tic behaviors.
Long-term Goal
Client will exhibit increased feeling of self-worth as evidenced
by verbal expression of positive aspects about self, past accom-
plishments, and future prospects.

1. Convey unconditional acceptance and positive regard. Com-
munication of client as worthwhile human being may increase
self-esteem.
2. Set limits on manipulative behavior. Take caution not to re-
inforce manipulative behaviors by providing desired atten-
tion. Identify the consequences of manipulation. Administer
consequences matter-of-factly when manipulation occurs.
Aversive reinforcement may work to decrease unacceptable
behaviors.
2506_Ch02_014-053.indd Sec1:47 10/1/10 9:33:25 AM

3. Help client understand that he or she uses this behavior in or-

der to try to increase own self-esteem. Interventions should
reect other actions to accomplish this goal. When client feels
better about self, the need to manipulate others will diminish.
4. If client chooses to suppress tics in the presence of others,
provide a specied tic time, during which client vents
tics, feelings, and behaviors (alone or with staff). Allows for
release of tics and assists in sense of control and manage-
ment of symptoms.
5. Ensure that client has regular one-to-one time with staff or
support person. One-to-one time gives nurse the opportu-
nity to provide client with information about the illness and
healthy ways to manage it. Exploring feelings about the illness
helps client incorporate the illness into a healthy sense of self.
Outcome Criteria
2. Client willingly participates in new activities and situations.
SEPARATION ANXIETY DISORDER
Dened
The APA (2000) de nes separation anxiety disorder as exces-
sive anxiety concerning separation from the home or from those
to whom the person is attached. Onset may occur as early as
preschool age, rarely as late as adolescence, but always before age
18, and is more common in girls than in boys.
1. Physiological
a. Genetics. The results of studies indicate that a greater
number of children with relatives who manifest anxiety
problems develop anxiety disorders themselves than do
children with no such family patterns.
b. Temperament. Studies have shown that differences in
temperamental characteristics at birth may be correlated
to the acquisition of fear and anxiety disorders in child-
hood. This may denote an inherited vulnerability or pre-
disposition toward developing these disorders.
2. Psychosocial
a. Stressful Life Events. Studies indicate that children who
are predisposed to anxiety disorders may be affected
signicantly by stressful life events.
b. Family Influences. Several theories exist that relate
the development of separation anxiety to the following
dynamics within the family:
An overattachment to the mother (primary caregiver)
Separation con icts between parent and child
2506_Ch02_014-053.indd Sec1:48 10/1/10 9:33:26 AM

Enmeshment of members within a family

Overprotection of the child by the parents
Transfer of parents fears and anxieties to the children
through role modeling

Symptoms of separation anxiety disorder include the following:
1. In most cases the child has difculty separating from the
mother, although occasionally the separation reluctance is
directed toward the father, siblings, or other signicant indi-
vidual to whom the child is attached.
2. Anticipation of separation may result in tantrums, crying,
screaming, complaints of physical problems, and clinging
behaviors.
3. Reluctance or refusal to attend school is especially common
in adolescence.
4. Younger children may shadow or follow around the person
from whom they are afraid to be separated.
5. During middle childhood or adolescence he or she may re-
fuse to sleep away from home (e.g., at a friends house or
at camp).
6. Worrying is common and relates to the possibility of harm
coming to self or to the attachment gure. Younger children
may have nightmares to this effect.
7. Specic phobias may be present.
8. Depressed mood is frequently present and often precedes the
onset of the anxiety symptoms, which commonly occur fol-
lowing a major stressor.

Interventions for the Client with Separation
Anxiety Disorder
ANXIETY (SEVERE)
panied by an autonomic response (the source is often nonspecific
or unknown to the individual); a feeling of apprehension caused by
anticipation of danger. It is an alerting signal that warns of impend-
ing danger and enables the individual to take measures to deal with
threat.
2506_Ch02_014-053.indd Sec1:49 10/1/10 9:33:26 AM


Heredity
[Birth temperament]
[Overattachment to parent]
[Negative role modeling]

[Excessive distress when separated from attachment gure]
[Fear of anticipation of separation from attachment gure]
[Fear of being alone or without attachment gure]
[Reluctance or refusal to go to school or anywhere else without
attachment gure]
[Nightmares about being separated from attachment gure]
[Somatic symptoms occurring as a result of fear of separation]
Goals/Objectives
Short-term Goal
Client will discuss fears of separation with trusted individual.
Long-term Goal
Client will maintain anxiety at no higher than moderate level in
the face of events that formerly have precipitated panic.

1. Establish an atmosphere of calmness, trust, and genuine pos-
itive regard. Trust and unconditional acceptance are neces-
sary for satisfactory nurseclient relationship. Calmness is
important because anxiety is easily transmitted from one
person to another.
2. Assure client of his or her safety and security. Symptoms of
panic anxiety are very frightening.
3. Explore childs or adolescents fears of separating from par-
ents. Explore with parents possible fears they may have of
separation from child. Some parents may have an underly-
ing fear of separation from child, of which they are un-
aware and which they are unconsciously transferring to
child.
4. Help parents and child initiate realistic goals (e.g.,
child to stay with sitter for 2 hours with minimal anxi-
ety or child to stay at friends house without parents until
9:00 pm without experiencing panic anxiety). Parents may
be so frustrated with childs clinging and demanding
behaviors that assistance with problem solving may be
required.
5. Give, and encourage parents to give, positive reinforcement
for desired behaviors. Positive reinforcement encourages
2506_Ch02_014-053.indd Sec1:50 10/1/10 9:33:26 AM

Outcome Criteria
1. Client and parents are able to discuss their fears regarding
separation.
2. Client experiences no somatic symptoms from fear of
separation.
3. Client maintains anxiety at moderate level when separation
occurs or is anticipated.
INEFFECTIVE COPING
available resources

[Unresolved separation con icts]
[Inadequate coping skills]

[Somatic complaints in response to occurrence or anticipation
of separation from attachment gure]
Goals/Objectives
Short-term Goal
Client will verbalize correlation of somatic symptoms to fear of
separation.
Long-term Goal
Client will demonstrate use of more adaptive coping strategies
(than physical symptoms) in response to stressful situations.

1. Encourage child or adolescent to discuss specic situations
in life that produce the most distress and describe his or her
response to these situations. Include parents in the discus-
sion. Client and family may be unaware of the correlation
between stressful situations and the exacerbation of physical
symptoms.
2. Help child or adolescent who is perfectionistic to recognize
that self-expectations may be unrealistic. Connect times
of unmet self-expectations to the exacerbation of physical
symptoms. Recognition of maladaptive patterns is the first
step in the change process.
3. Encourage parents and child to identify more adaptive cop-
ing strategies that child could use in the face of anxiety that
2506_Ch02_014-053.indd Sec1:51 10/1/10 9:33:27 AM

feels overwhelming. Practice through role-play. Practice fa-

cilitates the use of the desired behavior when individual is
actually faced with the stressful situation.
Outcome Criteria
1. Client and family verbalize the correlation between separa-
tion anxiety and somatic symptoms.
2. Client verbalizes the correlation between unmet self-
expectations and somatic symptoms.
3. Client responds to stressful situations without exhibiting
physical symptoms.

Denition: Insufficient or excessive quantity or ineffective quality
of social exchange

[Reluctance to be away from attachment gure]

[Symptoms of severe anxiety]
history
Goals/Objectives
Short-term Goal
Client will spend time with staff or other support person, with-
out presence of attachment gure, without excessive anxiety.
Long-term Goal
Client will be able to spend time with others (without presence
of attachment gure) without excessive anxiety.

1. Develop a trusting relationship with client. This is the first
step in helping client learn to interact with others.
2. Attend groups with child and support efforts to interact
with others. Give positive feedback. Presence of a trusted
individual provides security during times of distress. Positive
feedback encourages repetition.
2506_Ch02_014-053.indd Sec1:52 10/1/10 9:33:27 AM

3. Convey to the child the acceptability of his or her not par-

ticipating in group in the beginning. Gradually encourage
small contributions until client is able to participate more
fully. Small successes will gradually increase self-confi dence
and decrease self-consciousness, so that client will feel less
anxious in the group situation.
4. Help client set small personal goals (e.g., Today I will speak
to one person I dont know.). Simple, realistic goals provide
opportunities for success that increase self-confi dence and
may encourage client to attempt more difficult objectives in
the future.
Outcome Criteria
1. Client spends time with others using acceptable, age-
appropriate behaviors.
2. Client is able to interact with others away from the attach-
ment gure without excessive anxiety.
INTERNET REFERENCES
Additional information about attention-decit/hyperactivity
disorder may be located at the following websites:
a. http://www.chadd.org
b. http://www.nimh.nih.gov/health/topics/attention-decit-
hyperactivity-disorder-adhd/index.shtml
Additional information about autism may be located at the
following websites:
a. http://www.autism-society.org
b. http://www.nimh.nih.gov/health/topics/autism-spectrum-
disorders-pervasive-developmental-disorders/index.shtml
Additional information about medications to treat attention-
decit/hyperactivity disorder may be located at the following
websites:
a. http://www.fadavis.com/townsend
b. http://w w w.drugs.com /condition /attention-def icit-
disorder.html
c. http://www.nimh.nih.gov/health/publications/medica-
tions/complete-publication.shtml
Movie Connections
Bill (MR) Bill: On His Own (MR) Sling Blade (MR)
Forrest Gump (MR) Rain Man (autistic disorder) Mercury Rising
(autistic disorder) Niagara, Niagara (Tourettes disorder) Toughlove
(conduct disorder)
2506_Ch02_014-053.indd Sec1:53 10/1/10 9:33:27 AM

C H A P T E R
3
Delirium, Dementia,
and Amnestic Disorders
Delirium
De ned
The American Psychiatric Association (APA, 2000) Diagnostic
and Statistical Manual of Mental Disorders, Fourth Edition, Text
Revision (DSM-IV-TR) de nes delirium as a disturbance of
consciousness and a change in cognition that develop rapidly
over a short period. The symptoms of delirium usually begin
quite abruptly, and the duration is usually brief (e.g., 1 week;
rarely more than 1 month). The disorder subsides completely
on recovery from the underlying determinant. If the underly-
ing condition persists, the delirium may gradually shift to the
syndrome of dementia or progress to coma. The individual then
recovers, becomes chronically vegetative, or dies.
Predisposing Factors to Delirium
The DSM-IV-TR differentiates among the disorders of
delirium by their etiology, although they share a common
symptom presentation. Categories of delirium include the
following:
1. Delirium Due to a General Medical Condition. Certain
medical conditions, such as systemic infections, metabolic
disorders, uid and electrolyte imbalances, liver or kidney
disease, thiamine deciency, postoperative states, hyperten-
sive encephalopathy, postictal states, and sequelae of head
trauma, can cause the symptoms of delirium.
2. Substance-Induced Delirium. The symptoms of delirium
can be induced by the exposure to a toxin or the ingestion
of medications, such as anticonvulsants, neuroleptics, anx-
iolytics, antidepressants, cardiovascular medications, anti-
neoplastics, analgesics, antiasthmatic agents, antihistamines,
antiparkinsonian drugs, corticosteroids, and gastrointestinal
medications.
54
2506_Ch03_054-070.indd 54 10/1/10 9:33:37 AM

Delirium, Dementia, and Amnestic Disorders 55
3. Substance-Intoxication Delirium. Delirium symptoms can

occur in response to taking high doses of cannabis, cocaine,
hallucinogens, alcohol, anxiolytics, or narcotics.
4. Substance-Withdrawal Delirium. Reduction or termina-
tion of long-term, high-dose use of certain substances, such
as alcohol, sedatives, hypnotics, or anxiolytics, can result in
withdrawal delirium symptoms.
5. Delirium Due to Multiple Etiologies. Symptoms of delir-
ium may be related to more than one general medical condi-
tion or to the combined effects of a general medical condition
and substance use.
The following symptoms have been identied with the syndrome
of delirium:
1. Altered consciousness ranging from hypervigilance to stupor
or semicoma.
2. Extreme distractibility with difculty focusing attention.
3. Disorientation to time and place.
4. Impaired reasoning ability and goal-directed behavior.
5. Disturbance in the sleep-wake cycle.
6. Emotional instability as manifested by fear, anxiety,
depression, irritability, anger, euphoria, or apathy.
7. Misperceptions of the environment, including illusions and
hallucinations.
8. Autonomic manifestations, such as tachycardia, sweating,
ushed face, dilated pupils, and elevated blood pressure.
9. Incoherent speech.
10. Impairment of recent memory.
Dementia
De ned
Dementia is dened by a loss of previous levels of cogni-
tive, executive, and memory function in a state of full alertness
(Bourgeois, Seaman, & Servis, 2008). The disease usually has a
slow, insidious onset and is chronic, progressive, and irreversible.
Predisposing Factors to Dementia
Following are major etiologic categories for the syndrome of
dementia:
1. Dementia of the Alzheimers Type. The exact cause of
Alzheimers disease (AD) is unknown, but several theories
have been proposed, such as reduction in brain acetylcholine,
the formation of plaques and tangles, serious head trauma,
and genetic factors. Pathologic changes in the brain include
atrophy, enlarged ventricles, and the presence of numerous
neurobrillary plaques and tangles. Denitive diagnosis is
2506_Ch03_054-070.indd 55 10/1/10 9:33:38 AM

by biopsy or autopsy examination of brain tissue, although

renement of diagnostic criteria and new diagnostic tools
now enable clinicians to use specic clinical features to iden-
tify the disease at an accuracy rate of 70% to 90% (Bourgeois,
Seaman, & Servis, 2008).
2. Vascular Dementia. This type of dementia is caused by
signicant cerebrovascular disease. The client suffers the
equivalent of small strokes caused by arterial hypertension
or cerebral emboli or thrombi, which destroy many areas of
the brain. The onset of symptoms is more abrupt than in
AD and runs a highly variable course, progressing in steps
rather than as a gradual deterioration.
3. Dementia Due to HIV Disease. The immune dysfunction
associated with human immunodeciency virus (HIV) dis-
ease can lead to brain infections by other organisms. HIV
also appears to cause dementia directly.
4. Dementia Due to Head Trauma. The syndrome of symp-
toms associated with dementia can be brought on by a
traumatic brain injury.
5. Dementia Due to Lewy Body Disease. Clinically, Lewy
body disease is fairly similar to AD; however, it tends to
progress more rapidly, and there is an earlier appearance
of visual hallucinations and parkinsonian features (Rabins,
et al., 2006). This disorder is distinctive by the presence of
Lewy bodieseosinophilic inclusion bodiesseen in the
cerebral cortex and brainstem (Andreasen & Black, 2006).
6. Dementia Due to Parkinsons Disease. Parkinsons dis-
ease is caused by a loss of nerve cells in the substantia nigra
of the basal ganglia. The symptoms of dementia associated
with Parkinsons disease closely resemble those of AD.
7. Dementia Due to Huntingtons Disease. This disease is
transmitted as a Mendelian dominant gene, and damage oc-
curs in the areas of the basal ganglia and the cerebral cortex.
The average duration of the disease is based on age at onset.
One study concluded that juvenile-onset and late-onset cli-
ents have the shortest duration (Foroud et al., 1999). In this
study, the median duration of the disease was 21.4 years.
8. Dementia Due to Picks Disease. Pathology occurs from
atrophy in the frontal and temporal lobes of the brain.
Symptoms are strikingly similar to those of AD, and Picks
disease is often misdiagnosed as AD.
9. Dementia Due to Creutzfeldt-Jakob Disease. This form
of dementia is caused by a transmissible agent known as a
slow virus or prion. The clinical presentation is typical of
the syndrome of dementia, and the course is extremely rapid,
with progressive deterioration and death within 1 year after
onset.
2506_Ch03_054-070.indd 56 10/1/10 9:33:38 AM

10. Dementia Due to Other General Medical Conditions. A

number of other general medical conditions can cause demen-
tia. Some of these include endocrine conditions (e.g., hypogly-
cemia, hypothyroidism), pulmonary disease, hepatic or renal
failure, cardiopulmonary insufciency, uid and electrolyte
imbalances, nutritional deciencies, frontal or temporal lobe
lesions, central nervous system (CNS) or systemic infections,
uncontrolled epilepsy, and other neurological conditions such
as multiple sclerosis (APA, 2000).
11. Substance-Induced Persisting Dementia. This type of
dementia is related to the persisting effects of substances
such as alcohol, inhalants, sedatives, hypnotics, anxiolyt-
ics, other medications, and environmental toxins. The term
persisting is used to indicate that the dementia persists
long after the effects of substance intoxication or substance
withdrawal have subsided.
The following symptoms have been identied with the syndrome
of dementia:
1. Memory impairment (impaired ability to learn new informa-
tion or to recall previously learned information).
2. Impairment in abstract thinking, judgment, and impulse
control.
3. Impairment in language ability, such as difculty naming
objects. In some instances, the individual may not speak at
all (aphasia).
4. Personality changes are common.
5. Impaired ability to perform motor activities despite intact
motor abilities (apraxia).
6. Disorientation.
7. Wandering.
8. Delusions are common (particularly delusions of persecution).
Amnestic Disorders
De ned
Amnestic disorders are characterized by an inability to learn
new information (short-term memory decit) despite normal at-
tention and an inability to recall previously learned information
(long-term memory decit). No other cognitive decits exist.
Predisposing Factors to Amnestic Disorders
The DSM-IV-TR identies the following categories as etiologies
for the syndrome of symptoms known as amnestic disorders:
1. Amnestic Disorder Due to a General Medical Condi-
tion. The symptoms may be associated with head trauma,
cerebrovascular disease, cerebral neoplastic disease, cerebral
2506_Ch03_054-070.indd 57 10/1/10 9:33:39 AM

anoxia, herpes simplex encephalitis, poorly controlled in-

sulin dependent diabetes, and surgical intervention to the
brain (APA, 2000; Bourgeois, Seaman, & Servis, 2008).
Transient amnestic syndromes can also occur from epi-
leptic seizures, electroconvulsive therapy, severe migraine,
and drug overdose.
2. Substance-Induced Persisting Amnestic Disorder. This
type of amnestic disorder is related to the persisting effects
of substances such as alcohol, sedatives, hypnotics, anxiolyt-
ics, other medications, and environmental toxins. The term
persisting is used to indicate that the symptoms persist
long after the effects of substance intoxication or substance
withdrawal have subsided.
The following symptoms have been identied with amnestic
disorder:
1. Disorientation to place and time may occur with profound
amnesia.
2. There is an inability to recall events from the recent past and
events from the remote past. (Events from the very remote past
are often more easily recalled than recently occurring ones.)
3. The individual is prone to confabulation. That is, the in-
dividual may create imaginary events to ll in the memory
gaps.
4. Apathy, lack of initiative, and emotional blandness are
common.

Interventions for Delirium, Dementia,
and Amnestic Disorders
(Interventions are applicable to various health-care settings, such as
RISK FOR TRAUMA

De nition: [The client has] accentuated risk of accidental tissue
injury (e.g., wound, burn, fracture).

[Chronic alteration in structure or function of brain tissue,
secondary to the aging process, multiple infarcts, HIV dis-
ease, head trauma, chronic substance abuse, or progressively
2506_Ch03_054-070.indd 58 10/1/10 9:33:39 AM

dysfunctional physical condition resulting in the following

symptoms:
Disorientation; confusion
Weakness
Muscular incoordination
Seizures
Memory impairment
Poor vision
Extreme psychomotor agitation observed in the late stages
of delirium]
[Frequent shuf ing of feet and stumbling]
[Falls, caused by muscular incoordination or seizures]
[Bumping into furniture]
[Exposing self to frigid conditions with insufcient protective
clothing]
[Cutting self when using sharp instruments]
[History of attempting to light burner or oven and leaving gas
on in house]
[Smoking and leaving burning cigarettes in various places;
smoking in bed; falling asleep sitting on couch or chair with
lighted cigarette in hand]
[Purposeless, thrashing movements; hyperactivity that is out of
touch with the environment]
Goals/Objectives
Short-term Goals
1. Client will accept assistance when ambulating or carrying
out other activities.
2. Client will not experience physical injury.
Long-term Goal
Client will not experience physical injury.

1. Assess clients level of disorientation and confusion to deter-
mine specic requirements for safety. Knowledge of clients
level of functioning is necessary to formulate appropriate
plan of care.
2. Institute appropriate safety measures, such as the following:
a. Place furniture in room in an arrangement that best
accommodates clients disabilities.
b. Observe client behaviors frequently; assign staff on one-
to-one basis if condition warrants; accompany and assist
client when ambulating; use wheelchair for transporting
long distances.
2506_Ch03_054-070.indd 59 10/1/10 9:33:39 AM

c. Store items that client uses frequently within easy access.

d. Remove potentially harmful articles from clients room:
cigarettes, matches, lighters, sharp objects.
e. Remain with client while he or she smokes.
f. Pad side rails and headboard of client with seizure disor-
der. Institute seizure precautions as described in procedure
manual of individual institution.
g. If client is prone to wander, provide an area within which
wandering can be carried out safely.
3. Frequently orient client to reality and surroundings. Disori-
entation may endanger client safety if he or she unknowingly
wanders away from safe environment.
4. Use tranquilizing medications and soft restraints, as pre-
scribed by physician, for clients protection during periods
of excessive hyperactivity. Use restraints judiciously, because
they can increase agitation. They may be required, however,
to provide for client safety.
5. Teach prospective caregivers methods that have been successful
in preventing client injury. These caregivers will be responsible
for clients safety after discharge from the hospital. Sharing
successful interventions may be helpful.
Outcome Criteria
1. Client is able to accomplish daily activities within the envi-
ronment without experiencing injury.
2. Prospective caregivers are able to verbalize means of provid-
ing safe environment for client.

Denition: At risk for behaviors in which an individual demon-
strates that he or she can be physically, emotionally, and/or sexually
harmful [either to self or to others].

[Chronic alteration in structure or function of brain tissue,
secondary to the aging process, multiple infarcts, HIV dis-
ease, head trauma, chronic substance abuse, or progressively
dysfunctional physical condition resulting in the following
symptoms:
Delusional thinking
Suspiciousness of others
Hallucinations
Illusions
2506_Ch03_054-070.indd 60 10/1/10 9:33:40 AM

Disorientation or confusion
Impairment of impulse control]
[Inaccurate perception of the environment]
Body languagerigid posture, clenching of sts and jaw, hyper-
activity, pacing, breathlessness, and threatening stances
Suicidal ideation, plan, available means
[Depressed mood]
Goals/Objectives
Short-term Goals
1. Client will maintain agitation at manageable level so as not to
become violent.
Long-term Goal

1. Assess clients level of anxiety and behaviors that indicate
the anxiety is increasing. Recognizing these behaviors, nurse
may be able to intervene before violence occurs.
2. Maintain low level of stimuli in clients environment (low
lighting, few people, simple decor, low noise level). Anxiety
increases in a highly stimulating environment.
3. Remove all potentially dangerous objects from clients en-
vironment. In a disoriented, confused state, client may use
these objects to harm self or others.
4. Have sufcient staff available to execute a physical confronta-
tion, if necessary. Assistance may be required from others to
provide for physical safety of client or primary nurse or both.
5. Maintain a calm manner with client. Attempt to prevent
frightening client unnecessarily. Provide continual reas-
surance and support. Anxiety is contagious and can be
transferred to client.
6. Interrupt periods of unreality and reorient. Client safety is
jeopardized during periods of disorientation. Correcting
misinterpretations of reality enhances clients feelings of
self-worth and personal dignity.
7. Use tranquilizing medications and soft restraints, as pre-
scribed by physician, for protection of client and others during
periods of elevated anxiety. Use restraints judiciously, because
agitation sometimes increases; however, they may be required
to ensure client safety.
8. Sit with client and provide one-to-one observation if assessed
to be actively suicidal. Client safety is a nursing priority,
and one-to-one observation may be necessary to prevent a
suicidal attempt.
2506_Ch03_054-070.indd 61 10/1/10 9:33:40 AM

9. Teach relaxation exercises to intervene in times of increas-

ing anxiety.
10. Teach prospective caregivers to recognize client behaviors
that indicate anxiety is increasing and ways to intervene
before violence occurs.
Outcome Criteria
1. Prospective caregivers are able to verbalize behaviors
that indicate an increasing anxiety level and ways they
may assist client to manage the anxiety before violence
occurs.
2. With assistance from caregivers, client is able to control
impulse to perform acts of violence against self or others.
CHRONIC CONFUSION
De nition: Irreversible, long-standing, and/or progressive dete-
rioration of intellect and personality characterized by decreased
ability to interpret environmental stimuli; decreased capacity for
intellectual thought processes; and manifested by disturbances of
memory, orientation, and behavior.

[Alteration in structure/function of brain tissue, secondary to
the following conditions:
Advanced age
Vascular disease
Hypertension
Cerebral hypoxia
Long-term abuse of mood- or behavior-altering
substances
Exposure to environmental toxins
Various other physical disorders that predispose to
cerebral abnormalities (see Predisposing Factors)]

Altered interpretation
Altered personality
Altered response to stimuli
Clinical evidence of organic impairment
Impaired long-term memory
Impaired short-term memory
Impaired socialization
Longstanding cognitive impairment
No change in level of consciousness
Progressive cognitive impairment
2506_Ch03_054-070.indd 62 10/1/10 9:33:40 AM

Goals/Objectives
Short-term Goal
Client will accept explanations of inaccurate interpretations
within the environment.
Long-term Goal
With assistance from caregiver, client will be able to interrupt
nonreality-based thinking.

1. Frequently orient client to reality and surroundings. Allow
client to have familiar objects around him or her. Use oth-
er items, such as a clock, a calendar, and daily schedules, to
assist in maintaining reality orientation. Client safety is
jeopardized during periods of disorientation. Maintaining
reality orientation enhances clients sense of self-worth and
personal dignity.
2. Teach prospective caregivers how to orient client to time,
person, place, and circumstances, as required. These care-
givers will be responsible for client safety after discharge
from the hospital. Sharing successful interventions may be
helpful.
3. Give positive feedback when thinking and behavior are appro-
priate, or when client verbalizes that certain ideas expressed
are not based in reality. Positive feedback increases self-esteem
and enhances desire to repeat appropriate behaviors.
4. Use simple explanations and face-to-face interaction when
communicating with client. Do not shout message into cli-
ents ear. Speaking slowly and in a face-to-face position is
most effective when communicating with an elderly indi-
vidual experiencing a hearing loss. Visual cues facilitate
understanding. Shouting causes distortion of high-pitched
sounds and in some instances creates a feeling of discomfort
for client.
5. Express reasonable doubt if client relays suspicious beliefs
in response to delusional thinking. Discuss with client the
potential personal negative effects of continued suspicious-
ness of others. Reinforce accurate perception of people and
situations. Expressions of doubt by a trusted individual may
foster similar uncertainties about delusion on the part of
client.
6. Do not permit rumination of false ideas. When this begins,
talk to client about real people and real events. Reality ori-
entation increases clients sense of self-worth and personal
dignity.
7. Close observation of clients behavior is indicated if delusion-
al thinking reveals an intention for violence. Client safety is
a nursing priority.
2506_Ch03_054-070.indd 63 10/1/10 9:33:40 AM

CLINICAL PEARL Medications for Alzheimers disease. Cholinesterase

inhibitors are used for mild to moderate cognitive impairment in clients with
Alzheimers disease. Examples include tacrine (Cognex), donepezil (Aricept),
rivastigmine (Exelon), and galantamine (Razadyne). Common side effects include
dizziness, headache, and gastrointestinal upset. Memantine (Namenda), an NMDA
receptor antagonist, is used for treatment of moderate to severe cognitive impairment
in clients with Alzheimers disease. Common side effects of memantine include
dizziness, headache, and constipation. These medications do not stop or reverse the
disease process but may slow down the progression of the decline in functionality.
Outcome Criteria
1. With assistance from caregiver, client is able to distinguish
between reality-based and nonreality-based thinking.
2. Prospective caregivers are able to verbalize ways in which to
orient client to reality, as needed.
SELF-CARE DEFICIT
daily living (ADLs)] for self.


Inability to wash body
Inability to put on clothing
Inability to bring food from receptacle to mouth
[Inability to toilet self without assistance]
Goals/Objectives
Short-term Goal
Client will participate in ADLs with assistance from caregiver.
Long-term Goal
Client will accomplish ADLs to the best of his or her ability.
Unfullled needs will be met by caregiver.

1. Provide a simple, structured environment to minimize
confusion:
a. Identify self-care decits and provide assistance as
required.
b. Allow plenty of time for client to perform tasks.
c. Provide guidance and support for independent actions by
talking client through the task one step at a time.
2506_Ch03_054-070.indd 64 10/1/10 9:33:41 AM

d. Provide a structured schedule of activities that does not

change from day to day.
e. Ensure that ADLs follow home routine as closely as
possible.
f. Provide for consistency in assignment of daily caregivers.
2. In planning for discharge:
a. Perform ongoing assessment of clients ability to ful ll
nutritional needs, ensure personal safety, follow medi-
cation regimen, and communicate need for assistance
with those activities that he or she cannot accomplish
independently. Client safety and security are nursing
priorities.
b. Assess prospective caregivers ability to anticipate and
fulll clients unmet needs. Provide information to assist
caregivers with this responsibility. Ensure that caregivers
are aware of available community support systems from
which they can seek assistance when required. This will
facilitate transition to discharge from treatment center.
c. National support organizations can provide information:
National Parkinson Foundation, Inc.
1501 NW 9th Ave.
Miami, FL 33136-1494
1-800-327-4545
Alzheimers Association
225 N. Michigan Ave., Fl. 17
Chicago, IL 60601-7633
1-800-272-3900
Outcome Criteria
1. Client willingly participates in ADLs.
2. Client accomplishes ADLs to the best of his or her ability.
3. Clients unfullled needs are met by caregivers.
DISTURBED SENSORY PERCEPTION

(Specify)
Denition: Change in the amount or patterning of incoming stimuli
[either internally or externally initiated] accompanied by a diminished,
exaggerated, distorted, or impaired response to such stimuli.

[Alteration in structure/function of brain tissue, secondary to
the following conditions:
Advanced age
Vascular disease
2506_Ch03_054-070.indd 65 10/1/10 9:33:41 AM

Hypertension
Cerebral hypoxia
Abuse of mood- or behavior-altering substances
Exposure to environmental toxins
Various other physical disorders that predispose to cere-
bral abnormalities (see Predisposing Factors)]

Poor concentration
Sensory distortions
Hallucinations
[Disorientation to time, place, person, or circumstances]
[Inappropriate responses]
[Talking and laughing to self]
[Suspiciousness]
Goals/Objectives
Short-term Goal
With assistance from caregiver, client will maintain orientation
to time, place, person, and circumstances for specied period
of time.
Long-term Goal
Client will demonstrate accurate perception of the environ-
ment by responding appropriately to stimuli indigenous to the
surroundings.

1. Decrease the amount of stimuli in clients environment
(e.g., low noise level, few people, simple decor). This de-
creases the possibility of clients forming inaccurate sensory
perceptions.
2. Do not reinforce the hallucination. Let client know that you
do not share the perception. Maintain reality through re-
orientation and focus on real situations and people. Reality
orientation decreases false sensory perceptions and enhances
clients sense of self-worth and personal dignity.
3. Provide reassurance of safety if client responds with fear to
inaccurate sensory perception. Client safety and security are
nursing priorities.
4. Correct clients description of inaccurate perception, and de-
scribe the situation as it exists in reality. Explanation of and
participation in real situations and real activities interfere
with the ability to respond to hallucinations.
5. Allow for care to be given by same personnel on a regular
basis, if possible, to provide a feeling of security and stability
in clients environment.
2506_Ch03_054-070.indd 66 10/1/10 9:33:41 AM

6. Teach prospective caregivers how to recognize signs and

symptoms of clients inaccurate sensory perceptions. Explain
techniques they may use to restore reality to the situation.
Outcome Criteria
1. With assistance from caregiver, client is able to recognize
when perceptions within the environment are inaccurate.
2. Prospective caregivers are able to verbalize ways in which
to correct inaccurate perceptions and restore reality to the
situation.
LOW SELF-ESTEEM
capabilities.

[Loss of independent functioning]
[Loss of capacity for remembering]
[Loss of capability for effective verbal communication]

[Withdraws into social isolation]
Lack of eye contact
[Excessive crying alternating with expressions of anger]
[Refusal to participate in therapies]
[Refusal to participate in own self-care activities]
[Becomes increasingly dependent on others to perform
ADLs]
Goals/Objectives
Short-term Goal
Client will voluntarily spend time with staff and peers in day-
room activities (time dimension to be individually determined).
Long-term Goal
Client will exhibit increased feelings of self-worth as evidenced
by voluntary participation in own self-care and interaction
with others (time dimension to be individually determined).

1. Encourage client to express honest feelings in relation to
loss of prior level of functioning. Acknowledge pain of loss.
2506_Ch03_054-070.indd 67 10/1/10 9:33:42 AM

Support client through process of grieving. Client may be

fi xed in anger stage of grieving process, which is turned
inward on the self, resulting in diminished self-esteem.
2. Devise methods for assisting client with memory decit.
These aids may assist client to function more independently,
thereby increasing self-esteem. Examples follow:
a. Name sign on door identifying clients room.
b. Identifying sign on outside of dining room door.
c. Identifying sign on outside of restroom door.
d. Large clock, with oversized numbers and hands, appropri-
ately placed.
e. Large calendar, indicating one day at a time, with month,
day, and year identied in bold print.
f. Printed, structured daily schedule, with one copy for client
and one posted on unit wall.
g. News board on unit wall where current national and
local events may be posted.
3. Encourage clients attempts to communicate. If verbalizations
are not understandable, express to client what you think he or
she intended to say. It may be necessary to reorient client fre-
quently. The ability to communicate effectively with others
may enhance self-esteem.
4. Encourage reminiscence and discussion of life review. Also
discuss present-day events. Sharing picture albums, if pos-
sible, is especially good. Reminiscence and life review help
client resume progression through the grief process associ-
ated with disappointing life events and increase self-esteem
as successes are reviewed.
5. Encourage participation in group activities. Caregiver may
need to accompany client at rst, until he or she feels secure
that group members will be accepting, regardless of limita-
tions in verbal communication. Positive feedback from group
members will increase self-esteem.
6. Offer support and empathy when client expresses embar-
rassment at inability to remember people, events, and places.
Focus on accomplishments to lift self-esteem.
7. Encourage client to be as independent as possible in self-care
activities. Provide written schedule of tasks to be performed.
Intervene in areas where client requires assistance. The abil-
ity to perform independently preserves self-esteem.
Outcome Criteria
1. Client initiates own self-care according to written schedule
and willingly accepts assistance as needed.
2. Client interacts with others in group activities, maintaining
anxiety at minimal level in response to difculties with ver-
bal communication.
2506_Ch03_054-070.indd 68 10/1/10 9:33:42 AM

CAREGIVER ROLE STRAIN

De nition: Difficulty in performing family caregiver role.

Severity of care receivers illness
Chronicity of care receivers illness
[Lack of respite and recreation for caregiver]
Caregivers competing role commitments
Inadequate physical environment for providing care
Family or caregiver isolation
Complexity and amount of caregiving activities
Apprehension about possible institutionalization of care receiver
Apprehension about future regarding care receivers health and
caregivers ability to provide care
Difculty performing and/or completing required tasks
Apprehension about care receivers care if caregiver unable to
provide care
Goals/Objectives
Short-term Goal
Caregivers will verbalize understanding of ways to facilitate the
caregiver role.
Long-term Goal
Caregivers will demonstrate effective problem-solving skills and
develop adaptive coping mechanisms to regain equilibrium.

1. Assess caregivers ability to anticipate and fulll clients un-
met needs. Provide information to assist caregivers with this
responsibility. Caregivers may be unaware of what client will
realistically be able to accomplish. They may be unaware of
the progressive nature of the illness.
2. Ensure that caregivers are aware of available community
support systems from which they can seek assistance when
required. Examples include adult day-care centers, house-
keeping and homemaker services, respite-care services,
and a local chapter of the Alzheimers Association. This
organization sponsors a nationwide 24-hour hot line to
provide information and link families who need assistance
with nearby chapters and afliates. The hotline number is
1-800-272-3900. Caregivers require relief from the pressures
and strain of providing 24-hour care for their loved ones.
2506_Ch03_054-070.indd 69 10/1/10 9:33:42 AM

Studies show that elder abuse arises out of caregiving situa-

tions that place overwhelming stress on caregivers.
3. Encourage caregivers to express feelings, particularly anger.
Release of these emotions can serve to prevent psychopathol-
ogy, such as depression or psychophysiological disorders,
from occurring.
4. Encourage participation in support groups composed of
members with similar life situations. Hearing others who are
experiencing the same problems discuss ways in which they
have coped may help caregiver adopt more adaptive strate-
gies. Individuals who are experiencing similar life situations
provide empathy and support for each other.
Outcome Criteria
1. Caregivers are able to problem solve effectively regarding
care of elderly client.
2. Caregivers demonstrate adaptive coping strategies for dealing
with stress of caregiver role.
3. Caregivers express feelings openly.
4. Caregivers express desire to join support group of other
caregivers.
INTERNET REFERENCES
Additional information about Alzheimers disease may be
located at the following websites:
a. http://www.alz.org
b. http://www.nia.nih.gov/
c. http://www.ninds.nih.gov/disorders/alzheimersdisease/
alzheimersdisease.htm
Information on caregiving can be located at the following
website:
a. http://www.aarp.org
Additional information about medications to treat Alzheimers
disease may be located at the following websites:
b. http://www.nimh.nih.gov/publicat/medicate.cfm
c. http://www.drugs.com/condition/alzheimer-s-disease
html.
d. http://www.nlm.nih.gov/medlineplus/druginformation
html.
Movie Connections
The Notebook (Alzheimers disease) Away from Her
(Alzheimers disease) Iris (Alzheimers disease)
2506_Ch03_054-070.indd 70 10/1/10 9:33:43 AM

C H A P T E R
4
Substance-Related
Disorders
The substance-related disorders are composed of two groups:
the substance-use disorders (dependence and abuse) and the
substance-induced disorders (intoxication and withdrawal).
Other substance-induced disorders (delirium, dementia, am-
nesia, psychosis, mood disorder, anxiety disorder, and sexual
dysfunction) are included in the chapters with which they share
symptomatology (e.g., substance-induced anxiety disorder is
included in Chapter 8; substance-induced sexual dysfunction is
included in Chapter 11, etc.).
SUBSTANCE-USE DISORDERS
Substance Abuse
De ned
Revision (DSM-IV-TR) de nes substance abuse as a mal-
adaptive pattern of substance use manifested by recurrent and
signicant adverse consequences related to repeated use of the
substance. Symptoms include use of substances in physically
harmful circumstances, impaired role performance (school,
work, or home), repeated encounters with the legal system for
substance-related conduct, and experiencing personal problems
related to substance use.
Substance Dependence
De ned
Dependence is de ned as a compulsive or chronic requirement.
The need is so strong as to generate distress (either physical or
psychological) if left unfullled (Townsend, 2009). Dependence
on substances is identied by the appearance of unpleasant
effects characteristic of a withdrawal syndrome when a drug is
71
2506_Ch04_071-104.indd 71 10/1/10 9:33:54 AM

discontinued. Dependence on substances can also be associated

with tolerance, in which there is a need for increasingly larger
or more frequent doses of a substance to obtain the desired
effects originally produced by a lower dose. The individual who
is dependent on substances continues to increase the amount
consumed to achieve the desired effect and to relieve or avoid
withdrawal symptoms.
SUBSTANCE-INDUCED DISORDERS
Substance Intoxication
De ned
Intoxication is de ned as a physical and mental state of exhila-
ration and emotional frenzy or lethargy and stupor (Townsend,
2009). With substance intoxication, the individual experiences
a reversible syndrome of symptoms that occur with ingestion of
a substance and that are specic to the substance ingested. The
behavior changes can be attributed to the physiological effects
of the substance on the central nervous system (CNS).
Substance Withdrawal
De ned
Withdrawal is de ned as the physiological and mental read-
justment that accompanies the discontinuation of an addictive
substance (Townsend, 2009). The symptoms of withdrawal
are specic to the substance that has been ingested and oc-
cur after prolonged or heavy use of the substance. The effects
are of sufcient signicance to interfere with usual role
performance.
CLASSIFICATION OF SUBSTANCES
Alcohol
Although alcohol is a CNS depressant, it is considered sepa-
rately because of the complex effects and widespread nature
of its use. Low to moderate consumption produces a feeling
of well-being and reduced inhibitions. At higher concentra-
tions, motor and intellectual functioning are impaired, mood
becomes very labile, and behaviors characteristic of depres-
sion, euphoria, and aggression are exhibited. The only medical
use for alcohol (with the exception of its inclusion in a number
of pharmacological concentrates) is as an antidote for methanol
consumption.
E XAMPLES: Beer, wine, bourbon, scotch, gin, vodka, rum, tequila, liqueurs.
Common substances containing alcohol and used by some
dependent individuals to satisfy their need include liquid cough
medications, liquid cold preparations, mouthwashes, isopropyl
2506_Ch04_071-104.indd Sec1:72 10/1/10 9:33:55 AM

rubbing alcohol, nail polish removers, colognes, and aftershave

and preshave preparations.
Opioids
Opioids have a medical use as analgesics, antitussives, and an-
tidiarrheals. They produce the effects of analgesia and euphoria
by stimulating the opiate receptors in the brain, thereby mim-
icking the naturally occurring endorphins.
E XAMPLES: Opium, morphine, codeine, heroin, hydrocodone, oxycodone, meperidine, methadone.
C OMMON S TREET N AMES: Horse, junk, H (heroin); black stuff, poppy, big O (opium); M, morph
(morphine); dollies (methadone); terp (terpin hydrate or cough syrup with codeine); oxy, O.C.
(oxycodone); Vike (hydrocodone).
CNS Depressants
CNS depressants have a medical use as antianxiety agents, seda-
tives, hypnotics, anticonvulsants, and anesthetics. They depress
the action of the CNS, resulting in an overall calming, relax-
ing effect on the individual. At higher dosages they can induce
sleep.
E XAMPLES: Benzodiazepines, barbiturates, chloral hydrate, meprobamate, flunitrazepam.
C OMMON S TREET N AMES: Peter, Mickey (chloral hydrate); green and whites, roaches (Librium);
blues (Valium, 10 mg); yellows (Valium, 5 mg); candy, tranks (other benzodiazepines); red
birds, red devils (secobarbital); downers (barbiturates; tranquilizers); rophies, forget-me pill,
R2 (flunitrazepam [Rohypnol]).
CNS Stimulants
CNS stimulants have a medical use in the management of
hyperkinesia, narcolepsy, and weight control. They stimulate
the action of the CNS, resulting in increased alertness, excita-
tion, euphoria, increased pulse rate and blood pressure, insom-
nia, and loss of appetite.
E XAMPLES : Amphetamines, methylphenidate (Ritalin), phendimetrazine (Bontril), cocaine,
hydrochloride cocaine, caffeine, tobacco, methylenedioxymethamphetamine (MDMA).
C OMMON S TREET N AMES: Bennies, wake-ups, uppers, speed (amphetamines); coke, snow, gold
dust, girl (cocaine); crack, rock (hydrochloride cocaine); speedball (mixture of heroin and
cocaine); Adam, ecstasy, XTC (MDMA).
Hallucinogens
Hallucinogens act as sympathomimetic agents, producing
effects resembling those resulting from stimulation of the
sympathetic nervous system (e.g., excitation, increased energy,
distortion of the senses). Therapeutic medical uses for lysergic
acid diethylamide (LSD) have been proposed in the treatment
2506_Ch04_071-104.indd Sec1:73 10/1/10 9:33:55 AM

of chronic alcoholism and in the reduction of intractable pain,

such as terminal malignant disease and phantom limb sensa-
tions. At this time there is no real evidence of the safety and
efcacy of the drug in humans.
E XAMPLES: LSD, mescaline, phencyclidine (PCP), psilocybin.
C OMMON S TREET N AMES: Acid, cube, big D, California sunshine (LSD); angel dust, hog, peace pill,
crystal (PCP); cactus, mescal, mesc (mescaline); magic mushroom, shrooms (psilocybin).
Cannabinols
Cannabinols depress higher centers in the brain and consequently
release lower centers from inhibitory inuence. They produce an
anxiety-free state of relaxation characterized by a feeling of ex-
treme well-being. Large doses of the drug can produce hallucina-
tions. Marijuana has been used therapeutically in the relief of nau-
sea and vomiting associated with antineoplastic chemotherapy.
E XAMPLES: Marijuana, hashish.
C OMMON S TREET N AMES: Joints, reefers, pot, grass, Mary Jane (marijuana); hash (hashish).
Inhalants
Inhalant disorders are induced by inhaling the aliphatic
and aromatic hydrocarbons found in substances such as fuels,
solvents, adhesives, aerosol propellants, and paint thinners.
Inhalants are absorbed through the lungs and reach the CNS
very rapidly. Inhalants generally act as a CNS depressant. The
effects are relatively brief, lasting from several minutes to a
few hours, depending on the specic substance and amount
consumed.
E XAMPLES: Gasoline, varnish remover, lighter fluid, airplane glue, rubber cement, cleaning fluid,
spray paint, shoe conditioner, typewriter correction fluid.
A pro le summary of these psychoactive substances is

presented in Table 4-1.
PREDISPOSING FACTORS FOR

SUBSTANCE-RELATED DISORDERS
1. Physiological
a. Genetics. A genetic link may be involved in the develop-
ment of substance-related disorders. This is especially
evident with alcoholism, and less so with other substanc-
es. Children of alcoholics are three times more likely than
are other children to become alcoholics (Harvard Medical
School, 2001). Studies with monozygotic and dizygotic
twins have also supported the genetic hypothesis.
2506_Ch04_071-104.indd Sec1:74 10/1/10 9:33:56 AM

TABLE 4 1 Psychoactive Substances: A Profile Summary
Therapeutic Symptoms of
Class of Drugs Symptoms of Use Uses Overdose Trade Names Common Names
2506_Ch04_071-104.indd Sec1:75
CNS Depressants
Alcohol Relaxation, loss of Antidote for Nausea, vomiting; Ethyl alcohol, beer, Booze, alcohol, liquor,
inhibitions, lack methanol shallow respirations; gin, rum, vodka, drinks, cocktails,
of concentration, consumption; cold, clammy skin; bourbon, whiskey, highballs, nightcaps,
drowsiness, slurred ingredient in weak, rapid pulse; liqueurs, wine, moonshine, white
speech, sleep many phar- coma; possible death brandy, sherry, lightning, rewater
macological champagne
concentrates
Other Same as alcohol Relief from Anxiety, fever, agita- Seconal, Nembutal, Red birds, yellow birds,
(barbiturates and anxiety and tion, hallucinations, Amytal blue birds
nonbarbiturates) insomnia; as disorientation, Valium Blues/yellows
anticonvulsants tremors, delirium, Librium Green and whites
and anesthetics convulsions, Noctec Mickies
possible death Miltown Downers
Rohypnol Rophies, forget-me
pill, R2
CNS Stimulants
Amphetamines Hyperactivity, Management of Cardiac arrhythmias, Dexedrine, Didrex, Uppers, pep pills,
and related drugs agitation, euphoria, narcolepsy, hy- headache, convul- Tenuate, Bontril, wakeups, bennies,
insomnia, loss of perkinesia, and sions, hypertension, Ritalin, Focalin, eye-openers, speed,
appetite weight control rapid heart rate, Meridia, Provigil, black beauties,
coma, possible death Methylenedioxymet- sweet As ecstasy,
amphetamine Adam,
(MDMA) XTC
Continued
10/1/10 9:33:56 AM
TABLE 4 1 Psychoactive Substances: A Profile Summarycontd
Therapeutic Symptoms of
Class of Drugs Symptoms of Use Uses Overdose Trade Names Common Names
2506_Ch04_071-104.indd Sec1:76
Cocaine Euphoria, hyperactiv- Hallucinations, convul- Cocaine Coke, ake, snow,
ity, restlessness, talk- sions, pulmonary hydrochloride dust, happy dust,
ativeness, increased edema, respiratory gold dust, girl, cecil,
pulse, dilated pupils, failure, coma, cardiac C, toot, blow, crack
rhinitis arrest, possible death
Opioids
Euphoria, lethargy, As analgesics; Shallow breathing, Heroin Snow, stuff, H, harry,
drowsiness, lack of methadone in slowed pulse, Morphine horse, M, morph,
motivation, substitution clammy skin, Miss Emma
constricted therapy; heroin pulmonary edema, Codeine Schoolboy
pupils has no thera- respiratory arrest, Dilaudid Lords
peutic use convulsions, coma, Demerol Doctors
possible death Dolophine Dollies
Percodan Perkies
Talwin Ts
Opium Big O, black stuff
Hallucinogens
Visual hallucinations, LSD has been Agitation, extreme LSD Acid, cube, big D
disorientation, proposed in the hyperactivity, PCP Angel dust, hog, peace
confusion, paranoid treatment of violence, hallucina- pill
delusions, eupho- chronic alcohol- tions, psychosis, Mescaline Mesc
ria, anxiety, panic, ism, and in the convulsions, possible DMT Businessmans trip
increased pulse reduction of death STP Serenity and peace
intractable pain.
10/1/10 9:33:56 AM
No therapeutic
use at this time.
2506_Ch04_071-104.indd Sec1:77
Cannabinols
Relaxation, talkative- Marijuana has Fatigue, paranoia, Cannabis Marijuana, pot, grass,
ness, lowered been used for delusions, joint, Mary Jane, MJ
inhibitions, relief of nausea hallucinations,
euphoria, mood and vomiting possible Hashish Hash, rope, Sweet
swings associated with psychosis Lucy
antineoplastic
chemotherapy
and to reduce
eye pressure in
glaucoma
Inhalants
Dizziness, weakness, Can proceed to coma Gasoline
tremor, euphoria, and death Solvents
slurred speech, Adhesives
unsteady gait, Paint thinner
lethargy, nystag- Lighter uid
mus, blurred vision, Glue
diplopia Cleaning uid
10/1/10 9:33:57 AM
b. Biochemical. A second physiological hypothesis relates

to the possibility that alcohol may produce morphine-
like substances in the brain that are responsible for alco-
hol addiction. This occurs when the products of alcohol
metabolism react with biologically active amines.
2. Psychosocial
a. Psychodynamic Theory. The psychodynamic approach to
the etiology of substance abuse focuses on a punitive super-
ego and xation at the oral stage of psychosexual develop-
ment (Sadock & Sadock, 2007). Individuals with punitive
superegos turn to alcohol to diminish unconscious anxi-
ety and increase feelings of power and self-worth. Sadock
and Sadock (2007) stated, As a form of self-medication,
alcohol may be used to control panic, opioids to diminish
anger, and amphetamines to alleviate depression (p. 386).
b. Social Learning Theory. The effects of modeling, imita-
tion, and identication on behavior can be observed from
early childhood onward. In relation to drug consumption,
the family appears to be an important inuence. Various
studies have shown that children and adolescents are more
likely to use substances if they have parents who provide a
model for substance use. Peers often exert a great deal of
inuence in the life of the child or adolescent who is being
encouraged to use substances for the rst time. Modeling
may continue to be a factor in the use of substances once
the individual enters the work force. This is particularly
true in the work setting that provides plenty of leisure
time with coworkers and where drinking is valued and is
used to express group cohesiveness.
COMMON PATTERNS OF USE IN

Data)
Alcohol Abuse/Dependence
1. Begins with social drinking that provides feeling of
relaxation and well-being. Soon requires more and more to
produce the same effects.
2. Drinks in secret; hides bottles of alcohol; drinks rst thing
in the morning (to steady my nerves) and at any other
opportunity that arises during the day.
3. As the disease progresses, the individual may drink in binges.
During a binge, drinking continues until the individual is
too intoxicated or too sick to consume any more. Behavior
borders on the psychotic, with the individual wavering in and
out of reality.
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4. Begins to have blackouts. Periods of amnesia occur (in the

absence of intoxication or loss of consciousness) during
which the individual is unable to remember periods of time
or events that have occurred.
5. Experiences multisystem physiological impairments from
chronic use that include (but are not limited to) the following:
a. Peripheral Neuropathy: Numbness, tingling, pain in
extremities (caused by thiamine deciency).
b. Wernicke-Korsakoff Syndrome: Mental confusion, agita-
tion, diplopia (caused by thiamine deciency). Without
immediate thiamine replacement, rapid deterioration to
coma and death will occur.
c. Alcoholic Cardiomyopathy: Enlargement of the heart
caused by an accumulation of excess lipids in myocardial
cells. Symptoms of tachycardia, dyspnea, and arrhythmias
may be evident.
d. Esophagitis: Inammation of, and pain in, the esophagus.
e. Esophageal Varices: Distended veins in the esophagus,
with risk of rupture and subsequent hemorrhage.
f. Gastritis: Inammation of lining of stomach caused by
irritation from the alcohol, resulting in pain, nausea,
vomiting, and possibility of bleeding because of erosion of
blood vessels.
g. Pancreatitis: Inammation of the pancreas, resulting in
pain, nausea and vomiting, and abdominal distention.
With progressive destruction to the gland, symptoms of
diabetes mellitus could occur.
h. Alcoholic Hepatitis: Inammation of the liver, resulting
in enlargement, jaundice, right upper quadrant pain, and
fever.
i. Cirrhosis of the Liver: Fibrous and degenerative
changes occurring in response to chronic accumulation
of large amounts of fatty acids in the liver. In cirrhosis,
symptoms of alcoholic hepatitis progress to include the
following:
Portal Hypertension: Elevation of blood pressure through
the portal circulation resulting from defective blood flow
through the cirrhotic liver.
Ascites: An accumulation of serous fluid in the peritoneal
cavity.
Hepatic Encephalopathy: Liver disorder caused by in-
ability of the liver to convert ammonia to urea (the bodys
natural method of discarding excess ammonia); as serum
ammonia levels rise, confusion occurs, accompanied by
restlessness, slurred speech, fever, and, without interven-
tion, an eventual progression to coma and death.
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Alcohol Intoxication
1. Symptoms of alcohol intoxication include disinhibition
of sexual or aggressive impulses, mood lability, impaired
judgment, impaired social or occupational functioning,
slurred speech, incoordination, unsteady gait, nystagmus,
and ushed face.
2. Physical and behavioral impairment based on blood alcohol
concentrations differ according to gender, body size, physical
condition, and level of tolerance.
3. The legal denition of intoxication in most states in the
United States is a blood alcohol concentration of 80 or 100 mg
ethanol per deciliter of blood (mg/dL), which is also measured
as 0.08 to 0.10 g/dL.
4. Nontolerant individuals with blood alcohol concentrations
greater than 300 mg/dL are at risk for respiratory failure,
coma, and death (Sadock & Sadock, 2007).
Alcohol Withdrawal
1. Occurs within 4 to 12 hours of cessation of, or reduction in,
heavy and prolonged alcohol use.
2. Symptoms include coarse tremor of hands, tongue, or eye-
lids; nausea or vomiting; malaise or weakness; tachycardia;
sweating; elevated blood pressure; anxiety; depressed mood
or irritability; transient hallucinations or illusions; headache;
seizures; and insomnia.
3. Without aggressive intervention, the individual may prog-
ress to alcohol withdrawal delirium about the second or third
day following cessation of, or reduction in, prolonged, heavy
alcohol use. Symptoms include those described under the
syndrome of delirium (see Chapter 3).
Amphetamine (or Amphetamine-like)
Dependence/Abuse
1. The use of amphetamines is often initiated for their appetite-
suppressant effect in an attempt to lose or control weight.
2. Amphetamines are also taken for the initial feeling of well-
being and condence.
3. They are typically taken orally, intravenously, or by nasal
inhalation.
4. Chronic daily (or almost daily) use usually results in an
increase in dosage over time to produce the desired effect.
5. Episodic use often takes the form of binges, followed by
an intense and unpleasant crash in which the individual
experiences anxiety, irritability, and feelings of fatigue and
depression.
6. Continued use appears to be related to a craving for the
substance, rather than to prevention or alleviation of with-
drawal symptoms.
2506_Ch04_071-104.indd Sec1:80 10/1/10 9:33:58 AM


Intoxication
1. Amphetamine intoxication usually begins with a high feeling,
followed by the development of symptoms such as euphoria with
enhanced vigor, gregariousness, hyperactivity, restlessness, hy-
pervigilance, interpersonal sensitivity, talkativeness, anxiety,
tension, alertness, grandiosity, stereotypical and repetitive be-
havior, anger, ghting, and impaired judgment (APA, 2000).
2. Physical signs and symptoms that occur with amphetamine
intoxication include tachycardia or bradycardia, pupillary
dilation, elevated or lowered blood pressure, perspiration or
chills, nausea or vomiting, psychomotor retardation or agita-
tion, muscular weakness, respiratory depression, chest pain
or cardiac arrhythmias, confusion, seizures, dyskinesias, dys-
tonias, or coma (APA, 2000).
Withdrawal
1. Amphetamine withdrawal symptoms occur after cessation of
(or reduction in) amphetamine (or a related substance) use
that has been heavy and prolonged.
2. Symptoms of amphetamine withdrawal develop within a few
hours to several days and include fatigue; vivid, unpleasant
dreams; insomnia or hypersomnia; increased appetite; and
psychomotor retardation or agitation.
Cannabis Dependence/Abuse/
1. Cannabis preparations are almost always smoked but may
also be taken orally.
2. It is commonly regarded incorrectly to be a substance with-
out potential for dependence.
3. Tolerance to the substance may result in increased frequency
of its use.
4. Abuse is evidenced by participation in hazardous activities
while motor coordination is impaired from cannabis use.
Cannabis Intoxication
1. Cannabis intoxication is characterized by impaired motor
coordination, euphoria, anxiety, sensation of slowed time,
impaired judgment, and social withdrawal that develop dur-
ing or shortly after cannabis use (APA, 2000).
2. Physical symptoms of cannabis intoxication include conjuncti-
val injection, increased appetite, dry mouth, and tachycardia.
3. The impairment of motor skills lasts for 8 to 12 hours.
Cocaine Dependence/Abuse
1. Various forms are smoked, inhaled, injected, or taken orally.
2. Chronic daily (or almost daily) use usually results in an
increase in dosage over time to produce the desired effect.
2506_Ch04_071-104.indd Sec1:81 10/1/10 9:33:58 AM

3. Episodic use often takes the form of binges, followed by an in-

tense and unpleasant crash in which the individual experiences
anxiety, irritability, and feelings of fatigue and depression.
4. The drug user often abuses, or is dependent on, a CNS
depressant to relieve the residual effects of cocaine.
5. Cocaine abuse and dependence lead to tolerance of the
substance and subsequent use of increasing doses.
6. Continued use appears to be related to a craving for the
substance, rather than to prevention or alleviation of with-
drawal symptoms.
Cocaine Intoxication
1. Symptoms of cocaine intoxication develop during, or shortly
after, use of cocaine.
2. Symptoms of cocaine intoxication include euphoria or
affective blunting, changes in sociability, hypervigilance,
interpersonal sensitivity, anxiety, tension, anger, stereo-
typed behaviors, impaired judgment, and impaired social or
occupational functioning.
3. Physical symptoms of cocaine intoxication include tachycar-
dia or bradycardia, pupillary dilation, elevated or lowered
blood pressure, perspiration or chills, nausea or vomiting,
psychomotor agitation or retardation, muscular weakness,
respiratory depression, chest pain, cardiac arrhythmias, con-
fusion, seizures, dyskinesias, dystonias, or coma.
Cocaine Withdrawal
1. Symptoms of withdrawal occur after cessation of, or reduc-
tion in, cocaine use that has been heavy and prolonged.
2. Symptoms of cocaine withdrawal include dysphoric mood;
fatigue; vivid, unpleasant dreams; insomnia or hypersomnia;
increased appetite; psychomotor retardation or agitation.
Hallucinogen Dependence/Abuse
1. Hallucinogenic substances are taken orally.
2. The cognitive and perceptual impairment may last for up to
12 hours, so use is generally episodic, because the individual
must organize time during the daily schedule for its use.
3. Frequent use results in tolerance to the effects of the
substance.
4. Dependence is rare, and most people are able to resume their
previous lifestyle, following a period of hallucinogen use,
without much difculty.
5. Flashbacks may occur following cessation of hallucinogen use.
These episodes consist of visual or auditory misperceptions
usually lasting only a few seconds but sometimes lasting up to
several hours.
2506_Ch04_071-104.indd Sec1:82 10/1/10 9:33:58 AM

6. Hallucinogens are highly unpredictable in the effects they

may induce each time they are used.
Hallucinogen Intoxication
1. Symptoms of intoxication develop during or shortly after
hallucinogen use.
2. Symptoms include marked anxiety or depression, ideas of
reference, fear of losing ones mind, paranoid ideation, and
impaired judgment.
3. Other symptoms include subjective intensication of percep-
tions, depersonalization, derealization, illusions, hallucina-
tions, and synesthesias.
4. Physical symptoms include pupillar dilation, tachycar-
dia, sweating, palpitations, blurring of vision, tremors, and
incoordination (APA, 2000).
Inhalant Dependence/Abuse
1. Effects are induced by inhaling the vapors of volatile sub-
stances through the nose or mouth.
2. Examples of substances include glue, gasoline, paint, paint
thinners, various cleaning chemicals, and typewriter correc-
tion uid.
3. Use of inhalants often begins in childhood, and considerable
family dysfunction is characteristic.
4. Use may be daily or episodic, and chronic use may continue
into adulthood.
5. Tolerance has been reported among individuals with heavy
use, but a withdrawal syndrome from these substances has
not been well documented.
Inhalant Intoxication
1. Symptoms of intoxication develop during, or shortly after,
use of, or exposure to, volatile inhalants.
2. Symptoms of inhalant intoxication include belligerence,
assaultiveness, apathy, impaired judgment, and impaired
social or occupational functioning.
3. Physical symptoms of inhalant intoxication include dizzi-
ness, nystagmus, incoordination, slurred speech, unsteady
gait, lethargy, depressed reexes, psychomotor retardation,
tremor, generalized muscle weakness, blurred vision or dip-
lopia, stupor or coma, and euphoria (APA, 2000).
Nicotine Dependence
1. The effects of nicotine are induced through inhaling the
smoke of cigarettes, cigars, or pipe tobacco and orally through
the use of snuff or chewing tobacco.
2. Continued use results in a craving for the substance.
2506_Ch04_071-104.indd Sec1:83 10/1/10 9:33:59 AM

3. Nicotine is commonly used to relieve or to avoid withdrawal

symptoms that occur when the individual has been in a situ-
ation where use is restricted.
4. Continued use despite knowledge of medical problems related
to smoking is a particularly important health problem.
Nicotine Withdrawal
1. Symptoms of withdrawal develop within 24 hours after
abrupt cessation of (or reduction in) prolonged nicotine use.
2. Symptoms of nicotine withdrawal include dysphoric or
depressed mood, insomnia, irritability, frustration, anger,
anxiety, difculty concentrating, restlessness, decreased
heart rate, and increased appetite.
Opioid Dependence/Abuse
1. Various forms are taken orally, intravenously, by nasal inha-
lation, and by smoking.
2. Dependence occurs after recreational use of the substance
on the street or after prescribed use of the substance for
relief of pain or cough.
3. Chronic use leads to remarkably high levels of tolerance.
4. Once abuse or dependence is established, substance procure-
ment often comes to dominate the persons life.
5. Cessation or decreased consumption results in a craving for
the substance and produces a specic syndrome of withdrawal.
Opioid Intoxication
opioid use.
2. Symptoms of opioid intoxication include euphoria (initially)
followed by apathy, dysphoria, psychomotor agitation or
retardation, impaired judgment, and impaired social or
occupational functioning.
3. Physical symptoms of opioid intoxication include pupil-
lary constriction, drowsiness or coma, slurred speech, and
impairment in attention or memory (APA, 2000).
Opioid Withdrawal
1. Symptoms of opioid withdrawal occur after cessation of (or
reduction in) heavy and prolonged opioid use. Symptoms of
withdrawal can also occur after administration of an opioid
antagonist after a period of opioid use.
2. Symptoms of opioid withdrawal can occur within minutes
to several days following use (or antagonist), and include
dysphoric mood, nausea or vomiting, muscle aches, lacrima-
tion or rhinorrhea, pupillary dilation, piloerection, sweating,
abdominal cramping, diarrhea, yawning, fever, and insomnia.
2506_Ch04_071-104.indd Sec1:84 10/1/10 9:33:59 AM

Phencyclidine Dependence/Abuse
1. Phencyclidine (PCP) is taken orally, intravenously, or by
smoking or inhaling.
2. Use can be on a chronic daily basis but more often is taken
episodically in binges that can last several days.
3. Physical dependence does not occur with PCP; however, psy-
chological dependence characterized by craving for the drug
has been reported in chronic users, as has the development of
tolerance.
4. Tolerance apparently develops quickly with frequent use.
Phencyclidine Intoxication
PCP use.
2. Symptoms of PCP intoxication include belligerence, assaul-
tiveness, impulsiveness, unpredictability, psychomotor agita-
tion, and impaired judgment.
3. Physical symptoms occur within 1 hour of PCP use and
include vertical or horizontal nystagmus, hypertension or
tachycardia, numbness or diminished responsiveness to pain,
ataxia, dysarthria, muscle rigidity, seizures or coma, and
hyperacusis (APA, 2000).
Sedative, Hypnotic, or Anxiolytic Dependence/
Abuse
1. Effects are produced through oral intake of these substances.
2. Dependence can occur following recreational use of the
substance on the street or after prescribed use of the
substance for relief of anxiety or insomnia.
3. Chronic use leads to remarkably high levels of tolerance.
4. Once dependence develops, there is evidence of strong
substance-seeking behaviors (obtaining prescriptions from
several physicians or resorting to illegal sources to maintain
adequate supplies of the substance).
5. Abrupt cessation of these substances can result in life-
threatening withdrawal symptoms.
Sedative, Hypnotic, or Anxiolytic Intoxication
intake of sedatives, hypnotics, or anxiolytics.
2. Symptoms of intoxication include inappropriate sexual or
aggressive behavior, mood lability, impaired judgment, and
impaired social or occupational functioning.
3. Physical symptoms of sedative, hypnotic, or anxiolytic
intoxication include slurred speech, incoordination, unsteady
gait, nystagmus, impairment in attention or memory, stupor,
or coma (APA, 2000).
2506_Ch04_071-104.indd Sec1:85 10/1/10 9:33:59 AM

Sedative, Hypnotic, or Anxiolytic Withdrawal

1. Withdrawal symptoms occur after cessation of (or reduc-
tion in) heavy and prolonged use of sedatives, hypnotics, or
anxiolytics.
2. Symptoms of withdrawal occur within several hours to a few
days after abrupt cessation or reduction in use of the drug.
3. Symptoms of withdrawal include autonomic hyperactiv-
ity (e.g., sweating or pulse rate greater than 100); increased
hand tremor; insomnia; nausea or vomiting; transient visual,
tactile, or auditory hallucinations or illusions; psychomotor
agitation; anxiety; or grand mal seizures.
A summary of symptoms associated with the syndromes of
intoxication and withdrawal is presented in Table 4-2.
Common Nursing Diagnoses
and Interventions for Clients
with Substance-Related Disorders
RISK FOR INJURY

De nition: At risk for injury as a result of [internal or external]
environmental conditions interacting with the individuals adaptive
and defensive resources.

[Substance intoxication]
[Substance withdrawal]
[Disorientation]
[Seizures]
[Hallucinations]
[Psychomotor agitation]
[Unstable vital signs]
[Delirium]
[Flashbacks]
[Panic level of anxiety]
Goals/Objectives
Short-term Goal
Clients condition will stabilize within 72 hours.
Long-term Goal
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TABLE 4 2 Summary of Symptoms Associated with the Syndromes of Intoxication and Withdrawal
Class of Drugs Intoxication Withdrawal Comments
2506_Ch04_071-104.indd Sec1:87
Alcohol Aggressiveness, impaired judgment, Tremors, nausea/vomiting, malaise, Alcohol withdrawal begins within
impaired attention, irritability, weakness, tachycardia, sweating, 4 to 6 hr after last drink. May
euphoria, depression, emotional elevated blood pressure, anxiety, progress to delirium tremens
lability, slurred speech, incoordi- depressed mood, irritability, on second or third day. Use of
nation, unsteady gait, nystagmus, hallucinations, headache, Librium or Serax is common for
ushed face insomnia, seizures substitution therapy.
Amphetamines Fighting, grandiosity, hyper- Anxiety, depressed mood, irritability, Withdrawal symptoms usually
and related vigilance, psychomotor agitation, craving for the substance, fatigue, peak within 2 to 4 days, although
substances impaired judgment, tachycardia, insomnia or hypersomnia, depression and irritability
pupillary dilation, elevated blood psychomotor agitation, paranoid may persist for months.
pressure, perspiration or chills, and suicidal ideation Antidepressants may be used.
nausea and vomiting
Caffeine Restlessness, nervousness, Headache, fatigue, anxiety, irritability, Caffeine is contained in coffee, tea,
excitement, insomnia, ushed depression, nausea, vomiting, muscle colas, cocoa, chocolate, some
face, diuresis, gastrointestinal pain and stiffness. over-the-counter analgesics,
complaints, muscle twitching, cold preparations, and
rambling ow of thought and stimulants.
speech, cardiac arrhythmia,
periods of inexhaustibility,
psychomotor agitation
Cannabis Euphoria, anxiety, suspiciousness, Restlessness, irritability, insomnia, Intoxication occurs immediately
sensation of slowed time, impaired loss of appetite and lasts about 3 hours. Oral
Substance-Related Disorders
judgment, social withdrawal, ingestion is more slowly absorbed

tachycardia, conjunctival redness, and has longer-lasting effects.
87
increased appetite, hallucinations

Continued
10/1/10 9:34:00 AM
TABLE 4 2 Summary of Symptoms Associated with the Syndromes of Intoxication and Withdrawalcontd
Class of Drugs Intoxication Withdrawal Comments
2506_Ch04_071-104.indd Sec1:88
Cocaine Euphoria, ghting, grandiosity, Depression, anxiety, irritability, Large doses of the drug can result
hypervigilance, psychomotor fatigue, insomnia or hypersomnia, in convulsions or death from
agitation, impaired judgment, psychomotor agitation, paranoid cardiac arrhythmias or
tachycardia, elevated blood pres- or suicidal ideation, apathy, social respiratory paralysis.
sure, pupillary dilation, perspira- withdrawal
tion or chills, nausea/vomiting,
hallucinations, delirium
Inhalants Belligerence, assaultiveness, apathy, Intoxication occurs within 5 min of
impaired judgment, dizziness, inhalation. Symptoms last 60 to
nystagmus, slurred speech, 90 min. Large doses can result in
unsteady gait, lethargy, depressed death from CNS depression or
reexes, tremor, blurred vision, cardiac arrhythmia.
stupor or coma, euphoria, irrita-
tion around eyes, throat, and nose
Nicotine Craving for the drug, irritability, Symptoms of withdrawal begin
anger, frustration, anxiety, dif- within 24 hr of last drug use and
culty concentrating, restlessness, decrease in intensity over days,
decreased heart rate, increased weeks, or sometimes longer.

appetite, weight gain, tremor,
headaches, insomnia
10/1/10 9:34:00 AM
Opioids Euphoria, lethargy, somnolence, Craving for the drug, nausea/vomiting, Withdrawal symptoms appear
apathy, dysphoria, impaired muscle aches, lacrimation or rhinor- within 6 to 8 hr after last dose,
2506_Ch04_071-104.indd Sec1:89
judgment, pupillary constriction, rhea, pupillary dilation, piloerection reach a peak in the second or
drowsiness, slurred speech, or sweating, diarrhea, yawning, third day, and disappear in 7 to
constipation, nausea, decreased fever, insomnia 10 days. Times are shorter with
respiratory rate and blood meperidine and longer with
pressure methadone.
Phencyclidine Belligerence, assaultiveness, Delirium can occur within 24 hr
and related impulsiveness, psychomotor after use of phencyclidine, or
substances agitation, impaired judgment, may occur up to 1 week following
nystagmus, increased heart rate recovery from an overdose of the
and blood pressure, diminished drug.
pain response, ataxia, dysarthria,
muscle rigidity, seizures,
hyperacusis, delirium
Sedatives, Disinhibition of sexual or aggressive Nausea/vomiting, malaise, weakness, Withdrawal may progress to
hypnotics, impulses, mood lability, impaired tachycardia, sweating, anxiety, delirium, usually within 1 week of
and anxiolytics judgment, slurred speech, irritability, orthostatic hypotension, last use. Long-acting barbiturates
incoordination, unsteady gait, tremor, insomnia, seizures or benzodiazepines may be used in
impairment in attention or withdrawal substitution therapy.
memory, disorientation, confusion
Substance-Related Disorders
89
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1. Assess clients level of disorientation to determine specic
requirements for safety. Knowledge of clients level of func-
tioning is necessary to formulate appropriate plan of care.
2. Obtain a drug history, if possible, to determine the following:
a. Type of substance(s) used.
b. Time of last ingestion and amount consumed.
c. Length and frequency of consumption.
d. Amount consumed on a daily basis.
3. Obtain urine sample for laboratory analysis of substance
content. Subjective history is often not accurate. Knowledge
regarding substance ingestion is important for accurate as-
sessment of client condition.
4. Place client in quiet, private room. Excessive stimuli increase
client agitation.
5. Institute necessary safety precautions (CLIENT safety is a
nursing priority.):
a. Observe client behaviors frequently; assign staff on one-
to-one basis if condition is warranted; accompany and
assist client when ambulating; use wheelchair for trans-
porting long distances.
b. Be sure that side rails are up when client is in bed.
c. Pad headboard and side rails of bed with thick towels to
protect client in case of seizure.
d. Use mechanical restraints as necessary to protect client if
excessive hyperactivity accompanies the disorientation.
6. Ensure that smoking materials and other potentially harmful
objects are stored away from clients access. Client may harm
self or others in disoriented, confused state.
7. Frequently orient client to reality and surroundings. Disori-
entation may endanger client safety if he or she unknow-
ingly wanders away from safe environment.
8. Monitor clients vital signs every 15 minutes initially and less
frequently as acute symptoms subside. Vital signs provide
the most reliable information about client condition and
need for medication during acute detoxification period.
9. Follow medication regimen, as ordered by physician. Com-
mon medical intervention for detoxication from the follow-
ing substances includes:
a. Alcohol. Benzodiazepines are the most widely used
group of drugs for substitution therapy in alcohol with-
drawal. They are administered in decreasing doses until
withdrawal is complete. Commonly used agents include
chlordiazepoxide (Librium), oxazepam (Serax), diazepam
(Valium), and alprazolam (Xanax). In clients with liver
disease, accumulation of the longer-acting agents, such as
chlordiazepoxide (Librium), may be problematic, and the
2506_Ch04_071-104.indd Sec1:90 10/1/10 9:34:01 AM

use of shorter-acting benzodiazepines, such as oxazepam

(Serax), is more appropriate. Some physicians may order
anticonvulsant medication to be used prophylactically;
however, this is not a universal intervention. Multivitamin
therapy, in combination with daily thiamine (either orally
or by injection), is common protocol.
b. Narcotics. Narcotic antagonists, such as naloxone
(Narcan), naltrexone (ReVia), or nalmefene (Revex),
are administered intravenously for narcotic overdose.
Withdrawal is managed with rest and nutritional ther-
apy. Substitution therapy may be instituted to decrease
withdrawal symptoms using propoxyphene (Darvon),
methadone (Dolophine), or buprenorphine (Subutex).
c. Depressants. Substitution therapy may be instituted
to decrease withdrawal symptoms using a long-acting
barbiturate, such as phenobarbital (Luminal). The dos-
age required to suppress withdrawal symptoms is given.
When stabilization has been achieved, the dose is gradu-
ally decreased by 30 mg/day until withdrawal is complete.
Long-acting benzodiazepines are commonly used for
substitution therapy when the abused substance is a non-
barbiturate CNS depressant.
d. Stimulants. Treatment of stimulant intoxication usually
begins with minor tranquilizers such as chlordiazepoxide
(Librium) and progresses to major tranquilizers such as
haloperidol (Haldol). Antipsychotics should be adminis-
tered with caution because of their propensity to lower
seizure threshold. Repeated seizures are treated with
intravenous diazepam. Withdrawal treatment is usually
aimed at reducing drug craving and managing severe
depression. The client is placed in a quiet atmosphere
and allowed to sleep and eat as much as is needed or
desired. Suicide precautions may need to be instituted.
Antidepressant therapy may be helpful in treating symp-
toms of depression. Desipramine has been especially
successful with symptoms of cocaine withdrawal and
abstinence (Mack, Franklin, & Frances, 2003).
e. Hallucinogens and Cannabinols. Substitution therapy
is not required with these drugs. When adverse reactions,
such as anxiety or panic, occur, benzodiazepines (e.g.,
diazepam or chlordiazepoxide) may be prescribed to pre-
vent harm to the client or others. Psychotic reactions may
be treated with antipsychotic medications.
Outcome Criteria
1. Client is no longer exhibiting any signs or symptoms of sub-
stance intoxication or withdrawal.
2506_Ch04_071-104.indd Sec1:91 10/1/10 9:34:01 AM

2. Client shows no evidence of physical injury obtained during

substance intoxication or withdrawal.
INEFFECTIVE DENIAL
De nition: Conscious or unconscious attempt to disavow the
knowledge or meaning of an event to reduce anxiety/fear, but lead-
ing to the detriment of health.

[Weak, underdeveloped ego]
[Underlying fears and anxieties]
[Low self-esteem]
[Fixation in early level of development]

[Denies substance abuse or dependence]
[Denies that substance use creates problems in his or her life]
[Continues to use substance, knowing it contributes to impair-
ment in functioning or exacerbation of physical symptoms]
[Uses substance(s) in physically hazardous situations]
[Use of rationalization and projection to explain maladaptive
behaviors]
Unable to admit impact of disease on life pattern
Goals/Objectives
Short-term Goal
Client will divert attention away from external issues and focus
on behavioral outcomes associated with substance use.
Long-term Goal
Client will verbalize acceptance of responsibility for own behavior
and acknowledge association between substance use and personal
problems.
1. Begin by working to develop a trusting nurse-client relation-
ship. Be honest. Keep all promises. Trust is the basis of a
therapeutic relationship.
2. Convey an attitude of acceptance to client. Ensure that he
or she understands, It is not you but your behavior that is
unacceptable. An attitude of acceptance promotes feelings
of dignity and self-worth.
3. Provide information to correct misconceptions about sub-
stance abuse. Client may rationalize his or her behavior with
2506_Ch04_071-104.indd Sec1:92 10/1/10 9:34:02 AM

statements such as, Im not an alcoholic. I can stop drink-

ing any time I want. Besides, I only drink beer. or I only
smoke pot to relax before class. So what? I know lots of
people who do. Besides, you cant get hooked on pot. Many
myths abound regarding use of specific substances. Factual
information presented in a matter-of-fact, nonjudgmental
way explaining what behaviors constitute substance-related
disorders may help client focus on his or her own behaviors
as an illness that requires help.
4. Identify recent maladaptive behaviors or situations that have
occurred in clients life, and discuss how use of substances
may have been a contributing factor. The first step in decreas-
ing use of denial is for client to see the relationship between
substance use and personal problems.
5. Use confrontation with caring. Do not allow client to fanta-
size about his or her lifestyle. Confrontation interferes with
clients ability to use denial; a caring attitude preserves self-
esteem and avoids putting client on the defensive.
CLINICAL PEARL It is important to speak objectively and nonjudgmentally

to a person in denial. Examples: It is my understanding that the last time you drank
alcohol, you . . . or The lab report shows that your blood alcohol level was
250 when you were involved in that automobile accident.
6. Do not accept the use of rationalization or projection as

client attempts to make excuses for or blame his or her be-
havior on other people or situations. Rationalization and
projection prolong the stage of denial that problems exist in
clients life because of substance use.
7. Encourage participation in group activities. Peer feedback is
often more accepted than feedback from authority figures.
Peer pressure can be a strong factor as well as the association
with individuals who are experiencing or who have experi-
enced similar problems.
8. Offer immediate positive recognition of clients expres-
sions of insight gained regarding illness and acceptance of
responsibility for own behavior. Positive reinforcement en-
hances self-esteem and encourages repetition of desirable
behaviors.
Outcome Criteria
1. Client verbalizes understanding of the relationship between
personal problems and the use of substances.
2. Client verbalizes acceptance of responsibility for own behavior.
3. Client verbalizes understanding of substance dependence and
abuse as an illness requiring ongoing support and treatment.
2506_Ch04_071-104.indd Sec1:93 10/1/10 9:34:02 AM

INEFFECTIVE COPING
available resources.

[Underdeveloped ego]
[Possible hereditary factor]
[Personal vulnerability]

[Low self-esteem]
[Chronic anxiety]
[Chronic depression]
Inability to meet role expectations
[Alteration in societal participation]
Inability to meet basic needs
[Inappropriate use of defense mechanisms]
Abuse of chemical agents
[Low frustration tolerance]
[Need for immediate gratication]
[Manipulative behavior]
Goals/Objectives
Short-term Goal
Client will express true feelings associated with use of substances
as a method of coping with stress.
Long-term Goal
Client will be able to verbalize adaptive coping mechanisms to
use, instead of substance abuse, in response to stress.

1. Establish trusting relationship with client (be honest; keep
appointments; be available to spend time). The therapeutic
nurse-client relationship is built on trust.
2. Set limits on manipulative behavior. Be sure that client
knows what is acceptable, what is not, and the consequenc-
es for violating the limits set. Ensure that all staff main-
tain consistency with this intervention. Client is unable to
2506_Ch04_071-104.indd Sec1:94 10/1/10 9:34:02 AM

establish own limits, so limits must be set for him or her. Unless
administration of consequences for violation of limits is
consistent, manipulative behavior will not be eliminated.
3. Encourage client to verbalize feelings, fears, and anxiet-
ies. Answer any questions he or she may have regarding
the disorder. Verbalization of feelings in a nonthreaten-
ing environment may help client come to terms with long-
unresolved issues.
4. Explain the effects of substance abuse on the body. Empha-
size that prognosis is closely related to abstinence. Many
clients lack knowledge regarding the deleterious effects of
substance abuse on the body.
5. Explore with client the options available to assist with stress-
ful situations rather than resorting to substance abuse (e.g.,
contacting various members of Alcoholics Anonymous or
Narcotics Anonymous; physical exercise; relaxation tech-
niques; meditation). Client may have persistently resorted to
chemical abuse and thus may possess little or no knowledge
of adaptive responses to stress.
6. Provide positive reinforcement for evidence of gratica-
tion delayed appropriately. Positive reinforcement enhances
self-esteem and encourages client to repeat acceptable
behaviors.
7. Encourage client to be as independent as possible in
own self-care. Provide positive feedback for independent
decision-making and effective use of problem-solving skills.
Outcome Criteria
1. Client is able to verbalize adaptive coping strategies as alter-
natives to substance use in response to stress.
2. Client is able to verbalize the names of support people from
whom he or she may seek help when the desire for substance
use is intense.
IMBALANCED NUTRITION: LESS

THAN BODY REQUIREMENTS
De nition: Intake of nutrients insufficient to meet metabolic
needs.

[Drinking alcohol instead of eating nourishing food]
[Eating only junk food]
[Eating nothing (or very little) while on a binge]
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[No money for food (having spent what is available on substances)]

[Problems with malabsorption caused by chronic alcohol abuse]

Loss of weight
Pale conjunctiva and mucous membranes
Poor muscle tone
[Poor skin turgor]
[Edema of extremities]
[Electrolyte imbalances]
[Cheilosis (cracks at corners of mouth)]
[Scaly dermatitis]
[Weakness]
[Neuropathies]
[Anemias]
[Ascites]
Goals/Objectives
Short-term Goals
1. Client will gain 2 lb during next 7 days.
2. Clients electrolytes will be restored to normal within 1 week.
Long-term Goal
Client will exhibit no signs or symptoms of malnutrition by dis-
charge. (This is not a realistic goal for a chronic alcoholic in the
end stages of the disease. For such a client, it is more appropriate
to establish short-term goals, as realistic step objectives, to use
in the evaluation of care given.)

1. In collaboration with dietitian, determine number of calories
required to provide adequate nutrition and realistic (accord-
ing to body structure and height) weight gain.
2. Strict documentation of intake, output, and calorie count.
This information is necessary to make an accurate nutri-
tional assessment and maintain client safety.
3. Weigh daily. Weight loss or gain is important assessment
information.
4. Determine clients likes and dislikes and collaborate with di-
etitian to provide favorite foods. Client is more likely to eat
foods that he or she particularly enjoys.
5. Ensure that client receives small, frequent feedings, includ-
ing a bedtime snack, rather than three larger meals. Large
amounts of food may be objectionable, or even intolerable,
to client.
6. Administer vitamin and mineral supplements, as ordered by
physician, to improve nutritional state.
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7. If appropriate, ask family members or signicant others to

bring in special foods that client particularly enjoys.
8. Monitor laboratory work, and report signicant changes to
physician.
9. Explain the importance of adequate nutrition. Client may
have inadequate or inaccurate knowledge regarding the
contribution of good nutrition to overall wellness.
Outcome Criteria
1. Client has achieved and maintained at least 90% of normal
body weight.
2. Clients vital signs, blood pressure, and laboratory serum
studies are within normal limits.
3. Client is able to verbalize importance of adequate
nutrition.
CHRONIC LOW SELF-ESTEEM

De nition: Long-standing negative self-evaluating/feelings about
self or self-capabilities.

[Perceived failures]

[Difculty accepting positive reinforcement]
[Failure to take responsibility for self-care]
[Self-destructive behavior (substance abuse)]
Lack of eye contact
[Withdraws into social isolation]
[Highly critical and judgmental of self and others]
[Sense of worthlessness]
[Fear of failure]
[Unable to recognize own accomplishments]
[Setting self up for failure by establishing unrealistic goals]
[Unsatisfactory interpersonal relationships]
[Negative or pessimistic outlook]
[Rationalizing personal failures]
[Hypersensitivity to slight criticism]
[Grandiosity]
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Goals/Objectives
Short-term Goal
Client will accept responsibility for personal failures and verbalize
the role substances played in those failures.
Long-term Goal
By time of discharge, client will exhibit increased feelings of
self-worth as evidenced by verbal expression of positive aspects
about self, past accomplishments, and future prospects.
1. Be accepting of client and his or her negativism. An attitude
of acceptance enhances feelings of self-worth.
2. Spend time with client to convey acceptance and contribute
toward feelings of self-worth.
3. Help client to recognize and focus on strengths and accom-
plishments. Discuss past (real or perceived) failures, but
minimize amount of attention devoted to them beyond clients
need to accept responsibility for them. Client must accept re-
sponsibility for own behavior before change in behavior can
occur. Minimizing attention to past failures may help to
eliminate negative ruminations and increase clients sense of
self-worth.
4. Encourage participation in group activities from which cli-
ent may receive positive feedback and support from peers.
5. Help client identify areas he or she would like to change
about self and assist with problem solving toward this effort.
Low self-worth may interfere with clients perception of own
problem-solving ability. Assistance may be required.
6. Ensure that client is not becoming increasingly dependent
and that he or she is accepting responsibility for own behav-
iors. Client must be able to function independently if he or
she is to be successful within the less-structured community
environment.
7. Ensure that therapy groups offer client simple methods of
achievement. Offer recognition and positive feedback for
actual accomplishments. Successes and recognition increase
self-esteem.
8. Provide instruction in assertiveness techniques: the ability
to recognize the difference among passive, assertive, and
aggressive behaviors and the importance of respecting the
human rights of others while protecting ones own basic
human rights. Self-esteem is enhanced by the ability to in-
teract with others in an assertive manner.
9. Teach effective communication techniques, such as the use
of I messages and placing emphasis on ways to avoid mak-
ing judgmental statements.
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Outcome Criteria
1. Client is able to verbalize positive aspects about self.
2. Client is able to communicate assertively with others.
3. Client expresses an optimistic outlook for the future.
DEFICIENT KNOWLEDGE (Effects

of Substance Abuse on the Body)
De nition: Absence or deficiency of cognitive information
related to [the effects of substance abuse on the body and
its interference with achievement and maintenance of optimal
wellness].

Lack of interest in learning
[Low self-esteem]
[Denial of need for information]
[Denial of risks involved with substance abuse]
Unfamiliarity with information resources
[Abuse of substances]
[Statement of lack of knowledge]
[Statement of misconception]
[Request for information]
Verbalization of the problem
Goals/Objectives
Short-term Goal
Client will be able to verbalize effects of [substance used] on the
body following implementation of teaching plan.
Long-term Goal
Client will verbalize the importance of abstaining from use of
[substance] to maintain optimal wellness.

1. Assess clients level of knowledge regarding effects of
[substance] on body. Baseline assessment of knowledge
is required to develop appropriate teaching plan for
client.
2. Assess clients level of anxiety and readiness to learn. Learn-
ing does not take place beyond moderate level of anxiety.
3. Determine method of learning most appropriate for client
(e.g., discussion, question and answer, use of audio or visual
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aids, oral or written method). Level of education and devel-

opment are important considerations as to methodology
selected.
4. Develop teaching plan, including measurable objectives
for the learner. Measurable objectives provide criteria on
which to base evaluation of the teaching experience.
5. Include signicant others, if possible. Lifestyle changes of-
ten affect all family members.
6. Implement teaching plan at a time that facilitates and in
a place that is conducive to optimal learning (e.g., in the
evening when family members visit, in an empty, quiet class-
room or group therapy room). Learning is enhanced by an
environment with few distractions.
7. Begin with simple concepts and progress to the more com-
plex. Retention is increased if introductory material pre-
sented is easy to understand.
8. Include information on physical effects of [substance]:
substances capacity for physiological and psychologi-
cal dependence, its effects on family functioning, its
effects on a fetus (and the importance of contraceptive
use until abstinence has been achieved), and the impor-
tance of regular participation in an appropriate treatment
program.
9. Provide activities for client and signicant others in which
to participate actively during the learning exercise. Active
participation increases retention.
10. Ask client and signicant others to demonstrate knowledge
gained by verbalizing information presented. Verbalization
of knowledge gained is a measurable method of evaluating
the teaching experience.
11. Provide positive feedback for participation as well as for
accurate demonstration of knowledge gained. Positive feed-
back enhances self-esteem and encourages repetition of
acceptable behaviors.
12. Evaluate teaching plan. Identify strengths and weaknesses,
as well as any changes that may enhance the effectiveness
of the plan.
Outcome Criteria
1. Client is able to verbalize effects of [substance] on the
body.
2. Client verbalizes understanding of risks involved in use of
[substance].
3. Client is able to verbalize community resources for ob-
taining knowledge and support with substance-related
problems.
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DYSFUNCTIONAL FAMILY
PROCESSES
De nition: Psychosocial, spiritual, and physiological functions
of the family unit are chronically disorganized, which leads to con-
flict, denial of problems, resistance to change, ineffective problem
solving, and a series of self-perpetuating crises.

Abuse of alcohol
Genetic predisposition
Lack of problem-solving skills
Inadequate coping skills
Family history of alcoholism, resistance to treatment
Biochemical inuences
Addictive personality
Anxiety, anger/suppressed rage; shame and embarrassment
Emotional isolation/loneliness; vulnerability; repressed emotions
Disturbed family dynamics; closed communication systems,
ineffective spousal communication, and marital problems
Altered role function/disruption of family roles
Manipulation; dependency; blaming/criticizing; rationalization/
denial of problems
Enabling to maintain drinking; refusal to get help/inability to
accept and receive help appropriately
Goals/Objectives
Short-term Goals
1. Family members will participate in individual family pro-
grams and support groups.
2. Family members will identify ineffective coping behaviors
and consequences.
3. Family members will initiate and plan for necessary lifestyle
changes.
Long-term Goal
Family members will take action to change self-destructive
behaviors and alter behaviors that contribute to clients addiction.

1. Review family history; explore roles of family members,
circumstances involving alcohol use, strengths, areas of
growth. This information determines areas for focus and
potential for change.
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2. Explore how family members have coped with the clients

addiction (e.g., denial, repression, rationalization, hurt,
loneliness, projection). Persons who enable also suffer from
the same feelings as the client and use ineffective methods
for dealing with the situation, necessitating help in learn-
ing new and effective coping skills.
3. Determine understanding of current situation and previous
methods of coping with lifes problems. Provides informa-
tion on which to base present plan of care.
4. Assess current level of functioning of family members.
Affects individuals ability to cope with the situation.
5. Determine extent of enabling behaviors being evidenced
by family members; explore with each individual and client.
Enabling is doing for the client what he or she needs to do
for self (rescuing). People want to be helpful and do not want
to feel powerless to help their loved one to stop substance use
and change the behavior that is so destructive. However,
the substance abuser often relies on others to cover up own
inability to cope with daily responsibilities.
6. Provide information about enabling behavior and addictive
disease characteristics for both the user and nonuser. Aware-
ness and knowledge of behaviors (e.g., avoiding and shield-
ing, taking over responsibilities, rationalizing, and subserv-
ing) provide opportunity for individuals to begin the process
of change.
7. Identify and discuss sabotage behaviors of family members.
Even though family member(s) may verbalize a desire
for the individual to become substance-free, the reality of
interactive dynamics is that they may unconsciously not
want the individual to recover, as this would affect the
family members own role in the relationship. Addition-
ally, they may receive sympathy or attention from others
(secondary gain).
8. Encourage participation in therapeutic writing, e.g., journ-
aling (narrative), guided or focused. Serves as a release for
feelings (e.g., anger, grief, stress); helps move individual(s)
forward in treatment process.
9. Provide factual information to client and family about the
effects of addictive behaviors on the family and what to ex-
pect after discharge. Many people are unaware of the na-
ture of addiction. If client is using legally obtained drugs,
he or she may believe this does not constitute abuse.
10. Encourage family members to be aware of their own feel-
ings, to look at the situation with perspective and objectiv-
ity. They can ask themselves: Am I being conned? Am I
acting out of fear, shame, guilt, or anger? Do I have a need
to control? When the enabling family members become
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aware of their own actions that perpetuate the clients

problems, they need to decide to change themselves. If they
change, the client can then face the consequences of own
actions and may choose to get well.
11. Provide support for enabling family members. For change
to occur, families need support as much as the person who
has the problem with alcohol.
12. Assist the clients partner to become aware that clients
abstinence and drug use are not the partners responsibility.
Partners need to learn that the clients use of substances
may or may not change despite partners involvement in
treatment.
13. Help a recovering (former user) partner who is enabling to
distinguish between destructive aspects of own behavior and
genuine motivation to aid the client. Enabling behavior can
be a recovering individuals attempts at personal survival.
14. Note how the partner relates to the treatment team and staff.
Determines enabling style. A parallel exists between how
partner relates to client and to staff, based on the partners
feelings about self and situation.
15. Explore conicting feelings the enabling partner may have
about treatment (e.g., feelings similar to those of the sub-
stance abuser [blend of anger, guilt, fear, exhaustion, em-
barrassment, loneliness, distrust, grief, and possibly relief]).
This is useful in establishing the need for therapy for the
partner. This individuals own identity may have been
losthe or she may fear self-disclosure to staff and may
have difficulty giving up the dependent relationship.
16. Involve family members in discharge referral plans. Alcohol
abuse is a family illness. Because the family has been so in-
volved in dealing with the substance abuse behavior, family
members need help adjusting to the new behavior of sobriety/
abstinence. Incidence of recovery is almost doubled when
the family is treated along with the client.
17. Encourage involvement with self-help associations, such as
Alcoholics Anonymous, Al-Anon, Alateen, and professional
family therapy. Puts client and family in direct contact
with support systems necessary for continued sobriety and
assists with problem resolution.
Outcome Criteria
1. Family members verbalize understanding of dynamics of
enabling behaviors.
2. Family members demonstrate patterns of effective commu-
nication.
3. Family members regularly participate in self-help support
programs.
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4. Family members demonstrate behaviors required to change

destructive patterns of behavior that contribute to and enable
dysfunctional family process.
INTERNET REFERENCES
Additional information on addictions may be located at the
following websites:
a. http://www.samhsa.gov/index.aspx
b. http://www.ccsa.ca/Pages/Splash.htm
c. http://www.well.com/user/woa
d. http://www.apa.org/about/division/div50.html
Additional information on self-help organizations may be
a. http://www.ca.org (Cocaine Anonymous)
b. http://www.aa.org (Alcoholics Anonymous)
c. http://www.na.org (Narcotics Anonymous)
d. http://www.al-anon.org
Additional information about medications for treatment of
alcohol and drug dependence may be located at the following
websites:
b. http://www.nlm.nih.gov/medlineplus/
c. http://www.nimh.nih.gov/publicat/medicate.cfm
Movie Connections
Afiction (alcoholism) Days of Wine and Roses (alcoholism)
Ill Cry Tomorrow (alcoholism) When a Man Loves a Woman
(alcoholism) Clean and Sober (addictioncocaine) 28 Days
(alcoholism) Lady Sings the Blues (addictionheroin) Im Dancing
as Fast as I Can (addictionsedatives) The Rose (polysubstance addiction)
2506_Ch04_071-104.indd Sec1:104 10/1/10 9:34:05 AM

C H A P T E R
5
Schizophrenia and
Other Psychotic
Disorders
The syndrome of symptoms associated with schizophrenia and
other psychotic disorders reveals alterations in content and orga-
nization of thoughts, perception of sensory input, affect or emo-
tional tone, sense of identity, volition, psychomotor behavior, and
ability to establish satisfactory interpersonal relationships.
Categories
Paranoid Schizophrenia
Paranoid schizophrenia is characterized by extreme suspicious-
ness of others and by delusions and hallucinations of a perse-
cutory or grandiose nature. The individual is often tense and
guarded and may be argumentative, hostile, and aggressive.
Disorganized Schizophrenia
In disorganized schizophrenia, behavior is typically regressive and
primitive. Affect is inappropriate, with common characteristics
being silliness, incongruous giggling, facial grimaces, and extreme
social withdrawal. Communication is consistently incoherent.
Catatonic Schizophrenia
Catatonic schizophrenia manifests itself in the form of stupor
(marked psychomotor retardation, mutism, waxy exibility
[posturing], negativism, and rigidity) or excitement (extreme psy-
chomotor agitation, leading to exhaustion or the possibility of
hurting self or others if not curtailed).
Undifferentiated Schizophrenia
Undifferentiated schizophrenia is characterized by disorganized
behaviors and psychotic symptoms (e.g., delusions, hallucina-
tions, incoherence, and grossly disorganized behavior) that may
appear in more than one category.
105
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Residual Schizophrenia
Behavior in residual schizophrenia is eccentric, but psychotic
symptoms, if present at all, are not prominent. Social withdrawal
and inappropriate affect are characteristic. The patient has a his-
tory of at least one episode of schizophrenia in which psychotic
symptoms were prominent.
Schizoaffective Disorder
Schizoaffective disorder refers to behaviors characteristic of
schizophrenia, in addition to those indicative of disorders of
mood, such as depression or mania.
Brief Psychotic Disorder
The essential features of brief psychotic disorder include a sud-
den onset of psychotic symptoms that last at least 1 day but less
than 1 month and in which there is a virtual return to the pre-
morbid level of functioning. The diagnosis is further specied
by whether it follows a severe identiable stressor or whether the
onset occurs within 4 weeks postpartum.
Schizophreniform Disorder
The essential features of schizophreniform disorder are identical
to those of schizophrenia, with the exception that the duration is
at least 1 month but less than 6 months. The diagnosis is termed
provisional if a diagnosis must be made prior to recovery.
Delusional Disorder
Delusional disorder is characterized by the presence of one
or more nonbizarre delusions that last for at least 1 month.
Hallucinatory activity is not prominent. Apart from the delu-
sions, behavior and functioning are not impaired. The following
types are based on the predominant delusional theme (American
Medical Association [AMA], 2000):
1. Persecutory Type. Delusions that one is being malevolently
treated in some way.
2. Jealous Type. Delusions that ones sexual partner is
unfaithful.
3. Erotomanic Type. Delusions that another person of higher
status is in love with him or her.
4. Somatic Type. Delusions that the person has some physical
defect, disorder, or disease.
5. Grandiose Type. Delusions of inated worth, power, knowl-
edge, special identity, or special relationship to a deity or
famous person.
Shared Psychotic Disorder (Folie Deux)
In shared psychotic disorder, a delusional system develops in the
context of a close relationship with another person who already
has a psychotic disorder with prominent delusions.
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Schizophrenia and Other Psychotic Disorders 107
Psychotic Disorder Due to a General Medical

Condition
The American Psychiatric Association (APA, 2000) Diagnostic and
Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
(DSM-IV-TR) identies the essential features of this disorder as
prominent hallucinations and delusions that can be directly attrib-
uted to a general medical condition. Examples of general medical
conditions that may cause psychotic symptoms include neurologic
conditions (e.g., neoplasms, Huntingtons disease, central nervous
system [CNS] infections); endocrine conditions (e.g., hyperthy-
roidism, hypothyroidism, hypoadrenocorticism); metabolic condi-
tions (e.g., hypoxia, hypercarbia, hypoglycemia); autoimmune dis-
orders (e.g., systemic lupus erythematosus); and others (e.g., uid
or electrolyte imbalances, hepatic or renal diseases) (APA, 2000).
Substance-Induced Psychotic Disorder
The essential features of this disorder are the presence of promi-
nent hallucinations and delusions that are judged to be directly
attributable to the physiological effects of a substance (i.e., a
drug of abuse, a medication, or toxin exposure) (APA, 2000).
1. Physiological
a. Genetics. Studies show that relatives of individuals with
schizophrenia have a much higher probability of develop-
ing the disease than does the general population. Whereas
the lifetime risk for developing schizophrenia is about 1%
in most population studies, the siblings or offspring of
an identied client have a 5% to 10% risk of developing
schizophrenia (Andreasen & Black, 2006). Twin and adop-
tion studies add additional evidence for the genetic basis of
schizophrenia.
b. Histological Changes. Jonsson and associates (1997) have
suggested that schizophrenic disorders may in fact be a
birth defect, occurring in the hippocampus region of the
brain, and related to an inuenza virus encountered by
the mother during the second trimester of pregnancy.
The studies have shown a disordering of the pyramidal
cells in the brains of individuals with schizophrenia, but
the cells in the brains of individuals without the disorder
appeared to be arranged in an orderly fashion. Further
research is required to determine the possible link between
this birth defect and the development of schizophrenia.
c. The Dopamine Hypothesis. This theory suggests that
schizophrenia (or schizophrenia-like symptoms) may
be caused by an excess of dopamine-dependent neuronal
activity in the brain. This excess activity may be related to
2506_Ch05_105-124.indd 0107 10/1/10 9:34:17 AM

increased production or release of the substance at nerve

terminals, increased receptor sensitivity, too many dopa-
mine receptors, or a combination of these mechanisms
(Sadock & Sadock, 2007).
d. Anatomical Abnormalities. With the use of neuroimag-
ing technologies, structural brain abnormalities have been
observed in individuals with schizophrenia. Ventricular
enlargement is the most consistent nding; however, sulci
enlargement and cerebellar atrophy are also reported.
2. Environmental
a. Sociocultural Factors. Many studies have been conducted
that have attempted to link schizophrenia to social class.
Indeed, epidemiological statistics have shown that greater
numbers of individuals from the lower socioeconomic
classes experience symptoms associated with schizophre-
nia than do those from the higher socioeconomic groups
(Ho, Black, & Andreasen, 2003). This may occur as a
result of the conditions associated with living in poverty,
such as congested housing accommodations, inadequate
nutrition, absence of prenatal care, few resources for deal-
ing with stressful situations, and feelings of hopelessness
for changing ones lifestyle of poverty.
An alternative view is that of the downward drift
hypothesis. This hypothesis suggests that, because of the
characteristic symptoms of the disorder, individuals
with schizophrenia have difculty maintaining gainful
employment and drift down to a lower socioeconomic
level (or fail to rise out of a lower socioeconomic group).
Proponents of this notion view poor social conditions as
a consequence rather than a cause of schizophrenia.
b. Stressful Life Events. Studies have been conducted in an
effort to determine whether psychotic episodes may be
precipitated by stressful life events. There is no scientic
evidence to indicate that stress causes schizophrenia. It is
very probable, however, that stress contributes to the se-
verity and course of the illness. It is known that extreme
stress can precipitate psychotic episodes. Stress may
indeed precipitate symptoms in an individual who pos-
sesses a genetic vulnerability to schizophrenia. Stressful
life events may be associated with exacerbation of schizo-
phrenic symptoms and increased rates of relapse.
Symptomatology (Subjective/Objective Data)
1. Autism. There is a focus inward. The individual with psy-
chosis may create his or her own world. Words and events
may take on special meaning of a highly symbolic nature that
only the individual can understand.
2506_Ch05_105-124.indd 0108 10/1/10 9:34:17 AM

2. Emotional Ambivalence. Powerful emotions of love, hate,

and fear produce much con ict within the individual. Each
emotion tends to balance the other until an emotional neu-
tralization occurs, and the individual experiences apathy or
indifference.
3. Inappropriate Affect. The affect is blunted or at, and
often inappropriate (e.g., person who laughs when told of
the death of a parent).
4. Associative Looseness. This term describes the very
disorganized thoughts and verbalizations of the psychotic
person. Ideas shift from one unrelated subject to another.
When the condition is severe, speech may be incoherent.
5. Echolalia. The psychotic person often repeats words he or
she hears.
6. Echopraxia. The psychotic person often repeats move-
ments he or she sees in others. (Echolalia and echopraxia
are products of the persons very weak ego boundaries.)
7. Neologisms. Words that are invented by the psychotic per-
son that are meaningless to others but have symbolic mean-
ing to the individual.
8. Concrete Thinking. The psychotic person has difculty
thinking on the abstract level and may use literal transla-
tions concerning aspects of the environment.
9. Clang Associations. The individual uses rhyming words in
a nonsensical pattern.
10. Word Salad. The psychotic person may put together a ran-
dom jumble of words.
11. Mutism. Psychotic individuals may refuse or be unable to
speak.
12. Circumstantiality. Circumstantiality refers to a psychotic
persons delay in reaching the point of a communication
because of unnecessary and tedious details.
13. Tangentiality. Tangentiality differs from circumstantiality
in that the psychotic person never really gets to the point of
the communication. Unrelated topics are introduced, and
the original discussion is lost.
14. Perseveration. The individual with psychosis may persis-
tently repeat the same word or idea in response to different
questions.
15. Delusions. These are false ideas or beliefs. Types of delu-
sions include the following:
a. Grandeur. The psychotic person has an exaggerated feel-
ing of importance or power.
b. Persecution. The psychotic person feels threatened and
believes others intend harm or persecution toward him
or her in some way.
2506_Ch05_105-124.indd 0109 10/1/10 9:34:17 AM

c. Reference. All events within the environment are referred

by the psychotic person to himself or herself.
d. Control or Influence. The psychotic individual believes
certain objects or people have control over his or her
behavior.
16. Hallucinations. Hallucinations are false sensory percep-
tions that may involve any of the ve senses. Auditory and
visual hallucinations are most common, although olfactory,
tactile, and gustatory hallucinations can occur.
17. Regression. This is a primary ego defense mechanism
used in psychoses. Childlike mannerisms and comfort tech-
niques are employed. Socially inappropriate behavior may be
evident.
18. Religiosity. The psychotic person becomes preoccupied
with religious ideas, a defense mechanism thought to be
used in an attempt to provide stability and structure to dis-
organized thoughts and behaviors.
Interventions for Individuals with
Schizophrenia and Other Psychotic Disorders
RISK FOR SELF-DIRECTED

OR OTHER-DIRECTED VIOLENCE
ally harmful [either to self or to others.]

[Lack of trust (suspiciousness of others)]
[Catatonic excitement]
[Rage reactions]
[Command hallucinations]
[Delusional thinking]
Body languagerigid posture, clenching of sts and jaw,
hyperactivity, pacing, breathlessness, and threatening stances.
Impulsivity
2506_Ch05_105-124.indd 0110 10/1/10 9:34:18 AM


[Perception of the environment as threatening]
[Receiving auditory or visual commands of a threatening na-
ture]
Goals/Objectives
Short-term Goals
1. Within [a specied time], client will recognize signs of
increasing anxiety and agitation and report to staff for assis-
tance with intervention.
2. Client will not harm self or others
Long-term Goal

lighting, few people, simple decor, low noise level). Anxi-
ety level rises in a stimulating environment. A suspicious,
agitated client may perceive individuals as threatening.
2. Observe clients behavior frequently (every 15 minutes).
Do this while carrying out routine activities so as to avoid
creating suspiciousness in the individual. Close observation
is necessary so that intervention can occur if required to
ensure clients (and others) safety.
3. Remove all dangerous objects from clients environment so
that in his or her agitated, confused state client may not use
them to harm self or others.
4. Try to redirect the violent behavior with physical outlets for
the clients anxiety (e.g., punching bag). Physical exercise is
a safe and effective way of relieving pent-up tension.
5. Staff should maintain and convey a calm attitude toward
client. Anxiety is contagious and can be transmitted from
staff to client.
to client if it becomes necessary. This shows the client
evidence of control over the situation and provides some
physical security for staff.
cian. Monitor medication for its effectiveness and for any
adverse side effects. The avenue of the least restrictive
alternative must be selected when planning interventions
for a psychiatric client.
8. If client is not calmed by talking down or by medication, use
of mechanical restraints may be necessary. Restraints should
be used only as a last resort, after all other interventions have
been unsuccessful, and the client is clearly at risk of harm
2506_Ch05_105-124.indd 0111 10/1/10 9:34:18 AM

to self or others. Be sure to have sufcient staff available to

assist.
Follow protocol established by the institution. The Joint
Commission formerly the Joint Commission on Acredita-
tion of Healthcare Organizations [ JCAHO]) requires that
an in-person evaluation (by a physician, clinical psycholo-
gist, or other licensed independent practitioner responsible
for the care of the patient) be conducted within 1 hour of
initiating restraint or seclusion (The Joint Commission,
2010). The physician must physician reissue a new order for
restraints every 4 hours for adults and every 1 to 2 hours for
children and adolescents.
9. Observe the client in restraints every 15 minutes (or ac-
cording to institutional policy). Ensure that circulation to
extremities is not compromised (check temperature, color,
pulses). Assist client with needs related to nutrition, hy-
dration, and elimination. Position client so that comfort is
facilitated and aspiration can be prevented. Continuous
one-to-one monitoring may be necessary for the client who
is highly agitated or for whom there is a high risk of self- or
accidental injury. Client safety is a nursing priority.
10. As agitation decreases, assess clients readiness for restraint
removal or reduction. Remove one restraint at a time while
assessing clients response. This minimizes risk of injury to
client and staff.
Outcome Criteria
for aggression.
2. Client demonstrates trust of others in his or her environment.
3. Client maintains reality orientation.
4. Client causes no harm to self or others.
SOCIAL ISOLATION
De nition: Aloneness experienced by the individual and perceived
as imposed by others and as a negative or threatening state.

[Lack of trust]
[Regression to earlier level of development]
[Past experiences of difculty in interactions with others]
[Repressed fears]
Unaccepted social behavior
2506_Ch05_105-124.indd 0112 10/1/10 9:34:18 AM


[Staying alone in room]
Uncommunicative, withdrawn, no eye contact [mutism, autism]
Sad, dull affect
[Lying on bed in fetal position with back to door]
[Inappropriate or immature interests and activities for develop-
mental age or stage]
Preoccupation with own thoughts; repetitive, meaningless actions
[Approaching staff for interaction, then refusing to respond to
staffs acknowledgment]
Expression of feelings of rejection or of aloneness imposed by
others
Goals/Objectives
Short-term Goal
Client will willingly attend therapy activities accompanied by
trusted staff member within 1 week.
Long-term Goal
Client will voluntarily spend time with other clients and staff
members in group activities.

1. Convey an accepting attitude by making brief, frequent con-
tacts. An accepting attitude increases feelings of self-worth
and facilitates trust.
2. Show unconditional positive regard. This conveys your belief
in the client as a worthwhile human being.
3. Be with the client to offer support during group activities that
may be frightening or difcult for him or her. The presence
of a trusted individual provides emotional security for the
client.
4. Be honest and keep all promises. Honesty and dependability
promote a trusting relationship.
5. Orient client to time, person, and place, as necessary.
6. Be cautious with touch. Allow client extra space and an
avenue for exit if he or she becomes too anxious. A suspicious
client may perceive touch as a threatening gesture.
cian. Monitor for effectiveness and for adverse side effects.
Antipsychotic medications help to reduce psychotic symp-
toms in some individuals, thereby facilitating interactions
with others.
8. Discuss with client the signs of increasing anxiety and
techniques to interrupt the response (e.g., relaxation
exercises, thought stopping). Maladaptive behaviors such
as withdrawal and suspiciousness are manifested during
times of increased anxiety.
2506_Ch05_105-124.indd 0113 10/1/10 9:34:19 AM

9. Give recognition and positive reinforcement for clients vol-

untary interactions with others. Positive reinforcement en-
hances self-esteem and encourages repetition of acceptable
behaviors.
Outcome Criteria
1. Client demonstrates willingness and desire to socialize with
others.
2. Client voluntarily attends group activities.
3. Client approaches others in appropriate manner for one-
to-one interaction.
INEFFECTIVE COPING
De nition: Inability to form a valid appraisal of the stressors,
inadequate choices of practiced responses, and/or inability to use

[Low self-esteem]
[Negative role model]
[Repressed fears]
[Suspiciousness of others, resulting in:
Alteration in societal participation
Inappropriate use of defense mechanisms]
Goals/Objectives
Short-term Goal
Client will develop trust in at least one staff member within
1 week.
Long-term Goal
Client will demonstrate use of more adaptive coping skills as
evidenced by appropriateness of interactions and willingness to
participate in the therapeutic community.
2506_Ch05_105-124.indd 0114 10/1/10 9:34:19 AM


1. Encourage same staff to work with client as much as
possible in order to promote development of trusting
relationship.
2. Avoid physical contact. Suspicious clients may perceive touch
as a threatening gesture.
3. Avoid laughing, whispering, or talking quietly where client
can see but not hear what is being said. Suspicious clients
often believe others are discussing them, and secretive be-
haviors reinforce the paranoid feelings.
5. A creative approach may have to be used to encourage food
intake (e.g., canned food and own can opener or family-
style meals). Suspicious clients may believe they are being
poisoned and refuse to eat food from the individually pre-
pared tray.
6. Mouth checks may be necessary following medication
administration to verify whether client is swallowing the
tablets or capsules. Suspicious clients may believe they
are being poisoned with their medication and attempt to
discard the pills.
7. Activities should never include anything competitive.
Activities that encourage a one-to-one relationship with the
nurse or therapist are best. Competitive activities are very
threatening to suspicious clients.
8. Encourage client to verbalize true feelings. The nurse should
avoid becoming defensive when angry feelings are directed
at him or her. Verbalization of feelings in a nonthreaten-
ing environment may help client come to terms with long-
unresolved issues.
9. An assertive, matter-of-fact, yet genuine approach is least
threatening and most therapeutic. A suspicious person does
not have the capacity to relate to an overly friendly, overly
cheerful attitude.
Outcome Criteria
1. Client is able to appraise situations realistically and refrain
from projecting own feelings onto the environment.
2. Client is able to recognize and clarify possible misinterpreta-
tions of the behaviors and verbalizations of others.
3. Client eats food from tray and takes medications without
evidence of mistrust.
4. Client appropriately interacts and cooperates with staff and
peers in therapeutic community setting.
2506_Ch05_105-124.indd 0115 10/1/10 9:34:19 AM

DISTURBED SENSORY PERCEPTION:

AUDITORY/VISUAL
De nition: Change in the amount or patterning of incoming
stimuli [either internally or externally initiated] accompanied by a
diminished, exaggerated, distorted, or impaired response to such
stimuli.

[Stress sufciently severe to threaten an already weak ego]

[Listening pose (tilting head to one side as if listening)]
[Stops talking in middle of sentence to listen]
[Rapid mood swings]
[Disordered thought sequencing]
Disorientation
Poor concentration
Sensory distortions
Goals/Objectives
Short-term Goal
Client will discuss content of hallucinations with nurse or thera-
pist within 1 week.
Long-term Goal
Client will be able to de ne and test reality, eliminating the
occurrence of hallucinations. (This goal may not be realistic
for the individual with chronic illness who has experienced
auditory hallucinations for many years.) A more realistic goal
may be:
Client will verbalize understanding that the voices are a re-
sult of his or her illness and demonstrate ways to interrupt the
hallucination.

1. Observe client for signs of hallucinations (listening pose,
laughing or talking to self, stopping in mid-sentence). Early
intervention may prevent aggressive responses to command
hallucinations.
2506_Ch05_105-124.indd 0116 10/1/10 9:34:19 AM

2. Avoid touching the client before warning him or her that you
are about to do so. Client may perceive touch as threatening
and respond in an aggressive manner.
3. An attitude of acceptance will encourage the client to share
the content of the hallucination with you. This is important
in order to prevent possible injury to the client or others
from command hallucinations.
4. Do not reinforce the hallucination. Use words such as the
voices instead of they when referring to the hallucination.
Words like they validate that the voices are real.
CLINICAL PEARL Let the client who is hearing voices know that you do not
share the perception.
Say Even though I realize that the voices are real to you, I do not hear any
voices speaking. The nurse must be honest with the client so that he or she may
realize that the hallucinations are not real.
5. Try to connect the times of the hallucinations to times of

increased anxiety. Help the client to understand this con-
nection. If client can learn to interrupt escalating anxiety,
hallucinations may be prevented.
6. Try to distract the client away from the hallucination.
Involvement in interpersonal activities and explanation
of the actual situation will help bring the client back to
reality.
7. For some clients, auditory hallucinations persist after the
acute psychotic episode has subsided. Listening to the
radio or watching television helps distract some clients
from attention to the voices. Others have beneted from
an intervention called voice dismissal. With this technique,
the client is taught to say loudly, Go away! or Leave me
alone!, thereby exerting some conscious control over the
behavior.
Outcome Criteria
1. Client is able to recognize that hallucinations occur at times
of extreme anxiety.
2. Client is able to recognize signs of increasing anxiety and
employ techniques to interrupt the response.
DISTURBED THOUGHT PROCESSES

De nition: Disruption in cognitive operations and activities.
2506_Ch05_105-124.indd 0117 10/1/10 9:34:20 AM


[Repressed fears]
[Stress sufciently severe to threaten an already weak ego]

[Delusional thinking (false ideas)]
[Inability to concentrate]
Hypervigilance
[Altered attention span]distractibility
Inaccurate interpretation of the environment
[Impaired ability to make decisions, problem-solve, reason,
abstract or conceptualize, calculate]
[Inappropriate social behavior (reecting inaccurate thinking)]
Inappropriate [nonreality-based] thinking
Goals/Objectives
Short-term Goal
[By specied time deemed appropriate], client will recognize and
verbalize that false ideas occur at times of increased anxiety.
Long-term Goal
Depending on chronicity of disease process, choose the most
realistic long-term goal for the client:
1. By time of discharge from treatment, clients speech will re-
ect reality-based thinking.
2. By time of discharge from treatment, client will be able to
differentiate between delusional thinking and reality.

1. Convey your acceptance of clients need for the false belief,
while letting him or her know that you do not share the
belief. It is important to communicate to the client that you
do not accept the delusion as reality.
2. Do not argue or deny the belief. Use reasonable doubt as a
therapeutic technique: I understand that you believe this
is true, but I personally nd it hard to accept. Arguing
with the client or denying the belief serves no useful pur-
pose, because delusional ideas are not eliminated by this
approach, and the development of a trusting relationship
may be impeded.
3. Help client trye to connect the false beliefs to times of in-
creased anxiety. Discuss techniques that could be used to
2506_Ch05_105-124.indd 0118 10/1/10 9:34:20 AM

control anxiety (e.g., deep-breathing exercises, other re-

laxation exercises, thought stopping techniques). If the cli-
ent can learn to interrupt escalating anxiety, delusional
thinking may be prevented.
4. Reinforce and focus on reality. Discourage long ruminations
about the irrational thinking. Talk about real events and real
people. Discussions that focus on the false ideas are pur-
poseless and useless, and may even aggravate the psychosis.
5. Assist and support client in his or her attempt to verbalize
feelings of anxiety, fear, or insecurity. Verbalization of feel-
ings in a nonthreatening environment may help client come
to terms with long-unresolved issues.
Outcome Criteria
1. Verbalizations reect thinking processes oriented in reality.
2. Client is able to maintain activities of daily living (ADLs) to
his or her maximal ability.
3. Client is able to refrain from responding to delusional
thoughts, should they occur.
IMPAIRED VERBAL
COMMUNICATION
De nition: Decreased, delayed, or absent ability to receive,
process, transmit, and use a system of symbols [to communicate].

Altered perceptions
[Disordered, unrealistic thinking]

[Loose association of ideas]
[Use of words that are symbolic to the individual (neologisms)]
[Use of words in a meaningless, disconnected manner (word
salad)]
[Use of words that rhyme in a nonsensical fashion (clang
association)]
[Repetition of words that are heard (echolalia)]
[Does not speak (mutism)]
2506_Ch05_105-124.indd 0119 10/1/10 9:34:20 AM

[Verbalizations reect concrete thinking (inability to think in

abstract terms)]
[Poor eye contact (either no eye contact or continuous staring
into the other persons eyes)]
Goals/Objectives
Short-term Goal
Client will demonstrate ability to remain on one topic, using
appropriate, intermittent eye contact for 5 minutes with nurse
or therapist.
Long-term Goal
By time of discharge from treatment, client will demonstrate
ability to carry on a verbal communication in a socially accept-
able manner with staff and peers.

1. Use the techniques of consensual validation and seeking clari-
cation to decode communication patterns. (Examples: Is it
that you mean...? or I dont understand what you mean by
that. Would you please explain it to me?) These techniques
reveal to the client how he or she is being perceived by others,
and the responsibility for not understanding is accepted by
the nurse.
2. Maintain consistency of staff assignment over time, to facili-
tate trust and the ability to understand clients actions and
communication.
3. In a nonthreatening manner, explain to client how his or her
behavior and verbalizations are viewed by and may alienate
others.
4. If client is unable or unwilling to speak (mutism), use of the
technique of verbalizing the implied is therapeutic. (Example:
That must have been very difcult for you when....) This
may help to convey empathy, develop trust, and eventually
encourage client to discuss painful issues.
5. Anticipate and fulll clients needs until satisfactory com-
munication patterns return. Client comfort and safety are
nursing priorities.
Outcome Criteria
1. Client is able to communicate in a manner that is understood
by others.
2. Clients nonverbal messages are congruent with verbalizations.
3. Client is able to recognize that disorganized thinking and
impaired verbal communication occur at times of increased
anxiety and intervene to interrupt the process.
2506_Ch05_105-124.indd 0120 10/1/10 9:34:21 AM

SELF-CARE DEFICIT (Identify

Specic Area)
daily living (ADLs)].

[Regression to an earlier level of development]
Perceptual or cognitive impairment
[Difculty in bringing or] inability to bring food from
receptacle to mouth
Inability [or refusal] to wash body or body parts
[Impaired ability or lack of interest in selecting appropri-
ate clothing to wear, dressing, grooming, or maintaining
appearance at a satisfactory level]
[Inability or unwillingness to carry out toileting procedures
without assistance]
Goals/Objectives
Short-term Goal
Client will verbalize a desire to perform ADLs by end of
1 week.
Long-term Goal
By time of discharge from treatment, client will be able to
perform ADLs in an independent manner and demonstrate a
willingness to do so.
1. Encourage client to perform normal ADLs to his or her level
of ability. Successful performance of independent activities
enhances self-esteem.
2. Encourage independence, but intervene when client is unable
to perform. Client comfort and safety are nursing priorities.
3. Offer recognition and positive reinforcement for independent
accomplishments. (Example: Mrs. J., I see you have put on a
clean dress and combed your hair.) Positive reinforcement
enhances self-esteem and encourages repetition of desirable
behaviors.
4. Show client, on concrete level, how to perform activities with
which he or she is having difculty. (Example: If client is not
2506_Ch05_105-124.indd 0121 10/1/10 9:34:21 AM

eating, place spoon in his or her hand, scoop some food into it,
and say, Now, eat a bite of mashed potatoes (or other food).
Because concrete thinking prevails, explanations must be
provided at the clients concrete level of comprehension.
5. Keep strict records of food and uid intake. This information
is necessary to acquire an accurate nutritional assessment.
6. Offer nutritious snacks and uids between meals. Client may
be unable to tolerate large amounts of food at mealtimes
and may therefore require additional nourishment at other
times during the day to receive adequate nutrition.
7. If client is not eating because of suspiciousness and fears of
being poisoned, provide canned foods and allow client to
open them; or, if possible, suggest that food be served family-
style so that client may see everyone eating from the same
servings.
8. If client is soiling self, establish routine schedule for toilet-
ing needs. Assist client to bathroom on hourly or bi-hourly
schedule, as need is determined, until he or she is able to
fulll this need without assistance.
Outcome Criteria
1. Client feeds self without assistance.
2. Client selects appropriate clothing, dresses, and grooms self
daily without assistance.
3. Client maintains optimal level of personal hygiene by bathing
daily and carrying out essential toileting procedures without
assistance.
INSOMNIA
De nition: A disruption in amount and quality of sleep that
impairs functioning.

[Repressed fears]
[Hallucinations]

[Difculty falling asleep]
[Awakening very early in the morning]
[Pacing; other signs of increasing irritability caused by lack of
sleep]
[Frequent yawning, nodding off to sleep]
2506_Ch05_105-124.indd 0122 10/1/10 9:34:21 AM

Goals/Objectives
Short-term Goal
Within rst week of treatment, client will fall asleep within
30 minutes of retiring and sleep 5 hours without awakening,
with use of sedative if needed.
Long-term Goal
By time of discharge from treatment, client will be able to fall
asleep within 30 minutes of retiring and sleep 6 to 8 hours with-
out a sleeping aid.

1. Keep strict records of sleeping patterns. Accurate baseline
data are important in planning care to assist client with this
problem.
2. Discourage sleep during the day to promote more restful
sleep at night.
3. Administer antipsychotic medication at bedtime so client
does not become drowsy during the day.
4. Assist with measures that promote sleep, such as warm, non-
stimulating drinks; light snacks; warm baths; and back rubs.
5. Performing relaxation exercises to soft music may be helpful
prior to sleep.
6. Limit intake of caffeinated drinks such as tea, coffee, and
colas. Caffeine is a CNS stimulant and may interfere with
the clients achievement of rest and sleep.
Outcome Criteria
1. Client is able to fall asleep within 30 minutes after retiring.
2. Client sleeps at least 6 consecutive hours without waking.
3. Client does not require a sedative to fall asleep.
INTERNET REFERENCES
Additional information about schizophrenia may be located
at the following websites:
a. http://www.schizophrenia.com
b. http://www.nimh.nih.gov
c. http://www.nami.org/schizophrenia
d. http://mentalhealth.com
e. http://www.narsad.org
Additional information about medications to treat schizo-
phrenia may be located at the following websites:
a. http://www.medicinenet.com/medications/article.htm
b. http://www.fadavis.com/townsend
c. http://www.nlm.nih.gov/medlineplus
2506_Ch05_105-124.indd 0123 10/1/10 9:34:21 AM

Movie Connections
I Never Promised You a Rose Garden (schizophrenia) A Beautiful
Mind (schizophrenia) The Fisher King (schizophrenia) Benny & Joon
(schizophrenia) Out of Darkness (schizophrenia) Conspiracy Theory
(paranoia) The Fan (delusional disorder)
2506_Ch05_105-124.indd 0124 10/1/10 9:34:22 AM

C H A P T E R
6
Mood Disorders:
Depression
Mood is de ned as an individuals sustained emotional tone,
which signicantly inuences behavior, personality, and per-
ception. A disturbance in mood is the predominant feature of
the mood disorders (American Psychiatric Association [APA],
2000). Mood disorders are classied as depressive or bipolar.
Major Depressive Disorder

Major depressive disorder is described as a disturbance of mood
involving depression or loss of interest or pleasure in the usual
activities and pastimes. There is evidence of interference in
social and occupational functioning for at least 2 weeks. There
is no history of manic behavior and the symptoms cannot be
attributed to use of substances or a general medical condition.
The following speciers may be used to further describe the
depressive episode:
1. Single Episode or Recurrent: This specier identies
whether the individual has experienced prior episodes of
depression.
2. Mild, Moderate, or Severe: These categories are identied
by the number and severity of symptoms.
3. With Psychotic Features: Impairment of reality testing is
evident. The individual experiences hallucinations and/or
delusions.
4. With Catatonic Features: This category identies the
presence of psychomotor disturbances, such as severe psycho-
motor retardation, with or without the presence of waxy ex-
ibility or stupor or excessive motor activity. The client also
may manifest symptoms of negativism, mutism, echolalia, or
echopraxia.
5. With Melancholic Features: This is a typically severe
form of major depressive episode. Symptoms are exagger-
ated. There is a loss of interest in all activities. Depression is
125
2506_Ch06_125-144.indd 0125 10/1/10 9:34:32 AM

regularly worse in the morning. There is a history of major

depressive episodes that have responded well to somatic anti-
depressant therapy.
6. Chronic: This classication applies when the current episode
of depressed mood has been evident continuously for at least
the past 2 years.
7. With Seasonal Pattern: This diagnosis indicates the pres-
ence of depressive symptoms during the fall or winter months.
This diagnosis is made when the number of seasonal depres-
sive episodes substantially outnumbers the nonseasonal
depressive episodes that have occurred over the individuals
lifetime (APA, 2000). This disorder has previously been iden-
tied in the literature as seasonal affective disorder (SAD).
8. With Postpartum Onset: This specier is used when symp-
toms of major depression occur within 4 weeks postpartum.
Dysthymic Disorder
Dysthymic disorder is a mood disturbance with character-
istics similar to, if somewhat milder than, those ascribed to
major depressive disorder. There is no evidence of psychotic
symptoms.
Depressive Disorder Due to General Medical
Condition
This disorder is characterized by a prominent and persistent de-
pressed mood that is judged to be the direct result of the physi-
ological effects of a general medical condition (APA, 2000).
Substance-Induced Depressed Mood Disorder

The depressed mood associated with this disorder is considered
to be the direct result of the physiological effects of a substance
(e.g., use or abuse of a drug or a medication, or toxin exposure).
PREDISPOSING FACTORS TO DEPRESSION
1. Physiological
a. Genetic: Numerous studies have been conducted that sup-
port the involvement of heredity in depressive illness. The
disorder is 1.5 to 3 times more common among rst-degree
relatives of individuals with the disorder than among the
general population (APA, 2000).
b. Biochemical: A biochemical theory implicates the bio
genic amines norepinephrine, dopamine, and serotonin.
The levels of these chemicals have been found to be de-
cient in individuals with depressive illness.
c. Neuroendocrine Disturbances: Elevated levels of serum
cortisol and decreased levels of thyroid-stimulating
2506_Ch06_125-144.indd 0126 10/1/10 9:34:32 AM

hormone have been associated with depressed mood in

some individuals.
d. Medication Side Effects: A number of drugs can produce
a depressive syndrome as a side effect. Common ones in-
clude anxiolytics, antipsychotics, and sedative-hypnotics.
Antihypertensive medications such as propranolol and re-
serpine have been known to produce depressive symptoms.
e. Other Physiological Conditions: Depressive symptoms
may occur in the presence of electrolyte disturbances,
hormonal disturbances, nutritional deciencies, and
with certain physical disorders, such as cardiovascular
accident, systemic lupus erythematosus, hepatitis, and
diabetes mellitus.
2. Psychosocial
a. Psychoanalytical: Freud observed that melancholia occurs
after the loss of a loved object, either actually by death
or emotionally by rejection, or the loss of some other ab-
straction of value to the individual. Freud indicated that
in clients with melancholia, the depressed persons rage is
internally directed because of identication with the lost
object (Sadock & Sadock, 2007).
b. Cognitive: Beck and colleagues (1979) proposed that
depressive illness occurs as a result of impaired cognition.
Disturbed thought processes foster a negative evaluation
of self by the individual. The perceptions are of inade-
quacy and worthlessness. Outlook for the future is one of
pessimism and hopelessness.
c. Learning Theory: Learning theory (Seligman, 1973) pro-
poses that depressive illness is predisposed by the individ-
uals belief that there is a lack of control over his or her
life situation. It is thought that this belief arises out of
experiences that result in failure (either perceived or real).
Following numerous failures, the individual feels helpless
to succeed at any endeavor and therefore gives up trying.
This learned helplessness is viewed as a predisposition
to depressive illness.
d. Object Loss Theory: The theory of object loss suggests
that depressive illness occurs as a result of having been
abandoned by, or otherwise separated from, a signicant
other during the rst 6 months of life. Because during this
period the mother represents the childs main source of
security, she is the object. The response occurs not only
with a physical loss. This absence of attachment, which
may be either physical or emotional, leads to feelings of
helplessness and despair that contribute to lifelong pat-
terns of depression in response to loss.
2506_Ch06_125-144.indd 0127 10/1/10 9:34:33 AM

SYMPTOMATOLOGY (SUBJECTIVE
AND OBJECTIVE DATA)
1. The affect of a depressed person is one of sadness, dejection,
helplessness, and hopelessness. The outlook is gloomy and
pessimistic. A feeling of worthlessness prevails.
2. Thoughts are slowed and concentration is difcult. Obsessive
ideas and rumination of negative thoughts are common. In
severe depression (major depressive disorder or bipolar
depression), psychotic features such as hallucinations and
delusions may be evident, reecting misinterpretations of
the environment.
3. Physically, there is evidence of weakness and fatiguevery
little energy to carry on activities of daily living (ADLs).
The individual may express an exaggerated concern over
bodily functioning, seemingly experiencing heightened
sensitivity to somatic sensations.
4. Some individuals may be inclined toward excessive eating
and drinking, whereas others may experience anorexia and
weight loss. In response to a general slowdown of the body,
digestion is often sluggish, constipation is common, and
urinary retention is possible.
5. Sleep disturbances are common, either insomnia or
hypersomnia.
6. At the less severe level (dysthymic disorder), individuals
tend to feel their best early in the morning, then continu-
ally feel worse as the day progresses. The opposite is true of
persons experiencing severe depression. The exact cause of
this phenomenon is unknown, but it is thought to be related
to the circadian rhythm of the hormones and their effects
on the body.
7. A general slowdown of motor activity commonly accompa-
nies depression (called psychomotor retardation). Energy level
is depleted, movements are lethargic, and performance of
daily activities is extremely difcult. Regression is common,
evidenced by withdrawal into the self and retreat to the fetal
position. Severely depressed persons may manifest psycho-
motor activity through symptoms of agitation. These are
constant, rapid, purposeless movements, out of touch with
the environment.
8. Verbalizations are limited. When depressed persons do
speak, the content may be either ruminations regarding
their own life regrets or, in psychotic clients, a reection of
their delusional thinking.
9. Social participation is diminished. The depressed client
has an inclination toward egocentrism and narcissisman
intense focus on the self. This discourages others from
2506_Ch06_125-144.indd 0128 10/1/10 9:34:33 AM

pursuing a relationship with the individual, which increases

his or her feelings of worthlessness and penchant for isolation.

for Depression
RISK FOR SUICIDE

De nition: At risk for self-inflicted, life-threatening injury.

[Depressed mood]
Grief; hopelessness; social isolation
History of prior suicide attempt
[Has a suicide plan and means to carry it out]
Widowed or divorced
Chronic or terminal illness
Psychiatric illness or substance abuse
States desire to die
Threats of killing self
Goals/Objectives
Short-term Goals
1. Client will seek out staff when feeling urge to harm self.
2. Client will make short-term verbal (or written) contract with
nurse not to harm self.
3. Client will not harm self.
Long-term Goal
Client will not harm self.

1. Ask client directly: Have you thought about harming your-
self in any way? If so, what do you plan to do? Do you have the
means to carry out this plan? The risk of suicide is greatly
increased if the client has developed a plan and particularly
if means exist for the client to execute the plan.
2. Create a safe environment for the client. Remove all poten-
tially harmful objects from clients access (sharp objects,
straps, belts, ties, glass items). Supervise closely during meals
and medication administration. Perform room searches as
deemed necessary. Client safety is a nursing priority.
2506_Ch06_125-144.indd 0129 10/1/10 9:34:33 AM

3. Formulate a short-term verbal or written contract with the

client that he or she will not harm self during specic time
period. When that contract expires, make another, and so
forth. Discussion of suicidal feelings with a trusted indi-
vidual provides some relief to the client. A contract gets
the subject out in the open and places some of the respon-
sibility for the clients safety with the client. An attitude
of acceptance of the client as a worthwhile individual is
conveyed.
4. Secure promise from client that he or she will seek out
a staff member or support person if thoughts of suicide
emerge. Suicidal clients are often very ambivalent about
their feelings. Discussion of feelings with a trusted indi-
vidual may provide assistance before the client experiences
a crisis situation.
5. Maintain close observation of client. Depending on level of
suicide precaution, provide one-to-one contact, constant
visual observation, or every-15-minute checks. Place client
in room close to nurses station; do not assign to private
room. Accompany client to off-unit activities if attendance
is indicated. May need to accompany client to bathroom.
Close observation is necessary to ensure that client does
not harm self in any way. Being alert for suicidal and
escape attempts facilitates being able to prevent or inter-
rupt harmful behavior.
6. Maintain special care in administration of medications.
Prevents saving up to overdose or discarding and not
taking.
7. Make rounds at frequent, irregular intervals (especially at
night, toward early morning, at change of shift, or other
predictably busy times for staff). Prevents staff surveillance
from becoming predictable. To be aware of clients location
is important, especially when staff is busy, unavailable, or
less observable.
8. Encourage verbalizations of honest feelings. Through
exploration and discussion, help client to identify symbols of
hope in his or her life.
9. Encourage client to express angry feelings within appropriate
limits. Provide safe method of hostility release. Help client to
identify true source of anger and to work on adaptive coping
skills for use outside the treatment setting. Depression and
suicidal behaviors may be viewed as anger turned inward on
the self. If this anger can be verbalized in a nonthreatening
environment, the client may be able to eventually resolve
these feelings.
10. Identify community resources that client may use as sup-
port system and from whom he or she may request help
2506_Ch06_125-144.indd 0130 10/1/10 9:34:34 AM

if feeling suicidal. Having a concrete plan for seeking

assistance during a crisis may discourage or prevent self-
destructive behaviors.
11. Orient client to reality, as required. Point out sensory
misperceptions or misinterpretations of the environment.
Take care not to belittle clients fears or indicate disapproval
of verbal expressions.
12. Most important, spend time with client. This provides a
feeling of safety and security, while also conveying the mes-
sage, I want to spend time with you because I think you are
a worthwhile person.
Outcome Criteria
1. Client verbalizes no thoughts of suicide.
2. Client commits no acts of self-harm.
3. Client is able to verbalize names of resources outside the
hospital from whom he or she may request help if feeling
suicidal.
COMPLICATED GRIEVING
Denition: A disorder that occurs after the death of a significant
other [or any other loss of significance to the individual], in which the
experience of distress accompanying bereavement fails to follow
normative expectations and manifests in functional impairment.

[Real or perceived loss of any concept of value to the individual]
[Bereavement overload (cumulative grief from multiple unresolved
losses)]
[Thwarted grieving response to a loss]
[Absence of anticipatory grieving]
[Feelings of guilt generated by ambivalent relationship with lost
entity]

[Idealization of lost entity]
[Denial of loss]
[Excessive anger, expressed inappropriately]
[Obsessions with past experiences]
[Ruminations of guilt feelings, excessive and exaggerated out of
proportion to the situation]
[Developmental regression]
[Difculty in expressing loss]
[Prolonged difculty coping following a loss]
2506_Ch06_125-144.indd 0131 10/1/10 9:34:34 AM

[Reliving of past experiences with little or no reduction of

intensity of the grief]
[Prolonged interference with life functioning, with onset or
exacerbation of somatic or psychosomatic responses]
[Labile affect]
[Alterations in eating habits, sleep patterns, dream patterns,
activity level, libido]
Goals/Objectives
Short-term Goal
Client will express anger toward lost entity.
Long-term Goals
1. Client will be able to verbalize behaviors associated with the
normal stages of grief.
2. Client will be able to recognize own position in grief process
as he or she progresses at own pace toward resolution.

1. Determine stage of grief in which client is xed. Identify
behaviors associated with this stage. Accurate baseline as-
sessment data are necessary to effectively plan care for the
grieving client.
2. Develop trusting relationship with client. Show empathy and
caring. Be honest and keep all promises. Trust is the basis for
a therapeutic relationship.
3. Convey an accepting attitude, and enable the client to express
feelings openly. An accepting attitude conveys to the client
that you believe he or she is a worthwhile person. Trust is
enhanced.
4. Encourage client to express anger. Do not become defensive
if initial expression of anger is displaced on nurse or therapist.
Assist client to explore angry feelings so that they may be di-
rected toward the intended object or person. Verbalization of
feelings in a nonthreatening environment may help client
come to terms with unresolved issues.
5. Assist client to discharge pent-up anger through participation
in large motor activities (e.g., brisk walks, jogging, physical
exercises, volleyball, punching bag, exercise bike). Physical
exercise provides a safe and effective method for discharging
pent-up tension.
6. Teach the normal stages of grief and behaviors associated with
each stage. Help client to understand that feelings such as guilt
and anger toward the lost entity are appropriate and accept-
able during the grief process. Knowledge of acceptability of the
feelings associated with normal grieving may help to relieve
some of the guilt that these responses generate.
2506_Ch06_125-144.indd 0132 10/1/10 9:34:34 AM

7. Encourage client to review relationship with the lost entity.

With support and sensitivity, point out reality of the situa-
tion in areas where misrepresentations are expressed. Client
must give up an idealized perception and be able to accept
both positive and negative aspects about the lost entity be-
fore the grief process is complete.
8. Communicate to client that crying is acceptable. Use of
touch is therapeutic and appropriate with most clients.
Knowledge of cultural inuences specic to the client is
important before using this technique.
9. Assist client in problem solving as he or she attempts to deter-
mine methods for more adaptive coping with the experienced
loss. Provide positive feedback for strategies identied and
decisions made. Positive feedback increases self-esteem and
10. Encourage client to reach out for spiritual support during this
time in whatever form is desirable to him or her. Assess spiri-
tual needs of client and assist as necessary in the fulllment of
those needs.
Outcome Criteria
1. Client is able to verbalize normal stages of the grief process
and behaviors associated with each stage.
2. Client is able to identify own position within the grief pro-
cess and express honest feelings related to the lost entity.
3. Client is no longer manifesting exaggerated emotions and
behaviors related to complicated grieving and is able to carry
out ADLs independently.
LOW SELF-ESTEEM
De nition: Negative self-evaluation/feelings about self or self-
capabilities.

[Feelings of abandonment by signicant other]
[Numerous failures (learned helplessness)]
[Underdeveloped ego and punitive superego]
[Impaired cognition fostering negative view of self]

[Withdrawal into social isolation]
[Being highly critical and judgmental of self and others]
2506_Ch06_125-144.indd 0133 10/1/10 9:34:35 AM

[Expressions of worthlessness]
[Fear of failure]
[Inability to recognize own accomplishments]
[Setting self up for failure by establishing unrealistic goals]
[Unsatisfactory interpersonal relationships]
[Negative, pessimistic outlook]
[Hypersensitive to slight or criticism]
[Grandiosity]
Goals/Objectives
Short-term Goals
1. Within reasonable time period, client will discuss fear of
failure with nurse.
2. Within reasonable time period, client will verbalize things
he or she likes about self.
Long-term Goals
1. By time of discharge from treatment, client will exhibit
increased feelings of self-worth as evidenced by verbal
expression of positive aspects of self, past accomplishments,
and future prospects.
2. By time of discharge from treatment, client will exhibit
increased feelings of self-worth by setting realistic goals and
trying to reach them, thereby demonstrating a decrease in
fear of failure.

1. Be accepting of client and his or her negativism. An attitude
of acceptance enhances feelings of self-worth.
2. Spend time with client to convey acceptance and contribute
toward feelings of self-worth.
3. Help client to recognize and focus on strengths and
accomplishments. Minimize attention given to past (real or
perceived) failures. Lack of attention may help to eliminate
negative ruminations.
4. Encourage participation in group activities from which client
may receive positive feedback and support from peers.
5. Help client identify areas he or she would like to change
about self, and assist with problem solving toward this
effort. Low self-worth may interfere with clients percep-
tion of own problem-solving ability. Assistance may be
required.
6. Ensure that client is not becoming increasingly dependent
and that he or she is accepting responsibility for own behav-
iors. Client must be able to function independently if he or
she is to be successful within the less-structured community
environment.
2506_Ch06_125-144.indd 0134 10/1/10 9:34:35 AM

7. Ensure that therapy groups offer client simple methods of

achievement. Offer recognition and positive feedback for
actual accomplishments. Successes and recognition increase
self-esteem.
8. Teach assertiveness techniques: the ability to recognize the
differences among passive, assertive, and aggressive behaviors,
and the importance of respecting the human rights of others
while protecting ones own basic human rights. Self-esteem is
enhanced by the ability to interact with others in an assertive
manner.
9. Teach effective communication techniques, such as the use
of I messages. I-statements can be used to take owner-
ship for ones feelings rather than saying they are caused by
the other person. Example: I feel angry when you criticize
me in front of other people, and I would prefer that you stop
doing that. You-statements put the other individual on
the defensive. Example: You are a jerk for criticizing me in
front of other people!
10. Assist client in performing aspects of self-care when required.
Offer positive feedback for tasks performed independently.
Positive feedback enhances self-esteem and encourages rep-
etition of desirable behaviors.
Outcome Criteria
1. Client is able to verbalize positive aspects of self.
2. Client is able to communicate assertively with others.
3. Client expresses some optimism and hope for the future.
4. Client sets realistic goals for self and demonstrates willing
attempt to reach them.
SOCIAL ISOLATION/IMPAIRED
SOCIAL INTERACTION
Denition: Social isolation is the condition of aloneness experi-
enced by the individual and perceived as imposed by others and as a
negative or threatened state; impaired social interaction is an insuffi-
cient or excessive quantity or ineffective quality of social exchange.

[Egocentric behaviors (which offend others and discourage
relationships)]
Disturbed thought processes [delusional thinking]
[Fear of rejection or failure of the interaction]
[Impaired cognition fostering negative view of self]
2506_Ch06_125-144.indd 0135 10/1/10 9:34:35 AM

[Unresolved grief]
Absence of signicant others

Sad, dull affect
Being uncommunicative, withdrawn; lacking eye contact
Preoccupation with own thoughts; performance of repetitive,
meaningless actions
Seeking to be alone
[Assuming fetal position]
Expression of feelings of aloneness or rejection
Discomfort in social situations
Goals/Objectives
Short-term Goal
Client will develop trusting relationship with nurse or counselor
within time period to be individually determined.
Long-term Goals
1. Client will voluntarily spend time with other clients and
nurse or therapist in group activities by time of discharge
from treatment.
2. Client will refrain from using egocentric behaviors that offend
others and discourage relationships by time of discharge from
treatment.

1. Spend time with client. This may mean just sitting in silence
for a while. Your presence may help improve clients percep-
tion of self as a worthwhile person.
2. Develop a therapeutic nurse-client relationship through
frequent, brief contacts and an accepting attitude. Show un-
conditional positive regard. Your presence, acceptance, and
conveyance of positive regard enhance the clients feelings of
self-worth.
3. After client feels comfortable in a one-to-one relationship,
encourage attendance in group activities. May need to attend
with client the rst few times to offer support. Accept cli-
ents decision to remove self from group situation if anxiety
becomes too great. The presence of a trusted individual
provides emotional security for the client.
4. Verbally acknowledge clients absence from any group
activities. Knowledge that his or her absence was noticed
may reinforce the clients feelings of self-worth.
5. Teach assertiveness techniques. Interactions with others
may be discouraged by clients use of passive or aggressive
2506_Ch06_125-144.indd 0136 10/1/10 9:34:35 AM

behaviors. Knowledge of the use of assertive techniques

could improve clients relationships with others.
6. Provide direct feedback about clients interactions with others.
Do this in a nonjudgmental manner. Help client learn how to
respond more appropriately in interactions with others. Teach
client skills that may be used to approach others in a more
socially acceptable manner. Practice these skills through role-
play. Client may not realize how he or she is being perceived
by others. Direct feedback from a trusted individual may
help to alter these behaviors in a positive manner. Having
practiced these skills in role-play facilitates their use in real
situations.
7. The depressed client must have lots of structure in his or
her life because of the impairment in decision-making and
problem-solving ability. Devise a plan of therapeutic ac-
tivities and provide client with a written time schedule.
Remember: The client who is moderately depressed feels
best early in the day, whereas later in the day is a better
time for the severely depressed individual to participate in
activities. It is important to plan activities at a time when
the client has more energy and is more likely to gain from
the experience.
8. Provide positive reinforcement for clients voluntary interac-
tions with others. Positive reinforcement enhances self-esteem
and encourages repetition of desirable behaviors.
Outcome Criteria
others.
3. Client approaches others in appropriate manner for one-to-one
interaction.
POWERLESSNESS
De nition: Perception that ones own action will not significantly
affect an outcome; a perceived lack of control over a current situa-
tion or immediate happening.

Lifestyle of helplessness
Healthcare environment
[Complicated grieving process]
[Consistent negative feedback]
2506_Ch06_125-144.indd 0137 10/1/10 9:34:36 AM


Verbal expressions of having no control (e.g., over self-care,
situation, outcome)
Nonparticipation in care or decision making when opportunities
are provided
Expression of doubt regarding role performance
Reluctance to express true feelings
Apathy
Dependence on others that may result in irritability, resentment,
anger, and guilt
Passivity
Goals/Objectives
Short-term Goal
Client will participate in decision making regarding own care
within 5 days.
Long-term Goal
Client will be able to effectively problem solve ways to take
control of his or her life situation by time of discharge from
treatment, thereby decreasing feelings of powerlessness.

1. Encourage client to take as much responsibility as possible
for own self-care practices. Providing client with choices will
increase his or her feelings of control.
Examples:
a. Include client in setting the goals of care he or she wishes
to achieve.
b. Allow client to establish own schedule for self-care
activities.
c. Provide client with privacy as need is determined.
d. Provide positive feedback for decisions made. Respect
clients right to make those decisions independently, and
refrain from attempting to inuence him or her toward
those that may seem more logical.
2. Help client set realistic goals. Unrealistic goals set the client
up for failure and reinforce feelings of powerlessness.
3. Help client identify areas of life situation that he or she can
control. Clients emotional condition interferes with his or
her ability to solve problems. Assistance is required to per-
ceive the benefits and consequences of available alternatives
accurately.
4. Help client identify areas of life situation that are not within
his or her ability to control. Encourage verbalization of feel-
ings related to this inability in an effort to deal with unre-
solved issues and accept what cannot be changed.
2506_Ch06_125-144.indd 0138 10/1/10 9:34:36 AM

5. Identify ways in which client can achieve. Encourage partici-

pation in these activities, and provide positive reinforcement
for participation, as well as for achievement. Positive reinforce-
ment enhances self-esteem and encourages repetition of desir-
able behaviors.
Outcome Criteria
1. Client verbalizes choices made in a plan to maintain control
over his or her life situation.
2. Client verbalizes honest feelings about life situations over
which he or she has no control.
3. Client is able to verbalize system for problem solving as
required for adequate role performance.

De nition: Disruption in cognitive operations and activities.

[Underdeveloped ego; punitive superego]
[Impaired cognition fostering negative perception of self and
the environment]
Inaccurate interpretation of environment
Hypovigilance
Egocentricity
[Impaired ability to make decisions, problem solve, reason]
[Negative ruminations]
Goals/Objectives
Short-term Goal
Client will recognize and verbalize when interpretations of the
environment are inaccurate within 1 week.
Long-term Goal
By time of discharge from treatment, clients verbalizations will
reect reality-based thinking with no evidence of delusional or
distorted ideation.
while letting him or her know that you do not share the
delusion. A positive response would convey to the client that
you accept the delusion as reality.
2506_Ch06_125-144.indd 0139 10/1/10 9:34:36 AM


therapeutic technique: I understand that you believe this is
true, but I personally nd it hard to accept. Arguing with
the client or denying the belief serves no useful purpose, as
delusional ideas are not eliminated by this approach, and the
development of a trusting relationship may be impeded.
cation when communication reects alteration in thinking.
(Examples: Is it that you mean . . . ? or I dont understand
what you mean by that. Would you please explain?) These
techniques reveal to the client how he or she is being perceived
by others, while the responsibility for not understanding is
accepted by the nurse.
4. Reinforce and focus on reality. Talk about real events and real
people. Use real situations and events to divert client away
from long, purposeless, repetitive verbalizations of false ideas.
5. Give positive reinforcement as client is able to differenti-
ate between reality-based and nonreality-based thinking.
Positive reinforcement enhances self-esteem and encourages
6. Teach client to intervene, using thought-stopping techniques,
when irrational or negative thoughts prevail. Thought stop-
ping involves using the command stop! or a loud noise
(such as hand clapping) to interrupt unwanted thoughts. This
noise or command distracts the individual from the unde-
sirable thinking that often precedes undesirable emotions or
behaviors.
7. Use touch cautiously, particularly if thoughts reveal ideas of
persecution. Clients who are suspicious may perceive touch
as threatening and may respond with aggression.
Outcome Criteria
1. Clients thinking processes reect accurate interpretation of
the environment.
2. Client is able to recognize negative or irrational thoughts and
intervene to stop their progression.
IMBALANCED NUTRITION, LESS

Denition: Intake of nutrients insufficient to meet metabolic needs.

Inability to ingest food because of:
[Depressed mood]
[Loss of appetite]
2506_Ch06_125-144.indd 0140 10/1/10 9:34:37 AM

[Energy level too low to meet own nutritional needs]

[Regression to lower level of development]
[Ideas of self-destruction]

Loss of weight
Lack of interest in food
Pale mucous membranes
Poor muscle tone
[Amenorrhea]
[Poor skin turgor]
[Edema of extremities]
[Weakness]
[Constipation]
[Anemias]
Goals/Objectives
Short-term Goal
Client will gain 2 lb per week for the next 3 weeks.
Long-term Goal
Client will exhibit no signs or symptoms of malnutrition
by time of discharge from treatment (e.g., electrolytes
and blood counts will be within normal limits; a steady
weight gain will be demonstrated; constipation will be cor-
rected; client will exhibit increased energy in participation in
activities).

1. In collaboration with dietitian, determine number of calories
required to provide adequate nutrition and realistic (accord-
ing to body structure and height) weight gain.
2. To prevent constipation, ensure that diet includes foods high
in ber content. Encourage client to increase uid consump-
tion and physical exercise to promote normal bowel func-
tioning. Depressed clients are particularly vulnerable to
constipation because of psychomotor retardation. Constipa-
tion is also a common side effect of many antidepressant
medications.
3. Keep strict documentation of intake, output, and calorie
count. This information is necessary to make an accurate
nutritional assessment and maintain client safety.
4. Weigh client daily. Weight loss or gain is important assess-
ment information.
5. Determine clients likes and dislikes, and collaborate with
dietitian to provide favorite foods. Client is more likely to
eat foods that he or she particularly enjoys.
2506_Ch06_125-144.indd 0141 10/1/10 9:34:37 AM

6. Ensure that client receives small, frequent feedings, includ-

ing a bedtime snack, rather than three larger meals. Large
amounts of food may be objectionable, or even intolerable,
to the client.
7. Administer vitamin and mineral supplements and stool
softeners or bulk extenders, as ordered by physician.
8. If appropriate, ask family members or signicant others to
bring in special foods that client particularly enjoys.
9. Stay with client during meals to assist as needed and to offer
support and encouragement.
10. Monitor laboratory values, and report signicant changes to
physician. Laboratory values provide objective data regard-
ing nutritional status.
11. Explain the importance of adequate nutrition and uid
intake. Client may have inadequate or inaccurate knowl-
edge regarding the contribution of good nutrition to
overall wellness.
Outcome Criteria
1. Client has shown a slow, progressive weight gain during
hospitalization.
2. Vital signs, blood pressure, and laboratory serum studies are
within normal limits.
3. Client is able to verbalize importance of adequate nutrition
and uid intake.
DISTURBED SLEEP PATTERN

De nition: Time-limited interruptions of sleep amount and quality
due to [internal] or external factors.

[Depression]
[Repressed fears]
[Feelings of hopelessness]
[Anxiety]
[Hallucinations]
[Verbal complaints of difculty falling asleep]
[Awakening earlier or later than desired]
[Interrupted sleep]
Verbal complaints of not feeling well rested
[Awakening very early in the morning and being unable to go
back to sleep]
2506_Ch06_125-144.indd 0142 10/1/10 9:34:37 AM

[Excessive yawning and desire to nap during the day]

[Hypersomnia; using sleep as an escape]
Goals/Objectives
Short-term Goal
Client will be able to sleep 4 to 6 hours with the aid of a sleeping
medication within 5 days.
Long-term Goal
Client will be able to fall asleep within 30 minutes of retiring
and obtain 6 to 8 hours of uninterrupted sleep each night with-
out medication by time of discharge from treatment.

1. Keep strict records of sleeping patterns. Accurate baseline
data are important in planning care to assist client with this
problem.
2. Discourage sleep during the day to promote more restful
sleep at night.
3. Administer antidepressant medication at bedtime so client
does not become drowsy during the day.
4. Assist with measures that may promote sleep, such as warm,
nonstimulating drinks, light snacks, warm baths, back rubs.
5. Performing relaxation exercises to soft music may be helpful
prior to sleep.
6. Limit intake of caffeinated drinks, such as tea, coffee, and
colas. Caffeine is a central nervous system (CNS) stimulant
that may interfere with the clients achievement of rest and
sleep.
7. Administer sedative medications, as ordered, to assist client
to achieve sleep until normal sleep pattern is restored.
8. Some depressed clients may use excessive sleep as an escape.
For the client experiencing hypersomnia, set limits on time
spent in room. Plan stimulating diversionary activities on a
structured, daily schedule. Explore fears and feelings that
sleep is helping to suppress.
Outcome Criteria
1. Client is sleeping 6 to 8 hours per night without medication.
2. Client is able to fall asleep within 30 minutes of retiring.
3. Client is dealing with fears and feelings rather than escaping
from them through excessive sleep.
2506_Ch06_125-144.indd 0143 10/1/10 9:34:38 AM

INTERNET REFERENCES
Additional information about depressive disorders, including
psychosocial and pharmacological treatment of these disorders,
may be located at the following websites:
a. http://depression.about.com/
b. http://www.dbsalliance.org/
c. http://www.fadavis.com/townsend
d. http://www.mentalhealth.com/
e. http://www.mental-health-matters.com/disorders/
f. http://www.mentalhelp.net
g. http://www.nlm.nih.gov/medlineplus
h. http://www.cmellc.com/topics/depress.html
Movie Connections
Prozac Nation (depression) The Butcher Boy (depression)
night, Mother (depression) The Prince of Tides (depression/suicide)
2506_Ch06_125-144.indd 0144 10/1/10 9:34:38 AM

C H A P T E R
7
Mood Disorders:
Bipolar Disorders
Mood is de ned as an individuals sustained emotional tone,
which signicantly inuences behavior, personality, and percep-
tion. A disturbance in mood is the predominant feature of the
mood disorders American Psychiatric Association (APA, 2000).
Mood disorders are classied as depressive or bipolar.
Bipolar Disorders
Bipolar disorders are characterized by mood swings from pro-
found depression to extreme euphoria (mania), with intervening
periods of normalcy.
During an episode of mania, the mood is elevated, expansive,
or irritable. Motor activity is excessive and frenzied. Psychotic
features may be present. A somewhat milder form is called hypo-
mania. It is usually not severe enough to require hospitalization,
and it does not include psychotic features.
The diagnostic picture for bipolar depression is identical to that
described for major depressive disorder, with one exceptionthe
client must have a history of one or more manic episodes.
When the symptom presentation includes rapidly alternating
moods (sadness, irritability, euphoria) accompanied by symp-
toms associated with both depression and mania, the individual
is given a diagnosis of bipolar disorder, mixed.
Bipolar I Disorder
Bipolar I disorder is the diagnosis given to an individual who is
experiencing, or has experienced, a full syndrome of manic or
mixed symptoms. The client may also have experienced episodes
of depression.
Bipolar II Disorder
Bipolar II disorder is characterized by recurrent bouts of
major depression with the episodic occurrence of hypomania.
This individual has never experienced a full syndrome of manic
or mixed symptoms.
145
2506_Ch07_145-160.indd 0145 10/1/10 9:34:47 AM

Cyclothymic Disorder
The essential feature is a chronic mood disturbance of at least
2 years duration, involving numerous periods of depression and
hypomania, but not of sufcient severity and duration to meet
the criteria for either bipolar I or II disorder. There is an absence
of psychotic features.
Bipolar Disorder due to General Medical
Condition
This disorder is characterized by a prominent and persistent dis-
turbance in mood (bipolar symptomatology) that is judged to be
the direct result of the physiological effects of a general medical
condition (APA, 2000).
Substance-Induced Bipolar Disorder
The bipolar symptoms associated with this disorder are con-
sidered to be the direct result of the physiological effects of a
substance (e.g., use or abuse of a drug or a medication, or toxin
exposure).
PREDISPOSING FACTORS TO BIPOLAR
DISORDER
1. Biological
a. Genetics. Twin studies have indicated a concordance rate for
bipolar disorder among monozygotic twins at 60% to 80%
compared to 10% to 20% in dizygotic twins. Family studies
have shown that if one parent has bipolar disorder, the risk
that a child will have the disorder is around 28% (Dubovsky,
Davies, & Dubovsky, 2003). If both parents have the disor-
der, the risk is two to three times as great. Bipolar disorder
appears to be equally common in men and women (APA,
2000). Increasing evidence continues to support the role of
genetics in the predisposition to bipolar disorder.
b. Biochemical. Just as there is an indication of lowered lev-
els of norepinephrine and dopamine during an episode of
depression, the opposite appears to be true of an individ-
ual experiencing a manic episode. Thus, the behavioral
responses of elation and euphoria may be caused by an
excess of these biogenic amines in the brain. It has also
been suggested that manic individuals have increased
intracellular sodium and calcium. These electrolyte im-
balances may be related to abnormalities in cellular mem-
brane function in bipolar disorder.
2. Physiological
a. Neuroanatomical factors. Right-sided lesions in the
limbic system, temporobasal areas, basal ganglia,
and thalamus have been shown to induce secondary
2506_Ch07_145-160.indd 0146 10/1/10 9:34:48 AM

mania. Magnetic resonance imaging studies have revealed

enlarged third ventricles and subcortical white matter and
periventricular hyperintensities in clients with bipolar
disorder (Dubovsky, Davies, & Dubovsky, 2003).
3. Medication Side Effects. Certain medications used to treat
somatic illnesses have been known to trigger a manic re-
sponse. The most common of these are the steroids fre-
quently used to treat chronic illnesses such as multiple scle-
rosis and systemic lupus erythematosus. Some clients whose
rst episode of mania occurred during steroid therapy have
reported spontaneous recurrence of manic symptoms years
later. Amphetamines, antidepressants, and high doses of an-
ticonvulsants and narcotics also have the potential for initiat-
ing a manic episode (Dubovsky, Davies, & Dubovsky, 2003).
AND OBJECTIVE DATA)
(Note: The symptoms and treatment of bipolar depression are compara-
ble to those of major depression, which are addressed in Chapter 6. This
chapter will focus on the symptoms and treatment of bipolar mania.)
1. The affect of a manic individual is one of elation and
euphoriaa continuous high. However, the affect is very
labile and may change quickly to hostility (particularly in re-
sponse to attempts at limit setting), or to sadness, ruminating
about past failures.
2. Alterations in thought processes and communication pat-
terns are manifested by the following:
a. Flight of Ideas. There is a continuous, rapid shift from
one topic to another.
b. Loquaciousness. The pressure of the speech is so force-
ful and strong that it is difcult to interrupt maladaptive
thought processes.
c. Delusions of Grandeur. The individual believes he or she
is all important, all powerful, with feelings of greatness
and magnicence.
d. Delusions of Persecution. The individual believes some-
one or something desires to harm or violate him or her in
some way.
3. Motor activity is constant. The individual is literally moving
at all times.
4. Dress is often inappropriate: bright colors that do not match,
clothing inappropriate for age or stature, excessive makeup
and jewelry.
5. The individual has a meager appetite, despite excessive activ-
ity level. He or she is unable or unwilling to stop moving in
order to eat.
2506_Ch07_145-160.indd 0147 10/1/10 9:34:48 AM

6. Sleep patterns are disturbed. Client becomes oblivious to

feelings of fatigue, and rest and sleep are abandoned for days
or weeks.
7. Spending sprees are common. Individual spends large
amounts of money, which is not available, on numerous
items, which are not needed.
8. Usual inhibitions are discarded in favor of sexual and behav-
ioral indiscretions.
9. Manipulative behavior and limit testing are common in the
attempt to fulll personal desires. Verbal or physical hostil-
ity may follow failure in these attempts.
10. Projection is a major defense mechanism. The individual
refuses to accept responsibility for the negative consequences
of personal behavior.
11. There is an inability to concentrate because of a limited
attention span. The individual is easily distracted by even
the slightest stimulus in the environment.
12. Alterations in sensory perception may occur, and the indi-
vidual may experience hallucinations.
13. As agitation increases, symptoms intensify. Unless the client
is placed in a protective environment, death can occur from
exhaustion or injury.
COMMON NURSING DIAGNOSES

AND INTERVENTIONS FOR MANIA
RISK FOR INJURY

De nition: At risk of injury as a result of environmental conditions
interacting with the individuals adaptive and defensive resources

Biochemical dysfunction
Psychological (affective orientation)
[Extreme hyperactivity]
[Destructive behaviors]
[Anger directed at the environment]
[Hitting head (hand, arm, foot, etc.) against wall when angry]
[Temper tantrumsbecomes destructive of inanimate objects]
[Increased agitation and lack of control over purposeless, and
potentially injurious, movements]
2506_Ch07_145-160.indd 0148 10/1/10 9:34:49 AM

Goals/Objectives
Short-term Goal
Client will no longer exhibit potentially injurious movements
after 24 hours with administration of tranquilizing medication.
Long-term Goal
Client will experience no physical injury.

1. Reduce environmental stimuli. Assign a private room, if pos-
sible, with soft lighting, low noise level, and simple room
decor. In the hyperactive state, the client is extremely
distractible, and responses to even the slightest stimuli are
exaggerated.
2. Assign to a quiet unit, if possible. Milieu unit may be too
distracting.
3. Limit group activities. Help client try to establish one or two
close relationships. Clients ability to interact with others is
impaired. He or she feels more secure in a one-to-one rela-
tionship that is consistent over time.
4. Remove hazardous objects and substances from clients
environment (including smoking materials). Clients rational-
ity is impaired, and he or she may harm self inadvertently.
Client safety is a nursing priority.
5. Stay with the client to offer support and provide a feeling of
security as agitation grows and hyperactivity increases.
6. Provide structured schedule of activities that includes estab-
lished rest periods throughout the day. A structured schedule
provides a feeling of security for the client.
7. Provide physical activities as a substitution for purpose-
less hyperactivity (examples: brisk walks, housekeeping
chores, dance therapy, aerobics). Physical exercise pro-
vides a safe and effective means of relieving pent-up
tension.
8. Administer tranquilizing medication, as ordered by phy-
sician. Antipsychotic drugs are commonly prescribed for
rapid relief of agitation and hyperactivity. Atypical forms
commonly used include olanzapine, ziprasidone, and
aripiprazole. Examples of the typical forms include halo-
peridol and chlorpromazine. Observe for effectiveness and
evidence of adverse side effects (see Chapter 28).
Outcome Criteria
1. Client is no longer exhibiting signs of physical agitation.
2. Client exhibits no evidence of physical injury obtained while
experiencing hyperactive behavior.
2506_Ch07_145-160.indd 0149 10/1/10 9:34:49 AM


ally harmful [either to self or to others]

[Manic excitement]
[Biochemical alterations]
[Threat to self-concept]
[Suspicion of others]
[Paranoid ideation]
[Delusions]
[Hallucinations]
[Rage reactions]
Impulsivity
[Repetition of verbalizations (continuous complaints, requests,
and demands)]
Goals/Objectives
Short-term Goal
Clients agitation will be maintained at manageable level with
the administration of tranquilizing medication during rst week
of treatment (decreasing risk of violence to self or others).
Long-term Goal

1. Maintain low level of stimuli in clients environment (low light-
ing, few people, simple decor, low noise level). Anxiety and
agitation rise in a stimulating environment. Individuals may
be perceived as threatening by a suspicious, agitated client.
2. Observe clients behavior frequently (every 15 minutes).
Close observation is required so that intervention can occur
if required to ensure clients (and others) safety.
3. Remove all dangerous objects from clients environment
(sharp objects, glass or mirrored items, belts, ties, smoking
2506_Ch07_145-160.indd 0150 10/1/10 9:34:49 AM

materials) so that in his or her agitated, hyperactive state,

client may not use them to harm self or others.
4. Try to redirect the violent behavior with physical outlets for
the clients hostility (e.g., punching bag). Physical exercise is
a safe and effective way of relieving pent-up tension.
5. Intervene at the rst sign of increased anxiety, agitation, or
verbal or behavioral aggression. Offer empathetic response
to clients feelings: You seem anxious (or frustrated, or an-
gry) about this situation. How can I help? Validation of
the clients feelings conveys a caring attitude and offering
assistance reinforces trust.
6. Staff should maintain and convey a calm attitude to the
client. Respond matter-of-factly to verbal hostility. Anxiety
is contagious and can be transmitted from staff to client.
to client if necessary. This conveys to the client evidence of
control over the situation and provides some physical secu-
rity for staff.
cian. Monitor medication for effectiveness and for adverse
side effects.
9. If the client is not calmed by talking down or by medi-
cation, use of mechanical restraints may be necessary. The
avenue of the least restrictive alternative must be selected
when planning interventions for a violent client. Restraints
should be used only as a last resort, after all other interven-
tions have been unsuccessful, and the client is clearly at risk
of harm to self or others.
10. If restraint is deemed necessary, ensure that sufcient staff
is available to assist. Follow protocol established by the
institution. The Joint Commission formerly, the Joint
Commission on Accreditation of Healthcare Organiza-
tions [ JCAHO]) requires that an in-person evaluation (by a
physician, clinical psychologist, or other licensed indepen-
dent practitioner responsible for the care of the patient) be
conducted within 1 hour of initiating restraint or seclusion
(The Joint Commission, 2010). The physician must reissue
a new order for restraints every 4 hours for adults and every
1 to 2 hours for children and adolescents.
11. The Joint Commision requires that the client in restraints
be observed every 15 minutes to ensure that circulation to
pulses); to assist client with needs related to nutrition, hy-
dration, and elimination; and to position client so that com-
fort is facilitated and aspiration can be prevented. Some
2506_Ch07_145-160.indd 0151 10/1/10 9:34:50 AM

institutions may require continuous one-to-one monitoring

of restrained clients, particularly those who are highly agi-
tated, and for whom there is a high risk of self- or accidental
injury. Client safety is a nursing priority.
removal or reduction. Remove one restraint at a time, while
assessing clients response. This procedure minimizes the
risk of injury to client and staff.
Outcome Criteria
1. Client is able to verbalize anger in an appropriate manner.
2. There is no evidence of violent behavior to self or others.
3. Client is no longer exhibiting hyperactive behaviors.
IMBALANCED NUTRITION, LESS

needs

[Refusal or inability to sit still long enough to eat meals]
[Lack of appetite]
[Excessive physical agitation]
[Physical exertion in excess of energy produced through caloric
intake]
[Lack of interest in food]

Loss of weight
Poor muscle tone
[Amenorrhea]
[Poor skin turgor]
[Anemias]
Goals/Objectives
Short-term Goal
Client will consume sufcient nger foods and between-meal
snacks to meet recommended daily allowances of nutrients.
Long-term Goal
Client will exhibit no signs or symptoms of malnutrition.
2506_Ch07_145-160.indd 0152 10/1/10 9:34:50 AM


1. In collaboration with dietitian, determine the number of calo-
ries required to provide adequate nutrition for maintenance or
realistic (according to body structure and height) weight gain.
2. Provide client with high-protein, high-calorie, nutritious
nger foods and drinks that can be consumed on the run.
Because of hyperactive state, client has difficulty sitting
still long enough to eat a meal. The likelihood is greater
that he or she will consume food and drinks that can be
carried around and eaten with little effort.
3. Have juice and snacks available on the unit at all times.
Nutritious intake is required on a regular basis to
compensate for increased caloric requirements due to
hyperactivity.
4. Maintain accurate record of intake, output, and calorie
count. This information is necessary to make an accurate
nutritional assessment and maintain clients safety.
5. Weigh client daily. Weight loss or gain is important nutri-
tional assessment information.
6. Determine clients likes and dislikes, and collaborate with
dietitian to provide favorite foods. Client is more likely to
eat foods that he or she particularly enjoys.
7. Administer vitamin and mineral supplements, as ordered by
physician, to improve nutritional state.
8. Pace or walk with client as nger foods are taken. As agi-
tation subsides, sit with client during meals. Offer support
and encouragement. Assess and record amount consumed.
Presence of a trusted individual may provide feeling of
security and decrease agitation. Encouragement and posi-
tive reinforcement increase self-esteem and foster repeti-
tion of desired behaviors.
9. Monitor laboratory values, and report signicant changes to
physician. Laboratory values provide objective nutritional
assessment data.
10. Explain the importance of adequate nutrition and uid in-
take. Client may have inadequate or inaccurate knowledge
regarding the contribution of good nutrition to overall
wellness.
Outcome Criteria
1. Client has gained (maintained) weight during hospitalization.
3. Client is able to verbalize importance of adequate nutrition
and uid intake.
2506_Ch07_145-160.indd 0153 10/1/10 9:34:50 AM


De nition: Disruption in cognitive operations and activities

[Electrolyte imbalance]
[Psychotic process]
[Sleep deprivation]

Inaccurate interpretation of environment
Hypervigilance
Egocentricity
[Decreased ability to grasp ideas]
[Impaired ability to make decisions, problem-solve, reason]
[Delusions of grandeur]
[Delusions of persecution]
[Suspiciousness]
Goals/Objectives
Short-term Goal
Within 1 week, client will be able to recognize and verbalize
when thinking is nonreality-based.
Long-term Goal
By time of discharge from treatment, clients verbalizations will
reect reality-based thinking with no evidence of delusional
ideation.

while letting him or her know that you do not share the delu-
sion. A positive response would convey to the client that you
accept the delusion as reality.
therapeutic technique: I understand that you believe this is
true, but I personally nd it hard to accept. Arguing with the
client or denying the belief serves no useful purpose, because
delusional ideas are not eliminated by this approach and the
development of a trusting relationship may be impeded.
cation when communication reects alteration in think-
ing. (Examples: Is it that you mean...? or I dont under-
stand what you mean by that. Would you please explain?)
2506_Ch07_145-160.indd 0154 10/1/10 9:34:50 AM

These techniques reveal to the client how he or she is being

perceived by others, and the responsibility for not under-
standing is accepted by the nurse.
4. Reinforce and focus on reality. Talk about real events and
real people. Use real situations and events to divert client
from long, tedious, repetitive verbalizations of false ideas.
5. Give positive reinforcement as client is able to differenti-
ate between reality-based and nonreality-based thinking.
6. Teach client to intervene, using thought-stopping tech-
niques, when irrational thoughts prevail. Thought stop-
ping involves using the command Stop! or a loud noise
(such as hand clapping) to interrupt unwanted thoughts.
This noise or command distracts the individual from the
undesirable thinking, which often precedes undesirable
emotions or behaviors.
7. Use touch cautiously, particularly if thoughts reveal ideas of
persecution. Clients who are suspicious may perceive touch
as threatening and may respond with aggression.
Outcome Criteria
1. Thought processes reect an accurate interpretation of the
environment.
2. Client is able to recognize thoughts that are not based in
reality and intervene to stop their progression.

De nition: Change in the amount or patterning of incoming
stimuli [either internally or externally initiated] accompanied by a
diminished, exaggerated, distorted, or impaired response to such
stimuli

Biochemical imbalance
Electrolyte imbalance
[Sleep deprivation]
[Psychotic process]

Change in usual response to stimuli
Hallucinations
Disorientation
2506_Ch07_145-160.indd 0155 10/1/10 9:34:51 AM

[Rapid mood swings]
[Exaggerated emotional responses]
[Visual and auditory distortions]
[Listening pose (tilting head to one side as if listening)]
[Stops talking in middle of sentence to listen]
Goals/Objectives
Short-term Goal
Client will be able to recognize and verbalize when he or she is
interpreting the environment inaccurately.
Long-term Goal
Client will be able to de ne and test reality, eliminating the
occurrence of sensory misperceptions.

1. Observe client for signs of hallucinations (listening pose,
laughing or talking to self, stopping in midsentence). Early
intervention may prevent aggressive responses to command
hallucinations.
2. Avoid touching the client before warning him or her that you
are about to do so. Client may perceive touch as threatening
and respond in an aggressive manner.
3. An attitude of acceptance will encourage the client to share
the content of the hallucination with you. This is important
in order to prevent possible injury to the client or others
from command hallucinations.
4. Do not reinforce the hallucination. Use words such as the
voices instead of they when referring to the hallucination.
Words like they validate that the voices are real.
CLINICAL PEARL Let the client who is hearing voices know that you do not
share the perception.
Say, Even though I realize that the voices are real to you, I do not hear any
voices speaking. The nurse must be honest with the client so that he or she may
realize that the hallucinations are not real.
5. Try to connect the times of the misperceptions to times of

increased anxiety. Help client to understand this connection.
If client can learn to interrupt the escalating anxiety, real-
ity orientation may be maintained.
6. Try to distract the client away from the misperception.
Involvement in interpersonal activities and explana-
tion of the actual situation may bring the client back to
reality.
2506_Ch07_145-160.indd 0156 10/1/10 9:34:51 AM

Outcome Criteria
1. Client is able to differentiate between reality and unrealistic
events or situations.
2. Client is able to refrain from responding to false sensory
perceptions.


Disturbed thought processes
[Delusions of grandeur]
[Delusions of persecution]

Inability to receive or communicate a satisfying sense of social en-
gagement (e.g., belonging, caring, interest, or shared history)
[Excessive use of projectiondoes not accept responsibility for
own behavior]
[Verbal manipulation]
[Inability to delay gratication]
Goals/Objectives
Short-term Goal
Client will verbalize which of his or her interaction behaviors
are appropriate and which are inappropriate within 1 week.
Long-term Goal
Client will demonstrate use of appropriate interaction skills as
evidenced by lack of, or marked decrease in, manipulation of
others to fulll own desires.

1. Recognize the purpose these behaviors serve for the client: to
reduce feelings of insecurity by increasing feelings of power
and control. Understanding the motivation behind the ma-
nipulation may facilitate acceptance of the individual and his
or her behavior.
2506_Ch07_145-160.indd 0157 10/1/10 9:34:52 AM

2. Set limits on manipulative behaviors. Explain to client

what you expect and what the consequences are if the limits
are violated. Limits must be agreed upon by all staff
who will be working with the client. Client is unable to
establish own limits, so this must be done for him or her.
Unless administration of consequences for violation of
limits is consistent, manipulative behavior will not be
eliminated.
3. Do not argue, bargain, or try to reason with the client.
Merely state the limits and expectations. Be sure to follow
through with consequences if limits are violated. Consistency
is essential for success of this intervention. Do not let this
charmer talk you out of it. Ignoring these attempts may
work to decrease manipulative behaviors.
4. Provide positive reinforcement for nonmanipulative behaviors.
Explore feelings, and help the client seek more appropriate
ways of dealing with them. Positive reinforcement enhances
self-esteem and promotes repetition of desirable behaviors.
5. Help client recognize consequences of own behaviors and refrain
from attributing them to others. Client must accept responsibil-
ity for own behaviors before adaptive change can occur.
6. Help client identify positive aspects about self, recognize
accomplishments, and feel good about them. As self-esteem
is increased, client will feel less need to manipulate others
for own gratification.
Outcome Criteria
1. Client is able to verbalize positive aspects of self.
2. Client accepts responsibility for own behaviors.
3. Client does not manipulate others for gratication of own
needs.
INSOMNIA
De nition: A disruption in amount and quality of sleep that
impairs functioning

[Excessive hyperactivity]
[Agitation]

Difculty falling asleep
[Pacing in hall during sleeping hours]
2506_Ch07_145-160.indd 0158 10/1/10 9:34:52 AM

[Sleeping only short periods at a time]

[Numerous periods of wakefulness during the night]
[Awakening and rising extremely early in the morning; exhibit-
ing signs of restlessness]
Goals/Objectives
Short-term Goal
Within 3 days, with the aid of a sleeping medication, client will
sleep 4 to 6 hours without awakening.
Long-term Goal
By time of discharge from treatment, client will be able to
acquire 6 to 8 hours of uninterrupted sleep without sleeping
medication.
1. Provide a quiet environment, with a low level of stimulation.
Hyperactivity increases and ability to achieve sleep and rest
are hindered in a stimulating environment.
2. Monitor sleep patterns. Provide structured schedule of activ-
ities that includes established times for naps or rest. Accurate
baseline data are important in planning care to help client
with this problem. A structured schedule, including time
for naps, will help the hyperactive client achieve much-
needed rest.
3. Assess clients activity level. Client may ignore or be un-
aware of feelings of fatigue. Observe for signs such as
increasing restlessness, ne tremors, slurred speech, and
puffy, dark circles under eyes. Client can collapse from
exhaustion if hyperactivity is uninterrupted and rest is
not achieved.
4. Before bedtime, provide nursing measures that promote
sleep, such as back rub; warm bath; warm, nonstimulating
drinks; soft music; and relaxation exercises.
5. Prohibit intake of caffeinated drinks, such as tea, coffee, and
colas. Caffeine is a CNS stimulant and may interfere with
the clients achievement of rest and sleep.
6. Administer sedative medications, as ordered, to assist client
achieve sleep until normal sleep pattern is restored.
Outcome Criteria
1. Client is sleeping 6 to 8 hours per night without sleeping
medication.
2. Client is able to fall asleep within 30 minutes of retiring.
3. Client is dealing openly with fears and feelings rather than
manifesting denial of them through hyperactivity.
2506_Ch07_145-160.indd 0159 10/1/10 9:34:52 AM

INTERNET REFERENCES
Additional information about bipolar disorders, including psy-
chosocial and pharmacological treatment of these disorders,
a. http://www.dbsalliance.org/
b. http://www.fadavis.com/townsend
c. http://www.mentalhealth.com/
d. http://www.cmellc.com/topics/bipolar.html
e. http://www.mental-health-matters.com/disorders/
f. http://www.mentalhelp.net
g. http://www.nlm.nih.gov/medlineplus
Movie Connections
Lust for Life (bipolar disorder) Call Me Anna (bipolar disorder)
Blue Sky (bipolar disorder) A Woman Under the Inuence (bipolar disorder)
2506_Ch07_145-160.indd 0160 10/1/10 9:34:53 AM

C H A P T E R
8
Anxiety Disorders
The characteristic features of this group of disorders are symp-
toms of anxiety and avoidance behavior. Anxiety disorders are
categorized in the following manner:
Panic Disorder (with or without Agoraphobia)

Panic disorder is characterized by recurrent panic attacks, the
onset of which are unpredictable, and manifested by intense
apprehension, fear, or terror, often associated with feelings of
impending doom, and accompanied by intense physical discom-
fort. The attacks usually last minutes or, more rarely, hours. If
accompanied by agoraphobia, there is a fear of being in places or
situations from which escape might be difcult or in which help
might not be available in the event of a panic attack (American
Psychiatric Association [APA], 2000). Common agoraphobic sit-
uations include being outside the home alone; being in a crowd
or standing in a line; being on a bridge; and traveling in a bus,
train, or car.
Agoraphobia without History of Panic

Disorder
The APA (2000) Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition, Text Revision (DSM-IV-TR) identies
the essential feature of this disorder as fear of being in places
or situations from which escape might be difcult or in which
help might not be available in the event of suddenly developing
a symptom(s) that could be incapacitating or extremely embar-
rassing. Travel is restricted or the individual needs a companion
when away from home or else endures agoraphobic situations
despite intense anxiety.
Social Phobia
Social phobia is characterized by a persistent fear of behaving
or performing in the presence of others in a way that will be
humiliating or embarrassing to the individual. The individual
has extreme concerns about being exposed to possible scrutiny
161
2506_Ch08_161-175.indd 0161 10/1/10 9:35:02 AM

by others and fears social or performance situations in which

embarrassment may occur (APA, 2000). Exposure to the pho-
bic situation is avoided, or it is endured with intense anxiety.
Common social phobias include speaking or writing in front of
a group of people, eating in the presence of others, and using
public restrooms.
Specic Phobia
Formerly called simple phobia, this disorder is characterized by
persistent fears of specic objects or situations. These phobias
are fairly widespread among the general population, the most
common being fear of animals (zoophobia), fear of closed places
(claustrophobia), and fear of heights (acrophobia). Exposure to
the phobic stimulus is avoided or endured with intense anxiety.
Obsessive-Compulsive Disorder
This disorder is characterized by involuntary recurring thoughts
or images that the individual is unable to ignore and by recur-
ring impulse to perform a seemingly purposeless activity. These
obsessions and compulsions serve to prevent extreme anxiety on
the part of the individual.
Posttraumatic Stress Disorder
Posttraumatic stress disorder (PTSD) is characterized by the
development of physiological and behavioral symptoms follow-
ing a psychologically traumatic event that is generally outside
the range of usual human experience. The stressor, which would
be considered markedly distressing to almost anyone, has usu-
ally been experienced with intense fear, terror, and helplessness.
If duration of the symptoms is 3 months or longer, the diagnosis
is specied as chronic. If there is a delay of 6 months or longer
in the onset of symptoms, the diagnosis is specied as delayed
onset.
Acute Stress Disorder
Acute stress disorder is characterized by the development of
physiological and behavioral symptoms similar to those of
PTSD. The major difference in the diagnoses lies in the length
of time the symptoms exist. With acute stress disorder, the
symptoms must subside within 4 weeks of occurrence of the
stressor. If they last longer than 4 weeks, the individual is given
the diagnosis of PTSD.
Generalized Anxiety Disorder

This disorder is characterized by chronic, unrealistic, and exces-
sive anxiety and worry. The symptoms must have occurred more
days than not for at least 6 months and must cause clinically
2506_Ch08_161-175.indd 0162 10/1/10 9:35:03 AM

signicant distress or impairment in social, occupational, or

other important areas of functioning (APA, 2000). Symptoms
include restlessness, feeling on edge, becoming easily fatigued,
difculty concentrating, and irritability.
Anxiety Disorder Due to a General Medical

Condition
The symptoms of this disorder are judged to be the direct physi-
ological consequence of a general medical condition. Symptoms
may include prominent generalized anxiety symptoms, panic
attacks, or obsessions or compulsions (APA, 2000). Medical
conditions that have been known to cause anxiety disorders
include endocrine, cardiovascular, respiratory, metabolic, and
neurological disorders.
Substance-Induced Anxiety Disorder

The DSM-IV-TR (APA, 2000) describes the essential features of
this disorder as prominent anxiety symptoms that are judged to
be caused by the direct physiological effects of a substance (i.e.,
a drug of abuse, a medication, or toxin exposure). The symptoms
may occur during substance intoxication or withdrawal and may
involve intense anxiety, panic attacks, phobias, or obsessions or
compulsions.
PREDISPOSING FACTORS TO ANXIETY

DISORDERS
1. Physiological
a. Biochemical: Increased levels of norepinephrine have
been noted in panic and generalized anxiety disorders.
Abnormal elevations of blood lactate have also been
noted in clients with panic disorder. Decreased levels
of serotonin have been implicated in the etiology of
obsessive-compulsive disorder.
b. Genetic: Studies suggest that anxiety disorders are preva-
lent within the general population. It has been shown that
they are more common among rst-degree biological rel-
atives of people with the disorders than among the general
population (APA, 2000).
c. Medical or Substance-Induced: Anxiety disorders may be
caused by a variety of medical conditions or the ingestion
of various substances. (Refer to previous section on cat-
egories of anxiety disorders.)
2. Psychosocial
a. Psychodynamic Theory: The psychodynamic view focuses
on the inability of the ego to intervene when conict occurs
between the id and the superego, producing anxiety. For
2506_Ch08_161-175.indd 0163 10/1/10 9:35:03 AM

various reasons (unsatisfactory parent-child relationship;

conditional love or provisional gratication), ego develop-
ment is delayed. When developmental defects in ego func-
tions compromise the capacity to modulate anxiety, the
individual resorts to unconscious mechanisms to resolve
the conict. Overuse or ineffective use of ego defense
mechanisms results in maladaptive responses to anxiety.
b. Cognitive Theory: The main thesis of the cognitive view
is that faulty, distorted, or counterproductive thinking
patterns accompany or precede maladaptive behaviors and
emotional disorders (Sadock & Sadock, 2007). When there
is a disturbance in this central mechanism of cognition,
there is a consequent disturbance in feeling and behavior.
Because of distorted thinking, anxiety is maintained by
erroneous or dysfunctional appraisal of a situation. There
is a loss of ability to reason regarding the problem, wheth-
er it is physical or interpersonal. The individual feels
vulnerable in a given situation, and the distorted think-
ing results in an irrational appraisal, fostering a negative
outcome.
AND OBJECTIVE DATA)
An individual may experience a panic attack under any of the
following conditions:
As the predominant disturbance, with no apparent precipitant
When exposed to a phobic stimulus
When attempts are made to curtail ritualistic behavior
Following a psychologically traumatic event
Symptoms include the following (APA, 2000):

Pounding, rapid heart rate
Feeling of choking or smothering
Difculty breathing
Pain in the chest
Feeling dizzy or faint
Increased perspiration
Feeling of numbness or tingling in the extremities
Trembling
Fear that one is dying or going crazy
Sense of impending doom
Feelings of unreality (derealization and/or depersonalization)
Other symptoms of anxiety disorders include the following:

1. Restlessness, feeling on edge, excessive worry, being easily
fatigued, difculty concentrating, irritability, and sleep dis-
turbances (generalized anxiety disorder).
2506_Ch08_161-175.indd 0164 10/1/10 9:35:03 AM

2. Recurrent and intrusive recollections or dreams about the trau-

matic event, feeling of reliving the trauma (ashback episodes),
difculty feeling emotion (a numbing affect), insomnia, and
irritability or outbursts of anger (PTSD).
3. Repetitive, obsessive thoughts, common ones being related
to violence, contamination, and doubt; repetitive, compul-
sive performance of purposeless activity, such as handwash-
ing, counting, checking, and touching (obsessive-compulsive
disorder).
4. Marked and persistent fears of specic objects or situations
(specic phobia), social or performance situations (social
phobia), or being in a situation from which one has difculty
escaping (agoraphobia).

and Interventions
ANXIETY (PANIC)
panied by an autonomic response (the source often nonspecific or
unknown to the individual); a feeling of apprehension caused by
threat.

Unconscious con ict about essential values and goals of life
[Real or perceived] threat to self-concept
[Real or perceived] threat of death
Unmet needs
[Being exposed to a phobic stimulus]
[Attempts at interference with ritualistic behaviors]
[Traumatic experience]

Increased respiration
Increased pulse
Decreased or increased blood pressure
Nausea
Confusion
2506_Ch08_161-175.indd 0165 10/1/10 9:35:04 AM

Increased perspiration
Faintness
Trembling or shaking
Restlessness
Insomnia
[Nightmares or visual perceptions of traumatic event]
[Fear of dying, going crazy, or doing something uncontrolled
during an attack]
Goals/Objectives
Short-term Goal
Client will verbalize ways to intervene in escalating anxiety
within 1 week.
Long-term Goal
Client will be able to recognize symptoms of onset of anxiety
and intervene before reaching panic stage by time of discharge
from treatment.

1. Maintain a calm, nonthreatening manner while working
with client. Anxiety is contagious and may be transferred
from staff to client or vice versa. Client develops feeling of
security in presence of calm staff person.
2. Reassure client of his or her safety and security. This can be
conveyed by physical presence of nurse. Do not leave client
alone at this time. Client may fear for his or her life. Presence
of a trusted individual provides client with feeling of security
and assurance of personal safety.
3. Use simple words and brief messages, spoken calmly and
clearly, to explain hospital experiences to client. In an intense-
ly anxious situation, client is unable to comprehend anything
but the most elementary communication.
4. Keep immediate surroundings low in stimuli (dim lighting,
few people, simple decor). A stimulating environment may
increase level of anxiety.
5. Administer tranquilizing medication, as ordered by physi-
cian. Assess medication for effectiveness and for adverse side
effects.
6. When level of anxiety has been reduced, explore with client
possible reasons for occurrence. Recognition of precipitating
factor(s) is the first step in teaching client to interrupt
escalation of the anxiety.
7. Encourage client to talk about traumatic experience un-
der nonthreatening conditions. Help client work through
feelings of guilt related to the traumatic event. Help client
understand that this was an event to which most people
2506_Ch08_161-175.indd 0166 10/1/10 9:35:04 AM

would have responded in like manner. Support client during

ashbacks of the experience. Verbalization of feelings in a
nonthreatening environment may help client come to terms
with unresolved issues.
8. Teach signs and symptoms of escalating anxiety, and ways to
interrupt its progression (e.g., relaxation techniques, deep-
breathing exercises, physical exercises, brisk walks, jogging,
meditation).
Outcome Criteria
1. Client is able to maintain anxiety at level in which problem
solving can be accomplished.
2. Client is able to verbalize signs and symptoms of escalating
anxiety.
3. Client is able to demonstrate techniques for interrupting the
progression of anxiety to the panic level.
FEAR
De nition: Response to perceived threat that is consciously
recognized as a danger.

Phobic stimulus
[Being in place or situation from which escape might be
difcult]
[Causing embarrassment to self in front of others]
[Refuses to leave own home alone]
[Refuses to eat in public]
[Refuses to speak or perform in public]
[Refuses to expose self to (specify phobic object or situation)]
Identies object of fear
[Symptoms of apprehension or sympathetic stimulation in
presence of phobic object or situation]
Goals/Objectives
Short-term Goal
Client will discuss phobic object or situation with nurse or
therapist within 5 days.
Long-term Goal
Client will be able to function in presence of phobic object or
situation without experiencing panic anxiety by time of dis-
charge from treatment.
2506_Ch08_161-175.indd 0167 10/1/10 9:35:04 AM


1. Reassure client of his or her safety and security. At panic
level of anxiety, client may fear for own life.
2. Explore clients perception of threat to physical integrity
or threat to self-concept. It is important to understand the
clients perception of the phobic object or situation in order
to assist with the desensitization process.
3. Discuss reality of the situation with client in order to rec-
ognize aspects that can be changed and those that cannot.
Client must accept the reality of the situation (aspects that
cannot change) before the work of reducing the fear can
progress.
4. Include client in making decisions related to selection of
alternative coping strategies. (Example: Client may choose
either to avoid the phobic stimulus or attempt to eliminate
the fear associated with it.) Allowing the client choices pro-
vides a measure of control and serves to increase feelings of
self-worth.
5. If the client elects to work on elimination of the fear, tech-
niques of desensitization may be employed. This is a sys-
tematic plan of behavior modication, designed to expose
the individual gradually to the situation or object (either in
reality or through fantasizing) until the fear is no longer
experienced. This is also sometimes accomplished through
implosion therapy, in which the individual is ooded with
stimuli related to the phobic situation or object (rather than
in gradual steps) until anxiety is no longer experienced in
relation to the object or situation. Fear is decreased as the
physical and psychological sensations diminish in response
to repeated exposure to the phobic stimulus under non-
threatening conditions.
6. Encourage client to explore underlying feelings that may be
contributing to irrational fears. Help client to understand
how facing these feelings, rather than suppressing them,
can result in more adaptive coping abilities. Verbalization of
feelings in a nonthreatening environment may help client
Outcome Criteria
1. Client does not experience disabling fear when exposed to
phobic object or situation, or
2. Client verbalizes ways in which he or she will be able to
avoid the phobic object or situation with minimal change in
lifestyle.
3. Client is able to demonstrate adaptive coping techniques that
may be used to maintain anxiety at a tolerable level.
2506_Ch08_161-175.indd 0168 10/1/10 9:35:04 AM

INEFFECTIVE COPING

[Underdeveloped ego; punitive superego]
[Fear of failure]
Situational crises
Maturational crises
[Unmet dependency needs]

[Ritualistic behavior]
[Obsessive thoughts]
Goals/Objectives
Short-term Goal
Within 1 week, client will decrease participation in ritualistic
behavior by half.
Long-term Goal
By time of discharge from treatment, client will demonstrate abil-
ity to cope effectively without resorting to obsessive-compulsive
behaviors or increased dependency.

1. Assess clients level of anxiety. Try to determine the types of
situations that increase anxiety and result in ritualistic behav-
iors. Recognition of precipitating factors is the first step in
teaching the client to interrupt the escalating anxiety.
2. Initially meet clients dependency needs as required. Encour-
age independence and give positive reinforcement for inde-
pendent behaviors. Sudden and complete elimination of all
avenues for dependency would create intense anxiety on the
part of the client. Positive reinforcement enhances self-esteem
and encourages repetition of desired behaviors.
3. In the beginning of treatment allow plenty of time for ritu-
als. Do not be judgmental or verbalize disapproval of the
2506_Ch08_161-175.indd 0169 10/1/10 9:35:05 AM

behavior. To deny client this activity may precipitate panic

level of anxiety.
4. Support clients efforts to explore the meaning and purpose
of the behavior. Client may be unaware of the relationship
between emotional problems and compulsive behaviors.
Recognition is important before change can occur.
5. Provide structured schedule of activities for the client, includ-
ing adequate time for completion of rituals. Structure provides
a feeling of security for the anxious client.
6. Gradually begin to limit the amount of time allotted for
ritualistic behavior as client becomes more involved in unit
activities. Anxiety is minimized when client is able to replace
ritualistic behaviors with more adaptive ones.
7. Give positive reinforcement for nonritualistic behaviors.
repetition of desired behaviors.
8. Encourage recognition of situations that provoke obsessive
thoughts or ritualistic behaviors. Explain ways of interrupting
these thoughts and patterns of behavior (e.g., thought-stopping
techniques, relaxation techniques, physical exercise, or other
constructive activity with which client feels comfortable).
Outcome Criteria
1. Client is able to verbalize signs and symptoms of increasing
anxiety and intervene to maintain anxiety at manageable level.
2. Client demonstrates ability to interrupt obsessive thoughts
and refrain from ritualistic behaviors in response to stressful
situations.
POWERLESSNESS
De nition: The perception that ones own action will not signifi -
cantly affect an outcome; a perceived lack of control over a current
situation or immediate happening.

[Fear of disapproval from others]
[Consistent negative feedback]

Verbal expressions of having no control (e.g., over self-care, situ-
ation, outcome)
2506_Ch08_161-175.indd 0170 10/1/10 9:35:05 AM

Nonparticipation in care or decision making when opportunities

are provided
Expression of doubt regarding role performance
Apathy
Dependence on others that may result in irritability, resentment,
anger, and guilt
Passivity
Goals/Objectives
Short-term Goal
Client will participate in decision making regarding own care
within 5 days.
Long-term Goal
Client will be able to effectively problem-solve ways to take con-
trol of his or her life situation by discharge, thereby decreasing
feelings of powerlessness.
1. Allow client to take as much responsibility as possible for
own self-care practices. Providing client with choices will
increase his or her feelings of control.
Examples are as follows:
a. Include client in setting the goals of care he or she wishes
to achieve.
b. Allow client to establish own schedule for self-care
activities.
c. Provide client with privacy as need is determined.
d. Provide positive feedback for decisions made. Respect
clients right to make those decisions independently, and
refrain from attempting to inuence him or her toward
those that may seem more logical.
2. Help client set realistic goals. Unrealistic goals set the client
up for failure and reinforce feelings of powerlessness.
3. Help identify areas of life situation that client can control.
Clients emotional condition interferes with his or her
ability to solve problems. Assistance is required to perceive
the benefits and consequences of available alternatives
accurately.
4. Help client identify areas of life situation that are not with-
in his or her ability to control. Encourage verbalization of
feelings related to this inability in an effort to deal with
unresolved issues and accept what cannot be changed.
5. Identify ways in which client can achieve. Encourage par-
ticipation in these activities, and provide positive reinforce-
ment for participation, as well as for achievement. Positive
2506_Ch08_161-175.indd 0171 10/1/10 9:35:05 AM

reinforcement enhances self-esteem and encourages repeti-

tion of desirable behaviors.
Outcome Criteria
3. Client is able to verbalize system for problem-solving as
required for adequate role performance.
SOCIAL ISOLATION
De nition: Aloneness experienced by the individual and per-
ceived as imposed by others and as a negative or threatening
state.

[Past experiences of difculty in interactions with others]
[Need to engage in ritualistic behavior in order to keep anxiety
under control]
[Repressed fears]

[Stays alone in room]
Uncommunicative
Withdrawn
No eye contact
Developmentally [or culturally] inappropriate behaviors
Preoccupation with own thoughts; repetitive, meaningless
actions
Expression of feelings of rejection or of aloneness imposed by
others
Experiences feelings of differences from others
Insecurity in public
Goals/Objectives
Short-term Goal
Client will willingly attend therapy activities accompanied by
trusted support person within 1 week.
Long-term Goal
Client will voluntarily spend time with other clients and staff
members in group activities by time of discharge from treatment.
2506_Ch08_161-175.indd 0172 10/1/10 9:35:06 AM


1. Convey an accepting attitude by making brief, frequent con-
tacts. An accepting attitude increases feelings of self-worth
and facilitates trust.
3. Be with the client to offer support during group activities
that may be frightening or difcult for him or her. The pres-
ence of a trusted individual provides emotional security for
the client.
5. Be cautious with touch. Allow client extra space and an avenue
for exit if he or she becomes too anxious. A person in panic
anxiety may perceive touch as a threatening gesture.
cian. Monitor for effectiveness and for adverse side effects.
Short-term use of antianxiety medications, such as diaze-
pam, chlordiazepoxide, or alprazolam, helps to reduce level of
anxiety in most individuals, thereby facilitating interactions
with others.
7. Discuss with client the signs of increasing anxiety and techniques
for interrupting the response (e.g., relaxation exercises, thought
stopping). Maladaptive behaviors, such as withdrawal and sus-
piciousness, are manifested during times of increased anxiety.
8. Give recognition and positive reinforcement for clients volun-
tary interactions with others. Positive reinforcement enhances
self-esteem and encourages repetition of acceptable behaviors.
Outcome Criteria
1. Client demonstrates willingness or desire to socialize with
others.
3. Client approaches others in appropriate manner for one-to-one
interaction.
SELF-CARE DEFICIT (IDENTIFY

SPECIFIC AREA)
daily living (ADL) independently].

[Withdrawal; isolation from others]
2506_Ch08_161-175.indd 0173 10/1/10 9:35:06 AM

[Excessive ritualistic behavior]

[Disabling anxiety]
[Irrational fears]

[Unwillingness to bathe regularly]
[Uncombed hair; dirty clothes; offensive body and breath odor;
disheveled appearance]
[Eating only a few bites of food off meal tray]
[Lack of interest in selecting appropriate clothing to wear,
dressing, grooming, or maintaining appearance at a satisfac-
tory level]
[Incontinence]
Goals/Objectives
Short-term Goal
Client will verbalize desire to take control of self-care activities
within 5 days.
Long-term Goal
Client will be able to take care of own ADLs and demonstrate a
willingness to do so by time of discharge from treatment.

1. Urge client to perform normal ADLs to his or her level of
ability. Successful performance of independent activities
3. Offer recognition and positive reinforcement for independent
accomplishments. (Example: Mrs. J., I see you have put on a
clean dress and combed your hair.) Positive reinforcement
enhances self-esteem and encourages repetition of desired
behaviors.
4. Show client how to perform activities with which he or she is
having difculty. When anxiety is high, client may require
simple, concrete demonstrations of activities that would be
performed without difficulty under normal conditions.
5. Keep strict records of food and uid intake. This information
is necessary to formulate an accurate nutritional assessment.
6. Offer nutritious snacks and uids between meals. Client may
be unable to tolerate large amounts of food at mealtimes
and may therefore require additional nourishment at other
times during the day to receive adequate nutrition.
7. If client is incontinent, establish routine schedule for toilet-
ing needs. Assist client to bathroom on hourly or bihourly
schedule, as need is determined, until he or she is able to
fulll this need without assistance.
2506_Ch08_161-175.indd 0174 10/1/10 9:35:06 AM

Outcome Criteria
1. Client feeds self, leaving no more than a few bites of food on
food tray.
2. Client selects appropriate clothing and dresses and grooms
self daily.
assistance.
INTERNET REFERENCES
Additional information about anxiety disorders and medica-
tions to treat these disorders may be located at the following
websites:
a. http://www.adaa.org
b. http://www.mentalhealth.com
c. http://www.nimh.nih.gov
d. http://www.anxietynetwork.com/pdhome.html
e. http://www.fadavis.com/townsend
f. http://www.drugs.com/condition/anxiety.html
Movie Connections
As Good as It Gets (OCD) The Aviator (OCD) What About
Bob? (phobias) Copycat (agoraphobia) Analyze This (panic disorder)
Vertigo (specic phobia) Born on the Fourth of July (PTSD) The Deer
Hunter (PTSD)
2506_Ch08_161-175.indd 0175 10/1/10 9:35:06 AM

C H A P T E R
9
Somatoform Disorders
Somatoform disorders are characterized by physical symptoms
suggesting medical disease but without demonstrable organic
pathology or a known pathophysiological mechanism to account
for them. They are classied as mental disorders because patho-
physiological processes are not demonstrable or understandable
by existing laboratory procedures, and there is either evidence
or strong presumption that psychological factors are the major
cause of the symptoms. It is now well documented that a large
proportion of clients in general medical outpatient clinics and
private medical ofces do not have organic disease requiring
medical treatment. It is likely that many of these clients have
somatoform disorders, but they do not perceive themselves
as having a psychiatric problem and thus do not seek treat-
ment from psychiatrists. The American Psychiatric Association
(APA, 2000) Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition, Text Revision (DSM-IV-TR) identies the follow-
ing categories of somatoform disorders:
SOMATOFORM DISORDERS
Somatization Disorder
Somatization disorder is a chronic syndrome of multiple somatic
symptoms that cannot be explained medically and are associated
with psychosocial distress and long-term seeking of assistance
from health-care professionals. Symptoms can represent virtu-
ally any organ system but commonly are expressed as neuro-
logical, gastrointestinal, psychosexual, or cardiopulmonary dis-
orders. Onset of the disorder is usually in adolescence or early
adulthood and is more common in women than in men. The
disorder usually runs a uctuating course, with periods of re-
mission and exacerbation.
Pain Disorder
The essential feature of pain disorder is severe and prolonged
pain that causes clinically signicant distress or impairment in
176
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social, occupational, or other important areas of functioning

(APA, 2000). This diagnosis is made when psychological factors
have been judged to have a major role in the onset, severity, ex-
acerbation, or maintenance of the pain, even when the physical
examination reveals pathology that is associated with the pain.
Hypochondriasis
Hypochondriasis is an unrealistic preoccupation with the fear
of having a serious illness. The DSM-IV-TR suggests that this
fear arises out of an unrealistic interpretation of physical signs
and symptoms. Occasionally medical disease may be pres-
ent, but in the hypochondriacal individual, the symptoms are
grossly disproportionate to the degree of pathology. Individu-
als with hypochondriasis often have a long history of doctor
shopping and are convinced that they are not receiving the
proper care.
Conversion Disorder
Conversion disorder is a loss of or change in body function re-
sulting from a psychological conict, the physical symptoms of
which cannot be explained by any known medical disorder or
pathophysiological mechanism. The most common conversion
symptoms are those that suggest neurological disease such as
paralysis, aphonia, seizures, coordination disturbance, akinesia,
dyskinesia, blindness, tunnel vision, anosmia, anesthesia, and
paresthesia.
Body Dysmorphic Disorder

This disorder, formerly called dysmorphophobia, is charac-
terized by the exaggerated belief that the body is deformed or
defective in some specic way. The most common complaints
involve imagined or slight aws of the face or head, such as
thinning hair, acne, wrinkles, scars, vascular markings, facial
swelling or asymmetry, or excessive facial hair (APA, 2000).
PREDISPOSING FACTORS
TO SOMATOFORM DISORDERS
1. Physiological
a. Genetic. Studies have shown an increased incidence of
somatization disorder, conversion disorder, and hypo-
chondriasis in rst-degree relatives, implying a possible
inheritable predisposition (Sadock & Sadock, 2007; Soares
& Grossman, 2007; Yutzy, 2003).
b. Biochemical. Decreased levels of serotonin and endor-
phins may play a role in the etiology of pain disorder.
2506_Ch09_176-190.indd Sec1:177 10/1/10 9:35:17 AM

2. Psychosocial
a. Psychodynamic. Some psychodynamicists view hypochon-
driasis as an ego defense mechanism. They hypothesize
that physical complaints are the expression of low self-
esteem and feelings of worthlessness and that the individual
believes it is easier to feel something is wrong with the body
than to feel something is wrong with the self.
The psychodynamic theory of conversion disorder pro-
poses that emotions associated with a traumatic event that
the individual cannot express because of moral or ethical
unacceptability are converted into physical symptoms.
The unacceptable emotions are repressed and converted
to a somatic hysterical symptom that is symbolic in some
way of the original emotional trauma.
b. Family Dynamics. Some families have difculty expressing
emotions openly and resolving conicts verbally. When this
occurs, the child may become ill, and a shift in focus is made
from the open conict to the childs illness, leaving unre-
solved the underlying issues that the family cannot confront
openly. Thus, somatization by the child brings some stabil-
ity to the family, as harmony replaces discord and the childs
welfare becomes the common concern. The child in turn
receives positive reinforcement for the illness.
c. Sociocultural/Familial Factors. Somatic complaints are
often reinforced when the sick role relieves the individual
from the need to deal with a stressful situation, whether it
be within society or within the family. When the sick per-
son is allowed to avoid stressful obligations and postpone
unwelcome challenges, is excused from troublesome du-
ties, or becomes the prominent focus of attention because
of the illness, positive reinforcement virtually guarantees
repetition of the response.
d. Past Experience with Physical Illness. Personal experi-
ence, or the experience of close family members, with seri-
ous or life-threatening illness can predispose an individual
to hypochondriasis. Once an individual has experienced a
threat to biological integrity, he or she may develop a fear
of recurrence. The fear of recurring illness generates an
exaggerated response to minor physical changes, leading
to hypochondriacal behaviors.
e. Cultural and Environmental Factors. Some cultures and
religions carry implicit sanctions against verbalizing or
directly expressing emotional states, thereby indirectly
encouraging more acceptable somatic behaviors. Cross-
cultural studies have shown that the somatization symp-
toms associated with depression are relatively similar,
but the cognitive or emotional symptoms such as guilt
2506_Ch09_176-190.indd Sec1:178 10/1/10 9:35:17 AM

are predominantly seen in Western societies. In Middle

Eastern and Asian cultures, depression is almost exclusively
manifested by somatic or vegetative symptoms.
Environmental inuences may be signicant in the
predisposition to somatization disorder. Some studies have
suggested that a tendency toward somatization appears to be
more common in individuals who have low socioeconomic,
occupational, and educational status.
AND OBJECTIVE DATA)
1. Any physical symptom for which there is no organic basis
but for which evidence exists for the implication of psycho-
logical factors.
2. Depressed mood is common.
3. Loss or alteration in physical functioning, with no organic
basis. Examples include the following:
a. Blindness or tunnel vision
b. Paralysis
c. Anosmia (inability to smell)
d. Aphonia (inability to speak)
e. Seizures
f. Coordination disturbances
g. Pseudocyesis (false pregnancy)
h. Akinesia or dyskinesia
i. Anesthesia or paresthesia
4. La belle indifferencea relative lack of concern regard-
ing the severity of the symptoms just described (e.g., a
person is suddenly blind but shows little anxiety over the
situation).
5. Doctor shopping
6. Excessive use of analgesics
7. Requests for surgery
8. Assumption of an invalid role
9. Impairment in social or occupational functioning because
of preoccupation with physical complaints
10. Psychosexual dysfunction (impotence, dyspareunia [painful
coitus], sexual indifference)
11. Excessive dysmenorrhea
12. Excessive preoccupation with physical defect that is out of
proportion to the actual condition

2506_Ch09_176-190.indd Sec1:179 10/1/10 9:35:17 AM

CHRONIC PAIN
De nition: Unpleasant sensory and emotional experience aris-
ing from actual or potential tissue damage or described in terms of
such damage (International Association for the Study of Pain); sud-
den or slow onset of any intensity from mild to severe, constant or
recurring without an anticipated or predictable end and a duration
of greater than 6 months.

[Severe level of anxiety, repressed]
[Low self-esteem]
[Secondary gains from the sick role]

Verbal report of pain [in the absence of pathophysiological
evidence]
Reduced interaction with people
Facial mask [of pain]
Guarding behavior
[Demanding behaviors]
[Refuses to attend therapeutic activities because of pain]
[History of seeking assistance from numerous health-care
professionals]
[Excessive use of analgesics, without relief of pain]
Self-focusing
Goals/Objectives
Short-term Goal
Within 2 weeks, client will verbalize understanding of correla-
tion between pain and psychological problems.
Long-term Goal
By time of discharge from treatment, client will verbalize a
noticeable, if not complete, relief from pain.

1. Monitor physicians ongoing assessments and laboratory re-
ports to ascertain that organic pathology is clearly ruled out.
2. Recognize and accept that the pain is real to the individual,
even though no organic cause can be identied. Denying the
clients feelings is nontherapeutic and hinders the develop-
ment of a trusting relationship.
3. Observe and record the duration and intensity of the
pain. Note factors that precipitate the onset of pain.
Identification of the precipitating stressor is important
2506_Ch09_176-190.indd Sec1:180 10/1/10 9:35:18 AM

for assessment purposes. This information will be used

to develop a plan for assisting the client to cope more
adaptively.
4. Provide pain medication as prescribed by physician. Client
comfort and safety are nursing priorities.
5. Assist with comfort measures, such as back rub, warm bath,
and heating pad. Be careful, however, not to respond in a
way that reinforces the behavior. Secondary gains from
physical symptoms may prolong maladaptive behaviors.
6. Offer your attention at times when client is not focusing on
pain. Positive reinforcement encourages repetition of adap-
tive behaviors.
7. Identify activities that serve to distract client from focus on
self and pain. These distractors serve in a therapeutic man-
ner as a transition from focus on self or physical manifes-
tations to focus on unresolved psychological issues.
8. Encourage verbalization of feelings. Explore meaning that
pain holds for client. Help client connect symptoms of pain
to times of increased anxiety and to identify specic situa-
tions that cause anxiety to rise. Verbalization of feelings in
a nonthreatening environment facilitates expression and
resolution of disturbing emotional issues.
9. Encourage client to identify alternative methods of coping
with stress. These may avert the physical pain as a mal-
adaptive response to stress.
10. Explore ways to intervene as symptoms begin to intensify,
so that pain does not become disabling (e.g., visual or audi-
tory distractions, mental imagery, deep-breathing exercises,
application of hot or cold compresses, relaxation exercises).
11. Provide positive reinforcement for adaptive behaviors. Posi-
tive reinforcement enhances self-esteem and encourages
Outcome Criteria
1. Client verbalizes that pain does not interfere with comple-
tion of daily activities.
2. Client verbalizes an understanding of the relationship
between pain and emotional problems.
3. Client demonstrates ability to intervene as anxiety rises, to
prevent the onset or increase in severity of pain.
INEFFECTIVE COPING
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[Low self-esteem]
[History of self or loved one having experienced a serious
illness or disease]
[Regression to, or xation in, an earlier level of development]

[Numerous physical complaints verbalized, in the absence of
any pathophysiological evidence]
[Total focus on the self and physical symptoms]
[History of doctor shopping]
[Demanding behaviors]
[Refuses to attend therapeutic activities]
[Does not correlate physical symptoms with psychological
problems]
Inadequate problem-solving
Sleep disturbance
Goals/Objectives
Short-term Goal
Within 2 weeks, client will verbalize understanding of correla-
tion between physical symptoms and psychological problems.
Long-term Goal
ability to cope with stress by means other than preoccupation
with physical symptoms.
1. Monitor physicians ongoing assessments, laboratory reports,
and other data to maintain assurance that possibility of organic
pathology is clearly ruled out. Knowledge of these data is vital
for the provision of adequate and appropriate client care.
2. Recognize and accept that the physical complaint is indeed real
to the individual, even though no organic cause can be identi-
ed. Denial of the clients feelings is nontherapeutic and in-
terferes with establishment of a trusting relationship.
3. Identify gains that the physical symptom is providing for
the client: increased dependency, attention, distraction from
other problems. These are important assessment data to be
used in assisting the client with problem resolution.
2506_Ch09_176-190.indd Sec1:182 10/1/10 9:35:18 AM

4. Initially, ful ll clients most urgent dependency needs.

Failure to do this may cause client to become extremely
anxious, with an increase in maladaptive behaviors.
5. Gradually withdraw attention to physical symptoms. Minimize
time given in response to physical complaints. Lack of positive
response will discourage repetition of undesirable behaviors.
6. Explain to client that any new physical complaints will be
referred to the physician, and give no further attention to
them. Be sure to note physicians assessment of the com-
plaint. The possibility of organic pathology must always be
taken into consideration. Failure to do so could jeopardize
clients safety.
7. Encourage client to verbalize fears and anxieties. Explain
that attention will be withdrawn if rumination about physi-
cal complaints begins. Follow through. Without consistency
of limit setting, change will not occur.
8. Help client observe that physical symptoms occur because
of, or are exacerbated by, specic stressors. Discuss alterna-
tive coping responses to these stressors.
9. Give positive reinforcement for adaptive coping strategies.
Positive reinforcement encourages repetition of desired
behaviors.
10. Help client identify ways to achieve recognition from oth-
ers without resorting to physical symptoms. Positive rec-
ognition from others enhances self-esteem and minimizes
the need for attention through maladaptive behaviors.
11. Discuss how interpersonal relationships are affected by
clients narcissistic behavior. Explain how this behavior
alienates others. Client may not realize how he or she is
perceived by others.
12. Provide instruction in relaxation techniques and assertive-
ness skills. These approaches decrease anxiety and increase
self-esteem, which facilitate adaptive responses to stressful
situations.
Outcome Criteria
1. Client is able to demonstrate techniques that may be used in
response to stress to prevent the occurrence or exacerbation
of physical symptoms.
between emotional problems and physical symptoms.
DISTURBED BODY IMAGE

De nition: Confusion in mental picture of ones physical self.
2506_Ch09_176-190.indd Sec1:183 10/1/10 9:35:18 AM


[Low self-esteem]

[Preoccupation with real or imagined change in bodily
structure or function]
[Verbalizations about physical appearance that are out of pro-
portion to any actual physical abnormality that may exist]
Fear of reaction by others
Negative feelings about body
Change in social involvement
Goals/Objectives
Short-term Goal
Client will verbalize understanding that changes in bodily
structure or function are exaggerated out of proportion to the
change that actually exists. (Time frame for this goal must be
determined according to individual clients situation.)
Long-term Goal
Client will verbalize perception of own body that is realistic to
actual structure or function by time of discharge from treatment.
1. Establish trusting relationship with client. Trust enhances
therapeutic interactions between nurse and client.
2. If there is actual change in structure or function, encourage
client to progress through stages of grieving. Assess level of
knowledge and provide information regarding normal griev-
ing process and associated feelings. Knowledge of acceptable
feelings facilitates progression through the grieving process.
3. Identify misperceptions or distortions client has regarding
body image. Correct inaccurate perceptions in a matter-
of-fact, nonthreatening manner. Withdraw attention when
preoccupation with distorted image persists. Lack of atten-
tion may encourage elimination of undesirable behaviors.
4. Help client recognize personal body boundaries. Use of touch
may help him or her recognize acceptance of the individual
by others and reduce fear of rejection because of changes in
bodily structure or function.
5. Encourage independent self-care activities, providing as-
sistance as required. Self-care activities accomplished inde-
pendently enhance self-esteem and also create the necessity
for client to confront reality of his or her bodily condition.
2506_Ch09_176-190.indd Sec1:184 10/1/10 9:35:19 AM

6. Provide positive reinforcement for clients expressions of

realistic bodily perceptions. Positive reinforcement en-
hances self-esteem and encourages repetition of desired
behaviors.
Outcome Criteria
1. Client verbalizes realistic perception of bodily condition.
2. Client demonstrates acceptance of changes in bodily struc-
ture or function, as evidenced by expression of positive feel-
ings about body, ability or willingness to perform self-care
activities independently, and a focus on personal achievements
rather than preoccupation with distorted body image.

[either internally or externally initiated] accompanied by a dimin-
ished, exaggerated, distorted, or impaired response to such stimuli.

[Low self-esteem]
Psychological stress [narrowed perceptual elds caused by
anxiety]

[Loss or alteration in physical functioning suggesting a
physical disorder (often neurological in nature) but for which
organic pathology is not evident. Common alterations include
paralysis, anosmia, aphonia, deafness, blindness]
[La belle indifference]
Goals/Objectives
Short-term Goal
Client will verbalize understanding of emotional problems as a
contributing factor to alteration in physical functioning within
10 days.
Long-term Goal
Client will demonstrate recovery of lost function.
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1. Monitor physicians ongoing assessments, laboratory reports,
and other data to maintain assurance that possibility of or-
ganic pathology is clearly ruled out. Failure to do so may
jeopardize clients safety.
2. Identify gains that the physical symptom is providing for
the client: increased dependency, attention, distraction from
other problems. These are important assessment data to be
used in assisting the client with problem resolution.
3. Fulll clients needs related to activities of daily living (ADLs)
with which the physical symptom is interfering. Client com-
fort and safety are nursing priorities.
4. Do not focus on the disability, and allow client to be as inde-
pendent as possible. Intervene only when client requires as-
sistance. Positive reinforcement would encourage continual
use of the maladaptive response for secondary gains, such as
dependency.
5. Encourage client to participate in therapeutic activities to the
best of his or her ability. Do not allow client to use the disability
as a manipulative tool. Withdraw attention if client continues
to focus on physical limitation. Reinforce reality as required,
but ensure maintenance of a nonthreatening environment.
6. Encourage client to verbalize fears and anxieties. Help client
to recognize that the physical symptom appears at a time of
extreme stress and is a mechanism used for coping. Client
may be unaware of the relationship between physical symp-
tom and emotional stress.
7. Help client identify coping mechanisms that he or she could
use when faced with stressful situations rather than retreat-
ing from reality with a physical disability.
8. Explain assertiveness techniques and practice use of same
through role-playing. Use of assertiveness techniques en-
hances self-esteem and minimizes anxiety in interpersonal
relationships.
9. Help client identify a satisfactory support system within
the community from which he or she may seek assistance as
needed to cope with overwhelming stress.
Outcome Criteria
1. Client is no longer experiencing symptoms of altered physi-
cal functioning.
between extreme psychological stress and loss of physical
functioning.
3. Client is able to verbalize adaptive ways of coping with stress
and identify community support systems to which he or she
may go for help.
2506_Ch09_176-190.indd Sec1:186 10/1/10 9:35:19 AM

SELF-CARE DEFICIT (IDENTIFY

SPECIFIC AREA)
daily living ADLs independently]

[Paralysis of body part]
[Inability to see]
[Inability to hear]
[Inability to speak]
Pain, discomfort
Inability to bring food from a receptacle to the mouth
Inability to wash body or body parts; obtain or get to water
sources; regulate temperature or ow
Impaired ability to put on or take off necessary items of
clothing; obtain or replace articles of clothing; fasten
clothing; maintain appearance at a satisfactory level
Inability to get to toilet or commode [impaired mobility]
Inability to manipulate clothing for toileting
Inability to ush toilet or commode
Inability to sit on or rise from toilet or commode
Inability to carry out proper toilet hygiene
Goals/Objectives
Short-term Goal
Client will perform self-care needs independently, to the extent
that physical ability will allow, within 5 days.
Long-term Goal
By discharge from treatment, client will be able to perform
ADLs independently and demonstrate a willingness to do so.
1. Assess clients level of disability; note areas of strength
and impairment. This knowledge is required to develop
adequate plan of care for client.
2. Encourage client to perform normal ADLs to his or her level
of ability. Successful performance of independent activities
4. Ensure that nonjudgmental attitude is conveyed as nursing
assistance with self-care activities is provided. Remember
2506_Ch09_176-190.indd Sec1:187 10/1/10 9:35:20 AM

that the physical symptom is real to the client. It is not with-

in the clients conscious control. A judgmental attitude
interferes with the nurses ability to provide therapeutic
care for this client.
5. Feed client, if necessary, and provide assistance with con-
tainers, positioning, and other matters, as required. Client
comfort and safety are nursing priorities.
6. Bathe client, or assist with bath, depending on his or her level
of ability. Client comfort and safety are nursing priorities.
7. Assist client with dressing, oral hygiene, combing hair, and
applying makeup, as required. Client comfort and safety are
nursing priorities.
8. Provide bedpan, commode, or assistance to bathroom as
determined by clients level of ability. Client comfort and
safety are nursing priorities.
9. Provide positive reinforcement for ADLs performed inde-
pendently. Positive reinforcement enhances self-esteem and
encourages repetition of desired behaviors.
10. Take precautions against fostering dependency by inter-
vening when client is capable of performing independently.
Allow ample time for client to complete these activities to
the best of his or her ability without assistance. Allowing
the client to maintain dependency may provide secondary
gains and delay recovery from the disability.
11. Encourage client to discuss feelings regarding the disability
and the need for dependency it creates. Help client to see
the purpose this disability is serving for him or her. Self-
disclosure and exploration of feelings with a trusted in-
dividual may help client fulfill unmet needs and confront
unresolved issues.
Outcome Criteria
1. Client feeds self without assistance.
2. Client selects appropriate clothing and dresses and grooms
self daily.
assistance.
DEFICIENT KNOWLEDGE
(PSYCHOLOGICAL CAUSES
FOR PHYSICAL SYMPTOMS)
De nition: Absence or deficiency of cognitive information related
to a specific topic.
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[Severe level of anxiety]

[Denial of emotional problems]
[Statements such as, I dont know why the doctor put me on the
psychiatric unit. I have a physical problem.]
[History of shopping for a doctor who will substantiate symp-
toms as pathophysiological]
[Noncompliance with psychiatric treatment plan]
Goals/Objectives
Short-term Goal
Client will verbalize an understanding that no pathophysiologi-
cal condition exists to substantiate physical symptoms.
Long-term Goal
By time of discharge from treatment, client will be able to ver-
balize psychological cause(s) for physical symptoms.
1. Assess clients level of knowledge regarding effects of psy-
chological problems on the body. An adequate database
is necessary for the development of an effective teaching
plan.
ing does not occur beyond the moderate level of anxiety.
3. Discuss physical examinations and laboratory tests that have
been conducted. Explain purpose and results of each.
4. Explore feelings and fears held by client. Go slowly. These
feelings may have been suppressed or repressed for a very
long time and their disclosure will undoubtedly be a pain-
ful experience. Be supportive. Verbalization of feelings in a
nonthreatening environment may help client come to terms
with long-unresolved issues.
5. Have client keep a diary of appearance, duration, and intensity
of physical symptoms. A separate record of situations that the
client nds especially stressful should also be kept. Compari-
son of these records may provide objective data from which
to observe the relationship between physical symptoms and
stress.
6. Help client identify needs that are being met through the
sick role. Together, formulate a more adaptive means for
ful lling these needs. Practice by role-playing. Change
cannot occur until the client realizes that physical symp-
toms are used to fulfill unmet needs. Anxiety is relieved by
2506_Ch09_176-190.indd Sec1:189 10/1/10 9:35:20 AM

role-playing, since the client is able to anticipate responses

to stressful situations.
7. Explain assertiveness techniques to the client. Discuss the
importance of recognizing the differences among passive,
assertive, and aggressive behaviors, and of respecting the
human rights. Use of these techniques enhances self-esteem
and facilitates clients interpersonal relationships.
8. Discuss adaptive methods of stress management: relaxation
techniques, physical exercise, meditation, breathing exer-
cises, or mental imagery. These techniques may be employed
in an attempt to relieve anxiety and discourage the use of
physical symptoms as a maladaptive response.
Outcome Criteria
between psychological stress and physical symptoms.
2. Client demonstrates the ability to use therapeutic techniques
in the management of stress.
INTERNET REFERENCES
Additional information about somatoform disorders may be
a. http://psyweb.com/Mdisord/jsp/somatd.jsp
b. http://www.uib.no/med/avd/med_a/gastro/wilhelms/
hypochon.html
c. http://emedicine.medscape.com/article/805361-overview
d. http://psychological.com/somatofom_disorders.htm
e. http://emedicine.medscape.com/article/917864-overview
f. http://findarticles.com/p/articles/mi_g2601/is_0012/
ai_2601001276
Movie Connections
Bandits (hypochondriasis) Hannah and Her Sisters
(hypochondriasis) Send Me No Flowers (hypochondriasis)
2506_Ch09_176-190.indd Sec1:190 10/1/10 9:35:20 AM

C H A P T E R
10
Dissociative Disorders
The essential feature of the dissociative disorders is a disruption
in the usually integrated functions of consciousness, memory,
identity, or perception (APA, 2000). During periods of intoler-
able stress, the individual blocks off part of his or her life from
consciousness. The stressful emotion becomes a separate entity,
as the individual splits from it and mentally drifts into a fan-
tasy state. The following categories are de ned in the Diagnostic
Revision (DSM-IV-TR) (APA, 2000):
1. Dissociative Amnesia: An inability to recall important per-
sonal information, usually of a traumatic or stressful nature.
The extent of the disturbance is too great to be explained by
ordinary forgetfulness. Types of impairment in recall include
the following:
a. Localized Amnesia: Inability to recall all incidents asso-
ciated with a traumatic event for a specic time period
following the event (usually a few hours to a few days).
b. Selective Amnesia: Inability to recall only certain incidents
associated with a traumatic event for a specic period fol-
lowing the event.
c. Continuous Amnesia: Inability to recall events subse-
quent to a specic time up to and including the present.
(The memory does not return after a short period, as in
localized amnesia. The individual is unable to form new
memories.)
d. Systematized Amnesia: With this type of amnesia, the
individual cannot remember events that relate to a specic
category of information, such as ones family, or to one
particular person or event.
e. Generalized Amnesia: Failure of recall encompassing
ones entire life.
2. Dissociative Fugue. A sudden, unexpected travel away from
home or customary work locale with assumption of a new
identity and an inability to recall ones previous identity.
Following recovery, there is no recollection of events that
191
2506_Ch10_191-200.indd 0191 10/1/10 9:35:30 AM

took place during the fugue. Course is typically briefhours

to days, and rarely, months. Recurrences are rare.
3. Dissociative Identity Disorder (DID). The existence with-
in the individual of two or more distinct personalities, each of
which is dominant at a particular time. The original person-
ality usually is not aware (at least initially) of the existence of
subpersonalities. When there are more than two subperson-
alities, however, they are usually aware of each other. Transi-
tion from one personality to another is usually sudden and
often associated with psychosocial stress. The course tends
to be more chronic than in the other dissociative disorders.
4. Depersonalization Disorder. Characterized by a temporary
change in the quality of self-awareness, which often takes the
form of feelings of unreality, changes in body image, feelings
of detachment from the environment, or a sense of observing
oneself from outside the body.
PREDISPOSING FACTORS
TO DISSOCIATIVE DISORDER
1. Physiological
a. Genetics. The DSM-IV-TR suggests that DID is more
common in rst-degree relatives of people with the disor-
der than in the general population. The disorder is often
seen in more than one generation of a family.
b. Neurobiological. Some clinicians have suggested a possible
correlation between neurological alterations and dissocia-
tive disorders. Although available information is inadequate,
it is possible that dissociative amnesia and dissociative fugue
may be related to alterations in certain areas of the brain
that have to do with memory. These include the hippocam-
pus, mammillary bodies, amygdala, fornix, thalamus, and
frontal cortex. Some studies have suggested a possible link
between DID and certain neurological conditions, such
as temporal lobe epilepsy and severe migraine headaches.
Electroencephalographic abnormalities have been observed
in some clients with DID.
2. Psychosocial
a. Psychodynamic Theory. Freud (1962) believed that dis-
sociative behaviors occurred when individuals repressed
distressing mental contents from conscious awareness.
He believed that the unconscious was a dynamic entity in
which repressed mental contents were stored and unavail-
able to conscious recall. Current psychodynamic explana-
tions of dissociation are based on Freuds concepts.
b. Psychological Trauma. A growing body of evidence
points to the etiology of DID as a set of traumatic experi-
ences that overwhelms the individuals capacity to cope
2506_Ch10_191-200.indd 0192 10/1/10 9:35:30 AM

by any means other than dissociation. These experiences

usually take the form of severe physical, sexual, and/or
psychological abuse by a parent or signicant other in the
childs life. DID is thought to serve as a survival strategy
for the child in this traumatic environment, whereby he
or she creates a new being who is able to experience the
overwhelming pain of the cruel reality, while the primary
self can then escape awareness of the pain. It has been sug-
gested that the number of an individuals alternate per-
sonalities may be related to the number of different types
of abuse he or she suffered as a child. Individuals with
many personalities have usually been severely abused well
into adolescence.
AND OBJECTIVE DATA)
1. Impairment in recall.
a. Inability to remember specic incidents.
b. Inability to recall any of ones past life, including ones
identity.
2. Sudden travel away from familiar surroundings; assumption
of new identity, with inability to recall past.
3. Assumption of additional identities within the personality;
behavior involves transition from one identity to another as a
method of dealing with stressful situations.
4. Feeling of unreality; detachment from a stressful situation
may be accompanied by dizziness, depression, obsessive ru-
mination, somatic concerns, anxiety, fear of going insane, and
a disturbance in the subjective sense of time (APA, 2000).

INEFFECTIVE COPING
available resources

[Childhood trauma]
[Childhood abuse]
2506_Ch10_191-200.indd 0193 10/1/10 9:35:31 AM

[Low self-esteem]

[Dissociating self from painful situation by experiencing:
Memory loss (partial or complete)
Sudden travel away from home with inability to recall
previous identity
The presence of more than one personality within the
individual
Detachment from reality]
[Inappropriate use of defense mechanisms]
Goals/Objectives
Short-term Goal
1. Client will verbalize understanding that he or she is employ-
ing dissociative behaviors in times of psychosocial stress.
2. Client will verbalize more adaptive ways of coping in stress-
ful situations than resorting to dissociation.
Long-term Goal
Client will demonstrate ability to cope with stress (employing
means other than dissociation).

1. Reassure client of safety and security by your presence.
Dissociative behaviors may be frightening to the client.
Presence of a trusted individual provides feeling of security
and assurance of freedom from harm.
2. Identify stressor that precipitated severe anxiety. This infor-
mation is necessary to the development of an effective plan
of client care and problem resolution.
3. Explore feelings that client experienced in response to the
stressor. Help client understand that the disequilibrium
felt is acceptableindeed, even expectedin times of se-
vere stress. Clients self-esteem is preserved by the knowl-
edge that others may experience these behaviors in similar
circumstances.
4. As anxiety level decreases (and memory returns), use explo-
ration and an accepting, nonthreatening environment to
encourage client to identify repressed traumatic experiences
that contribute to chronic anxiety.
5. Have client identify methods of coping with stress in the
past and determine whether the response was adaptive or
2506_Ch10_191-200.indd 0194 10/1/10 9:35:31 AM

maladaptive. In times of extreme anxiety, client is unable

to evaluate appropriateness of response. This information
is necessary for client to develop a plan of action for the
future.
6. Help client de ne more adaptive coping strategies. Make
suggestions of alternatives that might be tried. Examine
benets and consequences of each alternative. Assist cli-
ent in the selection of those that are most appropriate for
him or her. Depending on current level of anxiety, client
may require assistance with problem-solving and decision-
making.
7. Provide positive reinforcement for clients attempts to change.
8. Identify community resources to which the individual may
go for support if past maladaptive coping patterns return.
Outcome Criteria
response to stress to prevent dissociation.
between severe anxiety and the dissociative response.

De nition: Disruption in cognitive operations and activities

[Childhood trauma]
[Childhood abuse]
[Threat to physical integrity]

[Memory lossinability to recall selected events related to a
stressful situation]
[Memory lossinability to recall events associated with entire
life]
[Memory lossinability to recall own identity]
Goals/Objectives
Short-term Goal
Client will verbalize understanding that loss of memory is related
to stressful situation and begin discussing stressful situation with
nurse or therapist.
2506_Ch10_191-200.indd 0195 10/1/10 9:35:31 AM

Long-term Goal
Client will recover decits in memory and develop more adap-
tive coping mechanisms to deal with stressful situations.
1. Obtain as much information as possible about client from
family and signicant others (likes, dislikes, important peo-
ple, activities, music, pets). A baseline assessment is impor-
tant for the development of an effective plan of care.
2. Do not ood client with data regarding his or her past life.
Individuals who are exposed to painful information from
which the amnesia is providing protection may decompen-
sate even further into a psychotic state.
3. Instead, expose client to stimuli that represent pleasant expe-
riences from the past, such as smells associated with enjoyable
activities, beloved pets, and music known to have been plea-
surable to client.
4. As memory begins to return, engage client in activities that
may provide additional stimulation. Recall may occur during
activities that simulate life experiences.
5. Encourage client to discuss situations that have been espe-
cially stressful and to explore the feelings associated with
those times. Verbalization of feelings in a nonthreatening
environment may help client come to terms with unre-
solved issues that may be contributing to the dissociative
process.
6. Identify specic con icts that remain unresolved, and assist
client to identify possible solutions. Unless these underlying
conflicts are resolved, any improvement in coping behaviors
must be viewed as only temporary.
7. Provide instruction regarding more adaptive ways to re-
spond to anxiety so that dissociative behaviors are no longer
needed.
Outcome Criteria
1. Client is able to recall all events of past life.
2. Client is able to demonstrate adaptive coping strategies that
may be used in response to severe anxiety to avert amnestic
behaviors.

De nition: Inability to maintain an integrated and complete
perception of self
2506_Ch10_191-200.indd 0196 10/1/10 9:35:32 AM


[Childhood trauma]
[Childhood abuse]
[Presence of more than one personality within the individual]
Goals/Objectives
Short-term Goal
Client will verbalize understanding of the existence of
multiple personalities within the self and be able to recog-
nize stressful situations that precipitate transition from one to
another.
Long-term Goal
Client will verbalize understanding of the need for, enter into,
and cooperate with long-term therapy for this disorder, with
the ultimate goal being integration into one personality.

1. The nurse must develop a trusting relationship with the
original personality and with each of the subpersonalities.
Trust is the basis of a therapeutic relationship. Each of the
personalities views itself as a separate entity and must ini-
tially be treated as such.
2. Help the client understand the existence of the subpersonali-
ties. Client may be unaware of this dissociative response to
stressful situations.
3. Help client identify the need each subpersonality serves in
the personal identity of the individual. Knowledge of these
unfulfilled needs is the first step toward integration of the
personalities and the clients ability to face unresolved issues
without dissociation.
4. Help the client identify stressful situations that precipitate
the transition from one personality to another. Carefully
observe and record these transitions. This knowledge is
required to assist the client in responding more adap-
tively and to eliminate the need for transition to another
personality.
5. Use nursing interventions necessary to deal with maladaptive
behaviors associated with individual subpersonalities. For ex-
ample, if one personality is suicidal, precautions must be taken
to guard against clients self-harm. If another personality has a
2506_Ch10_191-200.indd 0197 10/1/10 9:35:32 AM

tendency toward physical hostility, precautions must be taken

for the protection of others. Safety of the client and others is a
nursing priority.
CLINICAL PEARL It may be possible to seek assistance from one

of the personalities. For example, a strong-willed personality may
help to control the behaviors of a suicidal personality.
6. Help subpersonalities to understand that their being will

not be destroyed, but integrated into a unied identity within
the individual. Because subpersonalities function as sepa-
rate entities, the idea of total elimination generates fear and
defensiveness.
7. Provide support during disclosure of painful experiences
and reassurance when the client becomes discouraged with
lengthy treatment.
Outcome Criteria
1. Client recognizes the existence of more than one personality.
2. Client is able to verbalize the purpose these personalities serve.
3. Client verbalizes the intention of seeking long-term outpatient
psychotherapy.

(KINESTHETIC)
[either internally or externally initiated] accompanied by a dimin-
ished, exaggerated, distorted, or impaired response to such stimuli.

[Childhood trauma]
[Childhood abuse]

[Alteration in the perception or experience of the self]
[Loss of ones own sense of reality]
[Loss of the sense of reality of the external world]
2506_Ch10_191-200.indd 0198 10/1/10 9:35:32 AM

Goals/Objectives
Short-term Goal
Client will verbalize adaptive ways of coping with stress.
Long-term Goal
the ability to perceive stimuli correctly and maintain a sense of
reality during stressful situations.

1. Provide support and encouragement during times of deper-
sonalization. The client manifesting these symptoms may
express fear and anxiety at experiencing such behaviors.
They do not understand the response and may express a
fear of going insane. Support and encouragement from a
trusted individual provide a feeling of security when fears
and anxieties are manifested.
2. Explain the depersonalization behaviors and the pur-
pose they usually serve for the client. This knowledge may
help to minimize fears and anxieties associated with their
occurrence.
3. Explain the relationship between severe anxiety and deper-
sonalization behaviors. The client may be unaware that the
occurrence of depersonalization behaviors is related to severe
anxiety.
4. Help client relate these behaviors to times of severe psy-
chological stress that he or she has experienced personally.
Knowledge of this relationship is the first step in the process
of behavioral change.
5. Explore past experiences and possibly repressed painful
situations such as trauma or abuse. It is thought that trau-
matic experiences predispose individuals to dissociative
disorders.
6. Discuss these painful experiences with the client and en-
courage him or her to deal with the feelings associated
with these situations. Work to resolve the con icts these
repressed feelings have nurtured. These interventions
serve to decrease the need for the dissociative response to
anxiety.
7. Discuss ways the client may more adaptively respond to stress
and role-play with him or her to practice using these new
methods. Having practiced through role-play helps to pre-
pare client to face stressful situations by using these new
behaviors when they occur in real life.
2506_Ch10_191-200.indd 0199 10/1/10 9:35:32 AM

Outcome Criteria
1. Client perceives stressful situations correctly and is able to
maintain a sense of reality.
2. Client demonstrates use of adaptive strategies for coping
with stress.
INTERNET REFERENCES
Additional information about Dissociative Disorders may be
a. http://www.human-nature.com/odmh/dissociative.html
b. ht t p: //w w w. n a m i .or g /C o nt e nt /C o nt e nt G r oup s /
Helpline1/Dissociative_Disorders.htm
c. http://www.mental-health-matters.com/disorders
d. http://www.issd.org/
e. http://www.sidran.org/didbr.html
f. http://emedicine.medscape.com/article/294508-overview
g. http:// ndarticles.com/p/articles/mi_g2601/is_0004/ai_
2601000438
Movie Connections
Dead Again (amnesia) Mirage (amnesia) Suddenly Last
Summer (amnesia) The Three Lives of Karen (fugue) Sybil (DID)
The Three Faces of Eve (DID) Identity (DID)
2506_Ch10_191-200.indd 0200 10/1/10 9:35:33 AM

C H A P T E R
11
Sexual and Gender
Identity Disorders
The American Psychiatric Association (APA, 2000) Diagnos-
tic and Statistical Manual of Mental Disorders, Fourth Edition,
Text Revision (DSM-IV-TR) identies two categories of sexual
disorders: paraphilias and sexual dysfunctions. Paraphilias are
characterized by recurrent, intense sexual urges, fantasies, or
behaviors that involve unusual objects, activities, or situations
(APA, 2000). Sexual dysfunction disorders can be described as an
impairment or disturbance in any of the phases of the sexual
response cycle. These include disorders of desire, arousal, and
orgasm and disorders that relate to the experience of genital
pain during intercourse. Gender identity disorders are char-
acterized by strong and persistent cross-gender identication
accompanied by persistent discomfort with ones assigned sex
(APA, 2000).
Paraphilias
The term paraphilia is used to identify repetitive or preferred
sexual fantasies or behaviors that involve any of the following:
1. The preference for use of a nonhuman object.
2. Repetitive sexual activity with humans involving real or sim-
ulated suffering or humiliation.
3. Repetitive sexual activity with nonconsenting partners.
Types of paraphilias include the following:
1. Exhibitionism. The major symptoms include recurrent, in-
tense sexual urges, behaviors, or sexually arousing fantasies,
of at least 6 months duration, involving the exposure of ones
genitals to an unsuspecting stranger (APA, 2000). Masturba-
tion may occur during the exhibitionism. Most individuals
with paraphilias are men, and the behavior is generally estab-
lished in adolescence (Andreasen & Black, 2006).
2. Fetishism. Fetishism involves recurrent, intense sexual
urges or behaviors, or sexually arousing fantasies, of at least
201
2506_Ch11_201-217.indd 0201 10/1/10 9:35:43 AM

6 months duration, involving the use of nonliving objects

(APA, 2000). Common fetish objects include bras, womens
underpants, stockings, shoes, boots, or other wearing apparel.
The fetish object is generally used during masturbation or in-
corporated into sexual activity with another person to pro-
duce sexual excitation. When the fetish involves cross-dressing,
the disorder is called transvestic fetishism.
3. Frotteurism. This disorder is de ned as the recurrent pre-
occupation with intense sexual urges or fantasies, of at least
6 months duration, involving touching or rubbing against
a nonconsenting person (APA, 2000). Sexual excitement is
derived from the actual touching or rubbing, not from the
coercive nature of the act.
4. Pedophilia. The DSM-IV-TR describes the essential feature
of pedophilia as recurrent sexual urges, behaviors, or sexually
arousing fantasies, of at least 6 months duration, involving
sexual activity with a prepubescent child. The age of the mo-
lester is 16 or older and is at least 5 years older than the child.
This category of paraphilia is the most common of sexual
assaults.
5. Sexual Masochism. The identifying feature of this disor-
der is recurrent, intense sexual urges, behaviors, or sexually
arousing fantasies, of at least 6 months duration, involving
the act of being humiliated, beaten, bound, or otherwise
made to suffer (APA, 2000). These masochistic activities may
be fantasized, solitary, or with a partner. Examples include
becoming sexually aroused by self-in icted pain or by being
restrained, raped, or beaten by a sexual partner.
6. Sexual Sadism. The essential feature of sexual sadism is
identied as recurrent, intense, sexual urges, behaviors, or
sexually arousing fantasies, of at least 6 months duration,
involving acts in which the psychological or physical suffer-
ing (including humiliation) of the victim is sexually exciting
(APA, 2000). The sadistic activities may be fantasized or
acted on with a consenting or nonconsenting partner. In all
instances, sexual excitation occurs in response to the suffer-
ing of the victim. Examples include rape, beating, torture, or
even killing.
7. Voyeurism. This disorder is identied by recurrent, intense
sexual urges, behaviors, or sexually arousing fantasies,
of at least 6 months duration, involving the act of observ-
ing an unsuspecting person who is naked, in the process
of disrobing, or engaging in sexual activity (APA, 2000).
Sexual excitement is achieved through the act of looking,
and no contact with the person is attempted. Masturba-
tion usually accompanies the window peeping but may
2506_Ch11_201-217.indd 0202 10/1/10 9:35:43 AM

occur later as the individual fantasizes about the voyeuris-

tic act.
Predisposing Factors to Paraphilias
1. Physiological
a. Biological Factors: Various studies have implicated sev-
eral organic factors in the etiology of paraphilias. De-
struction of parts of the limbic system in animals has
been shown to cause hypersexual behavior (Becker &
Johnson, 2008). Temporal lobe diseases, such as psy-
chomotor seizures or temporal lobe tumors, have been
implicated in some individuals with paraphilias. Abnor-
mal levels of androgens also may contribute to inappro-
priate sexual arousal. The majority of studies involved
violent sex offenders, and the results cannot accurately
be generalized.
2. Psychosocial
a. Psychoanalytical Theory: The psychoanalytic approach
de nes a paraphiliac as one who has failed the normal
developmental process toward heterosexual adjustment
(Sadock & Sadock, 2007). This occurs when the indi-
vidual fails to resolve the Oedipal crisis and identies
with the parent of the opposite gender. This creates in-
tense anxiety, which leads the individual to seek sexual
gratication in ways that provide a safe substitution for
the parent (Becker & Johnson, 2008).
1. Exposure of ones genitals to a stranger.
2. Sexual arousal in the presence of nonliving objects.
3. Touching and rubbing ones genitals against an unconsent-
ing person.
4. Sexual attraction to, or activity with, a prepubescent
child.
5. Sexual arousal from being humiliated, beaten, bound, or
otherwise made to suffer (through fantasy, self-in iction, or
by a sexual partner).
6. Sexual arousal by in icting psychological or physical
suffering on another individual (either consenting or
nonconsenting).
7. Sexual arousal from dressing in the clothes of the opposite
gender.
8. Sexual arousal from observing unsuspecting people either
naked or engaged in sexual activity.
9. Masturbation often accompanies the activities described
when they are performed solitarily.
10. The individual is markedly distressed by these activities.
2506_Ch11_201-217.indd 0203 10/1/10 9:35:43 AM

Sexual Dysfunctions
Sexual dysfunctions may occur in any phase of the sexual response
cycle. Types of sexual dysfunctions include the following:
1. Sexual Desire Disorders
a. Hypoactive Sexual Desire Disorder: This disorder is
de ned by the DSM-IV-TR (APA, 2000) as a persistent
or recurrent deciency or absence of sexual fantasies and
desire for sexual activity. The complaint appears to be
more common among women than men.
b. Sexual Aversion Disorder: This disorder is character-
ized by a persistent or recurrent extreme aversion to, and
avoidance of, all (or almost all) genital sexual contact with
a sexual partner (APA, 2000).
2. Sexual Arousal Disorders
a. Female Sexual Arousal Disorder: This disorder is iden-
tied in the DSM-IV-TR (APA, 2000) as a persistent or
recurrent inability to attain, or to maintain until com-
pletion of the sexual activity, an adequate lubrication or
swelling response of sexual excitement.
b. Male Erectile Disorder: This disorder is characterized by
a persistent or recurrent inability to attain, or to maintain
until completion of the sexual activity, an adequate erec-
tion (APA, 2000).
3. Orgasmic Disorders
a. Female Orgasmic Disorder (Anorgasmia): This disorder
is de ned by the DSM-IV-TR as a persistent or recurrent
delay in, or absence of, orgasm following a normal sexual
excitement phase.
b. Male Orgasmic Disorder (Retarded Ejaculation): With
this disorder, the man is unable to ejaculate, even though
he has a rm erection and has had more than adequate
stimulation. The severity of the problem may range
from only occasional problems ejaculating to a history
of never having experienced an orgasm.
c. Premature Ejaculation: The DSM-IV-TR describes this
disorder as persistent or recurrent ejaculation with mini-
mal sexual stimulation before, on, or shortly after pen-
etration and before the person wishes it.
4. Sexual Pain Disorders
a. Dyspareunia: Dyspareunia is de ned as recurrent or per-
sistent genital pain associated with sexual intercourse, in
either a man or a woman, that is not caused by vaginismus,
lack of lubrication, another general medical condition, or
the physiological effects of substance use (APA, 2000).
b. Vaginismus: Vaginismus is characterized by an involun-
tary constriction of the outer third of the vagina, which
prevents penile insertion and intercourse.
2506_Ch11_201-217.indd 0204 10/1/10 9:35:44 AM

Predisposing Factors to Sexual Dysfunctions

1. Physiological Factors
a. Sexual Desire Disorders: In men, these disorders have
been linked to low levels of serum testosterone and to
elevated levels of serum prolactin. Evidence also exists
that suggests a relationship between serum testosterone
and increased female libido. Various medications, such as
antihypertensives, antipsychotics, antidepressants, anxio-
lytics, and anticonvulsants, as well as chronic use of drugs
such as alcohol and cocaine, have also been implicated in
sexual desire disorders.
b. Sexual Arousal Disorders: These may occur in response
to decreased estrogen levels in postmenopausal women.
Medications such as antihistamines and cholinergic
blockers may produce similar results. Erectile dysfunc-
tions in men may be attributed to arteriosclerosis, dia-
betes, temporal lobe epilepsy, multiple sclerosis, some
medications (antihypertensives, antidepressants, tran-
quilizers), spinal cord injury, pelvic surgery, and chronic
use of alcohol.
c. Orgasmic Disorders: In women these may be attributed
to some medical conditions (hypothyroidism, diabetes,
and depression) and certain medications (antihyperten-
sives, antidepressants). Medical conditions that may in-
terfere with male orgasm include genitourinary surgery
(e.g., prostatectomy), Parkinsons disease, and diabetes.
Various medications have also been implicated, including
antihypertensives, antidepressants, and antipsychotics.
Transient cases of the disorder may occur with excessive
alcohol intake.
d. Sexual Pain Disorders: In women these can be caused
by disorders of the vaginal entrance, irritation or damage
to the clitoris, vaginal or pelvic infections, endometrio-
sis, tumors, or cysts. Painful intercourse in men may be
attributed to penile infections, phimosis, urinary tract
infections, or prostate problems.
2. Psychosocial Factors
a. Sexual Desire Disorders: Phillips (2000) has identied
a number of individual and relationship factors that may
contribute to hypoactive sexual desire disorder. Individual
causes include religious orthodoxy; sexual identity con-
icts; past sexual abuse; nancial, family, or job problems;
depression; and aging-related concerns (e.g., changes in
physical appearance). Among the relationship causes are
interpersonal con icts; current physical, verbal, or sexual
abuse; extramarital affairs; and desire or practices differ-
ent from partner.
2506_Ch11_201-217.indd 0205 10/1/10 9:35:44 AM

b. Sexual Arousal Disorders: In the female these may be

attributed to doubts, fears, guilt, anxiety, shame, con-
ict, embarrassment, tension, disgust, resentment, grief,
anger toward the partner, and puritanical or moralistic
upbringing. A history of sexual abuse may also be an im-
portant etiologic factor (Leiblum, 1999). The etiology of
male erectile disorder may be related to chronic stress,
anxiety, or depression. Early developmental factors that
promote feelings of inadequacy and a sense of being un-
loving or unlovable may also result in impotence. Dif-
culties in the relationship may also be a contributing
factor.
c. Orgasmic Disorders: A number of factors have been im-
plicated in the etiology of female orgasm disorders. They
include fear of becoming pregnant, hostility toward men,
negative cultural conditioning, childhood exposure to
rigid religious orthodoxy, and traumatic sexual experi-
ences during childhood or adolescence. Orgasm disorders
in men may be related to a rigid, puritanical background
where sex was perceived as sinful and the genitals as dirty;
or interpersonal difculties, such as ambivalence about
commitment, fear of pregnancy, or unexpressed hostility,
may be implicated.
d. Sexual Pain Disorders: Vaginismus may occur after hav-
ing experienced painful intercourse for any organic rea-
son, after which involuntary constriction of the vagina
occurs in anticipation and fear of recurring pain. Other
psychosocial factors that have been implicated in the
etiology of vaginismus include negative childhood con-
ditioning of sex as dirty, sinful, and shameful; early child-
hood sexual trauma; homosexual orientation; traumatic
experience with an early pelvic examination; pregnancy
phobia; sexually transmitted disease phobia; or cancer
phobia (Phillips, 2000; King, 2005; Leiblum, 1999; Sadock
& Sadock, 2007).
1. Absence of sexual fantasies and desire for sexual activity.
2. Discrepancy between partners levels of desire for sexual
activity.
3. Feelings of disgust, anxiety, or panic responses to genital
contact.
4. Inability to produce adequate lubrication for sexual
activity.
5. Absence of a subjective sense of sexual excitement during
sexual activity.
2506_Ch11_201-217.indd 0206 10/1/10 9:35:45 AM

6. Failure to attain or maintain penile erection until comple-

tion of sexual activity.
7. Inability to achieve orgasm (in men, to ejaculate) following a
period of sexual excitement judged adequate in intensity and
duration to produce such a response.
8. Ejaculation occurs with minimal sexual stimulation or
before, on, or shortly after penetration and before the indi-
vidual wishes it.
9. Genital pain occurring before, during, or after sexual
intercourse.
10. Constriction of the outer third of the vagina prevents penile
penetration.

for Paraphilias and Sexual Dysfunctions
SEXUAL DYSFUNCTION
De nition: The state in which an individual experiences a change
in sexual function during the sexual response phases of desire,
excitation, and/or orgasm, which is viewed as unsatisfying, unre-
warding, or inadequate.

Ineffectual or absent role models
Physical [or sexual] abuse
Psychosocial abuse
Values con ict
Lack of privacy
Lack of signicant other
Altered body structure or function (pregnancy, recent childbirth,
drugs, surgery, anomalies, disease process, trauma, radiation)
Misinformation or decient knowledge
[Depression]
[Pregnancy phobia]
[Sexually transmitted disease phobia]
[Cancer phobia]
[Previous painful experience]
[Severe anxiety]
[Relationship difculties]
2506_Ch11_201-217.indd 0207 10/1/10 9:35:45 AM


Verbalization of problem:
[Absence of desire for sexual activity
Feelings of disgust, anxiety, or panic responses to genital
contact
Absence of lubrication or subjective sense of sexual excite-
ment during sexual activity
Failure to attain or maintain penile erection during sexual
activity
Inability to achieve orgasm or ejaculation
Premature ejaculation
Genital pain during intercourse
Constriction of the vagina that prevents penile penetration]
Inability to achieve desired satisfaction
Goals/Objectives
Short-term Goals
1. Client will identify stressors that may contribute to loss of
sexual function within 1 week or
2. Client will discuss pathophysiology of disease process that
contributes to sexual dysfunction within 1 week.
For client with permanent dysfunction due to disease process:
3. Client will verbalize willingness to seek professional assis-
tance from a sex therapist in order to learn alternative ways
of achieving sexual satisfaction with partner by (time is indi-
vidually determined).
Long-term Goal
Client will resume sexual activity at level satisfactory to self and
partner by (time is individually determined).
1. Assess clients sexual history and previous level of satisfac-
tion in sexual relationship. This establishes a database from
which to work and provides a foundation for goal setting.
2. Assess clients perception of the problem. Clients idea of
what constitutes a problem may differ from the nurses. It
is the clients perception on which the goals of care must be
established.
3. Help client determine time dimension associated with the
onset of the problem and discuss what was happening in his
or her life situation at that time. Stress in any areas of life
can affect sexual functioning. Client may be unaware of
correlation between stress and sexual dysfunction.
4. Assess clients mood and level of energy. Depression and
fatigue decrease desire and enthusiasm for participation in
sexual activity.
2506_Ch11_201-217.indd 0208 10/1/10 9:35:45 AM

5. Review medication regimen; observe for side effects. Many

medications can affect sexual functioning. Evaluation of
drug and individual response is important to ascertain
whether drug may be contributing to the problem.
6. Encourage client to discuss disease process that may be con-
tributing to sexual dysfunction. Ensure that client is aware
that alternative methods of achieving sexual satisfaction exist
and can be learned through sex counseling if he or she and
partner desire to do so. Client may be unaware that satis-
factory changes can be made in his or her sex life. He or she
may also be unaware of the availability of sex counseling.
7. Encourage client to ask questions regarding sexuality and
sexual functioning that may be troubling him or her. In-
creasing knowledge and correcting misconceptions can
decrease feelings of powerlessness and anxiety and facilitate
problem resolution.
8. Make referral to sex therapist, if necessary. Client may even
request that an initial appointment be made for him or her.
Complex problems are likely to require assistance from an in-
dividual who is specially trained to treat problems related to
sexuality. Client and partner may be somewhat embarrassed
to seek this kind of assistance. Support from a trusted nurse
can provide the impetus for them to pursue the help they need.
Outcome Criteria
1. Client is able to correlate physical or psychosocial factors
that interfere with sexual functioning.
2. Client is able to communicate with partner about their sexual
relationship without discomfort.
3. Client and partner verbalize willingness and desire to seek
assistance from professional sex therapist or
4. Client verbalizes resumption of sexual activity at level satis-
factory to self and partner.
INEFFECTIVE SEXUALITY PATTERN

De nition: Expressions of concern regarding own sexuality.

Lack of signicant other
Ineffective or absent role models
[Illness-related alterations in usual sexuality patterns]
Con icts with sexual orientation or variant preferences
[Unresolved Oedipal con ict]
[Delayed sexual adjustment]
2506_Ch11_201-217.indd 0209 10/1/10 9:35:45 AM


Reported difculties, limitations, or changes in sexual behaviors
or activities
[Expressed dissatisfaction with sexual behaviors]
[Reports that sexual arousal can only be achieved through
variant practices, such as pedophilia, fetishism, masochism,
sadism, frotteurism, exhibitionism, voyeurism]
[Desires to experience satisfying sexual relationship with an-
other individual without need for arousal through variant
practices]
Goals/Objectives
(Time elements to be determined by individual situation.)
Short-term Goals
1. Client will verbalize aspects about sexuality that he or she
would like to change.
2. Client and partner will communicate with each other
ways in which each believes their sexual relationship could
be improved.
Long-term Goals
1. Client will express satisfaction with own sexuality pattern.
2. Client and partner will express satisfaction with sexual
relationship.

1. Take sexual history, noting clients expression of areas of dis-
satisfaction with sexual pattern. Knowledge of what client
perceives as the problem is essential for providing the type of
assistance he or she may need.
2. Assess areas of stress in clients life and examine relationship
with sexual partner. Variant sexual behaviors are often as-
sociated with added stress in the clients life. Relationship
with partner may deteriorate as individual eventually gains
sexual satisfaction only from variant practices.
3. Note cultural, social, ethnic, racial, and religious factors that
may contribute to con icts regarding variant sexual prac-
tices. Client may be unaware of the influence these factors
exert in creating feelings of discomfort, shame, and guilt
regarding sexual attitudes and behavior.
4. Be accepting and nonjudgmental. Sexuality is a very per-
sonal and sensitive subject. The client is more likely to share
this information if he or she does not fear being judged by
the nurse.
5. Assist therapist in plan of behavior modication to help cli-
ent who desires to decrease variant sexual behaviors. Indi-
viduals with paraphilias are treated by specialists who have
2506_Ch11_201-217.indd 0210 10/1/10 9:35:46 AM

experience in modifying variant sexual behaviors. Nurses

can intervene by providing assistance with implementation
of the plan for behavior modification.
6. If altered sexuality patterns are related to illness or medi-
cal treatment, provide information to client and partner re-
garding the correlation between the illness and the sexual
alteration. Explain possible modications in usual sexual
patterns that client and partner may try in an effort to
achieve a satisfying sexual experience in spite of the limi-
tation. Client and partner may be unaware of alternate
possibilities for achieving sexual satisfaction, or anxiety
associated with the limitation may interfere with rational
problem solving.
7. Explain to client that sexuality is a normal human response
and does not relate exclusively to the sex organs or sexual be-
havior. Sexuality involves complex interrelationships among
ones self-concept, body image, personal history, and family
and cultural inuences; and all interactions with others. If client
feels abnormal or very unlike everyone else, the self-concept
is likely to be very lowhe or she may even feel worthless. To
increase the clients feelings of self-worth and desire to change
behavior, help him or her to see that even though the behavior
is variant, feelings and motivations are common.
Outcome Criteria
1. Client is able to verbalize fears about abnormality and inap-
propriateness of sexual behaviors.
2. Client expresses desire to change variant sexual behavior and
cooperates with plan of behavior modication.
3. Client and partner verbalize modications in sexual activi-
ties in response to limitations imposed by illness or medical
treatment.
4. Client expresses satisfaction with own sexuality pattern or a
satisfying sexual relationship with another.
Gender Identity Disorders

Gender identity is the sense of knowing to which gender one
belongsthat is, the awareness of ones masculinity or femininity.
Gender identity disorders occur when there is incongruity be-
tween anatomic sex and gender identity. An individual with gen-
der identity disorder has an intense desire to be, or insists that he
or she is of, the other gender. The DSM-IV-TR (APA, 2000) iden-
ties two categories of the disorder: gender identity disorder in
children and gender identity disorder in adolescents and adults.
Intervention with adolescents and adults with gender identity
disorder is difcult. Adolescents commonly act out and rarely
have the motivation required to alter their cross-gender roles.
2506_Ch11_201-217.indd 0211 10/1/10 9:35:46 AM

Adults generally seek therapy to learn how to cope with their

altered sexual identity, not to correct it.
Treatment of children with the disorder is aimed at helping
them to become more comfortable with their assigned gender
and to avoid the possible development of gender dissatisfaction
in adulthood.
Predisposing Factors to Gender Identity Disorder
1. Physiological
a. Studies of genetics and physiological alterations have
been conducted in an attempt to determine whether or
not a biological predisposition to gender identity disorder
exists. To date, no clear evidence has been demonstrated.
2. Psychosocial
a. Family Dynamics: It appears that family dynamics plays
the most inuential role in the etiology of gender disor-
ders. Sadock and Sadock (2007) state, Children develop
a gender identity consonant with their sex of rearing (also
known as assigned sex). Gender roles are culturally de-
termined, and parents encourage masculine or feminine
behaviors in their children. Although temperament may
play a role with certain behavioral characteristics being
present at birth, mothers usually foster a childs pride in
their gender. Sadock and Sadock (2007) state:
The fathers role is also important in the early years,
and his presence normally helps the separation-
individuation process. Without a father, mother and
child may remain overly close. For a girl, the father
is normally the prototype of future love objects; for
a boy, the father is a model for male identication
(p. 719).
b. Psychoanalytical Theory. This theory suggests that gen-
der identity problems begin during the struggle of the
Oedipal/Electra con ict. Problems may reect both real
family events and those created in the childs imagination.
These con icts, whether real or imagined, interfere with
the childs loving of the opposite-gender parent and iden-
tifying with the same-gender parent, and ultimately with
normal gender identity.
In children or adolescents:
1. Repeatedly stating intense desire to be of the opposite gender.
2. Insistence that one is of the opposite gender.
3. Preference in males for cross-dressing or simulating female
attire.
4. Insistence by females on wearing only stereotypical mascu-
line clothing.
2506_Ch11_201-217.indd 0212 10/1/10 9:35:46 AM

5. Fantasies of being of the opposite gender.

6. Strong desire to participate only in the stereotypical games
and pastimes of the opposite gender.
7. Strong preference for playmates (peers) of the opposite gender.
In adults:
1. A stated desire to be of the opposite gender.
2. Frequently passing as the opposite gender.
3. Desire to live or be treated as the opposite gender.
4. Stated conviction that one has the typical feelings and reac-
tions of the opposite gender.
5. Persistent discomfort with or sense of inappropriateness in
the assigned gender role.
6. Request for opposite gender hormones or surgery to alter
sexual characteristics.
for Gender Identity Disorder
NOTE: Because adults and adolescents rarely have the desire or
motivation to modify their gender identity, nursing interventions
in this section are focused on working with gender-disordered
children. Becker and Johnson (2008) state, It is important to note
that not all children with gender identity disorder become adults
with gender identity disorder. (p. 733).

De nition: Inability to maintain an integrated and complete per-
ception of self.

[Parenting patterns that encourage culturally unacceptable
behaviors for assigned gender]
[Unresolved Oedipal/Electra con ict]
[Statements of desire to be opposite gender]
[Statements that one is the opposite gender]
[Cross-dressing, or passing as the opposite gender]
[Strong preference for playmates (peers) of the opposite gender]
[Stated desire to be treated as the opposite gender]
[Statements of having feelings and reactions of the opposite
gender]
2506_Ch11_201-217.indd 0213 10/1/10 9:35:47 AM

Goals/Objectives
Short-term Goals
1. Client will verbalize knowledge of behaviors that are appro-
priate and culturally acceptable for assigned gender.
2. Client will verbalize desire for congruence between personal
feelings and behavior and assigned gender.
Long-term Goals
1. Client will demonstrate behaviors that are appropriate and
culturally acceptable for assigned gender.
2. Client will express personal satisfaction and feelings of being
comfortable in assigned gender.

1. Spend time with client and show positive regard. Trust and
unconditional acceptance are essential to the establishment
of a therapeutic nurse-client relationship.
2. Be aware of own feelings and attitudes toward this client
and his or her behavior. Attitudes influence behavior. The
nurse must not allow negative attitudes to interfere with the
effectiveness of interventions.
3. Allow client to describe his or her perception of the problem.
It is important to know how the client perceives the problem
before attempting to correct misperceptions.
4. Discuss with the client the types of behaviors that are more
culturally acceptable. Practice these behaviors through role-
playing or with play therapy strategies (e.g., male and female
dolls). Positive reinforcement or social attention may be given
for use of appropriate behaviors. No response is given for ste-
reotypical opposite-gender behaviors. The goal is to enhance
culturally appropriate same-gender behaviors, but not neces-
sarily to extinguish all coexisting opposite-gender behaviors.
Outcome Criteria
1. Client demonstrates behaviors that are culturally appropriate
for assigned gender.
2. Client verbalizes and demonstrates self-satisfaction with
assigned gender role.
3. Client demonstrates development of a close relationship with
the parent of the same gender.

ity of social exchange.
2506_Ch11_201-217.indd 0214 10/1/10 9:35:47 AM


[Socially and culturally unacceptable behavior]
[Low self-esteem]

Inability to receive or communicate a satisfying sense of belong-
ing, caring, interest, or shared history
Goals/Objectives
Short-term Goal
Client will verbalize possible reasons for ineffective interactions
with others.
Long-term Goal
Client will interact with others using culturally acceptable
behaviors.

1. Once client feels comfortable with the new behaviors in role
playing or one-to-one nurse-client interactions, the new be-
haviors may be tried in group situations. If possible, remain
with the client during initial interactions with others. Pres-
ence of a trusted individual provides security for the client
in a new situation. It also provides the potential for feedback
to the client about his or her behavior.
2. Observe client behaviors and the responses he or she
elicits from others. Give social attention (e.g., smile, nod)
to desired behaviors. Follow up these practice sessions
with one-to-one processing of the interaction. Give posi-
tive reinforcement for efforts. Positive reinforcement en-
courages repetition of desirable behaviors. One-to-one
processing provides time for discussing the appropriate-
ness of specifi c behaviors and why they should or should
not be repeated.
3. Offer support if client is feeling hurt from peer ridicule.
Matter-of-factly discuss the behaviors that elicited the rid-
icule. Offer no personal reaction to the behavior. Personal
reaction from the nurse would be considered judgmental.
Validation of clients feelings is important, yet it is also
important that client understand why his or her behav-
ior was the subject of ridicule and how to avoid it in the
future.
2506_Ch11_201-217.indd 0215 10/1/10 9:35:47 AM

Outcome Criteria
1. Client interacts appropriately with others demonstrating
culturally acceptable behaviors.
2. Client verbalizes and demonstrates comfort in assigned
gender role in interactions with others.
LOW SELF-ESTEEM
capabilities.

[Rejection by peers]
Lack of approval and/or affection
[Lack of personal satisfaction with assigned gender]

[Inability to form close, personal relationships]
[Negative view of self]
[Expressions of worthlessness]
[Social isolation]
[Hypersensitivity to slight or criticism]
Lack of eye contact
Goals/Objectives
Short-term Goal
Client will verbalize positive statements about self, including
past accomplishments and future prospects.
Long-term Goal
Client will verbalize and demonstrate behaviors that indicate
self-satisfaction with assigned gender, ability to interact with
others, and a sense of self as a worthwhile person.

1. To enhance the childs self-esteem:
a. Encourage the child to engage in activities in which he or
she is likely to achieve success.
b. Help the child to focus on aspects of his or her life for
which positive feelings exist. Discourage rumination
about situations that are perceived as failures or over
2506_Ch11_201-217.indd 0216 10/1/10 9:35:48 AM

which the client has no control. Give positive feedback for

these behaviors.
2. Help the client identify behaviors or aspects of life he or she
would like to change. If realistic, assist the child in problem
solving ways to bring about the change. Having some control
over his or her life may decrease feelings of powerlessness
and increase feelings of self-worth.
3. Offer to be available for support to the child when he or she is
feeling rejected by peers. Having an available support per-
son who does not judge the childs behavior and who provides
unconditional acceptance assists the child to progress toward
acceptance of self as a worthwhile person.
Outcome Criteria
2. Client verbalizes self-satisfaction about accomplishments
and demonstrates behaviors that reect self-worth.
INTERNET REFERENCES
Additional information about sexual disorders may be located
a. http://www.sexualhealth.com/
b. http://www.cmellc.com/topics/sexual.html
c. http://www.priory.com/sex.htm
d. http://web4health.info/en/answers/sex-menu.htm
e. http://allpsych.com/disorders/sexual/index.html
Additional information about gender identity disorders may be
a. http://www.avitale.com/
b. http://www.leaderu.com/jhs/rekers.html
d. http://psyweb.com/Mdisord/jsp/sexd.jsp
Movie Connections
Mystic River (pedophilia) Blue Velvet (sexual masochism)
Looking for Mr. Goodbar (sadism/masochism) Normal (transvestitism)
Transamerica (transvestitism)
2506_Ch11_201-217.indd 0217 10/1/10 9:35:48 AM

C H A P T E R
12
Eating Disorders
Revision (DSM-IV-TR) identies eating disorders as those char-
acterized by severe disturbances in eating behavior. Two such
disorders are described in the DSM-IV-TR: anorexia nervosa
and bulimia nervosa. Obesity is not classied as a psychiatric
disorder per se; however, because of the strong emotional fac-
tors associated with it, the DSM-IV-TR suggests that obesity
may be considered within the category of Psychological Factors
Affecting Medical Condition. A third category of eating disorder,
binge eating disorder, is also being considered by the American
Psychiatric Association.
Anorexia Nervosa
De ned
Anorexia nervosa is a clinical syndrome in which the person has a
morbid fear of obesity. It is characterized by the individuals gross
distortion of body image, preoccupation with food, and refusal to
eat. The disorder occurs predominantly in females 12 to 30 years
of age. Without intervention, death from starvation can occur.
1. Morbid fear of obesity. Preoccupied with body size. Reports
feeling fat even when in an emaciated condition.
2. Refusal to eat. Reports not being hungry, although it is
thought that the actual feelings of hunger do not cease until
late in the disorder.
3. Preoccupation with food. Thinks and talks about food at
great length. Prepares enormous amounts of food for friends
and family members but refuses to eat any of it.
4. Amenorrhea is common, often appearing even before notice-
able weight loss has occurred.
5. Delayed psychosexual development.
6. Compulsive behavior, such as excessive hand washing, may
be present.
218
2506_Ch12_218-235.indd Sec1:218 10/1/10 9:35:58 AM

7. Extensive exercising is common.

8. Feelings of depression and anxiety often accompany this
disorder.
9. May engage in the binge-and-purge syndrome from time to
time (see following section on bulimia nervosa).
Bulimia Nervosa
De ned
Bulimia nervosa is an eating disorder (commonly called the
binge-and-purge syndrome) characterized by extreme over-
eating, followed by self-induced vomiting and abuse of laxatives
and diuretics. The disorder occurs predominantly in females
and begins in adolescence or early adult life.
1. Binges are usually solitary and secret, and the individual may
consume thousands of calories in one episode.
2. After the binge has begun, there is often a feeling of loss of
control or inability to stop eating.
3. Following the binge, the individual engages in inappropriate
compensatory measures to avoid gaining weight (e.g., self-
induced vomiting; excessive use of laxatives, diuretics, or en-
emas; fasting; and extreme exercising).
4. Eating binges may be viewed as pleasurable but are followed
by intense self-criticism and depressed mood.
5. Individuals with bulimia are usually within normal weight
range, some a few pounds underweight, some a few pounds
overweight.
6. Obsession with body image and appearance is a predominant
feature of this disorder. Individuals with bulimia display
undue concern with sexual attractiveness and how they will
appear to others.
7. Binges usually alternate with periods of normal eating and
fasting.
8. Excessive vomiting may lead to problems with dehydration
and electrolyte imbalance.
9. Gastric acid in the vomitus may contribute to the erosion of
tooth enamel.
Predisposing Factors to Anorexia Nervosa
and Bulimia Nervosa
a. Genetics: A hereditary predisposition to eating disorders
has been hypothesized on the basis of family histories and
an apparent association with other disorders for which the
likelihood of genetic inuences exist. Anorexia nervosa is
more common among sisters and mothers of those with
2506_Ch12_218-235.indd Sec1:219 10/1/10 9:35:59 AM

the disorder than among the general population. Several

studies have reported a higher than expected frequency of
mood disorders among rst-degree biological relatives of
people with anorexia nervosa and bulimia nervosa and
of substance abuse and dependence in relatives of indi-
viduals with bulimia nervosa (APA, 2000).
b. Neuroendocrine Abnormalities: Some speculation has
occurred regarding a primary hypothalamic dysfunction
in anorexia nervosa. Studies consistent with this theory
have revealed elevated cerebrospinal uid cortisol levels
and a possible impairment of dopaminergic regulation in
individuals with anorexia (Halmi, 2008).
c. Neurochemical Influences: Neurochemical inuences in
bulimia may be associated with the neurotransmitters
serotonin and norepinephrine. This hypothesis has been
supported by the positive response these individuals
have shown to therapy with the selective serotonin reup-
take inhibitors (SSRIs). Some studies have found high
levels of endogenous opioids in the spinal uid of cli-
ents with anorexia, promoting the speculation that these
chemicals may contribute to denial of hunger (Sadock
& Sadock, 2007). Some of these individuals have been
shown to gain weight when given naloxone, an opioid
antagonist.
a. Psychodynamic Theory: The psychodynamic theory sug-
gests that behaviors associated with eating disorders reect
a developmental arrest in the very early years of childhood
caused by disturbances in mother-infant interactions. The
tasks of trust, autonomy, and separation-individuation
go unfullled, and the individual remains in the depen-
dent position. Ego development is retarded. The problem
is compounded when the mother responds to the childs
physical and emotional needs with food. Manifestations
include a disturbance in body identity and a distortion in
body image. When events occur that threaten the vulner-
able ego, feelings emerge of lack of control over ones body
(self). Behaviors associated with food and eating provide
feelings of control over ones life.
b. Family Dynamics: This theory proposes that the issue of
control becomes the overriding factor in the family of the
individual with an eating disorder. These families often
consist of a passive father, a domineering mother, and an
overly dependent child. A high value is placed on perfec-
tionism in this family, and the child feels he or she must
satisfy these standards. Parental criticism promotes an
increase in obsessive and perfectionistic behavior on the
2506_Ch12_218-235.indd Sec1:220 10/1/10 9:35:59 AM

part of the child, who continues to seek love, approval, and

recognition. The child eventually begins to feel helpless
and ambivalent toward the parents. In adolescence, these
distorted eating patterns may represent a rebellion against
the parents, viewed by the child as a means of gaining and
remaining in control. The symptoms are often triggered
by a stressor that the adolescent perceives as a loss of con-
trol in some aspect of his or her life.
Obesity
De ned
The following formula is used to determine the degree of
obesity in an individual:
weight (kg)
Body mass index (BMI) =
height (m)2
The BMI range for normal weight is 20 to 24.9. Studies by the
National Center for Health Statistics indicate that overweight is
de ned as a BMI of 25.0 to 29.9 (based on U.S. Dietary Guide-
lines for Americans). Based on criteria of the World Health
Organization, obesity is de ned as a BMI of 30.0 or greater.
These guidelines, which were released by the National Heart,
Lung, and Blood Institute in July 1998, markedly increased the
number of Americans considered to be overweight. The average
American woman has a BMI of 26, and fashion models typically
have BMIs of 18 (Priesnitz, 2005).
Obesity is known to contribute to a number of health prob-
lems, including hyperlipidemia, diabetes mellitus, osteoarthritis,
and increased workload on the heart and lungs.
Predisposing Factors to Obesity
a. Genetics: Genetics have been implicated in the develop-
ment of obesity in that 80% of offspring of two obese
parents are obese (Halmi, 2008). This hypothesis has also
been supported by studies of twins reared by normal and
overweight parents.
b. Physical Factors: Overeating and/or obesity has also been
associated with lesions in the appetite and satiety centers
of the hypothalamus, hypothyroidism, decreased insulin
production in diabetes mellitus, and increased cortisone
production in Cushings disease.
c. Lifestyle Factors: On a more basic level, obesity can be
viewed as the ingestion of a greater number of calories
than are expended. Weight gain occurs when caloric in-
take exceeds caloric output in terms of basal metabolism
and physical activity. Many overweight individuals lead
2506_Ch12_218-235.indd Sec1:221 10/1/10 9:35:59 AM

sedentary lifestyles, making it very difcult to burn off

calories.
a. Psychoanalytical Theory: This theory suggests that obe-
sity is the result of unresolved dependency needs, with
the individual being xed in the oral stage of psychosex-
ual development. The symptoms of obesity are viewed as
depressive equivalents, attempts to regain lost or frus-
trated nurturance and care.

for Anorexia and Bulimia
IMBALANCED NUTRITION: LESS

needs.

[Refusal to eat]
[Ingestion of large amounts of food, followed by self-induced
vomiting]
[Abuse of laxatives, diuretics, and/or diet pills]
[Physical exertion in excess of energy produced through caloric
intake]

[Loss of 15% of expected body weight (anorexia nervosa)]
Poor muscle tone
Excessive loss of hair [or increased growth of hair on body
(lanugo)]
[Amenorrhea]
[Poor skin turgor]
[Hypothermia]
[Bradycardia]
[Hypotension]
[Cardiac irregularities]
[Edema]
2506_Ch12_218-235.indd Sec1:222 10/1/10 9:36:00 AM

Goals/Objectives
Short-term Goal
Client will gain lbs per week (amount to be established by
client, nurse, and dietitian).
Long-term Goal
By discharge from treatment, client will exhibit no signs or
symptoms of malnutrition.

1. If client is unable or unwilling to maintain adequate oral in-
take, physician may order a liquid diet to be administered via
nasogastric tube. Nursing care of the individual receiving
tube feedings should be administered according to established
hospital procedures. The clients physical safety is a nursing
priority, and without adequate nutrition, a life-threatening
situation exists.
For oral diet:
2. In collaboration with dietitian, determine number of cal-
ories required to provide adequate nutrition and realistic
(according to body structure and height) weight gain. Ad-
equate calories are required to affect a weight gain of 2 to
3 lbs per week.
3. Explain to client details of behavior modication program
as outlined by physician. Explain benets of compliance
with prandial routine and consequences for noncompliance.
Behavior modification bases privileges granted or restricted
directly on weight gain and loss. Focus is placed on emo-
tional issues, rather than food and eating specifically.
4. Sit with client during mealtimes for support and to observe
amount ingested. A limit (usually 30 minutes) should be
imposed on time allotted for meals. Without a time limit,
meals can become lengthy, drawn-out sessions, providing
client with attention based on food and eating.
5. Client should be observed for at least 1 hour following meals.
This time may be used by client to discard food stashed from
tray or to engage in self-induced vomiting.
6. Client may need to be accompanied to bathroom if self-
induced vomiting is suspected.
7. Strict documentation of intake and output. This information
is required to promote client safety and plan nursing care.
8. Weigh client daily immediately on arising and following
rst voiding. Always use same scale, if possible. Client care,
privileges, and restrictions will be based on accurate daily
weights.
2506_Ch12_218-235.indd Sec1:223 10/1/10 9:36:00 AM

9. Do not discuss food or eating with client, once protocol has

been established. Do, however, offer support and positive
reinforcement for obvious improvements in eating behav-
iors. Discussing food with client provides positive feedback
for maladaptive behaviors.
10. Client must understand that if, because of poor oral intake,
nutritional status does not improve, tube feedings will be ini-
tiated to ensure clients safety. Staff must be consistent and
rm with this action, using a matter-of-fact, nonpunitive ap-
proach regarding the tube insertion and subsequent feedings.
11. As nutritional status improves and eating habits are estab-
lished, begin to explore with client the feelings associated
with his or her extreme fear of gaining weight. Emotional
issues must be resolved if maladaptive responses are to be
eliminated.
Outcome Criteria
1. Client has achieved and maintained at least 85% of expected
body weight.
3. Client verbalizes importance of adequate nutrition.
DEFICIENT FLUID VOLUME

De nition: Decreased intravascular, interstitial, and/or intracel-
lular fluid. This refers to dehydration, water loss alone without
change in sodium.

[Decreased uid intake]
[Abnormal uid loss caused by self-induced vomiting]
[Excessive use of laxatives or enemas]
[Excessive use of diuretics]
[Electrolyte or acid-base imbalance brought about by malnour-
ished condition or self-induced vomiting]

Decreased urine output
[Output greater than intake]
Increased urine concentration
Elevated hematocrit
Decreased blood pressure
Increased pulse rate
Increased body temperature
2506_Ch12_218-235.indd Sec1:224 10/1/10 9:36:00 AM

Dry skin
Decreased skin turgor
Weakness
Change in mental state
Dry mucous membranes
Goals/Objectives
Short-term Goal
Client will drink 125 mL of uid each hour during waking
hours.
Long-term Goal
By discharge from treatment, client will exhibit no signs or
symptoms of dehydration (as evidenced by quantity of urinary
output sufcient to individual client; normal specic gravity;
vital signs within normal limits; moist, pink mucous membranes;
good skin turgor; and immediate capillary rell).
1. Keep strict record of intake and output. Teach client
importance of daily uid intake of 2000 to 3000 mL. This
information is required to promote client safety and plan
nursing care.
2. Weigh client daily immediately on arising and following rst
voiding. Always use same scale, if possible. An accurate daily
weight is needed to plan nursing care for the client.
3. Assess and document condition of skin turgor and any chang-
es in skin integrity. Condition of skin provides valuable data
regarding client hydration.
4. Discourage client from bathing every day if skin is very dry.
Hot water and soap are drying to the skin.
5. Monitor laboratory serum values, and notify physician of
signicant alterations. Laboratory data provide an objective
measure for evaluating adequate hydration.
6. Client should be observed for at least 1 hour following meals
and may need to be accompanied to the bathroom if self-
induced vomiting is suspected. Vomiting causes active loss of
body fluids and can precipitate fluid volume deficit.
7. Assess and document moistness and color of oral mucous
membranes. Dry, pale mucous membranes may be indica-
tive of malnutrition or dehydration.
8. Encourage frequent oral care to moisten mucous membranes,
reducing discomfort from dry mouth, and to decrease bacte-
rial count, minimizing risk of tissue infection.
9. Help client identify true feelings and fears that contribute
to maladaptive eating behaviors. Emotional issues must be
resolved if maladaptive behaviors are to be eliminated.
2506_Ch12_218-235.indd Sec1:225 10/1/10 9:36:00 AM

Outcome Criteria
1. Clients vital signs, blood pressure, and laboratory serum
studies are within normal limits.
2. No abnormalities of skin turgor and dryness of skin and oral
mucous membranes are evident.
3. Client verbalizes knowledge regarding consequences of uid
loss due to self-induced vomiting and importance of adequate
uid intake.
INEFFECTIVE COPING

[Unfullled tasks of trust and autonomy]
[Feelings of helplessness and lack of control in life situation]
[Possible chemical imbalance caused by malfunction of
hypothalamus]
[Unrealistic perceptions]
[Preoccupation with extreme fear of obesity, and distortion of
own body image]
[Refusal to eat]
[Obsessed with talking about food]
[Compulsive behavior (e.g., excessive hand washing)]
[Excessive overeating, followed by self-induced vomiting and/or
abuse of laxatives and diuretics]
[Poor self-esteem]
[Chronic fatigue]
[Chronic anxiety]
[Chronic depression]
Destructive behavior toward self
Goals/Objectives
Short-term Goal
Within 7 days, client will eat regular meals and attend activities
without discussing food or physical appearance.
2506_Ch12_218-235.indd Sec1:226 10/1/10 9:36:01 AM

Long-term Goal
Client will be able to verbalize adaptive coping mechanisms that
can be realistically incorporated into his or her lifestyle, thereby
eliminating the need for maladaptive eating behaviors.

1. Establish a trusting relationship with client by being honest,
accepting, and available and by keeping all promises. The ther-
apeutic nurse-client relationship is built on trust.
2. Acknowledge clients anger at feelings of loss of con-
trol brought about by established eating regimen (refer to
INTERVENTIONS for Imbalanced Nutrition).
3. When nutritional status has improved, begin to explore with
client the feelings associated with his or her extreme fear
of gaining weight. Emotional issues must be resolved if mal-
adaptive behaviors are to be eliminated.
4. Explore family dynamics. Help client to identify his or her
role contributions and their appropriateness within the family
system. Assist client to identify specic concerns within the
family structure and ways to help relieve those concerns. Also,
discuss importance of clients separation of self as individu-
al within the family system, and of identifying independent
emotions and accepting them as his or her own. Client must
recognize how maladaptive eating behaviors are related to
emotional problemsoften issues of control within the fam-
ily structure.
5. Initially, allow client to maintain dependent role. To deprive
the individual of this role at this time could cause his or her
anxiety to rise to an unmanageable level. As trust is developed
and physical condition improves, encourage client to be as in-
dependent as possible in self-care activities. Offer positive rein-
forcement for independent behaviors and problem-solving and
decision-making. Client must learn to function indepen-
dently. Positive reinforcement increases self-esteem and en-
courages the client to use behaviors that are more acceptable.
6. Explore with client ways in which he or she may feel in con-
trol within the environment without resorting to maladap-
tive eating behaviors. When client feels control over major
life issues, the need to gain control through maladaptive
eating behaviors will diminish.
Outcome Criteria
1. Client is able to assess maladaptive coping behaviors
accurately.
2. Client is able to verbalize adaptive coping strategies that can
be used in the home environment.
2506_Ch12_218-235.indd Sec1:227 10/1/10 9:36:01 AM

ANXIETY (Moderate to Severe)

unknown to the individual); a feeling of apprehension caused by
threat.

[Low self-esteem]
[Feelings of helplessness and lack of control in life situation]
[Unfullled tasks of trust and autonomy]

Increased tension
Increased helplessness
Overexcited
Apprehensive; fearful
Restlessness
Poor eye contact
[Increased difculty taking oral nourishment]
[Inability to learn]
Goals/Objectives
Short-term Goal
Client will demonstrate use of relaxation techniques to maintain
anxiety at manageable level within 7 days.
Long-term Goal
By time of discharge from treatment, client will be able to rec-
ognize events that precipitate anxiety and intervene to prevent
disabling behaviors.

1. Be available to stay with client. Remain calm and provide re-
assurance of safety. Client safety and security is a nursing
priority.
2. Help client identify the situation that precipitated onset of
anxiety symptoms. Client may be unaware that emotional
issues are related to symptoms of anxiety. Recognition may
be the first step in elimination of this maladaptive response.
2506_Ch12_218-235.indd Sec1:228 10/1/10 9:36:01 AM

3. Review clients methods of coping with similar situations

in the past. In seeking to create change, it is helpful for
client to identify past responses and determine whether
they were successful and whether they could be employed
again. Client strengths should be identified and used to his
or her advantage.
4. Provide quiet environment. Reduce stimuli: low lighting, few
people. Anxiety level may be decreased in calm atmosphere
with few stimuli.
5. Administer antianxiety medications, as ordered by physician.
Monitor for effectiveness of medication as well as for adverse
side effects. Short-term use of antianxiety medications (e.g.,
from the immobilizing effects of anxiety, and facilitates
6. Teach client to recognize signs of increasing anxiety
and ways to intervene for maintaining the anxiety at a
manageable level (e.g., exercise, walking, jogging, relax-
ation techniques). Anxiety and tension can be reduced
safely and with benefit to the client through physical
activities.
Outcome Criteria
1. Client is able to verbalize events that precipitate anxiety and
demonstrate techniques for its reduction.
2. Client is able to verbalize ways in which he or she may gain
more control of the environment and thereby reduce feelings
of helplessness.
DISTURBED BODY IMAGE/LOW

SELF-ESTEEM
Negative self-evaluating/feelings about self or self-capabilities.

[Perceived failures]
[Unrealistic expectations (on the part of self and others)]
[Threat to security caused by dysfunctional family dynamics]
[Morbid fear of obesity]
[Perceived loss of control in some aspect of life]
2506_Ch12_218-235.indd Sec1:229 10/1/10 9:36:02 AM


[Distorted body image, views self as fat, even in the presence of
normal body weight or severe emaciation]
[Denial that problem with low body weight exists]
[Not taking responsibility for self-care (self-neglect)]
[Nonparticipation in therapy]
[Self-destructive behavior (self-induced vomiting; abuse of laxa-
tives or diuretics; refusal to eat)]
Lack of eye contact
[Depressed mood and self-deprecating thoughts following epi-
sode of binging and purging]
[Preoccupation with appearance and how others perceive them]
Goals/Objectives
Short-term Goal
Client will verbally acknowledge misperception of body image
as fat within specied time (depending on severity and chro-
nicity of condition).
Long-term Goal
Client will demonstrate an increase in self-esteem as manifested
by verbalizing positive aspects of self and exhibiting less preoc-
cupation with own appearance as a more realistic body image is
developed by time of discharge from therapy.

1. Help client reexamine negative perceptions of self and recog-
nize positive attributes. Clients own identification of strengths
and positive attributes can increase sense of self-worth.
2. Offer positive reinforcement for independently made deci-
sions inuencing clients life. Positive reinforcement en-
hances self-esteem and may encourage client to continue
functioning more independently.
3. Offer positive reinforcement when honest feelings related to
autonomy and dependence issues remain separated from mal-
adaptive eating behaviors.
4. Help client develop a realistic perception of body image and
relationship with food. Client needs to recognize that his or
her perception of body image is unhealthy and that main-
taining control through maladaptive eating behaviors is
dangerouseven life-threatening.
5. Promote feelings of control within the environment through
participation and independent decision making. Through
positive feedback, help client learn to accept self as is, in-
cluding weaknesses as well as strengths. Client must come
to understand that he or she is a capable, autonomous
2506_Ch12_218-235.indd Sec1:230 10/1/10 9:36:02 AM

individual who can perform outside the family unit and

who is not expected to be perfect. Control of his or her
life must be achieved in other ways besides dieting and
weight loss.
6. Help client realize that perfection is unrealistic, and explore
this need with him or her. As client begins to feel better about
self and identifies positive self-attributes, and develops the
ability to accept certain personal inadequacies, the need for
unrealistic achievements should diminish.
7. Help client claim ownership of angry feelings and recognize
that expressing them is acceptable if done so in an appropri-
ate manner. Be an effective role model. Unexpressed anger is
often turned inward on the self, resulting in depreciation of
self-esteem.
Outcome Criteria
1. Client is able to verbalize positive aspects about self.
2. Client expresses interest in welfare of others and less preoc-
cupation with own appearance.
3. Client verbalizes that image of body as fat was misper-
ception and demonstrates ability to take control of own life
without resorting to maladaptive eating behaviors.

for Obesity
IMBALANCED NUTRITION: MORE

De nition: Intake of nutrients that exceeds metabolic needs.

[Compulsive eating]
Excessive intake in relation to metabolic needs
[Sedentary lifestyle]
[Genetics]
[Unmet dependency needs xation in oral developmental
stage]
Weight 20% over ideal for height and frame
[Body mass index of 30 or more]
2506_Ch12_218-235.indd Sec1:231 10/1/10 9:36:02 AM

Goals/Objectives
Short-term Goal
Client will verbalize understanding of what must be done to lose
weight.
Long-term Goal
Client will demonstrate change in eating patterns resulting in a
steady weight loss.

1. Encourage the client to keep a diary of food intake. A food
diary provides the opportunity for the client to gain a realis-
tic picture of the amount of food ingested and provides data
on which to base the dietary program.
2. Discuss feelings and emotions associated with eating. This
helps to identify when client is eating to satisfy an emotional
need rather than a physiological one.
3. With input from the client, formulate an eating plan that in-
cludes food from the basic food pyramid with emphasis on
low-fat intake. It is helpful to keep the plan as similar to the
clients usual eating pattern as possible. Diet must eliminate
calories while maintaining adequate nutrition. Client is
more likely to stay on the eating plan if he or she is able to
participate in its creation and it deviates as little as possible
from usual types of foods.
4. Identify realistic increment goals for weekly weight loss.
Reasonable weight loss (1 to 2 lb/wk) results in more lasting
effects. Excessive, rapid weight loss may result in fatigue
and irritability and may ultimately lead to failure in meet-
ing goals for weight loss. Motivation is more easily sustained
by meeting stair-step goals.
5. Plan progressive exercise program tailored to individual goals
and choice. Exercise may enhance weight loss by burning
calories and reducing appetite, increasing energy, toning
muscles, and enhancing sense of well-being and accom-
plishment. Walking is an excellent choice for overweight
individuals.
6. Discuss the probability of reaching plateaus when weight
remains stable for extended periods. Client should know
that this is likely to happen as changes in metabolism occur.
Plateaus cause frustration, and client may need additional
support during these times to remain on the weight loss
program.
7. Provide instruction about medications to assist with weight
loss if ordered by the physician. Appetite-suppressant drugs
(e.g., sibutramine) and others that have weight loss as a
side effect (e.g., fluoxetine; topiramate) may be helpful to
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someone who is severely overweight. Drugs should be used

for this purpose for only a short period while the individual
attempts to adjust to the new pattern of eating.
Outcome Criteria
1. Client has established a healthy pattern of eating for weight
control with weight loss progressing toward a desired goal.
2. Client verbalizes plans for future maintenance of weight
control.
DISTURBED BODY IMAGE/LOW

SELF-ESTEEM
Negative self-evaluating/feelings about self or self-capabilities.

[Dissatisfaction with appearance]
[Lack of adequate nurturing by maternal gure]

Negative feelings about body (e.g., feelings of helplessness,
hopelessness, or powerlessness)
[Verbalization of desire to lose weight]
[Failure to take responsibility for self-care (self-neglect)]
Lack of eye contact
[Expressions of low self-worth]
Goals/Objectives
Short-term Goal
Client will begin to accept self based on self-attributes rather
than on appearance.
Long-term Goal
Client will pursue loss of weight as desired.

1. Assess clients feelings and attitudes about being obese. Obe-
sity and compulsive eating behaviors may have deep-rooted
psychological implications, such as compensation for lack of
love and nurturing or a defense against intimacy.
2. Ensure that the client has privacy during self-care activi-
ties. The obese individual may be sensitive or self-conscious
about his or her body.
2506_Ch12_218-235.indd Sec1:233 10/1/10 9:36:03 AM

3. Have client recall coping patterns related to food in family of

origin, and explore how these may affect current situation.
Parents are role models for their children. Maladaptive
eating behaviors are learned within the family system and
are supported through positive reinforcement. Food may be
substituted by the parent for affection and love, and eat-
ing is associated with a feeling of satisfaction, becoming the
primary defense.
4. Determine clients motivation for weight loss and set goals.
The individual may harbor repressed feelings of hostility,
which may be expressed inward on the self. Because of a poor
self-concept, the person often has difficulty with relation-
ships. When the motivation is to lose weight for someone
else, successful weight loss is less likely to occur.
5. Help client identify positive self-attributes. Focus on strengths
and past accomplishments unrelated to physical appearance.
It is important that self-esteem not be tied solely to size of the
body. Client needs to recognize that obesity need not interfere
with positive feelings regarding self-concept and self-worth.
6. Refer client to support or therapy group. Support groups can
provide companionship, increase motivation, decrease lone-
liness and social ostracism, and give practical solutions to
common problems. Group therapy can be helpful in dealing
with underlying psychological concerns.
Outcome Criteria
1. Client has established a healthy pattern of eating for weight
control with weight loss progressing toward a desired goal.
2. Client verbalizes plans for future maintenance of weight
control.
INTERNET REFERENCES
Additional information about anorexia nervosa and bulimia
nervosa may be located at the following websites:
a. http://www.aabainc.org
b. http://healthyminds.org/multimedia/eatingdisorders.pdf
c. http://www.mentalhealth.com/dis/p20-et01.html
d. http://www.anred.com/
e. http://www.mentalhealth.com/dis/p20-et02.html
f. http://www.nimh.nih.gov/publicat/eatingdisorders.cfm
g. http://medlineplus.nlm.nih.gov/medlineplus/eatingdisorders
.html
Additional information about obesity may be located at the
following websites:
a. http://www.shapeup.org/
b. http://www.obesity.org/
2506_Ch12_218-235.indd Sec1:234 10/1/10 9:36:03 AM

c. http://medlineplus.nlm.nih.gov/medlineplus/obesit y
.html
d. http://www.asbp.org/
e. http://win.niddk.nih.gov/publications/binge.htm
Movie Connections
The Best Little Girl in the World (anorexia nervosa) Kates Secret
(bulimia nnervosa) For the Love of Nancy (anorexia nervosa) Super Size
Me (obesity)
2506_Ch12_218-235.indd Sec1:235 10/1/10 9:36:03 AM

C H A P T E R
13
Adjustment Disorder
The essential feature of adjustment disorder is a maladaptive re-
action to an identiable psychosocial stressor that occurs within
3 months after the onset of the stressor and has persisted for no
longer than 6 months (American Psychiatric Association [APA],
2000). The response is considered maladaptive either because
there is impairment in social or occupational functioning or be-
cause the behaviors are exaggerated beyond the usual, expected
response to such a stressor. The impairment is corrected with
the disappearance of, or adaptation to, the stressor. The follow-
ing categories are de ned:
1. Adjustment Disorder with Depressed Mood. This cat-
egory is the most commonly diagnosed adjustment disorder.
The major symptoms include depressed mood, tearfulness,
and hopelessness. A differential diagnosis with the affective
disorders must be considered.
2. Adjustment Disorder with Anxiety. The major symptom of
this adjustment disorder is anxiety. Primary manifestations
include nervousness, worry, and restlessness. A differential
diagnosis with the anxiety disorders must be considered.
3. Adjustment Disorder with Mixed Anxiety and Depressed
Mood. This type of adjustment disorder is identied by a com-
bination of depression and anxiety. A differential diagnosis
must be made considering the affective and anxiety disorders.
4. Adjustment Disorder with Disturbance of Conduct. The
major response involves conduct in which there is violation
of the rights of others or of major age-appropriate societal
norms and rules. A differential diagnosis with conduct disor-
der or antisocial personality disorder must be considered.
5. Adjustment Disorder with Mixed Disturbance of Emo-
tions and Conduct. The behavioral manifestations include
both emotional symptoms (e.g., depression, anxiety) and dis-
turbances in conduct.
6. Adjustment Disorder Unspecified. This diagnosis is used
when the maladaptive reaction is not consistent with any of
236
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the other categories of adjustment disorder. Manifestations

may include physical complaints, social withdrawal, and
occupational or academic inhibition, without signicant
depressed or anxious mood.
1. Physiological
a. Developmental Impairment. Chronic conditions, such
as organic mental disorder or mental retardation, are
thought to impair the ability of an individual to adapt
to stress, causing increased vulnerability to adjustment
disorder. Sadock and Sadock (2007) suggest that genetic
factors also may inuence individual risks for maladaptive
response to stress.
2. Psychosocial Theories
a. Psychoanalytical Theory. Some proponents of psychoana-
lytical theory view adjustment disorder as a maladaptive
response to stress that is caused by early childhood trau-
ma, increased dependency, and retarded ego development.
Other psychoanalysts put considerable weight on the con-
stitutional factor, or birth characteristics that contribute to
the manner in which individuals respond to stress. In many
instances, adjustment disorder is precipitated by a specic
meaningful stressor having found a point of vulnerability
in an individual of otherwise adequate ego strength.
b. Developmental Model. Some studies relate a predispo-
sition to adjustment disorder to factors such as develop-
mental stage, timing of the stressor, and available support
systems. When a stressor occurs, and the individual does
not have the developmental maturity, available support
systems, or adequate coping strategies to adapt, normal
functioning is disrupted, resulting in psychological or
somatic symptoms. The disorder also may be related to
a dysfunctional grieving process. The individual may
remain in the denial or anger stage, with inadequate de-
fense mechanisms to complete the grieving process.
c. Stress-Adaptation Model. This model considers the type
of stressor the individual experiences, the situational con-
text in which it occurs, and intrapersonal factors in the
predisposition to adjustment disorder. It has been found
that continuous stressors (those to which an individual is
exposed over an extended period of time) are more com-
monly cited than sudden-shock stressors (those that occur
without warning) as precipitants to maladaptive function-
ing. The situational context in which the stressor occurs
may include factors such as personal and general economic
2506_Ch13_236-255.indd Sec1:237 10/1/10 9:36:14 AM

conditions; occupational and recreational opportunities;

the availability of social supports, such as family, friends,
and neighbors; and the availability of cultural or religious
support groups. Intrapersonal factors that have been
implicated in the predisposition to adjustment disorder
include birth temperament, learned social skills and cop-
ing strategies, the presence of psychiatric illness, degree
of exibility, and level of intelligence.

1. Depressed mood
2. Tearfulness
3. Hopelessness
4. Nervousness
5. Worry
6. Restlessness
7. Ambivalence
8. Anger, expressed inappropriately
9. Increased dependency
10. Violation of the rights of others
11. Violation of societal norms and rules, such as truancy, van-
dalism, reckless driving, ghting
12. Inability to function occupationally or academically
13. Manipulative behavior
14. Social isolation
15. Physical complaints, such as headache, backache, other
aches and pains, fatigue

and Interventions

ally harmful either to self or to others.

[Fixation in earlier level of development]
2506_Ch13_236-255.indd Sec1:238 10/1/10 9:36:14 AM


[Low self-esteem]
[Unresolved grief]
[Psychic overload]
[Extended exposure to stressful situation]
[Lack of support systems]
[Biological factors, such as organic changes in the brain]
Impulsivity
[Anger; rage]
[Increasing anxiety level]
[Depressed mood]
Goals/Objectives
Short-term Goals
1. Client will seek out staff member when hostile or suicidal
feelings occur.
2. Client will verbalize adaptive coping strategies for use when
hostile or suicidal feelings occur.
Long-term Goals
1. Client will demonstrate adaptive coping strategies for use
when hostile or suicidal feelings occur.

tine activities and interactions; avoid appearing watchful and
suspicious. Close observation is required so that intervention
can occur if required to ensure clients (and others) safety.
2. Observe for suicidal behaviors: verbal statements, such as
Im going to kill myself and Very soon my mother wont
have to worry herself about me any longer, and nonverbal
behaviors, such as giving away cherished items and mood
swings. Clients who are contemplating suicide often give
clues regarding their potential behavior. The clues may be
very subtle and require keen assessment skills by the nurse.
3. Determine suicidal intent and available means. Ask direct
questions, such as Do you plan to kill yourself? and How
do you plan to do it? The risk of suicide is greatly increased
if the client has developed a plan and particularly if means
exist for the client to execute the plan.
2506_Ch13_236-255.indd Sec1:239 10/1/10 9:36:14 AM

4. Obtain verbal or written contract from client agreeing not

to harm self and to seek out staff in the event that suicidal
ideation occurs. Discussion of suicidal feelings with a trusted
individual provides some relief to the client. A contract gets
the subject out in the open and places some of the responsibil-
ity for his or her safety with the client. An attitude of accep-
tance of the client as a worthwhile individual is conveyed.
5. Help client recognize when anger occurs and to accept
those feelings as his or her own. Have client keep an anger
notebook, in which feelings of anger experienced during a
24-hour period are recorded. Information regarding source
of anger, behavioral response, and clients perception of the
situation should also be noted. Discuss entries with client
and suggest alternative behavioral responses for those iden-
tied as maladaptive.
ings and give positive reinforcement to client for attempting
to conform. It is vital that the client express angry feelings,
because suicide and other self-destructive behaviors are often
viewed as the result of anger turned inward on the self.
7. Remove all dangerous objects from clients environment
(e.g., sharp items, belts, ties, straps, breakable items, smok-
ing materials). Client safety is a nursing priority.
8. Try to redirect violent behavior by means of physical outlets
for the clients anxiety (e.g., punching bag, jogging). Physi-
cal exercise is a safe and effective way of relieving pent-up
tension.
9. Be available to stay with client as anxiety level and tensions
begin to rise. Presence of a trusted individual provides a
feeling of security and may help to prevent rapid escalation
of anxiety.
10. Staff should maintain and convey a calm attitude to client.
Anxiety is contagious and can be transmitted from staff
members to client.
rity for staff.
cian or obtain an order if necessary. Monitor client response
for effectiveness of the medication and for adverse side ef-
fects. Short-term use of tranquilizing medications such as
anxiolytics or antipsychotics can induce a calming effect on
the client and may prevent aggressive behaviors.
13. Use of mechanical restraints or isolation room may be re-
quired if less restrictive interventions are unsuccessful.
Follow policy and procedure prescribed by the institu-
tion in executing this intervention. The Joint Commission
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(formerly the Joint Commission on Accreditation of Health-

care Organizations [ JCAHO]) requires that an in-person
evaluation (by a physician, clinical psychologist, or other
licensed independent practitioner responsible for the care
of the patient) be conducted within 1 hour of initiating
restraint or seclusion (The Joint Commission, 2010). The
physician must reevaluate and issue a new order for re-
straints every 4 hours for adults and every 1 to 2 hours for
children and adolescents.
14. Observe the client in restraints every 15 minutes (or ac-
cording to institutional policy). Ensure that circulation to
pulses). Assist client with needs related to nutrition, hy-
dration, and elimination. Position client so that comfort is
facilitated and aspiration can be prevented. Client safety is
a nursing priority.
removal or reduction. Remove one restraint at a time, while
assessing clients response. This minimizes risk of injury to
the client and staff.
Outcome Criteria
for aggression.
2. Client denies any ideas of self-destruction.
3. Client demonstrates use of adaptive coping strategies when
feelings of hostility or suicide occur.
4. Client verbalizes community support systems from which as-
sistance may be requested when personal coping strategies
are not successful.
ANXIETY (MODERATE TO SEVERE)

Denition: Vague uneasy feeling of discomfort or dread accom-
unknown to the individual); a feeling of apprehension caused by antic-
ipation of danger. It is an alerting signal that warns of impending dan-
ger and enables the individual to take measures to deal with threat.

[Low self-esteem]
[Feelings of powerlessness and lack of control in life situation]
2506_Ch13_236-255.indd Sec1:241 10/1/10 9:36:15 AM


Increased tension
[Increased helplessness]
Overexcited
Apprehensive; fearful
Restlessness
Poor eye contact
Feelings of inadequacy
Insomnia
Focus on the self
Increased cardiac and respiratory rates
Diminished ability to problem solve and learn
Goals/Objectives
Short-term Goal
anxiety at manageable level within 7 days.
Long-term Goal
By time of discharge from treatment, client will be able to rec-
ognize events that precipitate anxiety and intervene to prevent
disabling behaviors.

1. Be available to stay with client. Remain calm and provide
assurance of safety. Client safety and security is a nursing
priority.
2. Help client identify situation that precipitated onset of anxi-
ety symptoms. Client may be unaware that emotional issues
are related to symptoms of anxiety. Recognition may be the
first step in elimination of this maladaptive response.
3. Review clients methods of coping with similar situations in
the past. Discuss ways in which client may assume control
over these situations. In seeking to create change, it would be
helpful for client to identify past responses and to determine
whether they were successful and if they could be employed
again. A measure of control reduces feelings of powerlessness
in a situation, ultimately decreasing anxiety. Client strengths
should be identified and used to his or her advantage.
4. Provide quiet environment. Reduce stimuli: low lighting, few
people. Anxiety level may be decreased in calm atmosphere
with few stimuli.
5. Administer antianxiety medications as ordered by physician,
or obtain order if necessary. Monitor clients response for
effectiveness of the medication as well as for adverse side
effects. Short-term use of antianxiety medications (e.g.,
2506_Ch13_236-255.indd Sec1:242 10/1/10 9:36:15 AM

from the immobilizing effects of anxiety and facilitates

6. Discuss with client signs of increasing anxiety and ways of in-
tervening to maintain the anxiety at a manageable level (e.g.,
exercise, walking, jogging, relaxation techniques). Anxiety
and tension can be reduced safely and with benefit to the
client through physical activities.
Outcome Criteria
to demonstrate techniques for its reduction.
2. Client is able to verbalize ways in which he or she may gain
more control of the environment and thereby reduce feelings
of powerlessness.
INEFFECTIVE COPING

Situational crises
Maturational crises
[Low self-esteem]
[Unresolved grief]

[Increased dependency]
[Manipulation of others in the environment for purposes of ful-
lling own desires]
[Refusal to follow rules]
Goals/Objectives
Short-term Goal
By the end of 1 week, client will comply with rules of therapy
and refrain from manipulating others to ful ll own desires.
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Long-term Goal
By time of discharge from treatment, client will identify, de-
velop, and use socially acceptable coping skills.

1. Discuss with client the rules of therapy and consequences of
noncompliance. Carry out the consequences matter-of-factly
if rules are broken. Negative consequences may work to de-
crease manipulative behaviors.
2. Do not debate, argue, rationalize, or bargain with the client
regarding limit-setting on manipulative behaviors. Ignoring
these attempts may work to decrease manipulative behav-
iors. Consistency among all staff members is vital if this
intervention is to be successful.
3. Encourage discussion of angry feelings. Help client identify
the true object of the hostility. Provide physical outlets for
healthy release of the hostile feelings (e.g., punching bags,
pounding boards). Verbalization of feelings with a trusted
individual may help client work through unresolved issues.
Physical exercise provides a safe and effective means of re-
leasing pent-up tension.
4. Take care not to reinforce dependent behaviors. Encourage
client to perform as independently as possible, and provide
positive feedback. Independent accomplishment and positive
reinforcement enhance self-esteem and encourage repetition
of desirable behaviors.
5. Help client recognize some aspects of his or her life over which
a measure of control is maintained. Recognition of personal
control, however minimal, diminishes the feeling of power-
lessness and decreases the need for manipulation of others.
6. Identify the stressor that precipitated the maladaptive cop-
ing. If a major life change has occurred, encourage client to
express fears and feelings associated with the change. Assist
client through the problem-solving process:
a. Identify possible alternatives that indicate positive
adaptation.
b. Discuss benets and consequences of each alternative.
c. Select the most appropriate alternative.
d. Implement the alternative.
e. Evaluate the effectiveness of the alternative.
f. Recognize areas of limitation, and make modications.
Request assistance with this process, if needed.
7. Provide positive reinforcement for application of adaptive
coping skills and evidence of successful adjustment. Positive
reinforcement enhances self-esteem and encourages repeti-
tion of desirable behaviors.
2506_Ch13_236-255.indd Sec1:244 10/1/10 9:36:16 AM

Outcome Criteria
1. Client is able to verbalize alternative, socially acceptable, and
lifestyle-appropriate coping skills he or she plans to use in
response to stress.
2. Client is able to solve problems and fulll activities of daily
living independently.
3. Client does not manipulate others for own gratication.
RISK-PRONE HEALTH BEHAVIOR*

De nition: Impaired ability to modify lifestyle/behaviors in a man-
ner that improves health status.

[Low self-esteem]
[Intense emotional state]
[Negative attitudes toward health behavior]
[Absence of intent to change behavior]
Multiple stressors
[Absence of social support for changed beliefs and practices]
[Disability or health status change requiring change in lifestyle]
[Lack of motivation to change behaviors]

Minimizes health status change
Failure to achieve optimal sense of control
Failure to take action that prevents health problems
Demonstrates nonacceptance of health status change
Goals/Objectives
Short-term Goals
1. Client will discuss with primary nurse the kinds of lifestyle
changes that will occur because of the change in health
status.
2. With the help of primary nurse, client will formulate a plan
of action for incorporating those changes into his or her life-
style.
3. Client will demonstrate movement toward independence,
considering change in health status.
* According to the NANDA International de nition, this diagnosis is

appropriate for the person with adjustment disorder only if the pre-
cipitating stressor is a change in health status.
2506_Ch13_236-255.indd Sec1:245 10/1/10 9:36:16 AM

Long-term Goal
Client will demonstrate competence to function independently
to his or her optimal ability, considering change in health status,
by time of discharge from treatment.
1. Encourage client to talk about lifestyle prior to the change
in health status. Discuss coping mechanisms that were used
at stressful times in the past. It is important to identify the
clients strengths so that they may be used to facilitate adap-
tation to the change or loss that has occurred.
2. Encourage client to discuss the change or loss and particularly
to express anger associated with it. Some individuals may not
realize that anger is a normal stage in the grieving process. If
it is not released in an appropriate manner, it may be turned
inward on the self, leading to pathological depression.
3. Encourage client to express fears associated with the change
or loss, or alteration in lifestyle that the change or loss has
created. Change often creates a feeling of disequilibrium
and the individual may respond with fears that are irra-
tional or unfounded. He or she may benefit from feedback
that corrects misperceptions about how life will be with the
change in health status.
4. Provide assistance with activities of daily living (ADLs) as
required, but encourage independence to the limit that cli-
ents ability will allow. Give positive feedback for activities
accomplished independently. Independent accomplishments
and positive feedback enhance self-esteem and encourage
repetition of desired behaviors. Successes also provide hope
that adaptive functioning is possible and decrease feelings
of powerlessness.
5. Help client with decision making regarding incorporation
of change or loss into lifestyle. Identify problems that the
change or loss is likely to create. Discuss alternative solu-
tions, weighing potential benets and consequences of each
alternative. Support clients decision in the selection of an
alternative. The great amount of anxiety that usually ac-
companies a major lifestyle change often interferes with an
individuals ability to solve problems and to make appropri-
ate decisions. Client may need assistance with this process in
an effort to progress toward successful adaptation.
6. Use role-playing to decrease anxiety as client anticipates
stressful situations that might occur in relation to the health
status change. Role-playing decreases anxiety and provides
a feeling of security by providing client with a plan of action
for responding in an appropriate manner when a stressful
situation occurs.
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7. Ensure that client and family are fully knowledgeable re-

garding the physiology of the change in health status and its
necessity for optimal wellness. Encourage them to ask ques-
tions, and provide printed material explaining the change to
which they may refer following discharge. Increased knowl-
edge enhances successful adaptation.
8. Help client identify resources within the community from
which he or she may seek assistance in adapting to the change
in health status. Examples include self-help or support groups
and public health nurse, counselor, or social worker. Encour-
age client to keep follow-up appointments with physician, or
to call physicians ofce prior to follow-up date if problems or
concerns arise.
Outcome Criteria
1. Client is able to perform ADLs independently.
2. Client is able to make independent decisions regarding life-
style considering change in health status.
3. Client is able to express hope for the future with consider-
ation of change in health status.
De nition: A disorder that occurs after the death of a signifi -
cant other [or any other loss of significance to the individual], in
which the experience of distress accompanying bereavement
fails to follow normative expectations and manifests in functional
impairment.

[Real or perceived loss of any entity of value to the individual]
[Bereavement overload (cumulative grief from multiple unre-
solved losses)]
[Thwarted grieving response to a loss]
[Absence of anticipatory grieving]
[Feelings of guilt generated by ambivalent relationship with lost
entity]

[Verbal expression of distress at loss]
[Idealization of lost entity]
[Denial of loss]
[Excessive anger, expressed inappropriately]
[Altered activities of daily living]
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[Diminished sense of control]

[Persistent anxiety]
Depression
Goals/Objectives
Short-term Goal
By end of 1 week, client will express anger toward lost entity.
Long-term Goal
Client will be able to verbalize behaviors associated with the
normal stages of grief and identify own position in grief process,
while progressing at own pace toward resolution.

1. Determine stage of grief in which client is xed. Identify
behaviors associated with this stage. Accurate baseline as-
sessment data are necessary to plan effective care for the
grieving client.
2. Develop trusting relationship with client. Show empathy and
caring. Be honest and keep all promises. Trust is the basis for
3. Convey an accepting attitude so that the client is not afraid
to express feelings openly. An accepting attitude conveys to
the client that you believe he or she is a worthwhile person.
Trust is enhanced.
4. Allow client to express anger. Do not become defensive if
initial expression of anger is displaced on nurse or therapist.
Help client explore angry feelings so that they may be di-
rected toward the intended object or person. Verbalization
of feelings in a nonthreatening environment may help client
5. Help client discharge pent-up anger through participation
in large motor activities (e.g., brisk walks, jogging, physical
exercises, volleyball, punching bag, exercise bike). Physical
exercise provides a safe and effective method for discharging
pent-up tension.
6. Explain to client the normal stages of grief and the behaviors
associated with each stage. Help client to understand that
feelings such as guilt and anger toward the lost entity are
appropriate and acceptable during the grief process. Knowl-
edge of the acceptability of the feelings associated with nor-
mal grieving may help to relieve some of the guilt that these
responses generate.
7. Encourage client to review personal perception of the loss or
change. With support and sensitivity, point out reality of the
situation in areas where misrepresentations are expressed.
Client must give up an idealized perception and be able to
2506_Ch13_236-255.indd Sec1:248 10/1/10 9:36:17 AM

accept both positive and negative aspects about the painful

life change before the grief process is complete.
8. Communicate to client that crying is acceptable. Use of
touch is therapeutic and appropriate with most clients.
Knowledge of cultural inuences specic to the client is im-
portant before employing this technique. Touch is consid-
ered inappropriate in some cultures.
9. Help client solve problems as he or she attempts to determine
methods for more adaptive coping with the experienced loss.
Provide positive feedback for strategies identied and deci-
sions made. Positive reinforcement enhances self-esteem
and encourages repetition of desirable behaviors.
10. Encourage client to reach out for spiritual support during
this time in whatever form is desirable to him or her. As-
sess spiritual needs of client, and assist as necessary in the
fulllment of those needs. Spiritual support can enhance
successful adaptation to painful life experiences for some
individuals.
Outcome Criteria
1. Client is able to verbalize normal stages of grief process and
behaviors associated with each stage.
2. Client is able to identify own position within the grief pro-
cess and express honest feelings related to the lost entity.
3. Client is no longer manifesting exaggerated emotions and
behaviors related to complicated grieving and is able to carry
out ADLs independently.
LOW SELF-ESTEEM
capabilities.

Repeated failures
[Personal or situational factors such as dysfunctional family sys-
tem or absence of social support]

Exaggerates negative feedback about self
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Evaluation of self as unable to deal with events or situations
Hesitant to try new things or situations [because of fear of
failure]
[Rationalization of personal failures]
[Hypersensitivity to slight or criticism]
[Grandiosity]
Lack of eye contact
[Manipulation of one staff member against another in an
attempt to gain special privileges]
[Degradation of others in an attempt to increase own feelings
of self-worth]
Goals/Objectives
Short-term Goals
1. Client will discuss fear of failure with nurse within (realistic
time period).
2. Client will verbalize things he or she likes about self within
(realistic time period).
Long-term Goals
1. Client will exhibit increased feelings of self-worth as evi-
denced by verbal expression of positive aspects about self,
past accomplishments, and future prospects.
2. Client will exhibit increased feelings of self-worth by setting
realistic goals and trying to reach them, thereby demonstrat-
ing a decrease in fear of failure.

achieve something, so plan for activities in which success is
likely. Success enhances self-esteem.
2. Convey unconditional positive regard for the client. Promote
understanding of your acceptance for him or her as a worthwhile
human being. Unconditional positive regard and acceptance
promote trust and increase clients feelings of self-worth.
3. Spend time with the client, both on a one-to-one basis and in
group activities. This conveys to client that you feel he or she
is worth your time.
4. Help client identify positive aspects of self and to develop
plans for changing the characteristics he or she views as neg-
ative. Individuals with low self-esteem often have difficulty
recognizing their positive attributes. They may also lack
problem-solving ability and require assistance to formulate
a plan for implementing the desired changes.
2506_Ch13_236-255.indd Sec1:250 10/1/10 9:36:18 AM

5. Encourage and support client in confronting the fear of

failure by attending therapy activities and undertaking new
tasks. Offer recognition of successful endeavors and positive
reinforcement for attempts made. Recognition and positive
reinforcement enhance self-esteem.
6. Do not allow client to ruminate about past failures. With-
draw attention if he or she persists. Lack of attention to
these behaviors may discourage their repetition. Client
must focus on positive attributes if self-esteem is to be
enhanced.
7. Minimize negative feedback to client. Enforce limit-setting
in matter-of-fact manner, imposing previously established
consequences for violations. Negative feedback can be ex-
tremely threatening to a person with low self-esteem, pos-
sibly aggravating the problem. Consequences should convey
unacceptability of the behavior, but not the person.
8. Encourage independence in the performance of personal re-
sponsibilities, as well as in decision-making related to own
self-care. Offer recognition and praise for accomplishments.
The ability to perform self-care activities independently
enhances self-esteem. Positive reinforcement encourages
repetition of the desirable behavior.
9. Help client increase level of self-awareness through criti-
cal examination of feelings, attitudes, and behaviors. Help
him or her to understand that it is perfectly acceptable for
ones attitudes and behaviors to differ from those of others as
long as they do not become intrusive. As the client achieves
self-awareness and self-acceptance, the need for judging the
behavior of others will diminish.
Outcome Criteria
2. Client demonstrates ability to manage own self-care, make
independent decisions, and use problem-solving skills.
3. Client sets goals that are realistic and works to achieve those
goals without evidence of fear of failure.


[Fixation in an earlier level of development]
2506_Ch13_236-255.indd Sec1:251 10/1/10 9:36:18 AM



Inability to receive or communicate a satisfying sense of so-
cial engagement (e.g., belonging, caring, interest, shared
history)
[Exhibiting behaviors unacceptable for age, as de ned by domi-
nant cultural group]
Goals/Objectives
Short-term Goal
Client will develop trusting relationship with staff member
within (realistic time period), seeking that staff member out for
one-to-one interaction.
Long-term Goals
1. Client will be able to interact with others on a one-to-one
basis with no indication of discomfort.
2. Client will voluntarily spend time with others in group ac-
tivities demonstrating acceptable, age-appropriate behavior.

1. Develop trusting relationship with client. Be honest; keep all
promises; convey acceptance of person, separate from unac-
ceptable behaviors (It is not you, but your behavior, that is
unacceptable.) Unconditional acceptance of the client in-
creases his or her feelings of self-worth.
others on the unit. Presence of a trusted individual provides
a feeling of security.
3. Provide constructive criticism and positive reinforcement
for efforts. Positive reinforcement enhances self-esteem and
4. Confront client and withdraw attention when interactions
with others are manipulative or exploitative. Attention to the
unacceptable behavior may reinforce it.
5. Act as role model for client through appropriate interactions
with him or her, other clients, and staff members. Role mod-
eling is one of the strongest forms of learning.
6. Provide group situations for client. It is through these
group interactions, with positive and negative feedback
from his or her peers, that client will learn socially accept-
able behavior.
2506_Ch13_236-255.indd Sec1:252 10/1/10 9:36:18 AM

Outcome Criteria
1. Client seeks out staff member for social as well as therapeutic
interaction.
2. Client has formed and satisfactorily maintained one inter-
personal relationship with another client.
activities.
4. Client verbalizes reasons for inability to form close interper-
sonal relationships with others in the past.
RELOCATION STRESS SYNDROME*

De nition: Physiological and/or psychosocial disturbance fol-
lowing transfer from one environment to another.

Move from one environment to another
[Losses involved with decision to move]
Feelings of powerlessness
Lack of adequate support system
[Little or no preparation for the impending move]
Impaired psychosocial health [status]
Decreased [physical] health status

Anxiety
Depression
Loneliness
Verbalizes unwillingness to move
Sleep disturbance
Increased physical symptoms
Dependency
Insecurity
Withdrawal
Anger; fear
Goals/Objectives
Short-term Goal
Client will verbalize at least one positive aspect regarding re-
location to new environment within (realistic time period).
* This diagnosis would be appropriate for the individual with adjustment

disorder if the precipitating stressor was relocation to a new environment.
2506_Ch13_236-255.indd Sec1:253 10/1/10 9:36:19 AM

Long-term Goal
Client will demonstrate positive adaptation to new environment,
as evidenced by involvement in activities, expression of satis-
faction with new acquaintances, and elimination of previously
evident physical and psychological symptoms associated with
the relocation (time dimension to be determined individually).

1. Encourage individual to discuss feelings (concerns, fears,
anger) regarding relocation. Exploration of feelings with
a trusted individual may help the individual perceive
the situation more realistically and come to terms with the
inevitable change.
2. Encourage individual to discuss how the change will af-
fect his or her life. Ensure that the individual is involved in
decision-making and problem-solving regarding the move.
Taking responsibility for making choices regarding the relo-
cation will increase feelings of control and decrease feelings
of powerlessness.
3. Help the individual identify positive aspects about the move.
Anxiety associated with the opposed relocation may inter-
fere with the individuals ability to recognize anything posi-
tive about it. Assistance may be required.
4. Help the individual identify resources within the new com-
munity from which assistance with various types of services
may be obtained. Because of anxiety and depression, the in-
dividual may not be able to identify these resources alone.
Assistance with problem-solving may be required.
5. Identify groups within the community that specialize in
helping individuals adapt to relocation. Examples include
Newcomers Club, Welcome Wagon International, senior
citizens groups, and school and church organizations. These
groups offer support from individuals who may have en-
countered similar experiences. Adaptation may be enhanced
by the reassurance, encouragement, and support of peers
who exhibit positive adaptation to relocation stress.
6. Refer individual or family for professional counseling if
deemed necessary. An individual who is experiencing com-
plicated grieving over loss of previous residence may require
therapy to achieve resolution of the problem. It may be that
other unresolved issues are interfering with successful ad-
aptation to the relocation.
Outcome Criteria
1. The individual no longer exhibits signs of anxiety, depres-
sion, or somatic symptoms.
2506_Ch13_236-255.indd Sec1:254 10/1/10 9:36:19 AM

2. The individual verbalizes satisfaction with new environment.

3. The individual willingly participates in social and vocational
activities within his or her new environment.
INTERNET REFERENCES
Additional information about adjustment disorder may be
a. http://www.mentalhealth.com/rx/p23-aj01.html
b. http://psyweb.com/Mdisord/jsp/adjd.jsp
d. http://www.athealth.com/Consumer/disorders/Adjustment
.html
e. http://www.nlm.nih.gov/medlineplus/ency/article/000932
.htm
f. http://www.mayoclinic.com/health/adjustment-disorders/
DS00584
2506_Ch13_236-255.indd Sec1:255 10/1/10 9:36:19 AM

C H A P T E R
14
Impulse Control
Disorders
Impulse control disorders are characterized by a need or
desire that must be satised immediately, regardless of the con-
sequences. Many of the behaviors have adverse or even destruc-
tive consequences for the individuals affected, and seldom do
these individuals know why they do what they do or why it is
pleasurable.
The American Psychiatric Association (APA, 2000) Diag-
nostic and Statistical Manual of Mental Disorders, Fourth Edition,
Text Revision (DSM-IV-TR) describes the essential features of
impulse control disorders as follows:
1. The individual is unable to resist an impulse, drive, or
temptation to act in a way that is harmful to the person or
others.
2. The individual experiences an increasing sense of tension or
arousal before committing the act and pleasure, gratication,
or relief at the time of committing the act.
3. Afterward, he or she may experience regret, remorse, or
embarrassment.
The DSM-IV-TR (APA, 2000) describes the following
categories of impulse control disorders:
Intermittent Explosive Disorder

This disorder is characterized by episodes of loss of aggres-
sion control resulting in serious assaultive acts or destruc-
tion of property (APA, 2000). Some clients report changes in
sensorium, such as confusion during an episode or amnesia
for events that occurred during an episode. Symptoms usu-
ally appear suddenly without apparent provocation and ter-
minate abruptly, lasting only minutes to a few hours, followed
by feelings of genuine remorse and self-reproach about the
behavior.
256
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Kleptomania
Kleptomania is described by the DSM-IV-TR as the recurrent
failure to resist impulses to steal items not needed for personal
use or for their monetary value (APA, 2000, p. 667). Often the
stolen items (for which the individual usually has enough money
to pay) are given away, discarded, returned, or kept and hidden.
The individual with kleptomania steals purely for the sake of
stealing and for the sense of relief and gratication that follows
an episode.
Pathological Gambling
The DSM-IV-TR de nes pathological gambling as persistent
and recurrent maladaptive gambling behavior that disrupts per-
sonal, family, or vocational pursuits (APA, 2000, p. 671). The
preoccupation with gambling, and the impulse to gamble, in-
tensies when the individual is under stress. Many pathological
gamblers exhibit characteristics associated with narcissism and
grandiosity and often have difculties with intimacy, empathy,
and trust.
Pyromania
Pyromania is the inability to resist the impulse to set res. The
act itself is preceded by tension or affective arousal, and the indi-
vidual experiences intense pleasure, gratication, or relief when
setting the res, witnessing their effects, or participating in
their aftermath (APA, 2000). Motivation for the behavior is self-
gratication, and even though some individuals with pyromania
may take precautions to avoid apprehension, many are totally
indifferent to the consequences of their behavior.
Trichotillomania
This disorder is de ned by the DSM-IV-TR as the recurrent
pulling out of ones own hair that results in noticeable hair loss
(APA, 2000, p. 674). The impulse is preceded by an increasing
sense of tension, and the individual experiences a sense of release
or gratication from pulling out the hair.
Predisposing Factors to Impulse Control
Disorders
1. Physiological
a. Genetics. A familial tendency appears to be a factor in
some cases of intermittent explosive disorder and patho-
logical gambling.
b. Physical Factors. Brain trauma or dysfunction and mental
retardation have also been implicated in the predisposi-
tion to impulse control disorders.
2506_Ch14_256-263.indd Sec1:257 10/1/10 9:36:29 AM

2. Psychosocial
a. Family Dynamics. Various dysfunctional family patterns
have been suggested as contributors in the predisposition
to impulse control disorders. These include the following:
Child abuse or neglect
Parental rejection or abandonment
Harsh or inconsistent discipline
Emotional deprivation
Parental substance abuse
Parental unpredictability
Data)
1. Sudden inability to control violent, aggressive impulses
2. Aggressive behavior accompanied by confusion or amnesia
3. Feelings of remorse following aggressive behavior
4. Inability to resist impulses to steal
5. Increasing tension before committing the theft, followed by
pleasure or relief during and following the act
6. Sometimes discards, returns, or hides stolen items
7. Inability to resist impulses to gamble
8. Preoccupation with ways to obtain money with which to
gamble
9. Increasing tension that is relieved only by placing a bet
10. The need to gamble or loss of money interferes with social
and occupational functioning
11. Inability to resist the impulse to set res
12. Increasing tension that is relieved only by starting a re
13. Inability to resist impulses to pull out ones own hair
14. Increasing tension followed by a sense of release or gratica-
tion from pulling out the hair
15. Hair-pulling may be accompanied by other types of self-
mutilation (e.g., head-banging, biting, scratching)
and Interventions
RISK FOR OTHER-DIRECTED

VIOLENCE
ally harmful to others.
2506_Ch14_256-263.indd Sec1:258 10/1/10 9:36:29 AM


[Possible familial tendency]
[Dysfunctional family system, resulting in behaviors such as the
following:
Parental unpredictability]
Body language (e.g., rigid posture, clenching of sts and
jaw, hyperactivity, pacing, breathlessness, threatening
stances)
History of threats of violence [toward others or of destruc-
tion to the property of others]
Impulsivity
Neurological impairment
Goals/Objectives
Short-term Goal
Client will recognize signs of increasing tension, anxiety, and
agitation, and report to staff (or others) for assistance with inter-
vention (time dimension to be individually determined).
Long-term Goal
Client will not harm others or the property of others (time
dimension to be individually determined).
1. Convey an accepting attitude toward the client. Feelings of
rejection are undoubtedly familiar to him or her. Work on the
development of trust. Be honest, keep all promises, and con-
vey the message that it is not the person but the behavior that is
unacceptable. An attitude of acceptance promotes feelings of
self-worth. Trust is the basis of a therapeutic relationship.
lighting, few people, simple decor, low noise level). A stimu-
lating environment may increase agitation and promote
aggressive behavior. Make the clients environment as safe
as possible by removing all potentially dangerous objects.
3. Help client identify the true object of his or her hostility.
Because of weak ego development, client may be unable to
use ego defense mechanisms correctly. Helping him or her
recognize this in a nonthreatening manner may help reveal
unresolved issues so that they may be confronted.
4. Staff should maintain and convey a calm attitude. Anxiety
is contagious and can be transferred from staff to client. A
2506_Ch14_256-263.indd Sec1:259 10/1/10 9:36:29 AM

calm attitude provides the client with a feeling of safety and

security.
5. Help client recognize the signs that tension is increasing
and ways in which violence can be averted. Activities that
require physical exertion are helpful in relieving pent-up
tension.
6. Explain to the client that should explosive behavior occur,
staff will intervene in whatever way is required (e.g., tran-
quilizing medication, restraints, isolation) to protect client
and others. This conveys to the client evidence of control
over the situation and provides a feeling of safety and
security.
Outcome Criteria
for aggression.
2. The client is able to verbalize the symptoms of increasing
tension and adaptive ways of coping with it.
3. The client is able to inhibit the impulse for violence and
aggression.
RISK FOR SELF-MUTILATION

relief of tension.

[Central nervous system trauma]
[Mental retardation]
[Early emotional deprivation]
[Parental rejection or abandonment]
[History of self-mutilative behaviors in response to increasing
anxiety: hair-pulling, biting, head-banging, scratching]
Goals/Objectives
Short-term Goals
1. Client will cooperate with plan of behavior modication in
an effort to respond more adaptively to stress (time dimen-
sion ongoing).
2. Client will not harm self.
Long-term Goal
Client will not harm self.
2506_Ch14_256-263.indd Sec1:260 10/1/10 9:36:30 AM


1. Intervene to protect client when self-mutilative behaviors,
such as head-banging or hair-pulling, become evident. The
nurse is responsible for ensuring client safety.
2. A helmet may be used to protect against head-banging, hand
mitts to prevent hair-pulling, and appropriate padding to pro-
tect extremities from injury during hysterical movements.
3. Try to determine if self-mutilative behaviors occur in re-
sponse to increasing anxiety, and if so, to what the anxiety
may be attributed. Self-mutilative behaviors may be averted
if the cause can be determined.
4. Work on one-to-one basis with client to establish trust.
5. Assist with plan for behavior modication in an effort to
teach the client more adaptive ways of responding to stress.
6. Encourage client to discuss feelings, particularly anger, in an
effort to confront unresolved issues and expose internalized
rage that may be triggering self-mutilative behaviors.
7. Offer self to client during times of increasing anxiety, to pro-
vide feelings of security and decrease need for self-mutilative
behaviors.
Outcome Criteria
for self-mutilation.
2. Client demonstrates ability to use adaptive coping strategies
in the face of stressful situations.
INEFFECTIVE COPING

[Possible hereditary factors]
[Brain trauma or dysfunction]
[Mental retardation]
[Dysfunctional family system, resulting in behaviors such as the
following:
Parental unpredictability]
2506_Ch14_256-263.indd Sec1:261 10/1/10 9:36:30 AM


[Inability to control impulse of violence or aggression]
[Inability to control impulse to steal]
[Inability to control impulse to gamble]
[Inability to control impulse to set res]
[Inability to control impulse to pull out own hair]
[Feeling of intense anxiety and tension that precedes, and is
relieved by, engaging in these impulsive behaviors]
Goals/Objectives
Short-term Goal
Client will verbalize adaptive ways to cope with stress by means
other than impulsive behaviors (time dimension to be individu-
ally determined).
Long-term Goal
Client will be able to delay gratication and use adaptive coping
strategies in response to stress (time dimension to be individu-
ally determined).

1. Help client gain insight into his or her behaviors. Often these
individuals rationalize to such an extent that they deny that
what they have done is wrong. Client must come to under-
stand that certain behaviors will not be tolerated within the
society and that severe consequences will be imposed on those
individuals who refuse to comply. Client must WANT to
become a productive member of society before he or she can
be helped.
2. Talk about past behaviors with client. Discuss behaviors that
are acceptable by societal norms and those that are not. Help
client identify ways in which he or she has exploited others.
Encourage client to explore how he or she would feel if the
circumstances were reversed. An attempt may be made to
enlighten the client to the sensitivity of others by promoting
self-awareness in an effort to assist the client gain insight
into his or her own behavior.
3. Throughout relationship with client, maintain attitude of It
is not you, but your behavior, that is unacceptable. An attitude
of acceptance promotes feelings of dignity and self-worth.
4. Work with client to increase the ability to delay gratication.
Reward desirable behaviors, and provide immediate positive
feedback. Rewards and positive feedback enhance self-esteem
and encourage repetition of desirable behaviors.
5. Help client identify and practice more adaptive strategies for
coping with stressful life situations. The impulse to perform
the maladaptive behavior may be so great that the client is
unable to see any other alternatives to relieve stress.
2506_Ch14_256-263.indd Sec1:262 10/1/10 9:36:30 AM

Outcome Criteria
response to stress to prevent resorting to maladaptive impul-
sive behaviors.
2. Client verbalizes understanding that behavior is unaccept-
able and accepts responsibility for own behavior.
INTERNET REFERENCES
Additional information about impulse control disorders may
be located at the following websites:
a. http://www.ncpgambling.org/
b. http://www.gamblersanonymous.org/
c. http://www.crescentlife.com/disorders/pyromania.htm
d. http://www.biopsychiatry.com/klepto.htm
e. http://www.enotes.com/medicine-encyclopedia/impulse-
control-disorders
f. http://emedicine.medscape.com/article/915057-overview
g. http://emedicine.medscape.com/article/294626-overview
2506_Ch14_256-263.indd Sec1:263 10/1/10 9:36:31 AM

C H A P T E R
15
Psychological Factors
Affecting Medical
Condition
The American Psychiatric Association (APA, 2000, p. 731) Di-
agnostic and Statistical Manual of Mental Disorders, Fourth Edition,
Text Revision (DSM-IV-TR) identies psychological factors
affecting medical condition as the presence of one or more
specic psychological or behavioral factors that adversely affect
a general medical condition. These factors can adversely affect
the medical condition in several ways:
1. By inuencing the course of the medical condition (i.e., con-
tributing to the development or exacerbation of, or delayed
recovery from, the medical condition).
2. By interfering with treatment of the medical condition.
3. By constituting an additional health risk for the individual
(e.g., the individual who has peptic ulcers who continues to
drink and smoke).
Several types of psychological factors are implicated by the
DSM-IV-TR as those that can affect the general medical condi-
tion. They include:
1. Mental disorders (e.g., Axis I disorders, such as major
depression).
2. Psychological symptoms (e.g., depressed mood or anxiety).
3. Personality traits or coping style (e.g., denial of the need for
medical care).
4. Maladaptive health behaviors (e.g., smoking or overeating).
5. Stress-related physiological responses (e.g., tension head-
aches).
6. Other or unspecied psychological factors (e.g., interpersonal
or cultural factors).
264
2506_Ch15_264-274.indd Sec1:264 10/1/10 9:36:40 AM

Psychological Factors Affecting Medical Condition 265
Dened
This diagnosis is indicated when there is evidence of a physi-
cal symptom(s) or a physical disorder that is adversely affected
by psychological factors. The DSM-IV-TR (APA, 2000)
states,
Psychological and behavioral factors may affect the course of
almost every major category of disease, including cardiovascular
conditions, dermatological conditions, endocrinological condi-
tions, gastrointestinal conditions, neoplastic conditions, neuro-
logical conditions, pulmonary conditions, renal conditions, and
rheumatological conditions (p. 732).
This category differs from somatoform disorders and
conversion disorders in that there is evidence of either de-
monstrable organic pathology (e.g., the inammation as-
sociated with rheumatoid arthritis) or a known pathophysi-
ological process (e.g., the cerebral vasodilation of migraine
headaches).
1. Physiological
a. Physical Factors. Selye (1956) believed that psychophysi-
ological disorders can occur when the body is exposed to
prolonged stress, producing a number of physiological
effects under direct control of the pituitary-adrenal axis.
He also suggests that genetic predisposition inuences
which organ system will be affected and determines the
type of psychophysiological disorder the individual will
develop.
2. Psychosocial
a. Emotional Response Pattern. It has been hypothesized
that individuals exhibit specic physiological responses to
certain emotions. For example, in response to the emo-
tion of anger, one person may experience peripheral va-
soconstriction, resulting in an increase in blood pressure.
The same emotion, in another individual, may evoke the
response of cerebral vasodilation, manifesting a migraine
headache.
b. Personality Traits. Various studies have suggested that
individuals with specic personality traits are predisposed
to certain disease processes. Although personality cannot
account totally for the development of psychophysiologi-
cal disorders, the literature has alluded to the following
possible relationships:
2506_Ch15_264-274.indd Sec1:265 10/1/10 9:36:40 AM

Asthma Dependent personality characteristics
Ulcers, hypertension Repressed anger
Cancer Depressive personality
Rheumatoid arthritis, ulcerative colitis Self-sacrificing; suppressed anger
Migraine headaches Compulsive and perfectionistic
Coronary heart disease Aggressive and competitive
c. Learning Theory. A third psychosocial theory considers

the role of learning in the psychophysiological response
to stress. If a child grows up observing the attention,
increased dependency, or other secondary gain an indi-
vidual receives because of the illness, such behaviors may
be viewed as desirable responses and subsequently imi-
tated by the child.
d. Theory of Family Dynamics. This theory relates to the
predisposition of those individuals who are members of
dysfunctional family systems to use psychophysiological
problems to cover up interpersonal con icts. The anxi-
ety in a dysfunctional family situation is shifted from
the con ict to the ailing individual. Anxiety decreases,
the con ict is avoided, and the person receives positive
reinforcement for his or her symptoms. The situation
appears more comfortable, but the real problem remains
unresolved.

Data)
1. Complaints of physical illness that can be substantiated by
objective evidence of physical pathology or known patho-
physiological process
2. Moderate to severe level of anxiety
3. Denial of emotional problems; client is unable to see a
relationship between physical problems and response to
stress
4. Use of physical illness as excuse for noncompliance with
psychiatric treatment plan
5. Repressed anger or anger expressed inappropriately
6. Verbal hostility
7. Depressed mood
8. Low self-esteem
9. Dependent behaviors
10. Attention-seeking behaviors
11. Report (or other evidence) of numerous stressors occurring
in persons life
2506_Ch15_264-274.indd Sec1:266 10/1/10 9:36:41 AM


and Interventions*
INEFFECTIVE COPING

[Repressed anxiety]
[Inadequate coping methods]
[Low self-esteem]

[Initiation or exacerbation of physical illness (specify)]
[Denial of relationship between physical symptoms and emo-
tional problems]
[Use of sick role for secondary gains]
Goals/Objectives
Short-term Goals
1. Within 1 week, client will verbalize understanding of
correlation between emotional problems and physical
symptoms.
2. Within 1 week, client will verbalize adaptive ways of coping
with stressful situations.
* A number of nursing diagnoses common to specic physical disorders

or symptoms could be used (e.g., pain, activity intolerance, impaired
tissue integrity, diarrhea). For purposes of this chapter, only nursing
diagnoses common to the general category are presented.
2506_Ch15_264-274.indd Sec1:267 10/1/10 9:36:41 AM

Long-term Goal
Client will achieve physical wellness and demonstrate the ability
to prevent exacerbation of physical symptoms as a coping mech-
anism in response to stress.

1. Perform thorough physical assessment in order to deter-
mine specifi c care required for clients physical condition.
Monitor laboratory values, vital signs, intake and output,
and other assessments necessary to maintain an accurate,
ongoing appraisal.
2. Together with the client, identify goals of care and ways in
which client believes he or she can best achieve those goals.
Client may need assistance with problem-solving. Personal
involvement in his or her care provides a feeling of control
and increases chances for positive outcomes.
3. Encourage client to discuss current life situations that he
or she perceives as stressful and the feelings associated with
each. Verbalization of true feelings in a nonthreatening en-
vironment may help client come to terms with unresolved
issues.
4. During clients discussion, note times during which a sense
of powerlessness or loss of control over life situations emerges.
Focus on these times and discuss ways in which the client may
maintain a feeling of control. A sense of self-worth develops
and is maintained when an individual feels power over his
or her own life situations.
5. As client becomes able to discuss feelings more openly, as-
sist him or her, in a nonthreatening manner, to relate certain
feelings to the appearance of physical symptoms. Client may
be unaware of the relationship between physical symptoms
and emotional problems.
6. Discuss stressful times when physical symptoms did not
appear and the adaptive coping strategies that were used dur-
ing those situations. Therapy is facilitated by considering
areas of strength and using them to the clients benefit.
7. Provide positive reinforcement for adaptive coping mecha-
nisms identied or used. Suggest alternative coping strategies
but allow client to determine which can most appropriately be
incorporated into his or her lifestyle. Positive reinforcement
behaviors. Client may require assistance with problem-solving
but must be allowed and encouraged to make decisions
independently.
8. Help client to identify a resource within the community
(friend, signicant other, group) to use as a support system
2506_Ch15_264-274.indd Sec1:268 10/1/10 9:36:41 AM

for the expression of feelings. A positive support system

may help to prevent maladaptive coping through physical
illness.
Outcome Criteria
response to stress to prevent the occurrence or exacerbation
of physical symptoms.
between emotional problems and physical symptoms.
LOW SELF-ESTEEM
capabilities.

Evaluation of self as unable to deal with events
Hesitant to try new things or situations [because of fear of
failure]
[Hypersensitive to slight or criticism]
Lack of eye contact
of self-worth]
Goals/Objectives
Short-term Goals
1. Client will discuss fear of failure with nurse within 3 days.
2. Client will verbalize aspects he or she likes about self within
5 days.
Long-term Goals
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achieve something, so plan activities in which success is likely.
Success increases self-esteem.
2. Minimize amount of attention given to physical symptoms.
Client must perceive self as a worthwhile person, separate
and apart from the role of client. Lack of attention may
discourage use of undesirable behaviors.
3. Promote your acceptance of client as a worthwhile person
by spending time with him or her. Develop trust through
one-to-one interactions, then encourage client to participate
in group activities. Support group attendance with your pres-
ence until client feels comfortable attending alone. The feel-
ing of acceptance by others increases self-esteem.
4. Ask client to make a written list of positive and negative as-
pects about self. Discuss each item on the list with client.
Develop plans of change for the characteristics viewed as
negative. Assist client in implementing the plans. Provide
positive feedback for successful change. Individuals with low
self-esteem often have difficulty recognizing their positive
attributes. They may also lack problem-solving skills and
require assistance to formulate a plan for implementing the
desired changes. Positive feedback enhances self-esteem and
encourages repetition of desired behaviors.
5. Avoid fostering dependence by doing for the client. Allow
client to perform as independently as physical condition will
permit. Offer recognition and praise for accomplishments. The
ability to perform self-care activities independently provides
a feeling of self-control and enhances self-esteem. Positive re-
inforcement encourages repetition of the desirable behavior.
6. Allow client to be an active participant in his or her therapy.
Promote feelings of control or power by encouraging input
into the decision-making regarding treatment and for plan-
ning discharge from treatment. Provide positive feedback for
adaptive responses. Control over own life experiences pro-
motes feelings of self-worth.
Outcome Criteria
2. Client demonstrates ability to manage own self-care, make
independent decisions, and use problem-solving skills.
3. Client sets goals that are realistic and works to achieve those
goals without evidence of fear of failure.
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INEFFECTIVE ROLE PERFORMANCE

De nition: Patterns of behavior and self-expression that do not
match the environmental context, norms, and expectations.

[Physical illness accompanied by real or perceived disabling
symptoms]

Change in self-perception of role
Change in [physical] capacity to resume role
[Assumption of dependent role]
Change in usual patterns of responsibility [because of con ict
within dysfunctional family system]
Goals/Objectives
Short-term Goal
Client will verbalize understanding that physical symptoms in-
terfere with role performance in order to ll an unmet need.
Long-term Goal
Client will be able to assume role-related responsibilities by time
of discharge from treatment.

1. Determine clients usual role within the family system. Iden-
tify roles of other family members. An accurate database is
required in order to formulate appropriate plan of care for
the client.
2. Assess specic disabilities related to role expectations.
Assess relationship of disability to physical condition.
It is important to determine the realism of clients role
expectations.
3. Encourage client to discuss con icts evident within the fam-
ily system. Identify ways in which client and other family
members have responded to these con icts. It is necessary to
identify specific stressors, as well as adaptive and maladap-
tive responses within the system, before assistance can be
provided in an effort to create change.
4. Help client identify feelings associated with family con ict,
the subsequent exacerbation of physical symptoms, and the
accompanying disabilities. Client may be unaware of the
relationship between physical symptoms and emotional
2506_Ch15_264-274.indd Sec1:271 10/1/10 9:36:42 AM

problems. An awareness of the correlation is the first step

toward creating change.
5. Help client identify changes he or she would like to occur
within the family system. Encourage family participation in
the development of plans to effect positive change, and work
to resolve the con ict for which the clients sick role provides
relief. Input from the individuals who will be directly in-
volved in the change will increase the likelihood of a positive
outcome.
6. Allow all family members input into the plan for change:
knowledge of benets and consequences for each alternative,
selection of appropriate alternatives, methods for implemen-
tation of alternatives, and an alternate plan in the event ini-
tial change is unsuccessful. Family may require assistance
with this problem-solving process.
7. Ensure that client has accurate perception of role expecta-
tions within the family system. Use role-playing to practice
areas associated with his or her role that client perceives as
painful. Repetition through practice may help to desensitize
client to the anticipated distress.
8. As client is able to see the relationship between exacerba-
tion of physical symptoms and existing con ict, discuss more
adaptive coping strategies that may be used to prevent inter-
ference with role performance during times of stress.
CLINICAL PEARL Coping strategies are very individual, and only the client
knows what will work for him or her. The nurse may make suggestions and help
the client practice through role-play, but the client alone must decide what will be
adaptive in his or her personal situation. The nurse must be careful not to impose
on the client ideas that the nurse thinks are more appropriate but which may not be
adaptive for the client.
Outcome Criteria
1. Client is able to verbalize realistic perception of role
expectations.
2. Client is physically able to assume role-related responsibilities.
3. Client and family are able to verbalize plan for attempt at
con ict resolution.
DEFICIENT KNOWLEDGE
(PSYCHOLOGICAL FACTORS
AFFECTING MEDICAL CONDITION)
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[Severe level of anxiety]
[Low self-esteem]

[Denial of emotional problems]
[Statements such as, I dont know why the doctor put me on the
psychiatric unit. I have a physical problem.]
[History of numerous exacerbations of physical illness]
[Noncompliance with psychiatric treatment]
Inappropriate or exaggerated behaviors (e.g., hysterical, hostile,
agitated, apathetic)
Goals/Objectives
Short-term Goal
Client will cooperate with plan for teaching provided by pri-
mary nurse.
Long-term Goal
By time of discharge from treatment, client will be able to verbal-
ize psychological factors affecting his or her medical condition.

1. Assess clients level of knowledge regarding effects of psy-
chological problems on the body. An adequate database is
necessary for the development of an effective teaching plan.
3. Discuss physical examinations and laboratory tests that have
been conducted. Explain purpose and results of each. Fear
of the unknown may contribute to elevated level of anxiety.
The client has the right to know about and accept or refuse
any medical treatment.
4. Explore clients feelings and fears. Go slowly. These feelings
may have been suppressed or repressed for so long that their
disclosure may be very painful. Be supportive. Verbalization
of feelings in a nonthreatening environment and with a
trusting individual may help the client come to terms with
unresolved issues.
5. Have client keep a diary of appearance, duration, and intensi-
ty of physical symptoms. A separate record of situations that
the client nds especially stressful should also be kept. Com-
parison of these records may provide objective data from
which to observe the relationship between physical symptoms
and stress.
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6. Help client identify needs that are being met through the
sick role. Together, formulate more adaptive means for
ful lling these needs. Practice by role-playing. Repetition
through practice serves to reduce discomfort in the actual
situation.
7. Provide instruction in assertiveness techniques, especial-
ly the ability to recognize the differences among passive,
assertive, and aggressive behaviors and the importance of
respecting the human rights of others while protecting ones
own basic human rights. These skills will preserve clients
self-esteem while also improving his or her ability to form
satisfactory interpersonal relationships.
8. Discuss adaptive methods of stress management such as
relaxation techniques, physical exercise, meditation, breath-
ing exercises, and autogenics. Use of these adaptive tech-
niques may decrease appearance of physical symptoms in
response to stress.
Outcome Criteria
between psychological stress and exacerbation of physical
illness.
2. Client demonstrates the ability to use adaptive coping strate-
gies in the management of stress.
INTERNET REFERENCES
Additional information about psychophysiological disorders
discussed in this chapter may be located at the following
websites:
a. http://www.cancer.gov/
b. http://www.cancer.org
c. http://www.heart.org/HEARTORG/
d. http://www.headaches.org/
e. http://www.pslgroup.com/ASTHMA.HTM
f. http://www.gastro.org/
g. http://www.pslgroup.com/HYPERTENSION.HTM
h. http://www.arthritis.org
i. http://digestive.niddk.nih.gov/ddiseases/pubs/colitis/
2506_Ch15_264-274.indd Sec1:274 10/1/10 9:36:43 AM

C H A P T E R
16
Personality Disorders
The American Psychiatric Association (APA, 2000, p. 686) Di-
agnostic and Statistical Manual of Mental Disorders, Fourth Edition,
Text Revision (DSM-IV-TR) describes personality traits as en-
during patterns of perceiving, relating to, and thinking about
the environment and oneself that are exhibited in a wide range
of social and personal contexts. A personality disorder is said to
exist only when these traits become inexible and maladaptive
and cause either signicant functional impairment or subjective
distress.
The DSM-IV-TR groups the personality disorders into three
clusters. They are coded on Axis II in the DMS-IV-TR Classi-
cation. These clusters, and the disorders classied under each,
are described as follows:
1. Cluster A: Behaviors described as odd or eccentric
a. Paranoid personality disorder
b. Schizoid personality disorder
c. Schizotypal personality disorder
2. Cluster B: Behaviors described as dramatic, emotional, or
erratic
a. Antisocial personality disorder
b. Borderline personality disorder
c. Histrionic personality disorder
d. Narcissistic personality disorder
3. Cluster C: Behaviors described as anxious or fearful
a. Avoidant personality disorder
b. Dependent personality disorder
c. Obsessive-compulsive personality disorder
d. Passive-aggressive personality disorder
Note: The third edition of the DSM included passive-aggressive
personality disorder in Cluster C. In the DSM-IV-TR, this dis-
order is included in the section on Criteria Provided for Further
Study. For purposes of this text, passive-aggressive personality
disorder is described with the cluster C disorders.
275
2506_Ch16_275-309.indd 0275 10/1/10 9:36:54 AM

Categories of personality disorders described by the DSM-IV-TR

include the following:
1. Cluster A
a. Paranoid Personality Disorder. The essential feature is
a pervasive and unwarranted suspiciousness and mistrust
of people. There is a general expectation of being exploit-
ed or harmed by others in some way. Symptoms include
guardedness in relationships with others, pathological
jealousy, hypersensitivity, inability to relax, unemotional-
ity, and lack of a sense of humor. These individuals are
very critical of others but have much difculty accepting
criticism themselves.
b. Schizoid Personality Disorder. This disorder is character-
ized by an inability to form close, personal relationships.
Symptoms include social isolation; absence of warm, ten-
der feelings for others; indifference to praise, criticism,
or the feelings of others; and at, dull affect (appears cold
and aloof).
c. Schizotypal Personality Disorder. This disorder is char-
acterized by peculiarities of ideation, appearance, and be-
havior, and decits in interpersonal relatedness that are
not severe enough to meet the criteria for schizophrenia.
Symptoms include magical thinking; ideas of reference;
social isolation; illusions; odd speech patterns; aloof, cold,
suspicious behavior; and undue social anxiety.
2. Cluster B
a. Antisocial Personality Disorder. This disorder is charac-
terized by a pattern of socially irresponsible, exploitative,
and guiltless behavior, as evidenced by the tendency to
fail to conform to the law, to sustain consistent employ-
ment, to exploit and manipulate others for personal gain,
to deceive, and to fail to develop stable relationships. The
individual must be at least 18 years of age and have a his-
tory of conduct disorder before the age of 15. (Symptoms
of this disorder are identied later in this chapter, along
with predisposing factors and nursing care.)
b. Borderline Personality Disorder. The features of this dis-
order are described as marked instability in interpersonal
relationships, mood, and self-image. The instability is sig-
nicant to the extent that the individual seems to hover on
the border between neurosis and psychosis. (Symptoms of
this disorder are identied later in this chapter, along with
predisposing factors and nursing care.)
c. Histrionic Personality Disorder. The essential feature of
this disorder is described by the DSM-IV-TR as a perva-
sive pattern of excessive emotionality and attention-seeking
2506_Ch16_275-309.indd 0276 10/1/10 9:36:55 AM

behavior (APA, 2000, p. 711). Symptoms include exagger-

ated expression of emotions, incessant drawing of atten-
tion to oneself, overreaction to minor events, constantly
seeking approval from others, egocentricity, vain and de-
manding behavior, extreme concern with physical appear-
ance, and inappropriately sexually seductive appearance or
behavior.
d. Narcissistic Personality Disorder. This disorder is char-
acterized by a grandiose sense of self-importance; pre-
occupation with fantasies of success, power, brilliance,
beauty, or ideal love; a constant need for admiration
and attention; exploitation of others for fulllment of own
desires; lack of empathy; response to criticism or failure
with indifference or humiliation and rage; and preoccupa-
tion with feelings of envy.
3. Cluster C
a. Avoidant Personality Disorder. This disorder is charac-
terized by social withdrawal brought about by extreme
sensitivity to rejection. Symptoms include unwillingness
to enter into relationships unless given unusually strong
guarantees of uncritical acceptance; low self-esteem; and
social withdrawal despite a desire for affection and accep-
tance. Depression and anxiety are common. Social phobia
may be a complication of this disorder.
b. Dependent Personality Disorder. Individuals with this
disorder passively allow others to assume responsibility
for major areas of life because of their inability to func-
tion independently. They lack self-condence, are unable
to make decisions, perceive themselves as helpless and stu-
pid, possess fear of being alone or abandoned, and seek
constant reassurance and approval from others.
c. Obsessive-Compulsive Personality Disorder. This dis-
order is characterized by a pervasive pattern of perfec-
tionism and inexibility. Interpersonal relationships have
a formal and serious quality, and others often perceive
these individuals as stilted or stiff. Other symptoms in-
clude difculty expressing tender feelings, insistence that
others submit to his or her way of doing things, exces-
sive devotion to work and productivity to the exclusion
of pleasure, indecisiveness, perfectionism, preoccupation
with details, depressed mood, and being judgmental of
self and others.
d. Passive-Aggressive Personality Disorder. Characteristic
of this disorder is a passive resistance to demands for ad-
equate performance in both occupational and social func-
tioning (APA, 2000). Symptoms include obstructionism,
2506_Ch16_275-309.indd 0277 10/1/10 9:36:55 AM

procrastination, stubbornness, intentional inefciency,

dawdling, forgetfulness, criticism of persons in author-
ity, dependency, and low self-esteem. Oppositional deant
disorder in childhood or adolescence is a predisposing
factor.
Many of the behaviors associated with the various personal-
ity disorders may be manifested by clients with virtually every
psychiatric diagnosis, as well as by those individuals described as
healthy. It is only when personality traits or styles repetitively
interfere with an individuals ability to function within age-
appropriate cultural and developmental expectations, disrupt
interpersonal relationships, and distort a persons pattern of per-
ception and thinking about the environment that a diagnosis of
personality disorder is assigned.
Individuals with personality disorders may be encountered
in all types of treatment settings. They are not often treated in
acute care settings, but because of the instability of the borderline
client, hospitalization is necessary from time to time. The indi-
vidual with antisocial personality disorder also may be hospital-
ized as an alternative to imprisonment when a legal determination
is made that psychiatric intervention may be helpful. Because of
these reasons, suggestions for inpatient care of individuals with
these disorders are included in this chapter; however, these inter-
ventions may be used in other types of treatment settings as well.
Undoubtedly, these clients represent the ultimate challenge for
the psychiatric nurse.
BORDERLINE PERSONALITY DISORDER

Dened
This personality disorder is characterized by instability of
affect, behavior, object relationships, and self-image. The term
borderline came into being because these clients emotionally
unstable behavior seems to fall on the border between neurotic
and psychotic. Transient psychotic symptoms appear during
periods of extreme stress. The disorder is more commonly diag-
nosed in women than in men.
Predisposing Factors to Borderline

Personality Disorder
1. Physiological
a. Biochemical. Cummings and Mega (2003) have suggested
a possible serotonergic defect in clients with borderline
personality disorder. In positron emission tomography
using -[11C]methyl-l-tryptophan (-[11C]MTrp), which
reects serotonergic synthesis capability, clients with bor-
derline personality demonstrated signicantly decreased
-[11C]MTrp in medial frontal, superior temporal, and
2506_Ch16_275-309.indd 0278 10/1/10 9:36:56 AM

striatal regions of the brain. Cummings and Mega (2003)

stated:
These functional imaging studies support a medial and
orbitofrontal abnormality that may promote the impulsive
aggression demonstrated by patients with the borderline
personality disorder (p. 230).
b. Genetic. The decrease in serotonin may also have genetic
implications for borderline personality disorder. Sadock
and Sadock (2007) report that depression is common in
the family backgrounds of clients with borderline person-
ality disorder. They stated:
These patients have more relatives with mood disorders than
do control groups, and persons with borderline personality
disorder often have mood disorder as well (p. 791).
2. Psychosocial
a. Childhood Trauma. Studies have shown that many indi-
viduals with borderline personality disorder were reared
in families with chaotic environments. Lubit and Finley-
Belgrad (2008) stated, Risk factors [for borderline per-
sonality disorder] include family environments character-
ized by trauma, neglect, and/or separation; exposure to
sexual and physical abuse; and serious parental psychopa-
thology such as substance abuse and antisocial personality
disorder. From 40% to 71% of borderline personality dis-
order clients report having been sexually abused, usually
by a noncaregiver (National Institute of Mental Health
[NIMH], 2009). In some instances, this disorder has
been likened to posttraumatic stress disorder in response
to childhood trauma and abuse. Oldham and associates
(2006) stated:
Even when full criteria for comorbid PTSD are not present,
patients with borderline personality disorder may experi-
ence PTSD-like symptoms. For example, symptoms such as
intrusion, avoidance, and hyperarousal may emerge during
psychotherapy. Awareness of the trauma-related nature of
these symptoms can facilitate both psychotherapeutic and
pharmacological efforts in symptom relief (p. 1267).
b. Theory of Object Relations. This theory suggests that
the basis for borderline personality lies in the ways the
child relates to the mother and does not separate from her.
Mahler and associates (1975) de ne this process in a series
of phases described as follows:
Phase 1 (Birth to 1 month), Autistic Phase. Most of
the infants time is spent in a half-waking, half-sleeping
state. The main goal is fulllment of needs for survival
and comfort.
2506_Ch16_275-309.indd 0279 10/1/10 9:36:56 AM

Phase 2 (1 to 5 months), Symbiotic Phase. A type of

psychic fusion of mother and child. The child views the
self as an extension of the parenting gure, although
there is a developing awareness of external sources of
need fulllment.
Phase 3 (5 to 10 months), Differentiation Phase.
The child is beginning to recognize that there is separ-
ateness between the self and the parenting gure.
Phase 4 (10 to 16 months), Practicing Phase. This
phase is characterized by increased locomotor function-
ing and the ability to explore the environment indepen-
dently. A sense of separateness of the self is increased.
Phase 5 (16 to 24 months), Rapprochement Phase.
Awareness of separateness of the self becomes acute.
This is frightening to the child, who wants to regain
some lost closeness but not return to symbiosis. The
child wants the mother there as needed for emotional
refueling and to maintain feelings of security.
Phase 6 (24 to 36 months), On the Way to Object
Constancy Phase. In this phase, the child completes the
individuation process and learns to relate to objects in
an effective, constant manner. A sense of separateness
is established, and the child is able to internalize a sus-
tained image of the loved object or person when out of
sight. Separation anxiety is resolved.
The theory of object relations suggests that the individual
with borderline personality is xed in the rapprochement phase
of development. This xation occurs when the mother begins to
feel threatened by the increasing autonomy of her child and so
withdraws her emotional support during those times or she may
instead reward clinging, dependent behaviors. In this way, the
child comes to believe that
To grow up and be independent = a bad child.
To stay immature and dependent = a good child.
Mom withholds nurturing from bad child.
Consequently, the child develops a deep fear of abandon-
ment that persists into adulthood. In addition, because object
constancy is never achieved, the child continues to view objects
(people) as partseither good or bad. This is called splitting,
a primary defense mechanism of borderline personality.

Data)
Individuals with borderline personality always seem to be in
a state of crisis. Their affect is one of extreme intensity and
their behavior reects frequent changeability. These changes
2506_Ch16_275-309.indd 0280 10/1/10 9:36:57 AM

can occur within days, hours, or even minutes. Often these

individuals exhibit a single, dominant affective tone, such as
depression, which may give way periodically to anxious agitation
or inappropriate outbursts of anger.
Common symptoms include the following:
1. Chronic depression. Depression is so common in clients
with this disorder that before the inclusion of borderline
personality disorder in the DSM, many of these clients were
diagnosed as depressed. Depression occurs in response to
feelings of abandonment by the mother in early childhood
(see Predisposing Factors). Underlying the depression is a
sense of rage that is sporadically turned inward on the self
and externally on the environment. Seldom is the individual
aware of the true source of these feelings until well into long-
term therapy.
2. Inability to be alone. Because of this chronic fear of aban-
donment, clients with borderline personality disorder have
little tolerance for being alone. They prefer a frantic search
for companionship, no matter how unsatisfactory, to sitting
with feelings of loneliness, emptiness, and boredom (Sadock
& Sadock, 2007).
3. Clinging and distancing. The client with borderline person-
ality disorder commonly exhibits a pattern of interaction with
others that is characterized by clinging and distancing behav-
iors. When clients are clinging to another individual, they
may exhibit helpless, dependent, or even childlike behaviors.
They overidealize a single individual with whom they want
to spend all their time, with whom they express a frequent
need to talk, or from whom they seek constant reassurance.
Acting-out behaviors, even self-mutilation, may result when
they cannot be with this chosen individual. Distancing be-
haviors are characterized by hostility, anger, and devaluation
of others, arising from a feeling of discomfort with closeness.
Distancing behaviors also occur in response to separations,
confrontations, or attempts to limit certain behaviors. Deval-
uation of others is manifested by discrediting or undermining
their strengths and personal signicance.
4. Splitting. Splitting is a primitive ego defense mechanism that
is common in people with borderline personality disorder. It
arises from their lack of achievement of object constancy and
is manifested by an inability to integrate and accept both posi-
tive and negative feelings. In their view, peopleincluding
themselvesand life situations are either all good or all bad.
5. Manipulation. In their efforts to prevent the separation
they so desperately fear, clients with this disorder become
masters of manipulation. Virtually any behavior becomes an
acceptable means of achieving the desired result: relief from
2506_Ch16_275-309.indd 0281 10/1/10 9:36:57 AM

separation anxiety. Playing one individual against another is

a common ploy to allay these fears of abandonment.
6. Self-destructive behaviors. Repetitive, self-mutilative be-
haviors, such as cutting, scratching, and burning, are classic
manifestations of borderline personality disorder. Although
these acts can be fatal, most commonly they are manipulative
gestures designed to elicit a rescue response from signicant
others. Suicide attempts are not uncommon and often result
from feelings of abandonment following separation from a
signicant other.
7. Impulsivity. Individuals with borderline personality dis-
order have poor impulse control based on primary process
functioning. Impulsive behaviors associated with borderline
personality disorder include substance abuse, gambling, pro-
miscuity, reckless driving, and binging and purging (APA,
2000). Many times these acting-out behaviors occur in
response to real or perceived feelings of abandonment.
8. Feelings of unreality. Transient episodes of extreme stress
can precipitate periods of dissociation in the individual with
borderline personality disorder.
9. Rage reactions. Difculty controlling anger.
and Interventions
RISK FOR SELF-MUTILATION/

relief of tension. At risk for behaviors in which an individual demon-
ally harmful either to self or to others.

[Extreme fears of abandonment]
[Feelings of unreality]
[Depressed mood]
[Use of suicidal gestures for manipulation of others]
Low self-esteem
[Unresolved grief]
2506_Ch16_275-309.indd 0282 10/1/10 9:36:57 AM

[Rage reactions]
[Physically self-damaging acts (cutting, burning, drug overdose,
etc.)]
History or threats of violence toward self or others or of
destruction to the property of others
Impulsivity
History of suicide attempts
Goals/Objectives
Short-term Goals
1. Client will seek out staff member if feelings of harming self
or others emerge.
Long-term Goal

can occur if required to ensure clients (and others) safety.
2. Secure a verbal contract from client that he or she will seek
out a staff member when the urge for self-mutilation is expe-
rienced. Discussing feelings of self-harm with a trusted indi-
vidual provides some relief to the client. A contract gets the
subject out in the open and places some of the responsibility
for his or her safety with the client. An attitude of acceptance
of the client as a worthwhile individual is conveyed.
3. If self-mutilation occurs, care for the clients wounds in a
matter-of-fact manner. Do not give positive reinforcement
to this behavior by offering sympathy or additional attention.
Lack of attention to the maladaptive behavior may decrease
repetition of its use.
4. Encourage client to talk about feelings he or she was having just
prior to this behavior. To problem-solve the situation with the
client, knowledge of the precipitating factors is important.
ings and give positive reinforcement to the client when at-
tempts to conform are made. It is vital that the client express
angry feelings, because suicide and other self-destructive
behaviors are often viewed as a result of anger turned
inward on the self.
6. Remove all dangerous objects from the clients environment.
2506_Ch16_275-309.indd 0283 10/1/10 9:36:58 AM

7. Try to redirect violent behavior with physical outlets for the

clients anxiety (e.g., punching bag, jogging). Physical exer-
cise is a safe and effective way of relieving pent-up tension.
to the client if necessary. This conveys to the client evidence
of control over the situation and provides some physical
security for staff.
cian or obtain an order if necessary. Monitor the client for
effectiveness of the medication and for the appearance of
adverse side effects. Tranquilizing medications such as
anxiolytics or antipsychotics may have a calming effect on
the client and may prevent aggressive behaviors.
10. Use of mechanical restraints or isolation room may be
required if less restrictive interventions are unsuccessful.
Follow policy and procedure prescribed by the institu-
tion in executing this intervention. The Joint Commis-
sion (formerly the Joint Commission on Accreditation of
Healthcare Organizations [ JCAHO]) requires that an in-
person evaluation (by a physician, clinical psychologist, or
other licensed independent practitioner responsible for the
care of the patient) be conducted within 1 hour of initiat-
ing restraint or seclusion (The Joint Commission, 2010).
The physician must reevaluate and issue a new order for
restraints every 4 hours for adults and every 1 to 2 hours
for children and adolescents.
11. Observe the client in restraints every 15 minutes (or
according to institutional policy). Ensure that circulation to
pulses). Assist the client with needs related to nutrition,
hydration, and elimination. Position the client so that com-
fort is facilitated and aspiration can be prevented. Client
safety is a nursing priority.
12. May need to assign staff on a one-to-one basis if warranted
by acuity of the situation. Clients with borderline personal-
ity disorder have extreme fear of abandonment; leaving
them alone at such a time may cause an acute rise in level
of anxiety and agitation.
Outcome Criteria
2. Anxiety is maintained at a level in which client feels no need
for aggression.
3. Client denies any ideas of self-harm.
4. Client verbalizes community support systems from which as-
sistance may be requested when personal coping strategies
are unsuccessful.
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ANXIETY (SEVERE TO PANIC)

Denition: Vague uneasy feeling of discomfort or dread accom-
unknown to the individual); a feeling of apprehension caused by an-
ticipation of danger. It is an alerting signal that warns of impending
danger and enables the individual to take measures to deal with
threat.

Threat to self-concept
Unmet needs
[Extreme fear of abandonment]
Unconscious con icts [associated with xation in earlier level of
development]

[Transient psychotic symptoms in response to severe stress,
manifested by disorganized thinking, confusion, altered com-
munication patterns, disorientation, misinterpretation of the
environment]
[Excessive use of projection (attributing own thoughts and feel-
ings to others)]
[Depersonalization (feelings of unreality)]
[Derealization (a feeling that the environment is unreal)]
[Acts of self-mutilation in an effort to nd relief from feelings
of unreality]
Goals/Objectives
Short-term Goal
anxiety at manageable level.
Long-term Goal
Client will be able to recognize events that precipitate anxiety
and intervene to prevent disabling behaviors.

1. Symptoms of depersonalization often occur at the panic level
of anxiety. Clients with borderline personality disorder often
resort to cutting or other self-mutilating acts in an effort to
relieve the anxiety. Being able to feel pain or see blood is a
reassurance of existence to the person. If injury occurs, care
for the wounds in a matter-of-fact manner without providing
reinforcement for this behavior. Lack of reinforcement may
discourage repetition of the maladaptive behavior.
2506_Ch16_275-309.indd 0285 10/1/10 9:36:58 AM

2. During periods of panic anxiety, stay with the client and provide
reassurance of safety and security. Orient client to the reality of
the situation. Client comfort and safety are nursing priorities.
cian, or obtain order if necessary. Monitor client for effec-
tiveness of the medication as well as for adverse side effects.
Antianxiety medications (e.g., lorazepam, chlordiazepoxide,
alprazolam) provide relief from the immobilizing effects of
anxiety and facilitate clients cooperation with therapy.
4. Correct misinterpretations of the environment as expressed by
client. Confronting misinterpretations honestly, with a car-
ing and accepting attitude, provides a therapeutic orienta-
tion to reality and preserves the clients feelings of dignity
and self-worth.
5. Encourage the client to talk about true feelings. Help him or
her recognize ownership of these feelings rather than pro-
jecting them onto others in the environment. Exploration of
feelings with a trusted individual may help the client per-
ceive the situation more realistically and come to terms with
unresolved issues.
6. Help client work toward achievement of object constancy.
Client may feel totally abandoned when nurse or therapist
leaves at shift change or at end of therapy session. There may
even be feelings that the therapist ceases to exist. Leaving
a signed note or card with the client for reassurance may
help. It is extremely important for more than one nurse to
develop a therapeutic relationship with the borderline client.
It is also necessary that staff maintain open communication
and consistency in the provision of care for these individu-
als. Individuals with borderline personality disorder have a
tendency to cling to one staff member, if allowed, transfer-
ring their maladaptive dependency to that individual. This
dependency can be avoided if the client is able to establish
therapeutic relationships with two or more staff members
who encourage independent self-care activities.
Outcome Criteria
demonstrate techniques for its reduction.
2. Client manifests no symptoms of depersonalization.
3. Client interprets the environment realistically.
De nition: A disorder that occurs after the death of a significant
other [or any other loss of significance to the individual], in which
2506_Ch16_275-309.indd 0286 10/1/10 9:36:58 AM

the experience of distress accompanying bereavement fails to fol-

low normative expectations and manifests in functional impairment.

[Maternal deprivation during rapprochement phase of develop-
ment (internalized as a loss, with xation in the anger stage of
the grieving process)]

Persistent emotional distress
[Anger]
[Internalized rage]
Depression
[Labile affect]
[Extreme fear of being alone (fear of abandonment)]
[Acting-out behaviors, such as sexual promiscuity, suicidal
gestures, temper tantrums, substance abuse]
[Difculty expressing feelings]
[Reliving of past experiences with little or no reduction of
intensity of the grief]
[Feelings of inadequacy; dependency]
Goals/Objectives
Short-term Goal
Client will discuss with nurse or therapist maladaptive patterns
of expressing anger.
Long-term Goal
Client will be able to identify the true source of angry feelings,
accept ownership of these feelings, and express them in a so-
cially acceptable manner, in an effort to satisfactorily progress
through the grieving process.

1. Convey an accepting attitudeone that creates a nonthreat-
ening environment for the client to express feelings. Be hon-
est and keep all promises. An accepting attitude conveys to
Trust is enhanced.
2. Identify the function that anger, frustration, and rage serve
for the client. Allow the client to express these feelings within
reason. Verbalization of feelings in a nonthreatening envi-
ronment may help the client come to terms with unresolved
issues.
3. Encourage client to discharge pent-up anger through par-
ticipation in large motor activities (e.g., brisk walks, jogging,
2506_Ch16_275-309.indd 0287 10/1/10 9:36:59 AM

physical exercises, volleyball, punching bag, exercise bike).

Physical exercise provides a safe and effective method for
discharging pent-up tension.
4. Explore with client the true source of the anger. This is pain-
ful therapy that often leads to regression as the client deals
with the feelings of early abandonment. It seems that some-
times the client must get worse before he or she can get bet-
ter. Reconciliation of the feelings associated with this stage
is necessary before progression through the grieving process
can continue.
5. As anger is displaced onto the nurse or therapist, caution
must be taken to guard against the negative effects of coun-
tertransference. These are very diffi cult clients who have
the capacity for eliciting a whole array of negative feel-
ings from the therapist. The existence of negative feel-
ings by the nurse or therapist must be acknowledged, but
they must not be allowed to interfere with the therapeutic
process.
6. Explain the behaviors associated with the normal grieving
process. Help the client to recognize his or her position in
this process. Knowledge of the acceptability of the feelings
associated with normal grieving may help to relieve some of
the guilt that these responses generate.
7. Help client understand appropriate ways of expressing anger.
Give positive reinforcement for behaviors used to express
anger appropriately. Act as a role model. Positive rein-
forcement enhances self-esteem and encourages repetition
of desirable behaviors. It is appropriate to let the client
know when he or she has done something that has gener-
ated angry feelings in you. Role-modeling ways to express
anger in an appropriate manner is a powerful learning
tool.
8. Set limits on acting-out behaviors and explain consequences
of violation of those limits. Be supportive, yet consistent and
rm, in caring for this client. Client lacks sufficient self-
control to limit maladaptive behaviors, so assistance is re-
quired from staff. Without consistency on the part of all
staff members working with this client, a positive outcome
will not be achieved.
Outcome Criteria
1. Client is able to verbalize how anger and acting-out behav-
iors are associated with maladaptive grieving.
2. Client is able to discuss the original source of the anger
and demonstrates socially acceptable ways of expressing the
emotion.
2506_Ch16_275-309.indd 0288 10/1/10 9:36:59 AM



[Fixation in rapprochement phase of development]
[Extreme fears of abandonment and engulfment]
[Lack of personal identity]

[Alternating clinging and distancing behaviors]
[Inability to form satisfactory intimate relationship with an-
other person]
[Use of primitive dissociation (splitting) in their relationships
(viewing others as all good or all bad)]
Goals/Objectives
Short-term Goal
Client will discuss with nurse or therapist behaviors that impede
the development of satisfactory interpersonal relationships.
Long-term Goals
1. Client will interact with others in the therapy setting in both
social and therapeutic activities without difculty by time of
discharge from treatment.
2. Client will display no evidence of splitting or clinging and
distancing behaviors in relationships by time of discharge
from treatment.

1. Encourage client to examine these behaviors (to recognize
that they are occurring). Client may be unaware of splitting
or of clinging and distancing pattern of interaction with
others.
2. Help client realize that you will be available, without rein-
forcing dependent behaviors. Knowledge of your availability
may provide needed security for the client.
3. Give positive reinforcement for independent behaviors. Posi-
4. Rotate staff who work with the client in order to avoid clients
developing dependence on particular staff members. Client
must learn to relate to more than one staff member in an
2506_Ch16_275-309.indd 0289 10/1/10 9:36:59 AM

effort to decrease use of splitting and to diminish fears of

abandonment.
CLINICAL PEARL Recognize when the client is playing one staff member against
another. Remember that splitting is a primary defense mechanism of these individuals,
and the impressions they have of others as either good or bad are a manifestation
of this defense. Do not listen as the client tries to degrade other staff members.
Suggest that the client discuss the problem directly with the staff person involved.
5. Explore with client feelings that relate to fears of abandon-

ment and engulfment. Help client understand that cling-
ing and distancing behaviors are engendered by these fears.
Exploration of feelings with a trusted individual may help
client come to terms with unresolved issues.
6. Help client understand how these behaviors interfere with
satisfactory relationships. Client may be unaware of others
perception of him or her and why these behaviors are not
acceptable to others.
7. Assist the client to work toward achievement of object con-
stancy. Be available, without promoting dependency. This
may help client resolve fears of abandonment and develop
the ability to establish satisfactory intimate relationships.
Outcome Criteria
1. Client is able to interact with others in both social and thera-
peutic activities in a socially acceptable manner.
2. Client does not use splitting or clinging and distancing be-
haviors in relationships and is able to relate the use of these
behaviors to failure of past relationships.

De nition: Inability to maintain an integrated and complete per-
ception of self.

[Failure to complete tasks of separation/individuation stage of
development]
[Absence of, or rejection by, parental sex-role model]

[Excessive use of projection]
[Vague self-image]
2506_Ch16_275-309.indd 0290 10/1/10 9:37:00 AM

[Unable to tolerate being alone]

[Feelings of depersonalization and derealization]
[Self-mutilation (cutting, burning) to validate existence of self]
Gender confusion
Feelings of emptiness
Uncertainties about goals and values
Goals/Objectives
Short-term Goal
Client will describe characteristics that make him or her a
unique individual.
Long-term Goal
Client will be able to distinguish own thoughts, feelings, behav-
iors, and image from those of others, as the initial step in the
development of a healthy personal identity.

1. Help client recognize the reality of his or her separateness.
Do not attempt to translate clients thoughts and feelings into
words. Because of the blurred ego boundaries, client may
believe you can read his or her mind. For this reason, caution
should be taken in the use of empathetic understanding. For
example, avoid statements such as, I know how you must feel
about that.
2. Help client recognize separateness from nurse by clarifying
which behaviors and feelings belong to whom. If deemed
appropriate, allow client to touch your hand or arm. Touch
and physical presence provide reality for the client and serve
to strengthen weak ego boundaries.
3. Encourage client to discuss thoughts and feelings. Help
client recognize ownership of these feelings rather than pro-
jecting them onto others in the environment. Verbalization
of feelings in a nonthreatening environment may help client
4. Confront statements that project clients feelings onto others.
Ask client to validate that others possess those feelings. The
expression of reasonable doubt as a therapeutic technique may
be helpful (I nd that hard to believe).
5. If the problem is with gender identity, ask the client to
describe his or her perception of appropriate male and
female behaviors. Provide information about role behav-
iors and sex education, if necessary. Convey acceptance
of the person regardless of preferred identity. Client may
require clarifi cation of distorted ideas or misinformation.
An attitude of acceptance reinforces clients feelings of
self-worth.
2506_Ch16_275-309.indd 0291 10/1/10 9:37:00 AM

6. Always call client by his or her name. If client experiences

feelings of depersonalization or derealization, orientation to
the environment and correction of misperceptions may be
helpful. These interventions help to preserve clients feel-
ings of dignity and self-worth.
7. Help client understand that there are more adaptive ways of
validating his or her existence than self-mutilation. Contract
with the client to seek out staff member when these feel-
ings occur. A contract gets the subject out in the open and
places some of the responsibility for his or her safety with the
client. Client safety is a nursing priority.
8. Work with client to clarify values. Discuss beliefs, attitudes,
and feelings underlying his or her behaviors. Help client
to identify those values that have been (or are intended to
be) incorporated as his or her own. Care must be taken
by the nurse to avoid imposing his or her own value sys-
tem on the client. Because of underdeveloped ego and fi x-
ation in early developmental level, client may not have
established own value system. In order to accomplish this,
ownership of beliefs and attitudes must be identifi ed and
clarifi ed.
9. Use of photographs of the client may help to establish or
clarify ego boundaries. Photographs may help to increase
clients awareness of self as separate from others.
10. Alleviate anxiety by providing assurance to client that
he or she will not be left alone. Early childhood traumas
may predispose borderline clients to extreme fears of
abandonment.
11. Use of touch is sometimes therapeutic in identity con rma-
tion. Before this technique is used, however, assess cultural
inuences and degree of trust. Touch and physical presence
provide reality for the client and serve to strengthen weak
ego boundaries.
Outcome Criteria
1. Client is able to distinguish between own thoughts and feel-
ings and those of others.
2. Client claims ownership of those thoughts and feelings and
does not use projection in relationships with others.
3. Client has claried own feelings regarding sexual identity.
LOW SELF-ESTEEM
capabilities.
2506_Ch16_275-309.indd 0292 10/1/10 9:37:00 AM


[Repeated negative feedback, resulting in diminished self-
worth]

[Self-destructive behavior]
[Frequent use of derogatory and critical remarks against the
self]
Lack of eye contact
[Manipulation of one staff member against another in an
attempt to gain special privileges]
[Inability to tolerate being alone]
of self-worth]
Hesitancy to try new things or situations [because of fear of
failure]
Goals/Objectives
Short-term Goals
1. Client will discuss fear of failure with nurse or therapist.
2. Client will verbalize things he or she likes about self.
Long-term Goals

likely. Success increases self-esteem.
2. Convey unconditional positive regard for client. Promote
understanding of your acceptance for him or her as a worth-
while human being. Acceptance by others increases feelings
of self-worth.
3. Set limits on manipulative behavior. Identify the consequences
for violation of those limits. Minimize negative feedback to
2506_Ch16_275-309.indd 0293 10/1/10 9:37:00 AM

the client. Enforce the limits and impose the consequences

for violations in a matter-of-fact manner. Consistency among
all staff members is essential. Negative feedback can be ex-
tremely threatening to a person with low self-esteem and
possibly aggravate the problem. Consequences should convey
unacceptability of the behavior but not the person.
4. Encourage independence in the performance of personal re-
sponsibilities, as well as in decision-making related to clients
self-care. Offer recognition and praise for accomplishments.
5. Help client increase level of self-awareness through criti-
cal examination of feelings, attitudes, and behaviors. Self-
exploration in the presence of a trusted individual may help
the client come to terms with unresolved issues.
6. Help client identify positive self-attributes as well as those
aspects of the self he or she nds undesirable. Discuss ways
to effect change in these areas. Individuals with low self-
esteem often have difficulty recognizing their positive at-
tributes. They may also lack problem-solving ability and
require assistance to formulate a plan for implementing the
desired changes.
7. Discuss clients future. Assist client in the establishment of
short-term and long-term goals. What are his or her strengths?
How can he or she best use those strengths to achieve those
goals? Encourage client to perform at a level realistic to his or
her ability. Offer positive reinforcement for decisions made.
Outcome Criteria
1. Client verbalizes positive aspects about self.
2. Client demonstrates ability to make independent decisions
regarding management of own self-care.
3. Client expresses some optimism and hope for the future.
4. Client sets realistic goals for self and demonstrates willing-
ness to reach them.
ANTISOCIAL PERSONALITY DISORDER

Dened
Antisocial personality disorder is characterized by a pattern of
antisocial behavior that began before the age of 15. These behav-
iors violate the rights of others, and individuals with this disorder
display no evidence of guilt feelings at having done so. There is
often a long history of involvement with law-enforcement agen-
cies. Substance abuse is not uncommon. The disorder is more
frequently diagnosed in men than in women. Individuals with
antisocial personalities are often labeled sociopathic or psychopathic
in the lay literature.
2506_Ch16_275-309.indd 0294 10/1/10 9:37:01 AM

Predisposing Factors to Antisocial

Personality Disorder
1. Physiological
a. Genetics. The DSM-IV-TR reports that antisocial per-
sonality is more common among rst-degree biological
relatives of those with the disorder than among the gen-
eral population (APA, 2000). Twin and adoptive studies
have implicated the role of genetics in antisocial personal-
ity disorder (Skodol & Gunderson, 2008). These studies
of families of individuals with antisocial personality show
higher numbers of relatives with antisocial personality or
alcoholism than are found in the general population. Ad-
ditional studies have shown that children of parents with
antisocial behavior are more likely to be diagnosed as an-
tisocial personality, even when they are separated at birth
from their biological parents and reared by individuals
without the disorder.
b. Temperament. Characteristics associated with tempera-
ment in the newborn may be signicant in the predispo-
sition to antisocial personality. Parents who bring their
children with behavior disorders to clinics often report
that the child displayed temper tantrums from infancy
and would become furious when awaiting a bottle or a
diaper change. As these children mature, they commonly
develop a bullying attitude toward other children. Parents
report that they are undaunted by punishment and gener-
ally quite unmanageable. They are daring and foolhardy
in their willingness to chance physical harm, and they
seem unaffected by pain.
2. Psychosocial
a. Theories of Family Dynamics. Antisocial personality dis-
order frequently arises from a chaotic home environment.
Parental deprivation during the rst 5 years of life appears
to be a critical predisposing factor in the development of
antisocial personality disorder. Separation due to parental
delinquency appears to be more highly correlated with the
disorder than is parental loss from other causes. The pres-
ence or intermittent appearance of inconsistent impulsive
parents, not the loss of a consistent parent, is environmen-
tally most damaging.
Studies have shown that individuals with antisocial per-
sonality disorder often have been severely physically abused
in childhood. The abuse contributes to the development of
antisocial behavior in several ways. First, it provides a model
for behavior. Second, it may result in injury to the childs
central nervous system, thereby impairing the childs ability
to function appropriately. Finally, it engenders rage in the
2506_Ch16_275-309.indd 0295 10/1/10 9:37:01 AM

victimized child, which is then displaced onto others in the

environment.
Disordered family functioning has been implicated as an
important factor in determining whether an individual devel-
ops antisocial personality (Hill, 2003; Skodol & Gunderson,
2008; Ramsland, 2009). The following circumstances may be
influential in the predisposition to the disorder:
Absence of parental discipline
Extreme poverty
Removal from the home
Growing up without parental gures of both genders
Erratic and inconsistent methods of discipline
Being rescued each time they are in trouble (never hav-
ing to suffer the consequences of their own behavior)
Maternal deprivation

Data)
1. Extremely low-self esteem (abuses other people in an at-
tempt to validate his or her own superiority)
2. Inability to sustain satisfactory job performance
3. Inability to function as a responsible parent
4. Failure to follow social and legal norms; repeated perfor-
mance of antisocial acts that are grounds for arrest (whether
arrested or not)
5. Inability to develop satisfactory, enduring, intimate rela-
tionship with a sexual partner
6. Aggressive behaviors; repeated physical ghts; spouse or
child abuse
7. Extreme impulsivity
8. Repeated lying for personal benet
9. Reckless driving; driving while intoxicated
10. Inability to learn from punishment
11. Lack of guilt or remorse felt in response to exploitation of
others
12. Difculty with interpersonal relationships
13. Social extroversion; stimulation through interaction with
and abuse of others
14. Repeated failure to honor nancial obligations
COMMON NURSING DIAGNOSES

AND INTERVENTIONS
2506_Ch16_275-309.indd 0296 10/1/10 9:37:01 AM

RISK FOR OTHER-DIRECTED

VIOLENCE
ally harmful to others.

[Rage reactions]
History of witnessing family violence
Neurological impairment (e.g., positive electroencephalogram)
[Suspiciousness of others]
[Interruption of clients attempt to fulll own desires]
[Inability to tolerate frustration]
[Learned behavior within clients subculture]
[Vulnerable self-esteem]
Impulsivity
Availability of weapon(s)
[Substance abuse or withdrawal]
[Provocative behavior: Argumentative, dissatised, overreac-
tive, hypersensitive]
History of childhood abuse
Goals/Objectives
Short-term Goals
1. Client will discuss angry feelings and situations that precipi-
tate hostility.
2. Client will not harm others.
Long-term Goal
Client will not harm others.

1. Convey an accepting attitude toward this client. Feelings
of rejection are undoubtedly familiar to him or her. Work
on development of trust. Be honest, keep all promises, and
convey the message to the client that it is not him or her, but
the behavior that is unacceptable. An attitude of acceptance
promotes feelings of self-worth. Trust is the basis of a thera-
peutic relationship.
2506_Ch16_275-309.indd 0297 10/1/10 9:37:02 AM


lighting, few people, simple decor, low noise level). A stimu-
lating environment may increase agitation and promote
aggressive behavior.
can occur if needed to ensure clients (and others) safety.
4. Remove all dangerous objects from clients environment.
5. Help client identify the true object of his or her hostility
(e.g., You seem to be upset with...). Because of weak ego
development, client may be misusing the defense mecha-
nism of displacement. Helping him or her recognize this
in a nonthreatening manner may help reveal unresolved
issues so that they may be confronted.
6. Encourage client to gradually verbalize hostile feelings.
Verbalization of feelings in a nonthreatening environment
may help client come to terms with unresolved issues.
7. Explore with client alternative ways of handling frustration
(e.g., large motor skills that channel hostile energy into so-
cially acceptable behavior). Physically demanding activities
help to relieve pent-up tension.
8. Staff should maintain and convey a calm attitude toward
client. Anxiety is contagious and can be transferred from
staff to client. A calm attitude provides client with a feeling
of safety and security.
9. Have sufcient staff available to present a show of strength
rity for staff.
cian or obtain an order if necessary. Monitor client for ef-
fectiveness of the medication as well as for appearance of
adverse side effects. Antianxiety agents (e.g., lorazepam,
chlordiazepoxide, oxazepam) produce a calming effect and
may help to allay hostile behaviors. (NOTE: Medications
are often not prescribed for clients with antisocial personal-
ity disorder because of these individuals strong susceptibil-
ity to addictions.)
11. If client is not calmed by talking down or by medica-
tion, use of mechanical restraints may be necessary. Be sure
to have sufcient staff available to assist. Follow protocol
established by the institution in executing this intervention.
The Joint Commission requires that and in-person evalu-
ation by a licensed independent practitioner be conducted
within 1 hour of initiating restraint or seclusion. The physi-
cian must reevaluate and issue a new order for restraints
2506_Ch16_275-309.indd 0298 10/1/10 9:37:02 AM

every 4 hours for adults age 18 and older. Never use restraints
as a punitive measure but rather as a protective measure for
a client who is out of control.
12. Observe client in restraints every 15 minutes (or according
to institutional policy). Ensure that circulation to extremi-
ties is not compromised (check temperature, color, pulses).
Assist client with needs related to nutrition, hydration, and
elimination. Position client so that comfort is facilitated
and aspiration can be prevented. Client safety is a nursing
priority.
Outcome Criteria
1. Client is able to rechannel hostility into socially acceptable
behaviors.
2. Client is able to discuss angry feelings and verbalize ways to
tolerate frustration appropriately.
INEFFECTIVE COPING

[Inadequate coping method]
[Underdeveloped superego]
[Absent, erratic, or inconsistent methods of discipline]
[Extreme poverty]

[Disregard for societal norms and laws]
[Absence of guilt feelings]
[Inability to delay gratication]
[Extreme impulsivity]
[Inability to learn from punishment]
Goals/Objectives
Short-term Goal
Within 24 hours after admission, client will verbalize under-
standing of the rules and regulations of the treatment setting
and the consequences for violation of them.
2506_Ch16_275-309.indd 0299 10/1/10 9:37:02 AM

Long-term Goal
Client will be able to cope more adaptively by delaying gratica-
tion of own desires and following rules and regulations of the
treatment setting by time of discharge.
1. From the onset, client should be made aware of which be-
haviors will not be accepted in the treatment setting. Explain
consequences of violation of the limits. Consequences must
involve something of value to the client. All staff must be
consistent in enforcing these limits. Consequences should be
administered in a matter-of-fact manner immediately after
the infraction. Because client cannot (or will not) impose own
limits on maladaptive behaviors, these behaviors must be
delineated and enforced by staff. Undesirable consequences
may help to decrease repetition of these behaviors.
2. Do not attempt to coax or convince client to do the right
thing. Do not use the words You should (or shouldnt)...;
instead, use You will be expected to... . The ideal would be
for this client to eventually internalize societal norms, begin-
ning with this step-by-step, either/or approach on the unit
(either you do [dont do] this, or this will occur). Explanations
must be concise, concrete, and clear, with little or no capac-
ity for misinterpretation.
3. Provide positive feedback or reward for acceptable behaviors.
4. In an attempt to assist client to delay gratification, begin to
increase the length of time requirement for acceptable be-
havior in order to achieve the reward. For example, 2 hours
of acceptable behavior may be exchanged for a telephone
call; 4 hours of acceptable behavior for 2 hours of television;
1 day of acceptable behavior for a recreational therapy bowl-
ing activity; 5 days of acceptable behavior for a weekend pass.
5. A milieu unit provides an appropriate environment for the
client with antisocial personality. The democratic approach,
with specific rules and regulations, community meetings,
and group therapy sessions, emulates the type of societal
situation in which the client must learn to live. Feedback
from peers is often more effective than confrontation from
an authority figure. The client learns to follow the rules of
the group as a positive step in the progression toward inter-
nalizing the rules of society.
6. Help client gain insight into own behavior. Often, these indi-
viduals rationalize to such an extent that they deny that their
behavior is inappropriate. (For example, The owner of this
store has so much money, hell never miss the little bit I take.
2506_Ch16_275-309.indd 0300 10/1/10 9:37:03 AM

He has everything, and I have nothing. Its not fair! I deserve

to have some of what he has.) Client must come to under-
stand that certain behaviors will not be tolerated within the
society and that severe consequences will be imposed on those
individuals who refuse to comply. Client must want to be-
come a productive member of society before he or she can be
helped.
7. Talk about past behaviors with client. Discuss which behav-
iors are acceptable by societal norms and which are not. Help
client identify ways in which he or she has exploited others.
Encourage client to explore how he or she would feel if the
circumstances were reversed. An attempt may be made to
enlighten the client to the sensitivity of others by promoting
self-awareness in an effort to help the client gain insight
into his or her own behavior.
8. Throughout relationship with client, maintain attitude of It
is not you, but your behavior, that is unacceptable. An attitude
of acceptance promotes feelings of dignity and self-worth.
Outcome Criteria
1. Client follows rules and regulations of the milieu environ-
ment.
2. Client is able to verbalize which of his or her behaviors are
not acceptable.
3. Client shows regard for the rights of others by delaying grati-
cation of own desires when appropriate.
DEFENSIVE COPING
perceived threats to positive self-regard.

[Low self-esteem]

2506_Ch16_275-309.indd 0301 10/1/10 9:37:03 AM

Grandiosity
Lack of follow-through or participation in treatment or
therapy
Goals/Objectives
Short-term Goal
Client will verbalize personal responsibility for difculties ex-
perienced in interpersonal relationships within (time period
reasonable for client).
Long-term Goal
Client will demonstrate ability to interact with others with-
out becoming defensive, rationalizing behaviors, or expressing
grandiose ideas.
concept.
2. Encourage client to recognize and verbalize feelings of inad-
equacy and need for acceptance from others, and how these
feelings provoke defensive behaviors, such as blaming others
for own behaviors. Recognition of the problem is the first
step in the change process toward resolution.
about how he or she is being perceived by others. Providing
this information in a nonthreatening manner may help to
eliminate these undesirable behaviors.
4. Help client identify situations that provoke defensiveness and
practice through role-playing more appropriate responses.
Role-playing provides confi dence to deal with difficult situ-
ations when they actually occur.
6. Help client set realistic, concrete goals and determine
appropriate actions to meet those goals. Success increases
self-esteem.
7. Evaluate with client the effectiveness of the new behaviors
2506_Ch16_275-309.indd 0302 10/1/10 9:37:03 AM


to reassess and develop new strategies in the event that
certain of the new coping methods prove ineffective.
Outcome Criteria
grandiosity.
4. Client interacts with others in group situations without tak-
ing a defensive stance.
LOW SELF-ESTEEM
capabilities.

[Repeated negative feedback, resulting in diminished self-
worth]
[Absent, erratic, or inconsistent parental discipline]
[Extreme poverty]
[History of childhood abuse]

[Grandiosity]
[Frequent use of derogatory and critical remarks against
others]
[Manipulation of one staff member against another in an at-
tempt to gain special privileges]
Goals/Objectives
Short-term Goal
Client will verbalize an understanding that derogatory and criti-
cal remarks against others reects feelings of self-contempt.
2506_Ch16_275-309.indd 0303 10/1/10 9:37:04 AM

Long-term Goal
Client will experience an increase in self-esteem, as evidenced
by verbalizations of positive aspects of self and the lack of ma-
nipulative behaviors toward others.
likely. Success increases self-esteem.
2. Identify ways in which client is manipulating others. Set
limits on manipulative behavior. Because client is unable (or
unwilling) to limit own maladaptive behaviors, assistance
is required from staff.
3. Explain consequences of manipulative behavior. All staff
must be consistent and follow through with consequences
in a matter-of-fact manner. From the onset, client must be
aware of the outcomes his or her maladaptive behaviors will
effect. Without consistency of follow-through from all staff,
a positive outcome cannot be achieved.
4. Encourage client to talk about his or her behavior, the limits,
and consequences for violation of those limits. Discussion of
feelings regarding these circumstances may help the client
achieve some insight into his or her situation.
5. Discuss how manipulative behavior interferes with forma-
tion of close, personal relationships. Client may be unaware
of others perception of him or her and of why these behav-
iors are not acceptable to others.
6. Help client identify more adaptive interpersonal strategies.
Provide positive feedback for nonmanipulative behaviors.
Client may require assistance with solving problems. Posi-
7. Encourage client to confront the fear of failure by attending
therapy activities and undertaking new tasks. Offer recogni-
tion of successful endeavors.
8. Help client identify positive aspects of the self and develop
ways to change the characteristics that are socially unaccept-
able. Individuals with low self-esteem often have difficulty
recognizing their positive attributes. They may also lack
problem-solving ability and require assistance to formulate
a plan for implementing the desired changes.
9. Minimize negative feedback to client. Enforce limit-setting
in a matter-of-fact manner, imposing previously established
consequences for violations. Negative feedback can be ex-
tremely threatening to a person with low self-esteem, pos-
sibly aggravating the problem. Consequences should convey
unacceptability of the behavior but not the person.
2506_Ch16_275-309.indd 0304 10/1/10 9:37:04 AM

10. Encourage independence in the performance of personal

responsibilities and in decision-making related to own self-
care. Offer recognition and praise for accomplishments.
Positive reinforcement enhances self-esteem and encour-
ages repetition of desirable behaviors.
11. Help client increase level of self-awareness through critical
examination of feelings, attitudes, and behaviors. Help cli-
ent understand that it is perfectly acceptable for attitudes
and behaviors to differ from those of others, as long as they
do not become intrusive. As the client becomes more aware
and accepting of himself or herself, the need for judging the
behavior of others will diminish.
12. Teach client assertiveness techniques, especially the ability
to recognize the differences among passive, assertive, and
aggressive behaviors and the importance of respecting the
human rights. These techniques increase self-esteem while
enhancing the ability to form satisfactory interpersonal
relationships.
Outcome Criteria
1. Client verbalizes positive aspects about self.
2. Client does not manipulate others in an attempt to increase
feelings of self-worth.
3. Client considers the rights of others in interpersonal
interactions.


[Retarded superego development]
[Negative role-modeling]
Knowledge decit about ways to enhance mutuality

Inability to receive or communicate a satisfying sense of social
engagement (e.g., belonging, caring, interest, shared history)
2506_Ch16_275-309.indd 0305 10/1/10 9:37:04 AM


[Exploitation of others for the fulllment of own desires]
[Inability to develop satisfactory, enduring, intimate relation-
ship with a sexual partner]
[Physical and verbal hostility toward others when ful llment of
own desires is thwarted]
Goals/Objectives
Short-term Goal
Client will develop satisfactory relationship (no evidence
of manipulation or exploitation) with nurse or therapist within
1 week.
Long-term Goal
Client will interact appropriately with others, demonstrating
concern for the needs of others as well as for his or her own
needs, by time of discharge from treatment.

1. Develop therapeutic rapport with client. Establish trust by
always being honest; keep all promises; convey acceptance of
person, separate from unacceptable behaviors (It is not you,
but your behavior, that is unacceptable.) An attitude of ac-
ceptance promotes feelings of self-worth. Trust is the basis of
others. Presence of a trusted individual increases feelings of
security during uncomfortable situations.
3. Provide constructive criticism and positive reinforcement for
efforts. Positive feedback enhances self-esteem and encour-
ages repetition of desirable behaviors.
4. Confront client as soon as possible when interactions with
others are manipulative or exploitative. Establish con-
sequences for unacceptable behavior, and always follow
through. Because of the strong id influence on clients be-
havior, he or she should receive immediate feedback when
behavior is unacceptable. Consistency in enforcing the con-
sequences is essential if positive outcomes are to be achieved.
Inconsistency creates confusion and encourages testing of
limits.
tions with him or her and with others. Role-modeling is a
powerful and effective form of learning.
6. Provide group situations for client. It is through these
group interactions with positive and negative feedback
from his or her peers that client will learn socially accept-
able behavior.
2506_Ch16_275-309.indd 0306 10/1/10 9:37:04 AM

Outcome Criteria
activities.
2. Client has satisfactorily established and maintained one
interpersonal relationship with nurse or therapist, without
evidence of manipulation or exploitation.
3. Client demonstrates ability to interact appropriately with
others, showing respect for self and others.
4. Client is able to verbalize reasons for inability to form close
interpersonal relationships with others in the past.
DEFICIENT KNOWLEDGE (SELF-CARE

ACTIVITIES TO ACHIEVE AND
MAINTAIN OPTIMAL WELLNESS)

[Low self-esteem]
[Denial of need for information]
[Denial of risks involved with maladaptive lifestyle]
Unfamiliarity with information sources

[History of substance abuse]
[Statement of lack of knowledge]
[Statement of misconception]
[Request for information]
[Demonstrated lack of knowledge regarding basic health
practices]
[Reported or observed inability to take the responsibility
for meeting basic health practices in any or all functional pat-
tern areas]
[History of lack of health-seeking behavior]
Inappropriate or exaggerated behaviors (e.g., hysterical, hostile,
agitated, apathetic)
Goals/Objectives
Short-term Goal
Client will verbalize understanding of knowledge required
to ful ll basic health needs following implementation of teach-
ing plan.
2506_Ch16_275-309.indd 0307 10/1/10 9:37:05 AM

Long-term Goal
Client will be able to demonstrate skills learned for fulllment
of basic health needs by time of discharge from therapy.

1. Assess clients level of knowledge regarding positive self-
care practices. An adequate database is necessary for the
development of an effective teaching plan.
3. Determine method of learning most appropriate for client
(e.g., discussion, question and answer, use of audio or visual
aids, oral, written). Be sure to consider level of education
and development. Teaching will be ineffective if presented
at a level or by a method inappropriate to the clients ability
to learn.
4. Develop teaching plan, including measurable objectives for
the learner. Provide information regarding healthful strate-
gies for activities of daily living as well as about harmful
effects of substance abuse on the body. Include suggestions
for community resources to assist client when adaptability is
impaired. Client needs this information to promote effec-
tive health maintenance.
5. Include signicant others in the learning activity, if pos-
sible. Input from individuals who are directly involved in
the potential change increases the likelihood of a positive
outcome.
6. Implement teaching plan at a time that facilitates, and in a
place that is conducive to, optimal learning (e.g., in the eve-
ning when family members visit; in an empty, quiet class-
room or group therapy room). Learning is enhanced by an
environment with few distractions.
7. Begin with simple concepts and progress to the more com-
plex. Retention is increased if introductory material is easy
to understand.
8. Provide activities for client and signicant others in which
to actively participate during the learning exercise. Active
participation increases retention.
9. Ask client and signicant others to demonstrate knowledge
gained by verbalizing information regarding positive self-
care practices. Verbalization of knowledge gained is a mea-
surable method of evaluating the teaching experience.
10. Provide positive feedback for participation, as well as for
accurate demonstration of knowledge gained. Positive feed-
back enhances self-esteem and encourages repetition of
desirable behaviors.
2506_Ch16_275-309.indd 0308 10/1/10 9:37:05 AM

Outcome Criteria
1. Client is able to verbalize information regarding positive
self-care practices.
2. Client is able to verbalize available community resources for
obtaining knowledge about and help with decits related to
health care.
INTERNET REFERENCES
Additional information about personality disorders may be
a. http://www.mentalhealth.com/dis/p20-pe04.html
b. http://www.mentalhealth.com/dis/p20-pe08.html
c. http://www.mentalhealth.com/dis/p20-pe05.html
d. http://www.mentalhealth.com/dis/p20-pe09.html
e. http://www.mentalhealth.com/dis/p20-pe06.html
f. http://www.mentalhealth.com/dis/p20-pe07.html
g. http://www.mentalhealth.com/dis/p20-pe10.html
h. http://www.mentalhealth.com/dis/p20-pe01.html
i. http://www.mentalhealth.com/dis/p20-pe02.html
j. http://www.mentalhealth.com/dis/p20-pe03.html
k. http://www.mentalhealth.com/p13.html#Per
Movie Connections
Taxi Driver (schizoid personality) One Flew Over the Cuckoos
Nest (antisocial) The Boston Strangler (antisocial) Just Cause (antisocial)
The Dream Team (antisocial) Goodfellas (antisocial) Fatal Attraction
(borderline) Play Misty for Me (borderline) Girl, Interrupted (borderline)
Gone With the Wind (histrionic) Wall Street (narcissistic) The Odd
Couple (obsessive-compulsive) As Good As It Gets (obsessive-compulsive)
2506_Ch16_275-309.indd 0309 10/1/10 9:37:05 AM

UNIT THREE
SPECIAL TOPICS IN
PSYCHIATRIC/MENTAL
HEALTH NURSING
C H A P T E R
17
Problems Related
to Abuse or Neglect
Categories of Abuse and Neglect
Physical Abuse of a Child
Physical abuse of a child includes any nonaccidental physical in-
jury (ranging from minor bruises to severe fractures or death)
as a result of punching, beating, kicking, biting, burning, shak-
ing, throwing, stabbing, choking, hitting (with a hand, stick,
strap, or other object), burning, or otherwise harming a child,
that is in icted by a parent, caregiver, or other person who
has responsibility for the child (Child Welfare Information
Gateway [CWIG], 2008). The most obvious way to detect it is
by outward physical signs. However, behavioral indicators may
also be evident.
Sexual Abuse of a Child
This category is de ned as employment, use, persuasion, in-
ducement, enticement, or coercion of any child to engage in, or
assist any other person to engage in, any sexually explicit con-
duct or any simulation of such conduct for the purpose of pro-
ducing any visual depiction of such conduct; or the rape, and in
310
2506_Ch17_310-319.indd Sec1:310 10/1/10 9:37:14 AM

cases of caretaker or inter-familial relationships, statutory rape,

molestation, prostitution, or other form of sexual exploitation of
children, or incest with children (CWIG, 2008). Incest is the
occurrence of sexual contacts or interaction between, or sexual
exploitation of, close relatives, or between participants who are
related to each other by a kinship bond that is regarded as a pro-
hibition to sexual relations (e.g., caretakers, stepparents, stepsib-
lings) (Sadock & Sadock, 2007).
Neglect of a Child
Physical neglect of a child includes refusal of or delay in seeking
health care, abandonment, expulsion from the home or refusal
to allow a runaway to return home, and inadequate supervision.
Emotional neglect refers to a chronic failure by the parent or care-
taker to provide the child with the hope, love, and support nec-
essary for the development of a sound, healthy personality.
Physical Abuse of an Adult
Physical abuse of an adult may be de ned as behavior used
with the intent to cause harm and to establish power and con-
trol over another person. It may include slaps, punches, biting,
hair-pulling, choking, kicking, stabbing or shooting, or forcible
restraint.
Sexual Abuse of an Adult
Sexual abuse of an adult may be de ned as the expression of
power and dominance by means of sexual violence, most com-
monly by men over women, although men may also be victims of
sexual assault. Sexual assault is identied by the use of force and
executed against the persons will.
Predisposing Factors (that Contribute

to Patterns of Abuse)
1. Physiological
a. Neurophysiological Influences. Various components of
the neurological system in both humans and animals have
been implicated in both the facilitation and inhibition of
aggressive impulses. Areas of the brain that may be in-
volved include the temporal lobe, the limbic system, and
the amygdaloid nucleus (Tardiff, 2003).
b. Biochemical Influences. Studies show that various
neurotransmittersin particular norepinephrine, dopa-
mine, and serotoninmay play a role in the facilitation
and inhibition of aggressive impulses (Hollander, Berlin,
& Stein, 2008).
c. Genetic Influences. Some studies have implicated heredity
as a component in the predisposition to aggressive behav-
ior. Both direct genetic links and the genetic karyotype
2506_Ch17_310-319.indd Sec1:311 10/1/10 9:37:15 AM

312 SPECIAL TOPICS IN PSYCHIATRIC
XYY have been investigated as possibilities. Evidence

remains inconclusive.
d. Disorders of the Brain. Various disorders of the brain
including tumors, trauma, and certain diseases (e.g.,
encephalitis and epilepsy) have been implicated in the pre-
disposition to aggressive behavior.
2. Psychosocial
a. Psychodynamic Theory. The psychodynamic theorists
imply that unmet needs for satisfaction and security re-
sult in an underdeveloped ego and a weak superego. It is
thought that when frustration occurs, aggression and vio-
lence supply this individual with a dose of power and pres-
tige that boosts the self-image and validates a signicance
to his or her life that is lacking. The immature ego cannot
prevent dominant id behaviors from occurring, and the
weak superego is unable to produce feelings of guilt.
b. Learning Theory. This theory postulates that aggressive
and violent behaviors are learned from prestigious and
inuential role models. Individuals who were abused as
children or whose parents disciplined with physical pun-
ishment are more likely to behave in a violent manner as
adults (Tardiff, 2003).
c. Societal Influences. Social scientists believe that aggres-
sive behavior is primarily a product of ones culture and
social structure. Societal inuences may contribute to
violence when individuals believe that their needs and
desires cannot be met through conventional means, and
they resort to delinquent behaviors in an effort to obtain
desired ends.
Data)
1. Signs of physical abuse may include the following:
a. Bruises over various areas of the body. They may present
with different colors of bluish-purple to yellowish-green
(indicating various stages of healing).
b. Bite marks, skin welts, burns.
c. Fractures, scars, serious internal injuries, brain damage.
d. Lacerations, abrasions, or unusual bleeding.
e. Bald spots indicative of severe hair pulling.
f. In a child, regressive behaviors (such as thumb sucking
and enuresis) are common.
g. Extreme anxiety and mistrust of others.
2. Signs of neglect of a child may include the following:
a. Soiled clothing that does not t and may be inappropriate
for the weather.
b. Poor hygiene.
2506_Ch17_310-319.indd Sec1:312 10/1/10 9:37:16 AM

c. Always hungry, with possible signs of malnutrition (e.g.,

emaciated with swollen belly).
d. Listless and tired much of the time.
e. Unattended medical problems.
f. Social isolation; unsatisfactory peer relationships.
g. Poor school performance and attendance record.
3. Signs of sexual abuse of a child include the following:
a. Frequent urinary infections.
b. Difculty or pain in walking or sitting.
c. Rashes or itching in the genital area; scratching the area a
great deal or dgeting when seated.
d. Frequent vomiting.
e. Seductive behavior; compulsive masturbation; precocious
sex play.
f. Excessive anxiety and mistrust of others.
g. Sexually abusing another child.
4. Signs of sexual abuse of an adult include the following
(Burgess, 2009):
a. Contusions and abrasions about various parts of the body.
b. Headaches, fatigue, sleep-pattern disturbances.
c. Stomach pains, nausea, and vomiting.
d. Vaginal discharge and itching, burning on urination, rec-
tal bleeding and pain.
e. Rage, humiliation, embarrassment, desire for revenge,
self-blame.
f. Fear of physical violence and death.

and Interventions
RAPE-TRAUMA SYNDROME
De nition: Sustained maladaptive response to a forced, violent
sexual penetration against the victims will and consent.

[Having been the victim of sexual violence executed with the
use of force and against ones personal will and consent]

Disorganization
Change in relationships
2506_Ch17_310-319.indd Sec1:313 10/1/10 9:37:16 AM

Confusion
Physical trauma (e.g., bruising, tissue irritation)
Suicide attempts
Denial; guilt
Paranoia; humiliation, embarrassment
Aggression; muscle tension and/or spasms
Mood swings
Dependence
Powerlessness; helplessness
Nightmares and sleep disturbances
Sexual dysfunction
Revenge; phobias
Loss of self-esteem
Impaired decision-making
Substance abuse; depression
Anger; anxiety; agitation
Shame; shock; fear
Goals/Objectives
Short-term Goal
The clients physical wounds will heal without complication.
Long-term Goal
The client will begin a healthy grief resolution, initiating the
process of physical and psychological healing (time to be indi-

1. It is important to communicate the following to the victim of
sexual assault:
a. You are safe here.
b. Im sorry that it happened.
c. Im glad that you survived.
d. Its not your fault. No one deserves to be treated this
way.
e. You did the best that you could.
The woman who has been sexually assaulted fears for her
life and must be reassured of her safety. She may also be
overwhelmed with self-doubt and self-blame, and these
statements instill trust and validate self-worth.
2. Explain every assessment procedure that will be conducted
and why. Ensure that data collection is conducted in a car-
ing, nonjudgmental manner to decrease fear and anxiety and
increase trust.
3. Ensure that the client has adequate privacy for all immediate
post-crisis interventions. Try to have as few people as pos-
sible providing the immediate care or collecting immediate
2506_Ch17_310-319.indd Sec1:314 10/1/10 9:37:16 AM

evidence. The post-trauma client is extremely vulnerable.

Additional people in the environment increase this feeling
of vulnerability and may escalate anxiety.
4. Encourage the client to give an account of the assault. Lis-
ten, but do not probe. Nonjudgmental listening provides an
avenue for catharsis that the client needs to begin healing.
A detailed account may be required for legal follow-up, and
a caring nurse, as client advocate, may help to lessen the
trauma of evidence collection.
5. Discuss with the client whom to call for support or assistance.
Provide information about referrals for aftercare. Because of
severe anxiety and fear, client may need assistance from oth-
ers during this immediate postcrisis period. Provide referral
information in writing for later reference (e.g., psychothera-
pist, mental health clinic, community advocacy group).
Outcome Criteria
1. Client is no longer experiencing panic anxiety.
2. Client demonstrates a degree of trust in the primary nurse.
3. Client has received immediate attention to physical injuries.
4. Client has initiated behaviors consistent with the grief
response.
POWERLESSNESS

[Low self-esteem]
[Living with, or in a long-term relationship with, an individ-
ual who victimizes by in icting physical pain or injury with
the intent to cause harm, and continues to do so over a long
period of time]
[Lack of support network of caring others]
[Lack of nancial independence]

Verbal expressions of having no control [or inuence] over situ-
ation or outcome
Passivity
[Verbalizations of abuse]
2506_Ch17_310-319.indd Sec1:315 10/1/10 9:37:16 AM

[Lacerations over areas of body]

[Fear for personal and childrens safety]
[Verbalizations of no way to get out of relationship]
Goals/Objectives
Short-term Goal
Client will recognize and verbalize choices that are available,
thereby perceiving some control over life situation (time dimen-
sion to be individually determined).
Long-term Goal
Client will exhibit control over life situation by making deci-
sion about what to do regarding living with cycle of abuse (time
dimension to be individually determined).
1. In collaboration with physician, ensure that all physical
wounds, fractures, and burns receive immediate attention.
Take photographs if the victim will permit. Client safety is a
nursing priority. Photographs may be called in as evidence
if charges are filed.
2. Take the client to a private area to do the interview. If the cli-
ent is accompanied by the person who did the battering, she
or he is not likely to be truthful about the injuries.
3. If she has come alone or with her children, assure her of her
safety. (Authors note: Female gender is used here because most
intimate partner violence [IPV] is directed by men toward women
although it is understood that men are also victims of IPV.) En-
courage her to discuss the battering incident. Ask questions
about whether this has happened before, whether the abuser
takes drugs, whether the woman has a safe place to go, and
whether she is interested in pressing charges. Some women
will attempt to keep secret how their injuries occurred in an
effort to protect the partner or because they are fearful that
the partner will kill them if they tell.
4. Ensure that rescue efforts are not attempted by the nurse.
Offer support, but remember that the nal decision must be
made by the client. Making her own decision will give the
client a sense of control over her life situation. Imposing
judgments and giving advice are nontherapeutic.
5. Stress to the victim the importance of safety. She must be
made aware of the variety of resources that are available to
her. These may include crisis hotlines, community groups for
women who have been abused, shelters, counseling services,
and information regarding the victims rights in the civil
and criminal justice system. Following a discussion of these
available resources, the woman may choose for herself. If her
2506_Ch17_310-319.indd Sec1:316 10/1/10 9:37:17 AM

decision is to return to the marriage and home, this choice

also must be respected. Knowledge of available choices can
serve to decrease the victims sense of powerlessness, but
true empowerment comes only when she chooses to use that
knowledge for her own benefit.
Outcome Criteria
2. Client verbalizes assurance of her immediate safety.
3. Client discusses life situation with primary nurse.
4. Client is able to verbalize choices available to her from which
she may receive assistance.
RISK FOR DELAYED DEVELOPMENT

De nition: At risk for delay of 25% or more in one or more of the
areas of social or self-regulatory behavior, or in cognitive, lan-
guage, gross or fine motor skills.

[The in iction by caretakers of physical or sexual abuse, usually
occurring over an extended period of time]
[Ignoring the childs basic physiological needs]
[Indifference to the child]
[Ignoring the childs presence]
[Ignoring the childs social, educational, recreational, and devel-
opmental needs]
Goals/Objectives
Short-term Goal
Client will develop trusting relationship with nurse and report
how evident injuries were sustained (time dimension to be indi-
Long-term Goal
Client will demonstrate behaviors consistent with age-appropriate
growth and development.

1. Perform complete physical assessment of the child. Take par-
ticular note of bruises (in various stages of healing), lacera-
tions, and client complaints of pain in specic areas. Do not
overlook or discount the possibility of sexual abuse. Assess for
nonverbal signs of abuse: aggressive conduct, excessive fears,
extreme hyperactivity, apathy, withdrawal, age-inappropriate
2506_Ch17_310-319.indd Sec1:317 10/1/10 9:37:17 AM

behaviors. An accurate and thorough physical assessment is

required in order to provide appropriate care for the client.
2. Conduct an in-depth interview with the parent or adult who
accompanies the child. Consider: If the injury is being reported
as an accident, is the explanation reasonable? Is the injury
consistent with the explanation? Is the injury consistent with
the childs developmental capabilities? Fear of imprisonment
or loss of child custody may place the abusive parent on the
defensive. Discrepancies may be evident in the description of
the incident, and lying to cover up involvement is a common
defense that may be detectable in an in-depth interview.
3. Use games or play therapy to gain childs trust. Use these
techniques to assist in describing his or her side of the story.
Establishing a trusting relationship with an abused child
is extremely difficult. The child may not even want to be
touched. These types of play activities can provide a non-
threatening environment that may enhance the childs at-
tempt to discuss these painful issues.
4. Determine whether the nature of the injuries warrants re-
porting to authorities. Specic state statutes must enter into
the decision of whether to report suspected child abuse.
Individual state statues regarding what constitutes child
abuse and neglect may be found at http://www.childwelfare.
gov/systemwide/laws_policies/state/. A report is commonly
made if there is reason to suspect that a child has been in-
jured as a result of physical, mental, emotional, or sexual
abuse. Reason to suspect exists when there is evidence
of a discrepancy or inconsistency in explaining a childs
injury. Most states require that the following individuals
report cases of suspected child abuse: all health-care work-
ers, all mental health therapists, teachers, child-care pro-
viders, firefighters, emergency medical services personnel,
and law enforcement personnel. Reports are made to the
Department of Health and Human Services or a law en-
forcement agency.
Outcome Criteria
2. Client demonstrates trust in primary nurse by discussing
abuse through the use of play therapy.
3. Client is demonstrating a decrease in regressive behaviors.
INTERNET REFERENCES
Additional information related to child abuse may be located
a. http://www.childwelfare.gov
b. http://endabuse.org/
2506_Ch17_310-319.indd Sec1:318 10/1/10 9:37:17 AM

c. http://www.child-abuse.com
d. http://www.nlm.nih.gov/medlineplus/childabuse.html
Additional information related to sexual assault may be
a. http://www.vaw.umn.edu/
b. http://www.nlm.nih.gov/medlineplus/rape.html
Additional information related to intimate partner violence
a. http://www.ndvh.org/
b. http://home.cybergrrl.com/dv/book/toc.html
c. http://www.crisis-support.org/
d. http://w w w.ama-assn.org/ama/no-index /about-ama/
13577.shtml
e. http://www.nursingworld.org/MainMenuCategories/
A NA Market place/A NA Per iodicals/OJ I N/ Tableof
Contents/Volume72002/No1Jan2002.aspx
Movie Connections
The Burning Bed (domestic violence) Life With Billy (domestic
violence) Two Story House (child abuse) The Prince of Tides (domestic
violence) Radio Flyer (child abuse) Flowers in the Attic (child abuse)
A Case of Rape (sexual assault)
2506_Ch17_310-319.indd Sec1:319 10/1/10 9:37:18 AM

C H A P T E R
18
Premenstrual
Dysphoric Disorder
Dened
Premenstrual dysphoric disorder (PMDD) is identied by a
variety of physical and emotional symptoms that occur during
the last week of the luteal phase of the menstrual cycle and that
remit within a few days after the onset of the follicular phase.
In most women, these symptoms occur in the week before, and
remit within a few days after, the onset of menses. The disorder
has also been reported in nonmenstruating women who have
had a hysterectomy but retain ovarian function. The diagnosis
is given only when the symptoms are sufciently severe to cause
marked impairment in social or occupational functioning and
have occurred during a majority of menstrual cycles in the past
year (American Psychiatric Association [APA], 2000).
Predisposing Factors to PMDD

1. Physiological
a. Biochemical. An imbalance of the hormones estrogen and
progesterone has been implicated in the predisposition
to PMDD. It is postulated that excess estrogen or a high
estrogen-to-progesterone ratio during the luteal phase
causes water retention and that this hormonal imbalance
has other effects as well, resulting in the symptoms asso-
ciated with premenstrual syndrome.
b. Nutritional. A number of nutritional alterations have
been implicated in the etiology of PMDD, although
the exact role is unsubstantiated. Deciencies in the B
vitamins, calcium, magnesium, manganese, vitamin E,
and linolenic acid have been suggested. Glucose toler-
ance uctuations, abnormal fatty acid metabolism, and
sensitivity to caffeine and alcohol may also play a role
in contributing to the symptoms associated with this
disorder.
320
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Data)
The following symptoms have been associated with PMDD
(APA, 2000; Sadock & Sadock, 2007):
1. Feelings of depression and hopelessness
2. Increased anxiety and restlessness
3. Mood swings
4. Anger and irritability
5. Decreased interest in usual activities
6. Difculty concentrating
7. Anergia; increased fatigability
8. Appetite changes (e.g., food cravings)
9. Changes in sleep patterns (e.g., hypersomnia or insomnia)
10. Somatic complaints (e.g., breast tenderness, headaches,
edema)
Other subjective symptoms that have been reported include:
11. Cramps
12. Alcohol intolerance
13. Acne
14. Cystitis
15. Oliguria
16. Altered sexual drive
17. Forgetfulness
18. Suicidal ideations or attempts

and Interventions
ACUTE PAIN
De nition: Sudden or slow onset of any intensity from mild to
severe with an anticipated or predictable end and a duration of less
than 6 months.

[Imbalance in estrogen and progesterone levels]
[Possible nutritional alterations, including the following:
Vitamin B deciencies
Glucose tolerance uctuations
Abnormal fatty acid metabolism, which may contribute to
alterations in prostaglandin synthesis
2506_Ch18_320-328.indd Sec1:321 10/1/10 9:37:27 AM

Magnesium deciency
Vitamin E deciency
Caffeine sensitivity
Alcohol intolerance]
[Fluid retention]
[Subjective communication of:
Headache
Backache
Joint or muscle pain
A sensation of bloating
Abdominal cramping
Breast tenderness and swelling]
Facial mask [of pain]
Sleep disturbance
Self-focus
Changes in appetite [and eating]
Goals/Objectives
Short-term Goal
Client cooperates with efforts to manage symptoms of PMDD
and minimize feelings of discomfort.
Long-term Goal
Client verbalizes relief from discomfort associated with symp-
toms of PMDD.
1. Assess and record location, duration, and intensity of pain.
Background assessment data are necessary to formulate an
accurate plan of care for the client.
2. Provide nursing comfort measures with a matter-of-fact ap-
proach that does not give positive reinforcement to the pain
behavior (e.g., backrub, warm bath, heating pad). Give addi-
tional attention at times when client is not focusing on physi-
cal symptoms. These measures may serve to provide some
temporary relief from pain. Absence of secondary gains in
the form of positive reinforcement may discourage clients
use of the pain as attention-seeking behavior.
3. Encourage the client to get adequate rest and sleep and avoid
stressful activity during the premenstrual period. Fatigue
exaggerates symptoms associated with PMDD. Stress elicits
heightened symptoms of anxiety, which may contribute to
exacerbation of symptoms and altered perception of pain.
4. Assist client with activities that distract from focus on self
and pain. Demonstrate techniques such as visual or auditory
2506_Ch18_320-328.indd Sec1:322 10/1/10 9:37:27 AM

distractions, guided imagery, breathing exercises, massage,

application of heat or cold, and relaxation techniques that
may provide symptomatic relief. These techniques may help
to maintain anxiety at a manageable level and prevent the
discomfort from becoming disabling.
5. In an effort to correct the possible nutritional alterations
that may be contributing to PMDD, the following guide-
lines may be suggested:
a. Reduce intake of fats in the diet, particularly saturated
fats.
b. Limit intake of dairy products to two servings a day (exces-
sive dairy products block the absorption of magnesium).
c. Increase intake of complex carbohydrates (vegetables,
legumes, cereals, and whole grains) and cis-linoleic acid
containing foods (e.g., safower oil).
d. Decrease rened and simple sugars. (Excess sugar is thought
to cause nervous tension, palpitations, headache, dizziness,
drowsiness, and excretion of magnesium in the urine.)
e. Decrease salt intake to 3 g per day but not less than 0.5 g
per day. (Salt restriction prevents edema; too little salt
stimulates norepinephrine and causes sleep disturbances.)
f. Limit intake of caffeine (coffee, tea, colas, and chocolate)
and alcohol (one or two drinks a week). Caffeine increases
breast tenderness and pain. Alcohol can cause reactive
hypoglycemia and uid retention.
g. Because some women crave junk food during the pre-
menstrual period, it is important that they take a multiple
vitamin or mineral tablet daily to ensure that adequate
nutrients are consumed.
6. Administer medications as prescribed. Monitor client re-
sponse for effectiveness of the medication, as well as for ap-
pearance of adverse side effects. When other measures are
insuffi cient to bring about relief, physician may prescribe
symptomatic drug therapy. Provide client with information
about the medication to be administered. Client has the
right to know about the treatment she is receiving. Some
medications commonly used for symptomatic treatment
of PMDD are presented in Table 18-1. Some women have
experienced relief from the symptoms of PMDD through
the use of herbal medications; some of these are listed in
Table 18-2.
Outcome Criteria
1. Client demonstrates ability to manage premenstrual symp-
toms with minimal discomfort.
2. Client verbalizes relief of painful symptoms.
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TABLE 18 1 Medications for Symptomatic Relief of PMDD

Medication Indication
Fluoxetine (Sarafem), sertraline These medications have been

(Zoloft), paroxetine (Paxil) approved by the FDA for
treatment of PMDD.
Hydrochlorothiazide (Ezide, Diuretics may provide relief from
HydroDiuril), furosemide edema when diet and sodium
(Lasix) restriction are not sufcient.
Ibuprofen (Advil, Motrin), Nonsteroidal anti-inammatory
naproxen (Naprosyn, agents may provide relief
Aleve) from joint, muscle, and lower
abdominal pain related to
increased prostaglandins.
Propranolol (Inderal), verapamil -Blockers and calcium channel
(Isoptin) blockers are often given for pro-
phylactic treatment of migraine
headaches.
Sumatriptan (Imitrex), naratriptan These serotonin 5-HT1 receptor
(Amerge), rizatriptan (Maxalt), agonists are highly effective in
zolmitriptan (Zomig), frovatrip- the treatment of acute migraine
tan (Frova), almotriptan (Axert), attack.
eletriptan (Relpax)
Bromocriptine (Parlodel) This drug may be prescribed to
relieve breast pain and other
symptoms of PMDD that may be
caused by elevated prolactin.
TABLE 18 2 Herbals Used for Symptoms of Premenstrual

Syndrome
Precautions/Adverse
Herbal Effects Contraindications
Black cohosh May potentiate the effects Pregnancy

(Cimicifuga of antihypertensive
racemosa) medications. Some indi-
viduals may experience
nausea or headache.
Bugleweed No side effects known. Thyroid disease
(Lycopus Should not be taken
virginicus) concomitantly with
thyroid preparations.
Chaste tree Occasional rashes may Pregnancy and
(Vitex agnus- occur. Should not be lactation
castus) taken concomitantly
with dopamine-receptor
antagonists.
2506_Ch18_320-328.indd Sec1:324 10/1/10 9:37:28 AM

TABLE 18 2 Herbals Used for Symptoms of Premenstrual

Syndromecontd
Precautions/Adverse
Herbal Effects Contraindications
Evening primrose May lower the seizure

(Oenothera threshold. Should not be
biennis) taken concomitantly with
other drugs that lower the
seizure threshold.
Potentilla May cause stomach
(Potentilla irritation.
anserine)
Shepherds purse No side effects known. Pregnancy
(Capsella bursa-
pastoris)
Valerian With long-term use: Pregnancy and
(Valeriana headache, restless states, lactation
of cinalis) sleeplessness, mydriasis,
disorders of cardiac
function. Should not
be taken concomitantly
with CNS depressants.
Sources: PDR for Herbal Medicines (4th ed.). (2007). Montvale, NJ: Thomson
Healthcare Inc.; and Presser, A.M. (2000). Pharmacists guide to medicinal herbs.
Petaluma, CA: Smart Publications.
INEFFECTIVE COPING

[Imbalance in estrogen and progesterone levels]
[Possible nutritional alterations, including the following:
Vitamin B deciencies
Glucose tolerance uctuations
Abnormal fatty acid metabolism, which may contribute to
alterations in prostaglandin synthesis
Magnesium deciency
Vitamin E deciency
Caffeine sensitivity
Alcohol intolerance]
2506_Ch18_320-328.indd Sec1:325 10/1/10 9:37:28 AM


[Mood swings]
[Marked anger or irritability]
[Increased anxiety and restlessness]
[Feelings of depression and hopelessness]
[Decreased interest in usual activities]
[Anergia; easy fatigability]
[Difculty concentrating; forgetfulness]
[Changes in appetite]
[Hypersomnia or insomnia]
[Altered sexual drive]
[Suicidal ideations or attempts]
Goals/Objectives
Short-term Goals
1. Client will seek out support person if thoughts of suicide
emerge.
2. Client will verbalize ways to express anger in an appropriate
manner and maintain anxiety at a manageable level.
Long-term Goals
1. Client will not harm self while experiencing symptoms as-
sociated with PMDD.
2. Client will demonstrate adaptive coping strategies to use in
an effort to minimize disabling behaviors during the pre-
menstrual and perimenstrual periods.

1. Assess clients potential for suicide. Has she expressed feel-
ings of not wanting to live? Does she have a plan? A means?
Depression is the most prevalent disorder that precedes sui-
cide. The risk of suicide is greatly increased if the client has
developed a plan and particularly if means exist for the cli-
ent to execute the plan.
2. Formulate a short-term verbal contract with the client that
she will not harm herself during a specic period of time.
When that contract expires, make another, and so forth.
Discussion of suicidal feelings with a trusted individual
provides a degree of relief to the client. A contract gets the
subject out in the open and places some of the responsibility
for the clients safety with the client. An attitude of accep-
tance of the client as a worthwhile individual is conveyed.
3. Secure a promise from client that she will seek out a staff
member if thoughts of suicide emerge. Suicidal clients are
often very ambivalent about their feelings. Discussion of
2506_Ch18_320-328.indd Sec1:326 10/1/10 9:37:29 AM

feelings with a trusted individual may provide assistance

before the client experiences a crisis situation.
4. Encourage client to express angry feelings within appropri-
ate limits. Provide safe method of hostility release. Help cli-
ent to identify source of anger, if possible. Work on adaptive
coping skills for use outside the health-care system. Depres-
sion and suicidal behaviors are sometimes viewed as anger
turned inward on the self. If this anger can be verbalized
in a nonthreatening environment, the client may be able to
resolve these feelings, regardless of the discomfort involved.
5. Encourage client to discharge pent-up anger through par-
ticipation in large motor activities (e.g., brisk walks, jog-
ging, physical exercises, volleyball, punching bag, exercise
bike). Physical exercise provides a safe and effective method
for discharging pent-up tension.
6. Help client identify stressors that precipitate anxiety and
irritability and develop new methods of coping with these
situations (e.g., stress reduction techniques, relaxation, and
visualization skills). Knowing stress factors and ways of
handling them reduces anxiety and allows client to feel a
greater measure of control over the situation.
7. Identify extent of feelings and situations when loss of control
occurs. Assist with problem-solving to identify behaviors
for protection of self and others (e.g., call support person,
remove self from situation). Recognition of potential for
harm to self or others and development of a plan enables
client to take effective actions to meet safety needs.
8. Encourage client to reduce or shift workload and social
activities during the premenstrual period as part of a total
stress management program. Stress may play a role in the
exacerbation of symptoms.
9. At each visit, evaluate symptoms. Discuss those that may be
most troublesome and continue to persist well after initiation
of therapy. If traditional measures are inadequate, phar-
macological intervention may be required to enhance cop-
ing abilities. For example, antidepressants may be admin-
istered for depression that remains unresolved after other
symptoms have been relieved.
10. Encourage participation in support group, psychotherapy,
marital counseling, or other type of therapy as deemed nec-
essary. Professional assistance may be required to help the
client and family members learn effective coping strategies
and support lifestyle changes that may be needed.
Outcome Criteria
1. Client participates willingly in treatment regimen and initi-
ates necessary lifestyle changes.
2506_Ch18_320-328.indd Sec1:327 10/1/10 9:37:29 AM

2. Client demonstrates adaptive coping strategies to deal with

episodes of depression and anxiety.
3. Client verbalizes that she has no suicidal thoughts or
intentions.
INTERNET REFERENCES
a. http://www.aafp.org/afp/980700ap/daughert.html
b. http://www.drdonnica.com/display.asp?article=1086
c. ht t p://w w w.obg y n.net /women /women.asp?page=/
women/articles/coffee_talk/ct007
d. http://www.usdoctor.com/pms.htm
e. ht t p: //w w w. he a lt hy pl ac e .c om /depre s s ion /m a i n /
premenstrual-dysphoric-disorder-pmdd/menu-id-68/
f. http://familydoctor.org/752.xml
g. http://www.obgyn.net/pmspmdd/pmspmdd.asp
2506_Ch18_320-328.indd Sec1:328 10/1/10 9:37:29 AM

C H A P T E R
19
HIV Disease
The Immune Response to HIV
The cells responsible for nonspecic immune reactions include
neutrophils, monocytes, and macrophages. In the normal im-
mune response, they work to destroy an invasive organism and
initiate and facilitate repair to damaged tissue. If these cells are
not effective in accomplishing a satisfactory healing response,
specic immune mechanisms take over.
The elements of the cellular response include the T4 lym-
phocytes. T4 cells are also called CD4 cells. When the body is
invaded by a foreign antigen, these T4 cells divide many times,
producing antigen-specic T4 cells with other functions. One
of these is the T4 killer cell, which serves to help destroy the
antigen.
The most conspicuous immunologic abnormality associ-
ated with human immunodeciency virus (HIV) infection is a
striking depletion of T4 lymphocytes. The HIV infects the T4
lymphocyte, thereby destroying the very cell the body needs to
direct an attack on the virus. An individual with a healthy im-
mune system may present with a T4 count between 600/mm3 and
1200/mm3. The individual with HIV infection may experience
a drop at the time of acute infection, with a subsequent increase
when the acute stage subsides. Typically, the T-cell count is
about 500 to 600 when the individual begins to develop chronic
persistent generalized lymphadenopathy (PGL). Opportun-
istic infections are common when the T-cell count reaches 200.
T4 cell counts in individuals with advanced HIV disease drop
dramatically, in some cases down to zero (New Mexico AIDS
Education and Training Center, 2009).
Stages and Symptoms of HIV Disease

1. Early Stage (Category 1) HIV Disease (500 T4 cells/
mm3)
a. Acute (Primary) HIV Infection. Although some people
are asymptomatic at this stage, the acute HIV infection is
329
2506_Ch19_329-340.indd 0329 10/1/10 9:37:39 AM

often identied by a characteristic syndrome of symptoms

that occurs from 6 days to 6 weeks after exposure to the
virus. The symptoms have an abrupt onset, are somewhat
vague, and are similar to those sometimes seen in mono-
nucleosis. Symptoms of acute HIV infection include fever,
myalgia, malaise, lymphadenopathy, sore throat, anorexia,
nausea and vomiting, headaches, skin rash, and diarrhea
(Hare, 2006). Most symptoms resolve in 1 to 3 weeks,
with the exception of fever, myalgia, lymphadenopathy,
and malaise, which may continue for several months.
b. Seroconversion. Seroconversion, the detectability of HIV
antibodies in the blood, most often is detected between
6 and 12 weeks. Most people show positive for HIV by
3 months after infection. In some individuals it may take
up to 6 months. The time between infection and serocon-
version is called the window period.
c. Asymptomatic Infection. The acute infection progresses
to an asymptomatic stage. Probably the largest number of
HIV-infected individuals fall within this group. Individu-
als may remain in this asymptomatic stage for 10 years or
longer. The progression of the illness is faster in infants
and children than it is in adults.
2. Middle Stage (Category 2) Chronic HIV Disease (499 to
200 T4 cells/mm3)
a. Persistent Generalized Lymphadenopathy. Clients with
HIV infection may develop a generalized lymphadenopa-
thy, in which lymph nodes in at least two different loca-
tions in the body (usually the neck, armpit, and groin)
swell and remain swollen for months, with no other signs
of a related infectious disease.
b. Systemic Complaints. Fever, night sweats, chronic diar-
rhea, fatigue, minor oral infections, headaches.
3. Late Stage (Category 3) Clinical AIDS (<200 T4 cell/
mm3)
a. HIV Wasting Syndrome. Severe weight loss, large-
volume diarrhea, fever, and weakness. Involuntary weight
loss of more than 10% of baseline body weight is common.
b. Opportunistic Infections. Opportunistic infections are
those that occur because of the altered immune state of
the host. These infections, which include protozoan,
fungal, viral, and bacterial infections, have long been a
de ning characteristic of AIDS. The most common, life-
threatening opportunistic infection seen in clients with
AIDS is pneumocystis pneumonia (PCP).
c. AIDS-Related Malignancies. HIV-positive individuals
are at risk for developing certain types of malignancies.
2506_Ch19_329-340.indd 0330 10/1/10 9:37:39 AM

HIV Disease 331
These include Kaposis sarcoma, non-Hodgkins lympho-

ma, Hodgkins disease, squamous-cell carcinomas, malig-
nant melanoma, testicular cancers, and primary hepato-
cellular carcinoma.
d. Altered Mental States.
(1) The most common alterations in mental states observed
in AIDS clients include delirium (fluctuating conscious-
ness, abnormal vital signs, and psychotic phenomena)
and dementia (called HIV-associated dementia [HAD]).
Symptoms of HAD include cognitive, motor, and behav-
ioral changes similar to those seen in individuals with
other cognitive disorders [see Chapter 3]).
(2) Depression is the most common psychiatric disorder ob-
served among HIV-positive clients (Sagrestano, Rogers,
& Service, 2008). It can occur during any stage of the
disease process. Anticipatory or actual grief is an impor-
tant cause of depressive symptoms in clients with HIV
disease. Transient suicidal ideation on learning of HIV
positivity is quite common, although the incidence of
serious suicidal behavior is low. Depression in AIDS cli-
ents may be related to receiving a new diagnosis of HIV
positivity or AIDS, perceiving rejection by loved ones,
experiencing multiple losses of friends to the disease,
having an inadequate social and fi nancial support sys-
tem, and the presence of an early cognitive disorder.
Predisposing Factors to HIV Disease

1. Sexual Transmission
a. Heterosexual Transmission. Because the virus is found in
greater concentration in semen than in vaginal secretions, it
is more readily transmitted from men to women than from
women to men. However, female-to-male transmission is
possible, as HIV has been isolated in vaginal secretions.
b. Homosexual Transmission. The most signicant risk
factors for homosexual transmission of HIV are receptive
anal intercourse and the number of male sexual partners.
The lining of the anal canal is delicate and prone to tear-
ing and bleeding, making anal intercourse an easy way for
infections to be passed from one person to another.
2. Bloodborne Transmission
a. Transfusion with Blood Products. Although laboratory
tests are more than 99% sensitive, screening problems
may occur when donations are received from individuals
recently infected with HIV who have not yet developed
antibodies or from persistently antibody-negative donors
who are infected with HIV.
2506_Ch19_329-340.indd 0331 10/1/10 9:37:40 AM

b. Transmission by Needles Infected with HIV. The highest

number of cases occurring via this route is among IV drug
users who share needles and other equipment contami-
nated with HIV-infected blood. Other bloodborne modes
of transmission of HIV are by health-care workers who
experience accidental needle sticks with contaminated
needles and who may become infected from other con-
taminated equipment used for therapeutic purposes.
3. Perinatal Transmission
a. Modes of transmission include transplacental, through
exposure to maternal blood and vaginal secretions dur-
ing delivery, and through breast milk. The risk of perina-
tal transmission has been signicantly reduced in recent
years with the advent of free or low-cost prenatal care,
provision of access to anti-HIV medication during preg-
nancy, and education about the dangers of breastfeeding.
4. Other Possible Modes of Transmission
a. To date, HIV has been isolated from blood, semen, vaginal
secretions, saliva, tears, breast milk, cerebrospinal uid,
and amniotic uid. However, only blood, semen, vaginal
secretions, and breast milk have been epidemiologically
linked to transmission of the virus.

and Interventions*
INEFFECTIVE PROTECTION
De nition: Decrease in the ability to guard self from internal or
external threats such as illness or injury.

[Compromised immune status secondary to diagnosis of HIV
disease]

[Laboratory values indicating decreased numbers of T4 cells]
[Presence of opportunistic infections]
* The interventions for this care plan have been adapted from Nursing
Care Plan for the AIDS Patient, written by the nursing staff of Hospice,
Inc., Wichita, KS.
2506_Ch19_329-340.indd 0332 10/1/10 9:37:40 AM

HIV Disease 333
[Manifestations of
Fever, night sweats, diarrhea
Anorexia, weight loss
Fatigue, malaise
Swollen lymph glands
Cough, dyspnea
Rash, skin lesions, white patches in mouth
Headache
Ataxia
Bleeding, bruising
Neurological defects]
Goals/Objectives
Short-term Goal
Client will exhibit no new signs or symptoms of infection.
Long-term Goal
Client safety and comfort will be maximized.

1. To prevent infection in an immunocompromised individual:
a. Implement Universal Precautions.
b. Wash hands with antibacterial soap before entering and
on leaving clients room.
c. Monitor vital signs at regular intervals.
d. Monitor complete blood counts (CBCs) for leukopenia/
neutropenia.
e. Monitor for signs and symptoms of specic opportunistic
infections.
f. Protect client from individuals with infections.
g. Maintain meticulous sterile technique for dressing changes
and any invasive procedure.
h. Administer antibiotics as ordered.
2. To restore nutritional status and decrease nausea, vomit-
ing, and diarrhea:
a. Provide low-residue, high-protein, high-calorie, soft,
bland diet. Maintain hydration with adequate uid
intake.
b. Obtain daily weight and record intake and output.
c. Monitor serum electrolytes and CBCs.
d. If client is unable to eat, provide isotonic tube feedings as
tolerated. Check for gastric residual frequently.
e. If client is unable to tolerate oral intake or tube feedings,
consult physician regarding possibility of parenteral hy-
peralimentation. Observe hyperalimentation administra-
tion site for signs of infection.
f. Administer antidiarrheals and antiemetics as ordered.
2506_Ch19_329-340.indd 0333 10/1/10 9:37:40 AM

g. Perform frequent oral care. Promote prevention and heal-

ing of lesions in the mouth.
h. Have the client eat small, frequent meals with high-calorie
snacks rather than three large meals per day.
3. To promote improvement of skin and mucous membrane
integrity:
a. Monitor skin condition for signs of redness and break-
down.
b. Reposition client every 1 to 2 hours.
c. Encourage ambulation and chair activity as tolerated.
d. Use egg crate mattress or air mattress on bed.
e. Wash skin daily with soap and rinse well with water.
f. Apply lotion to skin to maintain skin softness.
g. Provide wound care as ordered for existing pressure sores
or lesions.
h. Cleanse skin exposed to diarrhea thoroughly and protect
rectal area with ointment.
i. Apply articial tears to eyes as appropriate.
j. Perform frequent oral care; apply ointment to lips.
4. To maximize oxygen consumption and minimize respira-
tory distress:
a. Assess respiratory status frequently:
(1) Monitor depth, rate, and rhythm of respirations.
(2) Auscultate lung fields every 2 hours and as needed.
(3) Monitor arterial blood gases.
(4) Check color of skin, nail beds, and sclerae.
(5) Assess sputum for color, odor, and viscosity.
b. Encourage coughing and deep-breathing exercises.
c. Provide humidied oxygen as ordered.
d. Suction as needed using sterile technique.
e. Space nursing care to allow client adequate rest periods
between procedures.
f. Administer analgesics or sedatives judiciously to prevent
respiratory depression.
g. Administer bronchodilators and antibiotics as ordered.
5. To minimize the potential for easy bleeding caused by
HIV-induced thrombocytopenia:
a. Follow protocol for maintenance of skin integrity.
b. Provide safe environment to minimize falling or bumping
into objects.
c. Provide soft toothbrush or toothette swabs for cleaning
teeth and gums.
d. Ensure that client does not take aspirin or other medica-
tions that increase the potential for bleeding.
e. Clean up areas contaminated by clients blood with house-
hold bleach diluted 1:10 with water.
2506_Ch19_329-340.indd 0334 10/1/10 9:37:41 AM

HIV Disease 335
6. To maintain near-normal body temperature:

a. Provide frequent tepid water sponge baths.
b. Provide antipyretic as ordered by physician (avoid aspirin).
c. Place client in cool room, with minimal clothing and bed
covers.
d. Encourage intake of cool liquids (if not contraindicated).
Outcome Criteria
1. Client does not experience respiratory distress.
2. Client maintains optimal nutrition and hydration.
3. Client has experienced no further weight loss.
4. Client maintains integrity of skin and mucous membranes.
5. Client shows no new signs or symptoms of infection.
INTERRUPTED FAMILY PROCESSES

De nition: Change in family relationships and/or functioning.

[Crisis associated with having a family member diagnosed with
HIV disease]

Changes in availability for affective responsiveness and intimacy
Changes in participation in problem-solving and decision-making
Changes in communication patterns
Changes in availability for emotional support
Changes in satisfaction with family
Changes in expressions of con ict within family
Goals/Objectives
Short-term Goal
Family members will express feelings regarding loved ones
diagnosis and prognosis.
Long-term Goal
Family will verbalize areas of dysfunction and demonstrate
ability to cope more effectively.

1. Create an environment that is comfortable, supportive, and
private and promotes trust. Basic needs of the family must be
met before crisis resolution can be attempted.
2. Encourage each individual member to express feelings re-
garding loved ones diagnosis and prognosis. Each individual
2506_Ch19_329-340.indd 0335 10/1/10 9:37:41 AM

is unique and must feel that his or her private needs can be
met within the family constellation.
3. If the client is homosexual, and this is the familys rst
awareness, help them deal with guilt and shame they may
experience. Help parents to understand they are not re-
sponsible and their child is still the same individual they
have always loved. Resolving guilt and shame enables fam-
ily members to respond adaptively to the crisis. Their re-
sponse can affect the clients remaining future as well as
the familys future.
4. Serve as facilitator between clients family and homosexual
partner. The family may have difculty accepting the part-
ner as a person who is as signicant as a spouse. Clarify
roles and responsibilities of family and partner. Do this by
bringing both parties together to de ne and distribute the
tasks involved in the clients care. By minimizing the lack of
legally defined roles and by focusing on the need for making
realistic decisions about the clients care, communication
and resolution of conflict are enhanced.
5. Encourage use of stress management techniques (e.g., relax-
ation exercises, guided imagery, attendance at support group
meetings for signicant others of clients with HIV disease).
Reduction of stress and support from others who share simi-
lar experiences enable individuals to begin to think more
clearly and develop new behaviors to cope with this situ-
ational crisis.
6. Provide educational information about HIV disease and
opportunity to ask questions and express concerns. Many
misconceptions about the disease abound within the public
domain. Clarification may calm some of the familys fears
and facilitate interaction with the client.
7. Make family referrals to community organizations that
provide supportive help or nancial assistance to clients
with HIV disease. Extended care can place a financial bur-
den on client and family members. Respite care may pro-
vide family members with occasional much-needed relief
away from the stress of physical and emotional caregiving
responsibilities.
Outcome Criteria
1. Family members are able to discuss feelings regarding clients
diagnosis and prognosis.
2. Family members are able to make rational decisions re-
garding care of their loved one and the effect on family
functioning.
2506_Ch19_329-340.indd 0336 10/1/10 9:37:41 AM

HIV Disease 337
DEFICIENT KNOWLEDGE
(PREVENTION OF TRANSMISSION
AND PROTECTION OF THE CLIENT)

Cognitive limitation
Information misinterpretation
Lack of exposure [to accurate information]

Verbalization of the problem
Inappropriate or exaggerated behaviors
Inaccurate follow-through of instruction
[Inaccurate statements by client and family]
Goals/Objectives
Short-term Goal
Client and family verbalize understanding about disease pro-
cess, modes of transmission, and prevention of infection.
Long-term Goals
1. Client and family demonstrate ability to execute precautions for
preventing transmission of HIV and infection of the client.
2. Transmission of HIV and infection of the client are
prevented.
1. Present the following information in an effort to clarify
misconceptions, calm fears, and support an environment of
appropriate interventions for care of the client with HIV
disease. Teach that HIV cannot be contracted from:
a. Casual or household contact with an individual with HIV
infection.
b. Shaking hands, hugging, social (dry) kissing, holding
hands, or other nonsexual physical contact.
c. Touching unsoiled linens or clothing, money, furniture,
or other inanimate objects.
d. Being near someone who has HIV disease at work, school,
restaurants, or in elevators.
e. Toilet seats, bathtubs, towels, showers, or swimming
pools.
2506_Ch19_329-340.indd 0337 10/1/10 9:37:41 AM

f. Dishes, silverware, or food handled by a person with HIV

disease.
g. Animals (pets may transmit opportunistic organisms).
h. (Very unlikely spread by) coughing, sneezing, spitting,
kissing, tears, or saliva.
2. HIV dies quickly outside the body because it requires living
tissue to survive. It is readily killed by soap, cleansers, hot
water, and disinfectants.
3. Teach client to protect self from infections by taking the
following precautions:
a. Avoid unpasteurized milk or milk products.
b. Cook all raw vegetables and fruits before eating. Raw or
improperly washed foods may transmit microbes.
c. Cook all meals well before eating.
d. Avoid direct contact with persons with known contagious
illnesses.
e. Consult physician before getting a pet. Pets require extra
infection control precautions because of the opportunistic
organisms carried by animals.
f. Avoid touching animal feces, urine, emesis, litter boxes,
aquariums, or bird cages. Always wear mask and gloves
when cleaning up after a pet.
g. Avoid traveling in countries with poor sanitation.
h. Avoid vaccines or vaccinations that contain live organ-
isms. Vaccination with live organisms may be fatal to
severely immunosuppressed persons.
i. Exercise regularly.
j. Control stress factors. A counselor or support group may
be helpful.
k. Stop smoking. Smoking predisposes to respiratory
infections.
l. Maintain good personal hygiene.
4. Teach client/signicant others about prevention of
transmission:
a. Do not donate blood, plasma, body organs, tissues, or
semen.
b. Inform physician, dentist, and anyone providing care that
you have HIV disease.
c. Do not share needles or syringes.
d. Do not share personal items, such as toothbrushes, razors,
or other implements that may be contaminated with blood
or body uids.
e. Do not eat or drink from the same dinnerware and
utensils without washing them between uses.
f. Avoid becoming pregnant if at risk for HIV infection.
g. Engage in only safer sexual practices (those not involv-
ing exchange of body uids).
2506_Ch19_329-340.indd 0338 10/1/10 9:37:42 AM

HIV Disease 339
h. Avoid sexual practices medically classied as unsafe,

such as anal or vaginal intercourse and oral sex.
i. Avoid the use of recreational drugs because of their
immunosuppressive effects.
5. Teach the home caregiver(s) to protect self from HIV infec-
tion by taking the following precautions:
a. Wash hands thoroughly with liquid antibiotic soap
before and after each client contact. Use moisturizing lotion
afterward to prevent dry, cracking skin.
b. Wear gloves when in contact with blood or body uids
(e.g., open wounds, suctioning, feces). Gown or aprons
may be worn if soiling is likely.
c. Wear a mask:
(1) When client has a productive cough and tuberculosis has
not been ruled out.
(2) To protect client if caregiver has a cold.
(3) During suctioning.
d. Bag disposable gloves and masks with clients trash.
e. Dispose of the following in the toilet:
(1) Organic material on clothes or linen before laundering.
(2) Blood or body fluids.
(3) Soiled tissue or toilet paper.
(4) Cleaners or disinfectants used to clean contaminated
articles.
(5) Solutions contaminated with blood or body fluids.
f. Double-bag clients trash and soiled dressings in an im-
penetrable, plastic bag. Tie the bag shut and discard with
household trash.
g. Do not recap needles, syringes, and other sharp items.
Use puncture-proof covered containers for disposal (e.g.,
coffee cans and jars are appropriate for home use).
h. Place soiled linen and clothing in a plastic bag and tie shut
until washed. Launder these separately from other laun-
dry. Use bleach or other disinfectant in hot water.
i. When house cleaning, all equipment used in care of the
client, as well as bathroom and kitchen surfaces, should be
cleaned with a 1:10 dilute bleach solution.
j. Mops, sponges, and other items used for cleaning should
be reserved specically for that purpose.
Outcome Criteria
1. Client, family, and signicant other(s) are able to verbalize in-
formation presented regarding ways in which HIV can and can-
not be transmitted, ways to protect the client from infections,
and ways to prevent transmission to caregivers and others.
2. Transmission to others and infection of the client have been
avoided.
2506_Ch19_329-340.indd 0339 10/1/10 9:37:42 AM

INTERNET REFERENCES
Additional information about HIV/AIDS may be located at
the following websites:
a. http://www.avert.org/
b. http://www.aegis.com/main/
c. http://www.HIVpositive.com/index.html
d. http://research.med.umkc.edu/teams/cml/AIDS.html
e. http://www.cdc.gov/hiv
f. http://hivinsite.ucsf.edu/InSite?page=KB
g. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5212a1
.htm
Movie Connections
Philadelphia Longtime Companion A Mothers Prayer
Breaking the Surface The Greg Louganis Story And the Band
Played On
2506_Ch19_329-340.indd 0340 10/1/10 9:37:42 AM

C H A P T E R
20
Homelessness
It is difcult to determine how many individuals are homeless
in the United States. Estimates have been made at somewhere
between 250,000 and 4 million.
Who are the Homeless?

1. Age. Studies have produced a variety of statistics related to
age of the homeless: 39% are younger than 18 years; indi-
viduals between the ages of 25 and 34 comprise 25%; and 6%
are ages 55 to 64.
2. Gender. More men than women are homeless. The National
Coalition for the Homeless (NCH, 2007) reports that single
men comprise 51% of the homeless population and single
women comprise 17%.
3. Families. Families with children are among the fastest grow-
ing segments of the homeless population. Families comprise
33% of the urban homeless population, but research indicates
that this number is higher in rural areas, where families,
single mothers, and children make up the largest group of
homeless people.
4. Ethnicity. The homeless population is estimated to be
42% African American, 39% white, 13% Hispanic, 4%
Native American, and 2% Asian (U.S. Conference of Mayors
[USCM], 2006). The ethnic makeup of homeless populations
varies according to geographic location.
Mental Illness and Homelessness

The USCM (2008) survey revealed that approximately 26%
of the homeless population has some form of mental illness.
Schizophrenia is frequently described as the most common
diagnosis. Other prevalent disorders include bipolar affective
disorder, substance abuse and dependence, depression, person-
ality disorders, and organic mental disorders.
341
2506_Ch20_341-347.indd 0341 10/1/10 9:37:51 AM

Predisposing Factors to Homelessness

Among the Mentally Ill
1. Deinstitutionalization. Deinstitutionalization is frequently
implicated as a contributing factor to homelessness among
persons with mental illness. Deinstitutionalization began out
of expressed concern by mental health professionals and oth-
ers who described the deplorable conditions under which
mentally ill individuals were housed. Some individuals be-
lieved that institutionalization deprived the mentally ill of
their civil rights. Not the least of the motivating factors for
deinstitutionalization was the nancial burden that these cli-
ents placed on state governments.
2. Poverty. Cuts in various government entitlement programs
have depleted the allotments available for individuals with
severe and persistent mental illness living in the community.
The job market is prohibitive for individuals whose behavior
is incomprehensible or even frightening to many. The stigma
and discrimination associated with mental illness may be di-
minishing slowly, but it is highly visible to those who suffer
from its effects.
3. A Scarcity of Affordable Housing. The NCH (2008b)
stated:
A lack of affordable housing and the limited scale of housing
assistance programs have contributed to the current housing
crisis and to homelessness. The gap between the number of
affordable housing units and the number of people needing
them has created a housing crisis for poor people. Between
1970 and 1995, the gap between the number of low-income
renters and the amount of affordable housing units sky-
rocketed from a nonexistent gap to a shortage of 4.4 million
affordable housing unitsthe largest shortfall on record.
In addition, the number of single-room-occupancy (SRO)
hotels has diminished drastically. These SRO hotels provid-
ed a means of relatively inexpensive housing, and although
some people believe that these facilities nurtured isola-
tion, they provided adequate shelter from the elements for
their occupants. So many individuals currently frequent the
shelters of our cities that there is concern that the shelters
are becoming mini-institutions for people with serious men-
tal illness.
4. Lack of Affordable Health Care. For families barely able to
scrape together enough money to pay for day-to-day living, a
catastrophic illness can create the level of poverty that starts
the downward spiral to homelessness.
5. Domestic Violence. The NCH (2008b) reports that approx-
imately half of all women and children experiencing home-
lessness are eeing domestic violence. Battered women are
2506_Ch20_341-347.indd 0342 10/1/10 9:37:51 AM

Homelessness 343
often forced to choose between an abusive relationship and

homelessness.
5. Addiction Disorders. For individuals with alcohol or drug ad-
dictions, in the absence of appropriate treatment, the chances
increase for being forced into life on the street. The following
have been cited as obstacles to addiction treatment for home-
less persons: lack of health insurance, lack of documentation,
waiting lists, scheduling difculties, daily contact require-
ments, lack of transportation, ineffective treatment methods,
lack of supportive services, and cultural insensitivity.
Symptomatology (Commonly Associated with

Homelessness)
1. Mobility and migration (the penchant for frequent move-
ment to various geographic locations)
2. Substance abuse
3. Nutritional deciencies
4. Difculty with thermoregulation
5. Increased incidence of tuberculosis
6. Increased incidence of sexually transmitted diseases
7. Increased incidence of gastrointestinal (GI) and respiratory
disorders
8. Among homeless children (compared with control samples),
increased incidence of:
a. Ear infections
b. GI and respiratory disorders
c. Infestational ailments
d. Developmental delays
e. Psychological problems

and Interventions
inpatient and partial hospitalization, community health clinic, street
clinic, and homeless shelters.)
INEFFECTIVE HEALTH
MAINTENANCE
De nition: Inability to identify, manage, and/or seek out help to
maintain health.

Perceptual/cognitive impairment
Decient communication skills
2506_Ch20_341-347.indd 0343 10/1/10 9:37:52 AM

Unachieved developmental tasks

Insufcient resources (e.g., equipment, nances)
Inability to make appropriate judgments
Ineffective individual coping
History of lack of health-seeking behavior
Impairment of personal support systems
Demonstrated lack of knowledge about basic health practices
Demonstrated lack of adaptive behaviors to environmental
changes
Inability to take responsibility for meeting basic health practices
Goals/Objectives
Short-term Goal
Client will seek and receive assistance with current health matters.
Long-term Goals
1. Client will assume responsibility for own health-care needs
within level of ability.
2. Client will adopt lifestyle changes that support individual
health-care needs.
1. The triage nurse in the emergency department, street clinic,
or shelter will begin the biopsychosocial assessment of the
homeless client. An adequate assessment is required to en-
sure appropriate nursing care is provided.
2. Assess developmental level of functioning and ability to com-
municate. Use language that the client can comprehend. This
information is essential to ensure that client achieves an ac-
curate understanding of information presented and that the
nurse correctly interprets what the client is attempting to
convey.
3. Assess clients use of substances, including use of tobacco.
Discuss eating and sleeping habits. These actions may be
contributing to current health problems.
4. Assess sexual practices, to determine level of personal risk.
5. Assess oral hygiene practices, to determine specific self-care
needs.
6. Assess clients ability to make decisions. Client may need as-
sistance in determining the type of care that is required,
how to determine the most appropriate time to seek that
care, and where to go to receive it.
7. It is important to ask the following basic questions of the
homeless client:
a. Do you understand what your problem is?
b. How will you get your prescriptions lled?
2506_Ch20_341-347.indd 0344 10/1/10 9:37:52 AM

Homelessness 345
c. Where are you going when you leave here, or where will
you sleep tonight?
Answers to these questions at admission will initiate dis-
charge planning for the client.
8. Teach client the basics of self-care (e.g., proper hygiene;
facts about nutrition). The client must have this type of
knowledge if he or she is to become more self-sufficient.
9. Teach client about safe sex practices in an effort to avoid
sexually transmitted diseases.
10. Identify immediate problems and assist with crisis inter-
vention. Emergency departments, storefront clinics,
or shelters may be the homeless clients only resource in a
crisis situation.
11. Tend to physical needs immediately. Ensure that client has thor-
ough physical examination. The client cannot deal with psycho-
social issues until physical problems have been addressed.
12. Assess mental health status. Many homeless individuals
have some form of mental illness. Ensure that appropriate
psychiatric care is provided. If possible, inquire about pos-
sible long-acting medication injections for client. The client
may be less likely to discontinue the medication if he or she
does not have to take pills every day.
13. Refer client to others who can provide assistance (e.g., case
manager; social worker). If the client is to be discharged
to a shelter, a case manager or social worker may be the
best link between the client and the health-care system to
ensure that he or she obtains appropriate follow-up care.
Outcome Criteria
1. Client verbalizes understanding of information presented
regarding optimal health maintenance.
2. Client is able to verbalize signs and symptoms that should be
reported to a health-care professional.
3. Client verbalizes knowledge of available resources from
which he or she may seek assistance as required.
POWERLESSNESS

[Homelessness]
2506_Ch20_341-347.indd 0345 10/1/10 9:37:52 AM


Verbal expressions of having no control (e.g., over self-care, situ-
ation, outcome)
Apathy
Inadequate coping patterns
Goals/Objectives
Short-term Goal
Client will identify areas over which he or she has control.
Long-term Goal
Client will make decisions that reect control over present situ-
ation and future outcome.

1. Provide opportunities for the client to make choices about
his or her present situation. Providing client with choices will
increase his or her feeling of control.
2. Avoid arguing or using logic with the client who feels power-
less. Client will not believe it can make a difference.
3. Accept expressions of feelings, including anger and hopeless-
ness. An attitude of acceptance enhances feelings of trust
and self-worth.
4. Help client identify personal strengths and establish realistic
life goals. Unrealistic goals set the client up for failure and
reinforce feelings of powerlessness.
5. Help client identify areas of life situation that he or she can
control. Clients emotional condition interferes with his or
her ability to solve problems. Assistance is required to ac-
curately perceive the benefits and consequences of available
alternatives.
6. Help client identify areas of life situation that are not within
his or her ability to control. Encourage verbalization of feel-
ings related to this inability in an effort to deal with unre-
solved issues and accept what cannot be changed.
7. Encourage client to seek out support group or shelter re-
sources. Social isolation promotes feelings of powerlessness
and hopelessness.
Outcome Criteria
3. Client is able to verbalize system for problem-solving as re-
quired to maintain hope for the future.
2506_Ch20_341-347.indd 0346 10/1/10 9:37:53 AM

Homelessness 347
INTERNET REFERENCES
a. http://www.nationalhomeless.org/
b. http://www.endhomelessness.org/
c. http://portal.hud.gov/portal/page/portal/HUD/topics/
homelessness
d. http://www.hhs.gov/homeless/
e. http://www.nrchmi.samhsa.gov/Default.aspx
f. http://www.abanet.org/homeless/
Movie Connections
The Soloist The Grapes of Wrath Generosity The Redemption
2506_Ch20_341-347.indd 0347 10/1/10 9:37:53 AM

C H A P T E R
21
Psychiatric Home
Nursing Care
Dramatic changes in the health care delivery system and sky-
rocketing costs have created a need to nd a way to provide
quality, cost-effective care to psychiatric clients. Home care
has become one of the fastest growing areas in the healthcare
system and is now recognized by many reimbursement agencies
as a preferred method of community-based service. Just what
is home health care? The American Nurses Association (ANA,
2008) contributed the following de nition:
Home health nursing is nursing practice applied to patients of all
ages in the patients residences, which may include private homes,
assisted living, or personal care facilities. Patients and their families
and other caregivers are the focus of home health nursing practice.
The goal of care is to maintain or improve the quality of life for
patients and the families and other caregivers, or to support patients
in their transition to end of life (p. 3).
The psychiatric home care nurse must have knowledge and
skills to meet both the physical and the psychosocial needs of
the homebound client. Serving health care consumers in their
home environment charges the nurse with the responsibility of
providing holistic care.
An increase in psychiatric home care may be associated with the
following factors:
1. Earlier hospital discharges
2. Increased demand for home care as an alternative to institu-
tional care
3. Broader third-party payment coverage
4. Greater physician acceptance of home care
5. The increasing need to contain health-care costs and the
growth of managed care
348
2506_Ch21_348-357.indd Sec1:348 10/1/10 9:38:01 AM

Psychiatric home nursing care is provided through private

home health agencies; private hospitals; public hospitals; gov-
ernment institutions, such as the Veterans Administration;
and community mental health centers. Most often, home care
is viewed as follow-up care to inpatient, partial, or outpatient
hospitalization.
The majority of home healthcare is paid for by Medicare.
Other sources include Medicaid, private insurance, self-pay, and
others. Medicare requires that the following criteria be met to
qualify for psychiatric home care (Jensen & Miller, 2004):
1. The client is con ned to the home.
2. The client must receive services under a plan of care estab-
lished and periodically reviewed by a physician.
3. The client must be in need of skilled nursing care on an
intermittent basis.
4. Services must be reasonable and necessary for treating the
clients psychiatric diagnosis and/or symptoms.
5. Home health psychiatric care must be provided by a skilled
psychiatric nurse.
Jensen and Miller (2004) reported:
Care can be provided in ones own home or residence, assisted liv-
ing, adult family homes, or retirement homes, but not in hospitals
or skilled nursing facilities. A home health psychiatric care patient
is unable to leave the home without considerable difculty or the as-
sistance of another person. The patient can leave home infrequently
or for a short duration, for example, going to church on Sunday. The
patient can also go out for medical treatment, partial hospitalization,
adult day care, or chemotherapy. A patient can also be homebound
for psychiatric reasons, such as depression, agoraphobia, paranoia,
or panic disorder (p. 3).
Although Medicare and Medicaid are the largest reimburse-
ment providers, a growing number of health maintenance or-
ganizations (HMOs) and preferred provider organizations
(PPOs) are recognizing the cost-effectiveness of psychiatric
home nursing care and are including it as part of their benet
packages. Most managed care agencies require that treatment,
or even a specic number of visits, be preauthorized for psychi-
atric home nursing care. The plan of treatment and subsequent
charting must explain why the clients psychiatric disorder keeps
him or her at home and justify the need for services.
Data)
Homebound psychiatric clients most often have diagnoses of de-
pression, dementia, anxiety disorders, bipolar affective disorder,
and schizophrenia. Psychiatric nurses also provide consultation
2506_Ch21_348-357.indd Sec1:349 10/1/10 9:38:02 AM

for clients with primary medical disorders. Many elderly clients

are homebound because of medical conditions that impair mo-
bility and necessitate home care. Psychiatric nurses may provide
the following types of home nursing care:
To clients with primary Axis I psychiatric diagnoses,
the symptoms of which are immobilizing, and the client
and family require assistance with management of the
symptoms
To clients who are homebound for medical conditions but
have a psychiatric condition for which they have been
receiving (and continue to need ongoing) treatment
To clients who are homebound with medical conditions
and who may develop serious psychiatric symptoms in
response to their medical illness
Table 21-1 identies some of the conditions for which a psy-
chiatric nursing home care consultation may be sought.
The following components should be included in the com-
prehensive assessment of the homebound client:
1. The clients perception of the problem and need for assistance
2. Information regarding the clients strengths and personal
habits
3. Health history, review of systems, and vital signs
4. Any recent changes (physical, psychosocial, and environmental)
5. Availability of support systems
6. Current medication regimen (including the clients under-
standing about the medications and reason for taking)
7. Nutritional and elimination assessment
8. Activities of daily living (ADLs) assessment
9. Substance use assessment
10. Neurological assessment
TABLE 21 1 Conditions that Warrant Psychiatric Nursing

Consultation

When a client has a new psychiatric diagnosis

When a new psychotropic medication has been added to the regimen

When the clients mental status exacerbates or causes deterioration in
his or her medical condition

When the client is suspected of abusing alcohol or drugs

When a client is expressing suicidal ideation

When a client is noncompliant with psychotropic medication

When a client develops a fundamental change in mood or a thought
disorder

When a client is immobilized by severe depression or anxiety
SOURCE: Adapted from Schroeder, 2009.
2506_Ch21_348-357.indd Sec1:350 10/1/10 9:38:02 AM

11. Mental status examination (see Appendix M)

12. Global Assessment of Functioning (GAF) scale rating (see
Appendix K)
Other important assessments include information about
acute or chronic medical conditions, patterns of sleep and rest,
solitude and social interaction, use of leisure time, education
and work history, issues related to religion or spirituality, and
adequacy of the home environment.
for Psychiatric Homebound Clients
INEFFECTIVE SELF-HEALTH
MANAGEMENT
De nition: Pattern of regulating and integrating into daily living a
therapeutic regime for treatment of illness and its sequelae that is
unsatisfactory for meeting specific health goals.

Perceived barriers
Social support decits
Powerlessness
Perceived benets
[Mistrust of regimen and/or health care personnel]
Knowledge decit
Complexity of therapeutic regimen

Makes choices in daily living ineffective for meeting health goals
Failure to include treatment regimens in daily living
Failure to take action to reduce risk factors
Verbalizes difculty with prescribed regimens
Verbalizes desire to manage the illness
Goals/Objectives
Short-term Goals
1. Client will verbalize understanding of barriers to self-health
management.
2. Client will participate in problem-solving efforts toward
adequate self-health management.
Long-term Goal
Client will incorporate changes in lifestyle necessary to main-
tain effective self-health management.
2506_Ch21_348-357.indd Sec1:351 10/1/10 9:38:03 AM


1. Assess clients knowledge of condition and treatment needs.
Client may lack full comprehension of need for treatment
regimen.
2. Identify clients perception of treatment regimen. Client
may be mistrustful of treatment regimen or of health care
system in general.
3. Promote a trusting relationship with the client by being
honest, encouraging client to participate in decision-making,
and conveying genuine positive regard.
4. Assist client in recognizing strengths and past successes.
Recognition of strengths and past successes increases self-
esteem and indicates to client that he or she can be successful
in managing therapeutic regimen.
5. Provide positive reinforcement for efforts. Positive rein-
forcement increases self-esteem and encourages repetition
of desirable behaviors.
6. Emphasize importance of need for treatment and/or medica-
tion. Client must understand that the consequence of lack of
follow-through is possible decompensation.
7. In an effort to incorporate lifestyle changes and promote
wellness, help client develop plans for managing therapeutic
regimen, such as support groups, social and family systems,
and nancial assistance.
Outcome Criteria
1. Client verbalizes understanding of information presented
regarding management of therapeutic regimen.
2. Client demonstrates desire and ability to perform strategies
necessary to maintain adequate management of therapeutic
regimen.
3. Client verbalizes knowledge of available resources from
which he or she may seek assistance as required.
RISK-PRONE HEALTH BEHAVIOR

De nition: Impaired ability to modify lifestyle/behaviors in a man-
ner that improves health status.

Inadequate comprehension
Inadequate social support
Low self-efcacy
Low socioeconomic status
Multiple stressors
2506_Ch21_348-357.indd Sec1:352 10/1/10 9:38:03 AM

Negative attitude toward healthcare

[Intense emotional state]

Demonstrates nonacceptance of health status change
Failure to achieve optimal sense of control
Failure to take actions that prevent health problems
Minimizes health status change
Goals/Objectives
Short-term Goals
1. Client will discuss with home health nurse the kinds of life-
style changes that will occur because of the change in health
status.
2. With the help of home health nurse, client will formulate a
plan of action for incorporating those changes into his or her
lifestyle.
3. Client will demonstrate movement toward independence,
considering change in health status.
Long-term Goal
Client will demonstrate competence to function independently
to his or her optimal ability, considering change in health status,
by time of discharge from home health care.

1. Encourage client to talk about lifestyle prior to the change
in health status. Discuss coping mechanisms that were used
at stressful times in the past. It is important to identify the
clients strengths so that they may be used to facilitate adap-
tation to the change or loss that has occurred.
2. Encourage client to discuss the change or loss and particu-
larly to express anger associated with it. Some individuals
may not realize that anger is a normal stage in the grieving
process. If it is not released in an appropriate manner, it
may be turned inward on the self, leading to pathological
depression.
3. Encourage client to express fears associated with the change
or loss or alteration in lifestyle that the change or loss has
created. Change often creates a feeling of disequilibrium
and the individual may respond with fears that are irra-
tional or unfounded. He or she may benefit from feedback
that corrects misperceptions about how life will be with the
change in health status.
4. Provide assistance with ADLs as required, but encourage in-
dependence to the limit that clients ability will allow. Give
positive feedback for activities accomplished independently.
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Independent accomplishments and positive feedback enhance

self-esteem and encourage repetition of desired behaviors.
Successes also provide hope that adaptive functioning is
possible and decrease feelings of powerlessness.
5. Help client with decision-making regarding incorporation
of change or loss into lifestyle. Identify problems that the
change or loss is likely to create. Discuss alternative solu-
tions, weighing potential benets and consequences of each
alternative. Support clients decision in the selection of
an alternative. The great amount of anxiety that usually
accompanies a major lifestyle change often interferes
with an individuals ability to solve problems and to make
appropriate decisions. Client may need assistance with
this process in an effort to progress toward successful
adaptation.
6. Use role-playing to decrease anxiety as client anticipates
stressful situations that might occur in relation to the health
status change. Role-playing decreases anxiety and provides
a feeling of security by arming the client with a plan of
action with which to respond in an appropriate manner
when a stressful situation occurs.
7. Ensure that client and family are fully knowledgeable re-
garding the physiology of the change in health status and its
necessity for optimal wellness. Encourage them to ask ques-
tions, and provide printed material explaining the change to
which they may refer following discharge.
8. Help client identify resources within the community from
which he or she may seek assistance in adapting to the
change in health status. Examples include self-help or sup-
port groups, counselor, or social worker. Encourage client to
keep follow-up appointments with physician or to call phy-
sicians ofce prior to follow-up date if problems or concerns
arise.
Outcome Criteria
1. Client is able to perform ADLs independently.
2. Client is able to make independent decisions regarding life-
style considering change in health status.
3. Client is able to express hope for the future with consider-
ation of change in health status.
SOCIAL ISOLATION
De nition: Aloneness experienced by the individual and perceived
as imposed by others and as a negative or threatening state.
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Alterations in mental status
Inability to engage in satisfying personal relationships
Unaccepted social values
Unaccepted social behavior
Inadequate personal resources
Immature interests
Alterations in physical appearance
Altered state of wellness

Expresses feelings of aloneness imposed by others
Expresses feelings of rejection
Developmentally inappropriate interests
Inability to meet expectations of others
Insecurity in public
Absence of supportive signicant other(s)
Projects hostility
Withdrawn; uncommunicative
Seeks to be alone
Preoccupation with own thoughts
Sad, dull affect
Goals/Objectives
Short-term Goal
Client will verbalize willingness to be involved with others.
Long-term Goal
Client will participate in interactions with others at level of abil-
ity or desire.

1. Convey an accepting attitude by making regular visits. An
accepting attitude increases feelings of self-worth and facili-
tates trust.
4. Be cautious with touch until trust has been established. A sus-
picious client may perceive touch as a threatening gesture.
5. Be with the client to offer support during activities that may
be frightening or difcult for him or her. The presence of a
trusted individual provides emotional security for the client.
6. Take walks with the client. Help him or her perform simple
tasks around the house. Increased activity enhances both
physical and mental status.
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7. Assess lifelong patterns of relationships. Basic personal-

ity characteristics will not change. Most individuals keep
the same style of relationship development that they had in
the past.
8. Help the client identify present relationships that are satisfying
and activities that he or she considers interesting. Only the cli-
ent knows what he or she truly likes, and these personal pref-
erences will facilitate success in reversing social isolation.
9. Consider the feasibility of a pet. There are many documented
studies of the benefits of companion animals.
Outcome Criteria
others.
2. Client independently pursues social activities with others.
RISK FOR CAREGIVER ROLE STRAIN

De nition: Caregiver is vulnerable for felt difficulty in performing
the family caregiver role.
Risk Factors
Caregiver not developmentally ready for caregiver role
Inadequate physical environment for providing care
Unpredictable illness course or instability in the care receivers
health
Psychological or cognitive problems in care receiver
Presence of abuse or violence
Past history of poor relationship between caregiver and care
receiver
Marginal caregivers coping patterns
Lack of respite and recreation for caregiver
Addiction or codependency
Caregivers competing role commitments
Illness severity of the care receiver
Duration of caregiving required
Family/caregiver isolation
Goals/Objectives
Short-term Goal
Caregivers will verbalize understanding of ways to facilitate the
caregiver role.
Long-term Goal
Caregivers will demonstrate effective problem-solving skills and
develop adaptive coping mechanisms to regain equilibrium.
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1. Assess caregivers ability to anticipate and ful ll clients un-
met needs. Provide information to assist caregivers with this
responsibility. Ensure that caregivers encourage client to be
as independent as possible. Caregivers may be unaware of
what the client can realistically accomplish. They may be
unaware of the nature of the illness.
2. Ensure that caregivers are aware of available community sup-
port systems from which they can seek assistance when re-
quired. Examples include respite care services, day treatment
centers, and adult day-care centers. Caregivers require relief
from the pressures and strain of providing 24-hour care for
their loved one. Studies have shown that abuse arises out of
caregiving situations that place overwhelming stress on the
caregivers.
3. Encourage caregivers to express feelings, particularly anger.
Release of these emotions can serve to prevent psychopathol-
ogy, such as depression or psychophysiological disorders,
from occurring.
4. Encourage participation in support groups composed of
members with similar life situations. Provide information
about support groups that may be helpful:
a. National Alliance for the Mentally Ill(800) 950-NAMI
b. American Association on Intellectual and Developmental
Disabilities(800) 424-3688
c. Alzheimers Association(800) 272-3900
Hearing others who are experiencing the same problems
discuss ways in which they have coped may help the caregiver
adopt more adaptive strategies. Individuals who are experi-
encing similar life situations provide empathy and support for
each other.
Outcome Criteria
1. Caregivers are able to problem-solve effectively regarding
care of the client.
2. Caregivers demonstrate adaptive coping strategies for deal-
ing with stress of caregiver role.
3. Caregivers openly express feelings.
4. Caregivers express desire to join support group of other
caregivers.
INTERNET REFERENCES
a. http://www.cms.hhs.gov/
b. http://www.nahc.org/
c. http://www.aahomecare.org/
2506_Ch21_348-357.indd Sec1:357 10/1/10 9:38:05 AM

C H A P T E R
22
Forensic Nursing
The International Association of Forensic Nurses (IAFN)
(2009) has de ned forensic nursing as:
The practice of nursing globally when health and legal systems
intersect (p. 3).
Belleld and Catalano (2009) have stated:
Forensic nursing is an emerging eld that forms an alliance between
nursing, law enforcement, and the forensic sciences. The term
forensic means anything belonging to, or pertaining to, the law.
Forensic nurses provide a continuum of care to victims and their
families beginning in the emergency room or crime scene and lead-
ing to participation in the criminal investigation and the courts of
law (p. 446).
Areas of forensic nursing include:
1. Clinical forensic nursing
2. The sexual assault nurse examiner (SANE)
3. Forensic psychiatric nursing specialty
4. Correctional/institutional nursing specialty
5. Nurses in general practice
Clinical Forensic Nursing in Trauma Care

Assessment
Lynch, Roach, and Sadler (2006) have stated, Forensic nurse
specialists are specically trained to deal with cases of sexual
assault, child abuse, acute psychiatric emergencies, and death
investigation (p. 603). All traumatic injuries in which liability
is suspected are considered within the scope of forensic nurs-
ing. Reports to legal agencies are required to ensure follow-up
investigation; however, the protection of clients rights remains
a nursing priority.
Several areas of assessment in which the clinical forensic
nurse specialist in trauma care may become involved include:
1. Preservation of Evidence. Evidence from both crime-
related and self-in icted traumas must be safeguarded in a
358
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manner consistent with the investigation. Evidence such as

clothing, bullets, bloodstains, hairs, bers, and small pieces
of material such as fragments of metal, glass, paint, and wood
should be saved and documented in all medical accident in-
stances that have legal implications.
2. Investigation of Wound Characteristics. Wounds that the
nurse must be able to identify include:
a. Sharp-Force Injuries: Sharp-force injuries including stab
wounds and other wounds resulting from penetration
with a sharp object.
b. Blunt-Force Injuries: Includes cuts and bruises resulting
from the impact of a blunt object against the body.
c. Dicing Injuries: Multiple, minute cuts and abrasions
caused by contact with shattered glass (e.g., often occur in
motor vehicle accidents).
d. Patterned Injuries: Specic injuries that reect the
pattern of the weapon used to in ict the injury.
e. Bite-Mark Injuries: A type of patterned injury in icted
by a human or an animal.
f. Defense Wounds: Injuries that reect the victims attempt
to defend himself or herself from attack.
g. Hesitation Wounds: Usually supercial, sharp-force
wounds; often found perpendicular to the lower part of
the body and may reect self-in icted wounds.
h. Fast-Force Injuries: Usually gunshot wounds; may reect
various patterns of injury.
3. Deaths in the Emergency Department. When deaths oc-
cur in the emergency department as a result of abuse or acci-
dent, evidence must be retained, the death must be reported
to legal authorities, and an investigation is conducted. It is
therefore essential that the nurse carefully document the
appearance, condition, and behavior of the victim upon ar-
rival at the hospital. The information gathered from the cli-
ent and family (or others accompanying the client) may serve
to facilitate the postmortem investigation and may be used
during criminal justice proceedings.
The critical factor is to be able to determine if the cause
of death is natural or unnatural. A death is deemed natural if
it occurs because of a congenital anomaly or a disease process
that interferes with vital organ functioning (Lynch, 2006). In
the emergency department, most deaths are sudden and un-
expected. Those that are considered natural most commonly
involve the cardiovascular, respiratory, and central nervous sys-
tems. Deaths that are considered unnatural include those from
trauma, from self-inflicted acts, or from injuries inflicted by an-
other. Legal authorities must be notified of all deaths related to
unnatural circumstances.
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for Forensic Nursing in Trauma Care
POST-TRAUMA SYNDROME
De nition: Sustained maladaptive response to a traumatic, over-
whelming event.

Physical and/or psychosocial abuse
Tragic occurrence involving multiple deaths
Sudden destruction of ones home or community
Epidemics
Disasters
Rape
Serious accidents (e.g., industrial, motor vehicle)
Witnessing mutilation, violent death, [or other horrors]
Serious threat or injury to self or loved ones
[Physical injuries related to trauma]
Avoidance
Repression
Difculty concentrating
Grieving; guilt
Intrusive thoughts
Neurosensory irritability
Palpitations
Anger and/or rage; aggression
Intrusive dreams; nightmares; ashbacks
Panic attacks; fear
Gastric irritability
Psychogenic amnesia
Substance abuse
Goals/Objectives
Short-term Goals
1. The clients physical wounds will heal without complication.
2. The client will begin a healthy grief resolution, initiating the
process of psychological healing.
Long-term Goal
The client will demonstrate ability to deal with emotional reac-
tions in an individually appropriate manner.
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1. It is important to communicate the following to the victim of
sexual assault:
a. You are safe here.
b. Im sorry that it happened.
c. I am very glad you survived.
d. It is not your fault. No one deserves to be treated this
way.
e. You did the best that you could.
The woman who has been sexually assaulted fears for her life
and must be reassured of her safety. She may also be over-
whelmed with self-doubt and self-blame, and these state-
ments instill trust and validate self-worth.
2. Explain every assessment procedure that will be conducted
and why it is being conducted. Ensure that data collection
is conducted in a caring, nonjudgmental manner to decrease
fear and anxiety and increase trust.
3. Ledray (2001) suggested the following ve essential compo-
nents of a forensic examination of the sexual assault survivor
in the emergency department:
a. Treatment and documentation of injuries. Samples of blood, se-
men, hair, and ngernail scrapings should be sealed in paper,
not plastic, bags, to prevent the possible growth of mildew
from accumulation of moisture inside the plastic container,
and the subsequent contamination of the evidence.
b. Maintaining the proper chain of evidence. Samples must be
properly labeled, sealed, and refrigerated when necessary
and kept under observation or properly locked until ren-
dered to the proper legal authority in order to ensure the
proper chain of evidence and freshness of the samples.
c. Treatment and evaluation of sexually transmitted diseases
(STDs). If conducted within 72 hours of the attack, sev-
eral tests and interventions are available for prophylactic
treatment of certain STDs.
d. Pregnancy risk evaluation and prevention. Prophylactic regi-
mens are 97% to 98% effective if started within 24 hours
of the sexual attack and are generally only recommended
within 72 hours (Ledray, 2001).
e. Crisis intervention and arrangements for follow-up counseling.
Because a survivor is often too ashamed or fearful to seek
follow-up counseling, it may be important for the nurse to
obtain the individuals permission to allow a counselor to
call her to make a follow-up appointment.
4. In the case of other types of trauma (e.g., gunshot victims;
automobile/pedestrian hit-and-run victims), ensure that any
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possible evidence is not lost. Clothing that is removed from a

victim should not be shaken, and each separate item of cloth-
ing should be placed carefully in a paper bag, which should be
sealed, dated, timed, and signed.
5. Ensure that the client has adequate privacy for all immediate
postcrisis interventions. Try to have as few people as possible
providing the immediate care or collecting immediate evi-
dence. The post-trauma client is extremely vulnerable. Ad-
ditional people in the environment may increase this feeling
of vulnerability and escalate anxiety.
6. Encourage the client to give an account of the trauma/
assault. Listen, but do not probe. Nonjudgmental listening
provides an opportunity for catharsis that the client needs to
begin healing. A detailed account may be required for legal
follow-up, and a caring nurse, as client advocate, may help
to lessen the trauma of evidence collection.
7. Discuss with the client whom to call for support or assistance.
Provide information about referrals for aftercare. Because of
severe anxiety and fear, client may need assistance from oth-
ers during this immediate postcrisis period. Provide referral
information in writing for later reference (e.g., psychothera-
pist, mental health clinic, community advocacy group).
8. In the event of a sudden and unexpected death in the trauma
care setting, the clinical forensic nurse may be called upon to
present information associated with an anatomical donation
request to the survivors. The clinical forensic nurse specialist
is an expert in legal issues and has the knowledge and sensi-
tivity to provide coordination between the medical examiner
and families who are grieving the loss of loved ones.
Outcome Criteria
1. The client is no longer experiencing panic anxiety.
2. The client demonstrates a degree of trust in the primary
nurse.
3. The client has received immediate attention to physical injuries.
4. The client has initiated behaviors consistent with the grief
response.
5. Necessary evidence has been collected and preserved in
order to proceed appropriately within the legal system.
Forensic Psychiatric Nursing in Correctional

Facilities
Assessment
It was believed that deinstitutionalization increased the freedom
of mentally ill individuals in accordance with the principle of
least restrictive alternative. However, because of inadequate
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community-based services, many of these individuals drift

into poverty and homelessness, increasing their vulnerability
to criminalization. Because the bizarre behavior of mentally ill
individuals living on the street is sometimes offensive to com-
munity standards, law enforcement ofcials have the authority
to protect the welfare of the public, as well as the safety of the
individual, by initiating emergency hospitalization. However,
legal criteria for commitment are so stringent in most cases,
that arrest becomes an easier way of getting the mentally ill
person off the street if a criminal statute has been violated.
According to the Bureau of Justice, more than half of all pris-
on and jail inmates have some form of mental health problem
( James & Glaze, 2006). Some of these individuals are incarcer-
ated as a result of the increasingly popular guilty but mentally
ill verdict. With this verdict, individuals are deemed mentally
ill, yet are held criminally responsible for their actions. The
individual is incarcerated and receives special treatment, if
needed, but it is no different from that available for and needed
by any prisoner.
Psychiatric diagnoses commonly identied at the time of
incarceration include schizophrenia, bipolar disorder, major
depression, personality disorders, and substance disorders, and
many have dual diagnoses (Yurkovich & Smyer, 2000). Com-
mon psychiatric behaviors include hallucinations, suspicious-
ness, thought disorders, anger/agitation, and impulsivity. De-
nial of problems is a common behavior among this population.
Use of substances and medication noncompliance are common
obstacles to rehabilitation. Substance abuse has been shown
to have a strong correlation with recidivism among the prison
population. Many individuals report that they were under the
inuence of substances at the time of their criminal actions,
and dual diagnoses are common. Detoxication frequency oc-
curs in jails and prisons, and some inmates have died from the
withdrawal syndrome because of inadequate treatment during
this process.

for Forensic Nursing in Correctional Facilities
DEFENSIVE COPING
perceived threats to positive self-regard.
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[Low self-esteem]

Grandiosity
Lack of follow-through or participation in treatment or therapy
Goals/Objectives
Short-term Goal
Client will verbalize personal responsibility for own actions,
successes, and failures.
Long-term Goal
Client will demonstrate ability to interact with others and adapt
to lifestyle goals without becoming defensive, rationalizing
behaviors, or expressing grandiose ideas.

concept.
2. Encourage client to recognize and verbalize feelings of inad-
equacy and need for acceptance from others, and how these
feelings provoke defensive behaviors, such as blaming others
for own behaviors. Recognition of the problem is the first
step in the change process toward resolution.
about how he or she is being perceived by others. Direct the
behavior in a nonthreatening manner to a more acceptable
behavior.
4. Help client identify situations that provoke defensiveness and
practice more appropriate responses through role-playing.
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Role-playing provides confidence to deal with difficult situa-

tions when they actually occur.
6. Help client set realistic, concrete goals and determine appropri-
ate actions to meet those goals. Success increases self-esteem.
7. Evaluate with client the effectiveness of the new behaviors
to reassess and develop new strategies, in the event that cer-
tain of the new coping methods prove ineffective.
8. Use confrontation judiciously to help client begin to iden-
tify defense mechanisms (e.g., denial and projection) that
are hindering development of satisfying relationships and
adaptive behaviors.
Outcome Criteria
grandiosity.
4. Client interacts with others in group situations without tak-
ing a defensive stance.
Denition: A disorder that occurs after the death of a significant
other [or any other loss of significance to the individual], in which the
experience of distress accompanying bereavement fails to follow
normative expectations and manifests in functional impairment.

[Loss of freedom]

[Anger]
[Internalized rage]
Depression
[Labile affect]
[Suicidal ideation]
[Difculty expressing feelings]
[Prolonged difculty coping]
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Goals/Objectives
Short-term Goal
Client will verbalize feelings of grief related to loss of freedom.
Long-term Goal
Client will progress satisfactorily through the grieving process.

1. Convey an accepting attitudeone that creates a nonthreat-
ening environment for the client to express feelings. Be hon-
est and keep all promises. An accepting attitude conveys to
Trust is enhanced.
2. Identify the function that anger, frustration, and rage serve
for the client. Allow the client to express these feelings within
reason. Verbalization of feelings in a nonthreatening envi-
ronment may help the client come to terms with unresolved
grief.
3. Encourage the client to discharge pent-up anger through
participation in large motor activities (e.g., physical exercises,
volleyball, punching bag). Physical exercise provides a safe
and effective method for discharging pent-up tension.
4. Anger may be displaced onto the nurse or therapist, and cau-
tion must be taken to guard against the negative effects of
countertransference. These are very difcult clients who have
the capacity for eliciting a whole array of negative feelings
from the therapist. These feelings must be acknowledged but
not allowed to interfere with the therapeutic process.
5. Explain the behaviors associated with the normal grieving
process. Help the client to recognize his or her position in this
process. This knowledge about normal grieving may help fa-
cilitate the clients progression toward resolution of grief.
6. Help the client understand appropriate ways to express anger.
Give positive reinforcement for behaviors used to express an-
ger appropriately. Act as a role model. Positive reinforcement
behaviors. It is appropriate to let the client know when he or
she has done something that has generated angry feelings in
you. Role-modeling ways to express anger in an appropriate
manner is a powerful learning tool.
7. Set limits on acting-out behaviors and explain consequences
of violation of those limits. Be supportive, yet consistent and
rm in working with this client. Client lacks sufficient self-
control to limit maladaptive behaviors; therefore, assistance
is required from staff. Without consistency on the part of all
staff members working with the client, a positive outcome
will not be achieved.
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8. Provide a safe and protective environment for the client

against risk of self-directed violence. Depression is the emo-
tion that most commonly precedes suicidal attempts.
Outcome Criteria
1. Client is able to verbalize ways in which anger and acting-out
behaviors are associated with maladaptive grieving.
2. Client is expresses anger and hostility outwardly in a safe and
acceptable manner.
RISK FOR INJURY

De nition: At risk of injury as a result of [internal or external] en-
vironmental conditions interacting with the individuals adaptive
and defensive resources.

[Substance use/detoxication at time of incarceration, exhibit-
ing any of the following:
Substance intoxication
Substance withdrawal
Disorientation
Seizures
Hallucinations
Psychomotor agitation
Unstable vital signs
Delirium
Flashbacks
Panic level of anxiety]
Goals/Objectives
Short-term Goal
Clients condition will stabilize within 72 hours.
Long-term Goal
1. Assess clients level of disorientation to determine spe-
cic requirements for safety. Knowledge of clients level
of functioning is necessary to formulate appropriate plan
of care.
2. Obtain a drug history, if possible, to determine
a. Type of substance(s) used.
b. Time of last ingestion and amount consumed.
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c. Duration and frequency of consumption.

d. Amount consumed on a daily basis.
3. Obtain urine sample for laboratory analysis of substance
content. Subjective history often is not accurate. Knowledge
regarding substance ingestion is important for accurate as-
sessment of client condition.
4. Place client in quiet room, if possible. Excessive stimuli in-
crease client agitation.
5. Institute necessary safety precautions. Client safety is a
nursing priority.
a. Observe client behaviors frequently; assign staff on one-
to-one basis if condition warrants it; accompany and assist
client when ambulating; use wheelchair for transporting
long distances.
b. Be sure that side rails are up when client is in bed.
c. Pad headboard and side rails of bed with thick towels to
protect client in case of seizure.
d. Use mechanical restraints as necessary to protect client if
excessive hyperactivity accompanies the disorientation.
6. Ensure that smoking materials and other potentially harmful
objects are stored outside clients access. Client may harm
self or others in disoriented, confused state.
7. Monitor vital signs every 15 minutes initially and less fre-
quently as acute symptoms subside. Vital signs provide the
most reliable information regarding client condition and
need for medication during acute detoxification period.
8. Follow medication regimen, as ordered by physician. Com-
mon medical interventions for detoxication from the fol-
lowing substances include:
a. Alcohol. Benzodiazepines are the most widely used group
of drugs for substitution therapy in alcohol withdrawal.
The approach to treatment is to start with relatively high
doses and reduce the dosage by 20% to 25% each day until
withdrawal is complete. In clients with liver disease, ac-
cumulation of the longer-acting agents, such as chlordi-
azepoxide (Librium), may be problematic, and the use of
the shorter-acting benzodiazepine, oxazepam (Serax), is
more appropriate. Some physicians may order anticonvul-
sant medication to be used prophylactically; however, this
is not a universal intervention. Multivitamin therapy, in
combination with daily thiamine (either orally or by injec-
tion), is common protocol.
b. Narcotics. Narcotic antagonists, such as naloxone (Narcan),
naltrexone (ReVia), or nalmefene (Revex), are admin-
istered for opioid intoxication. Withdrawal is managed
with rest and nutritional therapy. Substitution therapy
may be instituted to decrease withdrawal symptoms using
propoxyphene (Darvon) for weaker effects or methadone
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(Dolophine) for longer effects. In October 2002, the

U.S. Food and Drug Administration approved two forms
of the drug buprenorphine for treating opiate dependence.
Buprenorphine is less powerful than methadone but is
considered to be somewhat safer and causes fewer side
effects, making it especially attractive for clients who are
mildly or moderately addicted.
c. Depressants. Substitution therapy may be instituted to
decrease withdrawal symptoms using a long-acting barbi-
turate, such as phenobarbital (Luminal). Some physicians
prescribe oxazepam (Serax) as needed for objective symp-
toms, gradually decreasing the dosage until the drug is dis-
continued. Long-acting benzodiazepines are commonly
used for substitution therapy when the abused substance is
a nonbarbiturate central nervous system depressant.
d. Stimulants. Treatment of stimulant intoxication is geared
toward stabilization of vital signs. Intravenous antihyper-
tensives may be used, along with intravenous diazepam
(Valium) to control seizures. Minor tranquilizers, such as
chlordiazepoxide, may be administered orally for the rst
few days while the client is crashing. Treatment is aimed
at reducing drug craving and managing severe depression.
Suicide precautions may be required. Therapy with anti-
depressant medication is not uncommon.
e. Hallucinogens and Cannabinols. Medications are nor-
mally not prescribed for withdrawal from these substances.
However, in the event of overdose or the occurrence of
adverse reactions (e.g., anxiety or panic), benzodiazepines
(e.g., diazepam or chlordiazepoxide) may be given as
needed to decrease agitation. Should psychotic reactions
occur, they may be treated with antipsychotics.
Outcome Criteria
1. Client is no longer exhibiting any signs or symptoms of sub-
stance intoxication or withdrawal.
2. Client shows no evidence of physical injury obtained during
substance intoxication or withdrawal.
INTERNET REFERENCES
Additional information related to forensic nursing may be found
a. http://www.forensiceducation.com/
b. http://www.iafn.org/
c. http://www.amrn.com/
d. http://nursing.advanceweb.com/common/Editorial/
Editorial.aspx?CC=40302
e. http://www.forensicnursemag.com
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C H A P T E R
23
Complementary
Therapies
INTRODUCTION
The connection between mind and body, and the inuence of
each on the other, is well recognized by all clinicians, and par-
ticularly by psychiatrists. Traditional medicine as it is currently
practiced in the United States is based on scientic methodol-
ogy. Traditional medicine is also known as allopathic medicine
and is the type historically taught in U.S. medical schools.
The term alternative medicine has come to be recognized as
practices that differ from the usual traditional practices in the
treatment of disease. Alternative refers to an intervention that
is used instead of conventional treatment. Complementary ther-
apy is an intervention that is different from, but used in conjunc-
tion with, traditional or conventional medical treatment. In the
United States, approximately 38% of adults and 12% of children
use some form of complementary or alternative therapy (National
Institutes of Health [NIH], 2008). When prayer specically for
health reasons is included in the de nition of alternative medi-
cine, the numbers are even higher. More than $27 billion a year
is spent on alternative medical therapies in the United States.
In 1991, an Ofce of Alternative Medicine (OAM) was estab-
lished by the NIH to study nontraditional therapies and to eval-
uate their usefulness and their effectiveness. Since that time, the
name has been changed to the National Center for Complemen-
tary Medicine and Alternative Medicine (NCCAM or CAM).
The mission statement of the CAM states (NIH, 2008):
NCCAMs mission is to explore complementary and alternative
healing practices in the context of rigorous science, train CAM
researchers, and disseminate authoritative information to the public
and professionals.
Some health insurance companies and health maintenance
organizations (HMOs) appear to be bowing to public pressure
by including alternative providers in their networks of providers
370
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for treatments such as acupuncture and massage therapy. Chi-

ropractic care has been covered by some third-party payers for
many years. Individuals who seek alternative therapy, however,
are often reimbursed at lower rates than are those who choose
traditional practitioners.
Client education is an important part of complementary care.
Positive lifestyle changes are encouraged, and practitioners serve
as educators as well as treatment specialists. Complementary
medicine is viewed as holistic health-care, which deals with not
only the physical perspective but also the emotional and spir-
itual components of the individual. Dr. Tom Coniglione, former
professor of medicine at the University of Oklahoma Health
Sciences Center, has stated,
We must look at treating the total person in order to be more
efcient and balanced within the medical community. Even nd-
ing doctors who are well-rounded and balanced has become a cri-
terion in the admitting process for medical students. Medicine has
changed from just looking at the scientist perspective of organ and
disease to the total perspective of lifestyle and real impact/results
to the patient. This evolution is a progressive and very positive shift
in the right direction (Coniglione, 1998, p. 2).
Terms such as harmony and balance are often associated with
complementary care. In fact, restoring harmony and balance
between body and mind is often the goal of complementary
health-care approaches.
TYPES OF COMPLEMENTARY THERAPIES

Herbal Medicine
The use of plants to heal is probably as old as humankind. Virtually
every culture in the world has relied on herbs and plants to treat
illness. Clay tablets from about 4000 b.c. reveal that the Sumerians
had apothecaries for dispensing medicinal herbs. At the root of
Chinese medicine is the Pen Tsao, a Chinese text written around
3000 b.c. that contained hundreds of herbal remedies. When the
Pilgrims came to America in the 1600s, they brought with them a
variety of herbs to be established and used for medicinal purposes.
The new settlers soon discovered that the Native Americans had
their own varieties of plants that they used for healing.
Many people are seeking a return to herbal remedies, because
they perceive these remedies as being less potent than prescrip-
tion drugs and as being free of adverse side effects. However,
because the U.S. Food and Drug Administration (FDA) clas-
sies herbal remedies as dietary supplements or food additives,
their labels cannot indicate medicinal uses. They are not subject
to FDA approval, and they lack uniform standards of quality
control.
2506_Ch23_370-389.indd Sec1:371 10/1/10 9:38:28 AM

Several organizations have been established to attempt reg-

ulation and control of the herbal industry. They include the
Council for Responsible Nutrition, the American Herbal Asso-
ciation, and the American Botanical Council. The Commission
E of the German Federal Health Agency is the group respon-
sible for researching and regulating the safety and efcacy of
herbs and plant medicines in Germany. All of the Commission
E monographs of herbal medicines have been translated into
English and compiled into one text (Blumenthal, 1998).
Until more extensive testing has been completed on hu-
mans and animals, the use of herbal medicines must be
approached with caution and responsibility. The notion that some-
thing being natural means it is therefore completely safe is a myth.
In fact, some of the plants from which prescription drugs are de-
rived are highly toxic in their natural state. Also, because of lack
of regulation and standardization, ingredients may be adulter-
ated. Their method of manufacture also may alter potency. For
example, dried herbs lose potency rapidly because of exposure to
air. In addition, it is often safer to use preparations that contain
only one herb. There is a greater likelihood of unwanted side
effects with combined herbal preparations.
Table 23-1 lists information about common herbal remedies,
with possible implications for psychiatric/mental health nursing.
Botanical names, medicinal uses, and safety proles are included.
TABLE 23 1 Herbal Remedies

Common Name Medicinal Uses/ Safety
(Botanical Name) Possible Action Profile
Black cohosh May provide relief of Generally considered safe in

(Cimicifuga menstrual cramps; low doses. Occasionally
racemosa) improved mood; causes GI discomfort.
calming effect. Toxic in large doses,
Extracts from the causing dizziness, nausea,
roots are thought to headaches, stiffness, and
have action similar trembling. Should not
to estrogen. take with heart problems,
concurrently with anti-
hypertensives, or during
pregnancy.
Cascara sagrada Relief of constipation Generally recognized
(Rhamnus as safe; sold as
purshiana) over-the-counter
drug in the U.S. Should
not be used during
pregnancy.
Contraindicated in
bowel obstruction or
inammation.
2506_Ch23_370-389.indd Sec1:372 10/1/10 9:38:29 AM

TABLE 23 1 Herbal Remediescontd

Chamomile As a tea, is effective as Generally recognized as

(Matricaria a mild sedative in safe when consumed in
chamomilla) the relief of insom- reasonable amounts.
nia. May also aid
digestion, relieve
menstrual cramps,
and settle upset
stomach.
Echinacea Stimulates the immune Considered safe in reason-
(Echinacea system; may have able doses.
angustifolia and value in ghting Observe for side effects or
Echinacea pur- infections and eas- allergic reaction.
purea) ing the symptoms of
colds and u.
Fennel Used to ease stomach- Generally recognized as
(Foeniculum aches and to aid safe when consumed in
vulgare or digestion. Taken in reasonable amounts.
Foeniculum a tea or in extracts
of cinale) to stimulate the
appetites of people
with anorexia
(1-2 tsp. seeds
steeped in boiling
water for making
tea)
Feverfew Prophylaxis and treat- A small percentage of
(Tanacetum ment of migraine individuals may experi-
parthenium) headaches. Effective ence the adverse effect
in either the fresh of temporary mouth
leaf or freeze-dried ulcers. Considered safe in
forms (2-3 fresh reasonable doses.
leaves [or equivalent]
per day)
Ginger Ginger tea to ease Generally recognized
(Zingiber stomachaches and to as safe in designated
of cinale) aid digestion. Two therapeutic doses.
powdered ginger-
root capsules have
been shown to be
effective in prevent-
ing motion sickness.
Continued
2506_Ch23_370-389.indd Sec1:373 10/1/10 9:38:29 AM


Ginkgo Used to treat senility, Safety has been established

(Ginkgo short-term memory with recommended
biloba) loss, and peripheral dosages. Possible side
insufciency. Has effects include head-
been shown to dilate ache, GI problems, and
blood vessels. dizziness. Contraindi-
Usual dosage is cated in pregnancy and
120-240 mg/day. lactation and in patients
with bleeding disorder.
Possible compound effect
with concomitant use of
aspirin or anticoagulants.
Ginseng The ancient Chinese Generally considered safe.
(Panax saw this herb as Side effects may include
ginseng) one that increased headache, insomnia, anxi-
wisdom and longev- ety, skin rashes, diarrhea.
ity. Current studies Avoid concomitant use
support a possible with anticoagulants.
positive effect on
the cardiovascular
system. Action not
known.
Hops Used in cases of ner- Generally recognized as
(Humulus vousness, mild anxi- safe when consumed in
lupulus) ety, and insomnia. recommended dosages.
Also may relieve the
cramping associated
with diarrhea. May
be taken as a tea, in
extracts, or capsules.
Kava-Kava Used to reduce anxiety Scaly skin rash may occur
(Piper while promoting when taken at high
methylsticum) mental acuity. dosage for long periods.
Dosage: 150-300 mg Motor reexes and judg-
BID. ment when driving may
be reduced while taking
the herb.
Concurrent use with CNS
depressants may produce
additive tranquilizing
effects.
Reports of potential for
liver damage. Investiga-
tions continue.
Should not be taken for
longer than 3 months
without a physicians
supervision.
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Passion ower Used in tea, capsules, Generally recognized as

(Passi ora or extracts to treat safe in recommended
incarnata) nervousness and doses.
insomnia. Depresses
the central nervous
system to produce a
mild sedative effect.
Peppermint Used as a tea to relieve Considered to be safe when
(Mentha upset stomachs and consumed in designated
piperita) headaches and as a therapeutic dosages.
mild sedative. Pour
boiling water over
1 tbsp. dried leaves
and steep to make
a tea. Oil of pep-
permint is also used
for inammation of
the mouth, pharynx,
and bronchus.
Psyllium Psyllium seeds are a Approved as an
(Plantago popular bulk laxative over-the-counter
ovata) commonly used for drug in the U.S.
chronic constipa-
tion. Also found
to be useful in the
treatment of hyper-
cholesterolemia.
Scullcap Used as a sedative for Considered safe in reason-
(Scutellaria mild anxiety and able amounts.
lateri ora) nervousness.
St. Johns Wort Used in the treatment Generally recognized as
(Hypericum of mild to moderate safe when taken at recom-
perforatum) depression. May mended dosages. Side
block reuptake effects include mild GI
of serotonin/ irritation that is lessened
norepinephrine with food; photosensitiv-
and have a mild ity when taken in high
monoamine dosages over long peri-
oxide-inhibiting ods. Should not be taken
effect. Effective with other psychoactive
dose: 900 mg/day. medications.
May also have
antiviral, anti-
bacterial, and
anti-inammatory
properties.
Continued
2506_Ch23_370-389.indd Sec1:375 10/1/10 9:38:30 AM


Valerian Used to treat nervous- Generally recognized as

(Valeriana ness and insomnia. safe when taken at recom-
of cinals) Produces restful mended dosages. Side
sleep without morn- effects may include mild
ing hangover. The headache or upset stom-
root may be used ach. Taking doses higher
to make a tea, or than recommended may
capsules are avail- result in severe headache,
able in a variety of nausea, morning grog-
dosages. Mechanism giness, blurry vision.
of action is similar Should not be taken
to benzodiazepines, concurrently with CNS
but without addict- depressants.
ing properties. Daily
dosage range:
100-1000 mg.
Sources: Sadock and Sadock (2007), Trivieri and Anderson (2002), Holt and
Kouzi (2002), PDR for Herbal Medicines (2007), and Pranthikanti (2007).
Acupressure and Acupuncture

Acupressure and acupuncture are healing techniques based on
the ancient philosophies of traditional Chinese medicine dating
back to 3000 b.c. The main concept behind Chinese medicine
is that healing energy (qi) ows through the body along specic
pathways called meridians. It is believed that these meridians
of qi connect various parts of the body in a way similar to the
way in which lines on a road map link various locations. The
pathways link a conglomerate of points, called acupoints. There-
fore, it is possible to treat a part of the body distant to another
because they are linked by a meridian. Trivieri and Anderson
(2002) have stated, The proper ow of qi along energy channels
(meridians) within the body is crucial to a persons health and
vitality.
In acupressure, the ngers, thumbs, palms, or elbows are
used to apply pressure to the acupoints. This pressure is thought
to dissolve any obstructions in the ow of healing energy and
to restore the body to a healthier functioning. In acupuncture,
hair-thin, sterile, disposable, stainless-steel needles are inserted
into acupoints to dissolve the obstructions along the meridians.
The needles may be left in place for a specied length of time,
they may be rotated, or a mild electric current may be applied.
An occasional tingling or numbness is experienced, but little to
no pain is associated with the treatment (NCCAM, 2007).
2506_Ch23_370-389.indd Sec1:376 10/1/10 9:38:30 AM

The Western medical philosophy regarding acupressure and

acupuncture is that they stimulate the bodys own painkilling
chemicalsthe morphine-like substances known as endorphins.
The treatment has been found to be effective in the treatment
of asthma, dysmenorrhea, cervical pain, insomnia, anxiety,
depression, substance abuse, stroke rehabilitation, nausea of
pregnancy, postoperative and chemotherapy-induced nausea
and vomiting, tennis elbow, bromyalgia, low back pain, car-
pal tunnel syndrome, and many other conditions (Council of
Acupuncture and Oriental Medicine Associations [CAOMA],
2009; NCCAM, 2007; Sadock & Sadock, 2007). Recent studies
suggest that acupuncture may aid in the treatment of cocaine
dependence and chronic daily headaches (Avants et al., 2000;
Coeytaux et al., 2005).
Acupuncture is gaining wide acceptance is the United States
by both patients and physicians. This treatment can be admin-
istered at the same time other techniques are being used, such
as conventional Western techniques, although it is essential that
all health-care providers have knowledge of all treatments being
received. Acupuncture should be administered by a physician
or an acupuncturist who is licensed by the state in which the
service is provided. Typical training for licensed acupuncturists,
doctors of oriental medicine, and acupuncture physicians is a
3- or 4-year program of 2500 to 3500 hours.
Diet and Nutrition

The value of nutrition in the healing process has long been un-
derrated. Lutz and Przytulski (2006) stated:
Today many diseases are linked to lifestyle behaviors such as smok-
ing, lack of adequate physical activity, and poor nutritional habits.
The World Health Organization (WHO) reports that nearly one-
third of early death and disability stems from nutritional or dietary
causes. Healthcare providers emphasize the relationship between
lifestyle and the risk of disease. Many people, at least in industrial-
ized countries, are increasingly managing their health problems and
making personal commitments to lead healthier lives. Nutrition is,
in part, a preventive science. Given sufcient resources, how and
what one eats is a lifestyle choice (p. 4).
Individuals select the foods they eat based on a number of fac-
tors, not the least of which is enjoyment. Eating must serve social
and cultural, as well as nutritional, needs. The U.S. Department
of Agriculture (USDA) and Department of Health and Human
Services (USDHHS) have collaborated on a set of guidelines to
help individuals understand what types of foods to eat and the
healthy lifestyle they need to pursue in order to promote health
and prevent disease. Following is a list of key recommendations
from these guidelines (USDA/USDHHS, 2005).
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1. Adequate Nutrients within Calorie Needs

a. Consume a variety of nutrient-dense foods and beverages
within and among the basic food groups while choosing
foods that limit the intakes of fat, cholesterol, added sug-
ars, salt, and alcohol.
b. Meet recommended intakes within energy needs by
adopting a balanced eating pattern, such as the guidelines
in Table 23-2. Table 23-3 provides a summary of informa-
tion about essential vitamins and minerals.
TABLE 23 2 Sample USDA Food Guide at the 2000-Calorie

Level
Food Groups and USDA Food Guide Examples/
Subgroups Daily Amount Equivalent Amounts
1
Fruit group 2 cups (4 servings) 2 cup equivalent is:
1

2 cup fresh, frozen,
or canned fruit

1 medium fruit
1

4 cup dried fruit
1

2 cup fruit juice
1
Vegetable group 2.5 cups (5 servings) 2 cup equivalent is:
1

Dark green vegetables:
2 cup cut-up raw or
3 cups/week cooked vegetable

Orange vegetables:
1 cup raw leafy
2 cups/week vegetable
1

Legumes (dry beans/
2 cup vegetable juice
peas): 3 cups/week

Starchy vegetables:
3 cups/week

Other vegetables:
6.5 cups/week
Grain group 6 ounce-equivalents 1 ounce-equivalent is:

Whole grains:
1 slice bread
3 ounce-equivalents
1 cup dry cereal
1

Other grains: 3
2 cup cooked rice,
ounce-equivalents pasta, cereal
Meat and beans 5.5 ounce-equivalents 1 ounce-equivalent is:
group
1 oz. cooked lean
meat, poultry, or sh

1 egg
1

4 cup cooked dry
beans or tofu

1 tbsp. peanut butter
1

2 oz. nuts or seeds
2506_Ch23_370-389.indd Sec1:378 10/1/10 9:38:31 AM

TABLE 23 2 Sample USDA Food Guide at the 2000-Calorie

Levelcontd
Food Groups and USDA Food Guide Examples/
Subgroups Daily Amount Equivalent Amounts
Milk group 3 cups 1 cup equivalent is:

1 cup low fat/fat-free
milk

1 cup low fat/fat-free
yogurt

11 2 oz low-fat or fat-
free natural cheese

2 oz. low-fat or fat-
free processed cheese
Oils 24 grams (6 tsp.) 1 tsp. equivalent is:

1 tbsp. low-fat mayo

2 tbsp. light salad
dressing

1 tsp. vegetable oil

1 tsp. soft margarine
with zero trans-fat
Discretionary 267 calories 1 tbsp. added sugar
calorie allowance Example of distribution: equivalent is:
1

Solid fats 18 grams
2 oz. jelly beans
(e.g., saturated & trans
8 oz. lemonade
fats) Examples of solid fats:

Added sugars
Fat in whole milk/ice
32 grams (8 tsp.) (e.g., cream
sweetened cereals)
Fatty meats
Essential oils (above)
are not considered
part of the discre-
tionary calories
Source: Dietary Guidelines for Americans 2005. Washington, D.C.: USDA/USDHHS,

2005.
2. Weight Management
a. Maintain body weight in a healthy range; balance calories
from foods and beverages with calories expended.
b. To prevent gradual weight gain over time, make small de-
creases in food and beverage calories and increase physi-
cal activity.
3. Physical Activity
a. Engage in regular physical activity and reduce sedentary
activities to promote health, psychological well-being,
and a healthy body weight.
b. To reduce the risk of chronic disease in adulthood, en-
gage in at least 30 minutes of moderate-intensity physical
activity, above usual activity, at work or home on most
days of the week.
2506_Ch23_370-389.indd Sec1:379 10/1/10 9:38:32 AM

TABLE 23 3 Essential Vitamins and Minerals
380
Vitamin/
Mineral Function New DRI (UL)* Food Sources Comments
2506_Ch23_370-389.indd Sec1:380
Vitamin A Prevention of night Men: 900 mcg Liver, butter, cheese, whole May be of benet in prevention
blindness; calcication (3000 mcg) milk, egg yolk, sh, green of cancer, because of its anti-
of growing bones; resis- Women: 700 mcg leafy vegetables, carrots, oxidant properties, which are
tance to infection (3000 mcg) pumpkin, sweet potatoes associated with control of free
radicals that damage DNA and
cell membranes.
Vitamin D Promotes absorption of Men and women: Fortied milk and dairy products, Without vitamin D, very little
calcium and phosphorus 5 mcg (50 mcg) egg yolk, sh liver oils, liver, dietary calcium can be
in the small intestine; (510 for ages 5070 oysters; formed in the skin by absorbed.
prevention of rickets and 15 for >70) exposure to sunlight
Vitamin E An antioxidant that prevents Men and women: Vegetable oils, wheat germ, As an antioxidant, may have
cell membrane destruction 15 mg (1000 mg) whole grain or fortied implications in the prevention
cereals, green leafy of Alzheimers disease, heart
SPECIAL TOPICS IN PSYCHIATRIC
vegetables, nuts disease, breast cancer

Vitamin K Synthesis of prothrombin Men: 120 mcg (ND)*** Green vegetables (collards, Individuals on anticoagulant
and other clotting factors; Women: 90 mcg spinach, lettuce, kale, broccoli, therapy should monitor
normal blood coagulation (ND)*** brussels sprouts, cabbage), vitamin K intake.
plant oils, and margarine
Vitamin C Formation of collagen in con- Men: 90 mg (2000 mg) Citrus fruits, tomatoes, pota- As an antioxidant, may have im-
nective tissues; a powerful Women: 75 mg toes, green leafy vegetables, plications in the prevention of
antioxidant; facilitates iron (2000 mg) strawberries cancer, cataracts, heart disease.
absorption; aids in the It may stimulate the immune
release of epinephrine from system to ght various types of
the adrenal glands during infection.
stress
10/1/10 9:38:32 AM
Vitamin B1 Essential for normal function- Men: 1.2 mg (ND)*** Whole grains, legumes, Large doses may improve mental
(thiamine) ing of nervous tissue; Women: 1.1 mg nuts, egg yolk, meat, performance in people with
2506_Ch23_370-389.indd Sec1:381
coenzyme in carbohydrate (ND)*** green leafy vegetables Alzheimers disease.
metabolism
Vitamin B2 Coenzyme in the metabolism Men: 1.3 mg (ND)*** Meat, dairy products, whole May help in the prevention of
(riboavin) of protein and carbohydrate Women: 1.1 mg or enriched grains, legumes, cataracts; high-dose therapy
for energy (ND)*** nuts may be effective in migraine
prophylaxis (Schoenen et al.,
1998).
Vitamin B3 Coenzyme in the metabolism Men: 16 mg (35 mg) Milk, eggs, meats, legumes, High doses of niacin have been
(niacin) of protein and carbohydrates Women: 14 mg whole grain and enriched successful in decreasing
for energy (35 mg) cereals, nuts levels of cholesterol in some
individuals.
Vitamin B6 Coenzyme in the synthesis Men and women: Meat, sh, grains, legumes, May decrease depression in some
(pyridoxine) and catabolism of amino 1.3 mg (100 mg) bananas, nuts, white and individuals by increasing levels
acids; essential for metabo- After age 50: sweet potatoes of serotonin; deciencies may
lism of tryptophan to Men: 1.7 mg contribute to memory prob-
niacin Women: 1.5 mg lems; also used in the treatment
of migraines and premenstrual
discomfort.
Vitamin B12 Necessary in the formation of Men and women: Found in animal products (e.g., Deciency may contribute to
DNA and the production of 2.4 mcg (ND)*** meats, eggs, dairy products) memory problems. Vegetarians
red blood cells; associated can get this vitamin from forti-
Complementary Therapies
with folic acid metabolism ed foods. Intrinsic factor must

be present in the stomach for

absorption of vitamin B12.
381
Continued
10/1/10 9:38:32 AM
TABLE 23 3 Essential Vitamins and Mineralscontd
382
Vitamin/
Mineral Function New DRI (UL)* Food Sources Comments
2506_Ch23_370-389.indd Sec1:382
.Folic acid Necessary in the formation of Men and women: Meat; green leafy vegetables; Important in women of child-
(folate) DNA and the production of 400 mcg (1000 mcg) beans; peas; fortied cereals, bearing age to prevent fetal
red blood cells Pregnant women: breads, rice, and pasta neural tube defects; may con-
600 mcg tribute to prevention of heart
disease and colon cancer.
Calcium Necessary in the formation Men and women: Dairy products, kale, broccoli, Calcium has been associated with
of bones and teeth; neuron 1000 mg (2500 mg) spinach, sardines, oysters, preventing headaches, muscle
and muscle functioning; After age 50: salmon cramps, osteoporosis, and pre-
blood clotting Men and women: menstrual problems. Requires
1200 mg vitamin D for absorption.
Phosphorus Necessary in the forma- Men and women: Milk, cheese, sh, meat, yogurt,
tion of bones and teeth; a 700 mg (4000 mg) ice cream, peas, eggs
SPECIAL TOPICS IN PSYCHIATRIC
component of DNA, RNA,

ADP, and ATP; helps
control acid-base balance in
the blood
Magnesium Protein synthesis and carbo- Men: 420 mg Green vegetables, legumes, May aid in prevention of asth-
hydrate metabolism; mus- (350 mg)** seafood, milk, nuts, meat matic attacks and migraine
cular relaxation following Women: 320 mg headaches. Deciencies may
contraction; bone formation (350 mg)** contribute to insomnia, pre-
menstrual problems.
10/1/10 9:38:33 AM
Iron Synthesis of hemoglobin Men: 8 mg (45 mg) Meat, sh, poultry, eggs, nuts, Iron deciencies can result in
and myoglobin; cellular Women: (45 mg) dark green leafy vegetables, headaches and feeling
2506_Ch23_370-389.indd Sec1:383
oxidation Childbearing age: dried fruit, enriched pasta and chronically fatigued.
18 mg; Over 50: 8 mg; bread
Pregnant: 27 mg;
Breastfeeding: 9 mg
Iodine Aids in the synthesis of T3 Men and women: Iodized salt, seafood Exerts strong controlling
and T4 150 mcg (1100 mcg) inuence on overall body
metabolism.
Selenium Works with Vitamin E to Men and women: Seafood, low-fat meats, dairy As an antioxidant combined with
protect cellular compounds 55 mcg (400 mcg) products, liver vitamin E, may have some
from oxidation anti-cancer effect. Deciency
has also been associated with
depressed mood.
Zinc Involved in synthesis of DNA Men: 11 mg (40 mg) Meat, seafood, fortied cereals, An important source for the
and RNA; energy metabo- Women: 8 mg (40 mg) poultry, eggs, milk prevention of infection and
lism and protein synthesis; improvement in wound
wound healing; increased healing.
immune functioning; nec-
essary for normal smell and
taste sensation.
* Dietary Reference Intakes (UL), the most recent set of dietary recommendations for adults established by the Food and Nutrition Board of the Institute
Complementary Therapies
of Medicine, 2004. UL is the upper limit of intake considered to be safe for use by adults (includes total intake from food, water, and supplements). In
addition to the UL, DRIs are composed of the Recommended Dietary Allowance (RDA, the amount considered sufcient to meet the requirements of

97% to 98% of all healthy individuals) and the Adequate Intake (AI, the amount considered sufcient where no RDA has been established).
** UL for magnesium applies only to intakes from dietary supplements, excluding intakes from food and water.
383
*** ND = Not determined

Source: Adapted from National Academies of Sciences (2004).
10/1/10 9:38:33 AM
c. To help manage body weight and prevent gradual, unhealthy

body weight gain in adulthood, engage in approximately
60 minutes of moderate- to vigorous-intensity activity on
most days of the week while not exceeding caloric intake
requirements.
d. To sustain weight loss in adulthood, participate in at least
60 to 90 minutes of daily moderate-intensity physical
activity while not exceeding caloric intake requirements.
e. Achieve physical tness by including cardiovascular con-
ditioning, stretching exercises for exibility, and resis-
tance exercises or calisthenics for muscle strength and
endurance.
4. Food Groups to Encourage
a. Fruits and Vegetables. Choose a variety of fruits and
vegetables each day. In particular, select from all ve veg-
etable subgroups several times a week.
b. Whole Grains. Half the daily servings of grains should
come from whole grains.
c. Milk and Milk Products. Daily choices of fat-free or
low-fat milk or milk products are important. To help meet
calcium needs, non-dairy calcium-containing alterna-
tives may be selected by individuals with lactose intoler-
ance or those who choose to avoid all milk products (e.g.,
vegans).
5. Food Groups to Moderate
a. Fats. Keep total fat intake between 20% and 35% of calo-
ries, with most fats coming from sources of polyunsatu-
rated and monounsaturated fatty acids, such as sh, nuts,
and vegetable oils. Consume less than 10% of calories
from saturated fatty acids and less than 300 mg/day of
cholesterol, and keep transfatty acid consumption as low
as possible.
b. Carbohydrates. Carbohydrate intake should comprise
45% to 64% of total calories, with the majority coming
from ber-rich foods. Important sources of nutrients from
carbohydrates include fruits, vegetables, whole grains,
and milk. Added sugars, caloric sweeteners, and rened
starches should be used prudently.
c. Sodium Chloride. Consume less than 2300 mg (approxi-
mately 1 teaspoon of salt) of sodium per day. Choose and
prepare foods with little salt. At the same time, consume
potassium-rich foods, such as fruits and vegetables.
d. Alcoholic Beverages. Individuals who choose to drink al-
coholic beverages should do so sensibly and in moderation
de ned as the consumption of up to one drink per day for
women and up to two drinks per day for men. One drink
should count as:
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12 ounces of regular beer (150 calories)

5 ounces of wine (100 calories)
1.5 ounces of 80-proof distilled spirits (100 calories)
Alcohol should be avoided by individuals who are unable to
restrict their intake; women who are pregnant, may become
pregnant, or are breastfeeding and individuals who are taking
medications that may interact with alcohol or who have specic
medical conditions.
Chiropractic Medicine
Chiropractic medicine is probably the most widely used form
of alternative healing in the United States. It was developed in
the late 1800s by a self-taught healer named David Palmer. It
was later reorganized and expanded by his son Joshua, a trained
practitioner. Palmers objective was to nd a cure for disease and
illness that did not use drugs but instead relied on more natu-
ral methods of healing (Trivieri & Anderson, 2002). Palmers
theory of chiropractic medicine was that energy ows from the
brain to all parts of the body through the spinal cord and spinal
nerves. When vertebrae of the spinal column become displaced,
they may press on a nerve and interfere with the normal nerve
transmission. Palmer named the displacement of these verte-
brae subluxation, and he alleged that the way to restore normal
function was to manipulate the vertebrae back into their normal
positions. These manipulations are called adjustments.
Adjustments are usually performed by hand, although some
chiropractors have special treatment tables equipped to facilitate
these manipulations. Other processes used to facilitate the out-
come of the spinal adjustment by providing muscle relaxation in-
clude massage tables, application of heat or cold, and ultrasound
treatments.
The chiropractor takes a medical history and performs a clini-
cal examination, which usually includes x-ray lms of the spine.
Todays chiropractors may practice straight therapythat is, the
only therapy provided is that of subluxation adjustments. Mixer is
a term applied to a chiropractor who combines adjustments with
adjunct therapies, such as exercise, heat treatments, or massage.
Individuals seek treatment from chiropractors for many types
of ailments and illnesses; the most common is back pain. In ad-
dition, chiropractors treat clients with headaches, neck injuries,
scoliosis, carpal tunnel syndrome, respiratory and gastrointes-
tinal disorders, menstrual difculties, allergies, sinusitis, and
certain sports injuries (Trivieri & Anderson, 2002). Some chi-
ropractors are employed by professional sports teams as their
team physicians.
Chiropractors are licensed to practice in all 50 states and
treatment costs are covered by government and most private
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insurance plans. They treat more than 20 million people in the

United States annually (Sadock & Sadock, 2007).
Therapeutic Touch and Massage

Therapeutic Touch
The technique of therapeutic touch was developed in the 1970s by
Dolores Krieger, a nurse associated with the New York University
School of Nursing. This therapy is based on the philosophy that the
human body projects a eld of energy around it. When this eld
of energy becomes blocked, pain or illness occurs. Practitioners
of therapeutic touch use this technique to correct the blockages,
thereby relieving the discomfort and improving health.
Based on the premise that the energy eld extends beyond
the surface of the body, the practitioner need not actually touch
the clients skin. The therapists hands are passed over the
clients body, remaining 2 to 4 inches from the skin. The goal
is to repattern the energy eld by performing slow, rhythmic,
sweeping hand motions over the entire body. Heat should be felt
where the energy is blocked. The therapist massages the en-
ergy eld in that area, smoothing it out, and thus correcting the
obstruction. Therapeutic touch is thought to reduce pain and
anxiety and promote relaxation and health maintenance. It has
been useful in the treatment of chronic health conditions.
Massage
Massage is the technique of manipulating the muscles and soft
tissues of the body. Chinese physicians prescribed massage for
the treatment of disease more than 5000 years ago. The East-
ern style focuses on balancing the bodys vital energy (qi) as it
ows through pathways (meridians), as described earlier in the
discussion of acupressure and acupuncture. The Western style
of massage affects muscles, connective tissues (e.g., tendons and
ligaments), and the cardiovascular system. Swedish massage,
which is probably the best-known Western style, uses a variety
of gliding and kneading strokes along with deep circular move-
ments and vibrations to relax the muscles, improve circulation,
and increase mobility (Trivieri & Anderson, 2002).
Massage has been shown to be benecial in the following
conditions: anxiety, chronic back and neck pain, arthritis, sciat-
ica, migraine headaches, muscle spasms, insomnia, pain of labor
and delivery, stress-related disorders, and whiplash. Massage is
contraindicated in certain conditions, such as high blood pres-
sure, acute infection, osteoporosis, phlebitis, skin conditions,
and varicose veins. It also should not be performed over the site
of a recent injury, bruise, or burn.
Massage therapists require specialized training in a program
accredited by the American Massage Therapy Association and
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must pass the National Certication Examination for Thera-

peutic Massage and Bodywork.
Yoga
Yoga is thought to have developed in India some 5000 years
ago and is attributed to an Indian physician and Sanskrit scholar
named Patanjali. The objective of yoga is to integrate the phys-
ical, mental, and spiritual energies that enhance health and
well-being (Trivieri & Anderson, 2002). Yoga has been found
to be especially helpful in relieving stress and in improving
overall physical and psychological wellness. Proper breathing is
a major component of yoga. It is believed that yoga breathinga
deep, diaphramatic breathingincreases oxygen to the brain
and body tissues, thereby easing stress and fatigue and boosting
energy.
Another component of yoga is meditation. Individuals who
practice the meditation and deep breathing associated with yoga
nd that they are able to achieve a profound feeling of relaxation.
The most familiar type of yoga practiced in Western coun-
tries is hatha yoga. Hatha yoga uses body postures, along with
the meditation and breathing exercises, to achieve a balanced,
disciplined workout that releases muscle tension, tones the
internal organs, and energizes the mind, body, and spirit, to
allow natural healing to occur. The complete routine of poses
is designed to work all parts of the bodystretching and ton-
ing muscles and keeping joints exible. Studies have shown that
yoga has provided benecial effects to some individuals with
back pain, stress, migraine, insomnia, high blood pressure,
rapid heart rates, and limited mobility (Sadock & Sadock, 2007;
Steinberg, 2002; Trivieri & Anderson, 2002).
Pet Therapy
The therapeutic value of pets is no longer just theory. Evidence
has shown that animals can directly inuence a persons mental
and physical well-being. Many pet-therapy programs have been
established across the country and the numbers are increasing
regularly.
Several studies have provided information about the positive
results of human interaction with pets. Some of these include
the following:
1. Petting a dog or cat has been shown to lower blood pressure.
In one study, volunteers experienced a 7.1 mm Hg drop in
systolic and an 8.1 mm Hg decrease in diastolic blood pres-
sure when they talked to and petted their dogs, as opposed to
reading aloud or resting quietly (Whitaker, 2000).
2. Bringing a pet into a nursing home or other institution for
the elderly has been shown to enhance a clients mood and
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social interaction (Godenne, 2001). Another study revealed

that animal-assisted therapy with nursing home residents
signicantly reduced loneliness for those in the study group
(Banks & Banks, 2002).
3. One study of 96 patients who had been admitted to a cor-
onary care unit for heart attack or angina revealed that in
the year following hospitalization, the mortality rate among
those who did not own pets was 22% higher than that among
pet owners (Whitaker, 2000).
4. Individuals with AIDS who have pets are less likely to suffer
from depression than people with AIDS who do not own pets
(Siegel et al., 1999).
Some researchers believe that animals may actually retard
the aging process among those who live alone. Loneliness often
results in premature death, and having a pet mitigates the ef-
fects of loneliness and isolation.
Whitaker (2000) has suggested:
Though owning a pet doesnt make you immune to illness, pet own-
ers are, on the whole, healthier than those who dont own pets. Study
after study shows that people with pets have fewer minor health
problems, require fewer visits to the doctor and less medication, and
have fewer risk factors for heart disease, such as high blood pressure
or cholesterol levels (p. 7).
It may never be known precisely why animals affect humans
they way they do, but for those who have pets to love, the thera-
peutic benets come as no surprise. Pets provide unconditional,
nonjudgmental love and affection, which can be the perfect an-
tidote for a depressed mood or a stressful situation. The role of
animals in the human healing process requires more research,
but its validity is now widely accepted in both the medical and
lay communities.
SUMMARY
Complementary therapies help the practitioner view the client
in a holistic manner. Most complementary therapies consider
the mind and body connection and strive to enhance the bodys
own natural healing powers. The OAM of the NIH has estab-
lished a list of alternative therapies to be used in practice and for
investigative purposes. More than $27 billion a year is spent on
alternative medical therapies in the United States.
This chapter examined herbal medicine, acupressure, acu-
puncture, diet and nutrition, chiropractic medicine, therapeutic
touch, massage, yoga, and pet therapy. Nurses must be familiar
with these therapies, as more and more clients seek out the heal-
ing properties of these complementary care strategies.
2506_Ch23_370-389.indd Sec1:388 10/1/10 9:38:35 AM

INTERNET REFERENCES
a. http://www.herbalgram.org/
b. http://www.herbmed.org/
c. http://nutritiondata.self.com/
d. http://www.nutrition.gov/
e. http://www.chiropractic.org/
f. http://www.pawssf.org/
g. http://www.therapydogs.com/
h. http://www.angelonaleash.org/
i. http://www.holisticmed.com/www/acupuncture.html
j. http://www.americanyogaassociation.org/
2506_Ch23_370-389.indd Sec1:389 10/1/10 9:38:35 AM

C H A P T E R
24
Loss and Bereavement
Loss is the experience of separation from something of personal
importance. Loss is anything that is perceived as such by the
individual. The separation from loved ones or the giving up of
treasured possessions, for whatever reason; the experience of
failure, either real or perceived; or life events that create change
in a familiar pattern of existenceall can be experienced as loss,
and all can trigger behaviors associated with the grieving pro-
cess. Loss and bereavement are universal events encountered by
all beings who experience emotions. Following are examples of
some notable forms of loss:
1. A signicant other (person or pet) through death, divorce, or
separation for any reason.
2. Illness or debilitating conditions. Examples include (but are
not limited to) diabetes, stroke, cancer, rheumatoid arthritis,
multiple sclerosis, Alzheimers disease, hearing or vision loss,
and spinal cord or head injuries. Some of these conditions
not only incur a loss of physical and/or emotional wellness
but may also result in the loss of personal independence.
3. Developmental/maturational changes or situations, such as
menopause, andropause, infertility, empty nest syndrome,
aging, impotence, or hysterectomy.
4. A decrease in self-esteem, if one is unable to meet
self-expectations or the expectations of others (even if
these expectations are only perceived by the individual
as unful lled). This includes a loss of potential hopes and
dreams.
5. Personal possessions that symbolize familiarity and security
in a persons life. Separation from these familiar and per-
sonally valued external objects represents a loss of material
extensions of the self.
Some texts differentiate the terms mourning and grief by
describing mourning as the psychological process (or stages)
through which the individual passes on the way to successful
adaptation to the loss of a valued object. Grief may be viewed
390
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as the subjective states that accompany mourning, or the emo-

tional work involved in the mourning process. For purposes of
this text, grief work and the process of mourning are collectively
referred to as the grief response.
Theoretical Perspectives on Loss

and Bereavement (Symptomatology)
Stages of Grief
Behavior patterns associated with the grief response include
many individual variations. However, sufcient similarities have
been observed to warrant characterization of grief as a syndrome
that has a predictable course with an expected resolution. Early
theorists, including Kbler-Ross (1969), Bowlby (1961), and
Engel (1964), described behavioral stages through which indi-
viduals advance in their progression toward resolution. A num-
ber of variables inuence ones progression through the grief
process. Some individuals may reach acceptance, only to revert
to an earlier stage; some may never complete the sequence; and
some may never progress beyond the initial stage.
A more contemporary grief specialist, J. William Worden
(2009), offers a set of tasks that must be processed to complete
the grief response. He suggests that it is possible for a person to
accomplish some of these tasks and not others, resulting in an
incomplete bereavement and thus impairing further growth and
development.
ELISABETH KBLER-ROSS
These well-known stages of the grief process were identied by
Kbler-Ross in her extensive work with dying patients. Behaviors
associated with each of these stages can be observed in individuals
experiencing the loss of any concept of personal value.
Stage I: Denial. The individual does not acknowledge that
the loss has occurred. He or she may say, No, it cant be
true! or Its just not possible. This stage may protect the
individual against the psychological pain of reality.
Stage II: Anger. This is the stage when reality sets in.
Feelings associated with this stage include sadness, guilt,
shame, helplessness, and hopelessness. Self-blame or blam-
ing of others may lead to feelings of anger toward the self
and others. The anxiety level may be elevated, and the in-
dividual may experience confusion and a decreased ability
to function independently. He or she may be preoccupied
with an idealized image of what has been lost. Numerous
somatic complaints are common.
Stage III: Bargaining. The individual attempts to strike a
bargain with God for a second chance or for more time.
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The person acknowledges the loss, or impending loss, but

holds out hope for additional alternatives, as evidenced by
such statements as, If only I could... or If only I had... .
Stage IV: Depression. The individual mourns for that which
has been or will be lost. This is a very painful stage, dur-
ing which the individual must confront feelings associated
with having lost someone or something of value (called
reactive depression). An example might be the individual
who is mourning a change in body image. Feelings associ-
ated with an impending loss (called preparatory depression)
are also confronted. Examples include permanent life-
style changes related to the altered body image or even an
impending loss of life itself. Regression, withdrawal, and
social isolation may be observed behaviors with this stage.
Therapeutic intervention should be available, but not
imposed, and with guidelines for implementation based on
client readiness.
Stage V: Acceptance. The individual has worked through
the behaviors associated with the other stages and either
accepts or is resigned to the loss. Anxiety decreases, and
methods for coping with the loss have been established.
The client is less preoccupied with what has been lost and
increasingly interested in other aspects of the environ-
ment. If this is an impending death of self, the individual is
ready to die. The person may become very quiet and with-
drawn, seemingly devoid of feelings. These behaviors are
an attempt to facilitate the passage by slowly disengaging
from the environment.
JOHN BOWLBY
John Bowlby hypothesized four stages in the grief process. He
implied that these behaviors can be observed in all individu-
als who have experienced the loss of something or someone of
value, even in infants as young as 6 months.
Stage I: Numbness or Protest. This stage is characterized
by a feeling of shock and disbelief that the loss has occurred.
Reality of the loss is not acknowledged.
Stage II: Disequilibrium. During this stage, the individual
has a profound urge to recover what has been lost. Behaviors
associated with this stage include a preoccupation with the
loss, intense weeping and expressions of anger toward the
self and others, and feelings of ambivalence and guilt associ-
ated with the loss.
Stage III: Disorganization and Despair. Feelings of
despair occur in response to the realization that the loss
has occurred. Activities of daily living become increasingly
disorganized, and behavior is characterized by restlessness
2506_Ch24_390-405.indd 0392 10/1/10 9:38:45 AM

and aimlessness. Efforts to regain productive patterns of

behavior are ineffective and the individual experiences fear,
helplessness, and hopelessness. Somatic complaints are com-
mon. Perceptions of visualizing or being in the presence of
that which has been lost may occur. Social isolation is com-
mon, and the individual may feel a great deal of loneliness.
Stage IV: Reorganization. The individual accepts or becomes
resigned to the loss. New goals and patterns of organization
are established. The individual begins a reinvestment in new
relationships and indicates a readiness to move forward with-
in the environment. Grief subsides and recedes into valued
remembrances.
GEORGE ENGEL
Stage I: Shock and Disbelief. The initial reaction to a loss
is a stunned, numb feeling and refusal by the individual
to acknowledge the reality of the loss. Engel states that
this stage is an attempt by the individual to protect the self
against the effects of the overwhelming stress by raising
the threshold against its recognition or against the painful
feelings evoked thereby.
Stage II: Developing Awareness. This stage begins within
minutes to hours of the loss. Behaviors associated with this
stage include excessive crying and regression to a state of
helplessness and a childlike manner. Awareness of the loss
creates feelings of emptiness, frustration, anguish, and de-
spair. Anger may be directed toward the self or toward others
in the environment who are held accountable for the loss.
Stage III: Restitution. The various rituals associated with
loss within a culture are performed. Examples include
funerals, wakes, special attire, a gathering of friends and
family, and religious practices customary to the spiritual
beliefs of the bereaved. Participation in these rituals is
thought to assist the individual to accept the reality of the
loss and to facilitate the recovery process.
Stage IV: Resolution of the Loss. This stage is characterized
by a preoccupation with the loss. The concept of the loss
is idealized, and the individual may even imitate admired
qualities of a person who has been lost. Preoccupation with
the loss gradually decreases over a year or more, and the
individual eventually begins to reinvest feelings in others.
Stage V: Recovery. Obsession with the loss has ended, and
the individual is able to go on with his or her life.
J. WILLIAM WORDEN
Worden views the bereaved as active and self-determining rather
than passive participants in the grief process. He proposes that
bereavement includes a set of tasks that must be reconciled in
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order to complete the grief process. Wordens four tasks of

mourning include the following:
Task I: Accepting the Reality of the Loss. When some-
thing of value is lost, it is common for individuals to refuse
to believe that the loss has occurred. Behaviors include
misidentifying individuals in the environment for their
lost loved one, retaining possessions of the lost loved one
as though he or she has not died, and removing all remind-
ers of the lost loved one so as not to have to face the reality
of the loss. Worden (2009) stated:
Coming to an acceptance of the reality of the loss takes time since
it involves not only an intellectual acceptance but also an emotional
one. The bereaved person may be intellectually aware of the nal-
ity of the loss long before the emotions allow full acceptance of the
information as true (p. 42).
Belief and denial are intermittent while grappling with
this task. It is thought that traditional rituals such as the
funeral help some individuals move toward acceptance of
the loss.
Task II: Processing the Pain of Grief. Pain associated
with a loss includes both physical pain and emotional pain.
This pain must be acknowledged and worked through.
To avoid or suppress it serves only to delay or prolong the
grieving process. People accomplish this by refusing to
allow themselves to think painful thoughts, by idealizing
or avoiding reminders of what has been lost, and by using
alcohol or drugs. The intensity of the pain and the manner
in which it is experienced are different for all individuals.
But the commonality is that it must be experienced. Failure
to do so generally results in some form of depression that
commonly requires therapy, which then focuses on work-
ing through the pain of grief that the individual failed to
work through at the time of the loss. In this very dif-
cult Task II, individuals must allow themselves to process
the painto feel it and to know that one day it will pass
(Worden, 2009, p. 45).
Task III: Adjusting to a World without the Lost Entity.
It usually takes a number of months for a bereaved person
to realize what his or her world will be like without the lost
entity. In the case of a lost loved one, how the environment
changes will depend on the types of roles that person ful-
lled in life. In the case of a changed lifestyle, the individual
will be required to make adaptations to his or her environ-
ment in terms of the changes as they are presented in daily
life. In addition, those individuals who had dened their
identity through the lost entity will require an adjustment
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to their own sense of self. Worden (2009) stated, The cop-

ing strategy of redening the loss in such a way that it can
redound to the benet of the survivor is often part of the
successful completion of Task III (p. 47).
If the bereaved person experiences failures in his or her
attempt to adjust in an environment without the lost entity,
feelings of low self-esteem may result. Regressed behav-
iors and feelings of helplessness and inadequacy are not
uncommon. Worden (2009) stated:
[Another] area of adjustment may be to ones sense of the world.
Loss through death can challenge ones fundamental life values
and philosophical beliefsbeliefs that are inuenced by our fami-
lies, peers, education, and religion as well as life experiences. The
bereaved person searches for meaning in the loss and its attendant
life changes in order to make sense of it and to regain some control
of his or her life (pp. 4849).
To be successful in Task III, bereaved individuals must devel-
op new skills to cope and adapt to their new environment
without the lost entity. Successful achievement of this task
determines the outcome of the mourning processthat of
continued growth or a state of arrested development.
Task IV: Finding an Enduring Connection with the Lost
Entity in the Midst of Embarking on a New Life. This
task allows for the bereaved person to identify a special
place for the lost entity. Individuals need not purge from
their history or nd a replacement for that which has been
lost. Instead, there is a kind of continued presence of the
lost entity that only becomes relocated in the life of the
bereaved. Successful completion of Task IV involves letting
go of past attachments and forming new ones. However,
there is also the recognition that although the relationship
between the bereaved and what has been lost is changed, it
is nonetheless still a relationship. Worden (2009) suggests
that one never loses memories of a signicant relationship.
He stated:
For many people Task IV is the most difcult one to accomplish.
They get stuck at this point in their grieving and later realize that
their life in some way stopped at the point the loss occurred (p. 52).
Worden (2009) relates the story of a teenaged girl who had

a difcult time adjusting to the death of her father. After
2 years, when she began to nally fulll some of the tasks
associated with successful grieving, she wrote these words
that express rather clearly what bereaved people in Task IV
are struggling with: There are other people to be loved,
and it doesnt mean that I love Dad any less (p. 52).
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Length of the Grief Process

Stages of grief allow bereaved persons an orderly approach to the
resolution of mourning. Each stage presents tasks that must be
overcome through a painful experiential process. Engel (1964)
stated that successful resolution of the grief response is thought
to have occurred when a bereaved individual is able to remem-
ber comfortably and realistically both the pleasures and disap-
pointments of [what has been lost]. The duration of the grief
process depends on the individual and can last for a number of
years without being maladaptive. The acute phase of normal
grieving usually lasts 6 to 8 weekslonger in older adultsbut
complete resolution of the grief response may take much longer.
Sadock and Sadock (2007) stated:
Ample evidence suggests that the bereavement process does not end
within a prescribed interval; certain aspects persist inde nitely for
many otherwise high-functioning, normal individuals. Common
manifestations of protracted grief occur intermittently. Most grief
does not fully resolve or permanently disappear; rather grief be-
comes circumscribed and submerged only to reemerge in response
to certain triggers (p. 64).
A number of factors inuence the eventual outcome of the

grief response. The grief response can be more difcult if:
The bereaved person was strongly dependent on or per-
ceived the lost entity as an important means of physical
and/or emotional support.
The relationship with the lost entity was highly ambiva-
lent. A love-hate relationship may instill feelings of guilt
that can interfere with the grief work.
The individual has experienced a number of recent losses.
Grief tends to be cumulative, and if previous losses have
not been resolved, each succeeding grief response becomes
more difcult.
The loss is that of a young person. Grief over loss of a child
is often more intense than it is over the loss of an elderly
person.
The state of the persons physical or psychological health is
unstable at the time of the loss.
The bereaved person perceives (whether real or imagined)
some responsibility for the loss.
The grief response may be facilitated if:
The individual has the support of signicant others to
assist him or her through the mourning process.
The individual has the opportunity to prepare for the
loss. Grief work is more intense when the loss is sudden
and unexpected. The experience of anticipatory grieving is
thought to facilitate the grief response that occurs at the
time of the actual loss.
2506_Ch24_390-405.indd 0396 10/1/10 9:38:47 AM

Worden (2009) stated:

There is a sense in which mourning can be nished, when people
regain an interest in life, feel more hopeful, experience gratication
again, and adapt to new roles. There is also a sense in which mourn-
ing is never nished. [People must understand] that mourning is a
long-term process, and the culmination [very likely] will not be to a
pre-grief state (p. 77).
Anticipatory Grief
Anticipatory grieving is the experiencing of the feelings and
emotions associated with the normal grief response before the
loss actually occurs. One dissimilar aspect relates to the fact that
conventional grief tends to diminish in intensity with the pas-
sage of time. Anticipatory grief can become more intense as the
expected loss becomes imminent.
Although anticipatory grief is thought to facilitate the actual
mourning process following the loss, there may be some problems.
In the case of a dying person, difculties can arise when the family
members complete the process of anticipatory grief, and detach-
ment from the dying person occurs prematurely. The person who
is dying experiences feelings of loneliness and isolation as the psy-
chological pain of imminent death is faced without family support.
Another example of difculty associated with premature comple-
tion of the grief response is one that can occur on the return of
persons long absent and presumed dead (e.g., soldiers missing in
action or prisoners of war). In this instance, resumption of the pre-
vious relationship may be difcult for the bereaved person.
Anticipatory grieving may serve as a defense for some indi-
viduals to ease the burden of loss when it actually occurs. It may
prove to be less functional for others who, because of interper-
sonal, psychological, or sociocultural variables, are unable in
advance of the actual loss to express the intense feelings that
accompany the grief response.
Maladaptive Responses to Loss

When, then, is the grieving response considered to be mal-
adaptive? Three types of pathological grief reactions have
been described. These include delayed or inhibited grief, an
exaggerated or distorted grief response, and chronic or pro-
longed grief.
Delayed or Inhibited Grief
Delayed or inhibited grief refers to the absence of evidence of
grief when it ordinarily would be expected. Many times, cultural
inuences, such as the expectation to keep a stiff upper lip,
cause the delayed response.
Delayed or inhibited grief is potentially pathological because
the person is simply not dealing with the reality of the loss.
2506_Ch24_390-405.indd 0397 10/1/10 9:38:47 AM

He or she remains xed in the denial stage of the grief proc-

ess, sometimes for many years. When this occurs, the grief re-
sponse may be triggered, sometimes many years later, when the
individual experiences a subsequent loss. Sometimes the grief
process is triggered spontaneously or in response to a seemingly
insignicant event. Overreaction to another persons loss may
be one manifestation of delayed grief.
The recognition of delayed grief is critical because, depend-
ing on the profoundness of the loss, the failure of the mourning
process may prevent assimilation of the loss and thereby delay
a return to satisfying living. Delayed grieving most commonly
occurs because of ambivalent feelings toward the lost entity,
outside pressure to resume normal function, or perceived lack of
internal and external resources to cope with a profound loss.
Distorted (Exaggerated) Grief Response
In the distorted grief reaction, all of the symptoms associated
with normal grieving are exaggerated. Feelings of sadness, help-
lessness, hopelessness, powerlessness, anger, and guilt, as well
as numerous somatic complaints, render the individual dysfunc-
tional in terms of management of daily living. Murray, Zentner,
and Yakimo (2009) described an exaggerated grief reaction in
the following way:
An intensication of grief to the point that the person is over-
whelmed, demonstrates prolonged maladaptive behavior, manifests
excessive symptoms and extensive interruptions in healing, and does
not progress to integration of the loss, nding meaning in the loss,
and resolution of the mourning process (p. 706).
When the exaggerated reaction occurs, the individual remains
xed in the anger stage of the grief response. This anger may
be directed toward others in the environment to whom the in-
dividual may be attributing the loss. However, many times the
anger is turned inward on the self. When this occurs, depression
is the result. Depressive mood disorder is a type of exaggerated
grief reaction.
Chronic or Prolonged Grieving
Some authors have discussed a chronic or prolonged grief
response as a type of maladaptive grief response. Care must be
taken in making this determination because, as was stated previ-
ously, length of the grief response depends on the individual. An
adaptive response may take years for some people. A prolonged
process may be considered maladaptive when certain behaviors
are exhibited. Prolonged grief may be a problem when behav-
iors such as maintaining personal possessions aimed at keeping a
lost loved one alive (as though he or she will eventually reenter
the life of the bereaved) or disabling behaviors that prevent the
2506_Ch24_390-405.indd 0398 10/1/10 9:38:47 AM

bereaved from adaptively performing activities of daily living

are in evidence. Another example is of a widow who refused to
participate in family gatherings following the death of her hus-
band. For many years until her own death, she took a sandwich
to the cemetery on holidays, sat on the tombstone, and ate her
holiday meal with her husband. Other bereaved individuals
have been known to set a place at the table for the deceased loved
one long after the completed mourning process would have been
expected.
Normal versus Maladaptive Grieving
Several authors have identied one crucial difference between
normal and maladaptive grieving: the loss of self-esteem.
Marked feelings of worthlessness are indicative of depression
rather than uncomplicated bereavement. Corr, Nabe, and Corr
(2008) have stated, Normal grief reactions do not include the
loss of self-esteem commonly found in most clinical depression
(p. 215).
Cheong, Herkov, and Goodman (2009) af rmed:
Although both conditions may have depressed mood, loss of appetite,
sleep disturbance, and decreased energy, people with depression usu-
ally experience a sense of worthlessness, guilt and/or low self-esteem
that is not common in normal grief reactions.
It is thought that this major difference between normal
grieving and maladaptive grieving (the feeling of worthlessness
or low self-esteem) ultimately precipitates depression.
Concepts of DeathDevelopmental Issues
Children
Birth to Age 2. Infants are unable to recognize and under-
stand death, but they can experience the feelings of loss and
separation. Infants who are separated from their mothers
may become quiet, lose weight, and sleep less. Children at
this age will likely sense changes in the atmosphere of the
home where a death has occurred. They often react to the
emotions of adults by becoming more irritable and crying
more.
Ages 3 to 5. Preschoolers and kindergartners have some
understanding about death but often have difculty distin-
guishing between fantasy and reality. They believe death
is reversible, and their thoughts about death may include
magical thinking. For example, they may believe that their
thoughts or behaviors caused a person to become sick or
to die.
Children of this age are capable of understanding at least
some of what they see and hear from adult conversations or
2506_Ch24_390-405.indd 0399 10/1/10 9:38:48 AM

media reports. They become frightened if they feel a threat

to themselves or to their loved ones. They are concerned
with safety issues and require a great deal of personal reas-
surance that they will be protected. Regressive behaviors,
such as loss of bladder or bowel control, thumb sucking,
and temper tantrums, are not uncommon. Changes in eat-
ing and sleeping patterns may also occur.
Ages 6 to 9. Children at this age begin to understand the
nality of death. They are able to understand a more de-
tailed explanation of why or how the person died, although
the concept of death is often associated with old age or with
accidents. They may believe that death is contagious and
avoid association with individuals who have experienced a
loss by death. Death is often personied in the form of
a bogey man or a monstersomeone who takes people
away or someone whom they can avoid if they try hard
enough. It is difcult for them to perceive their own death.
Normal grief reactions at this age include regressive and
aggressive behaviors, withdrawal, school phobias, somatic
symptoms, and clinging behaviors.
Ages 10 to 12. Preadolescent children are able to understand
that death is nal and eventually affects everyone, includ-
ing themselves. They are interested in the physical aspects
of dying and the nal disposition of the body. They may
ask questions about how the death will affect them per-
sonally. Feelings of anger, guilt, and depression are com-
mon. Peer relationships and school performance may be
disrupted. There may be a preoccupation with the loss and
a withdrawal into the self. They will require reassurance of
their own safety and self-worth.
Adolescents
Adolescents are usually able to view death on an adult level.
They understand death to be universal and inevitable; however,
they have difculty tolerating the intense feelings associated
with the death of a loved one. They may or may not cry. They
may withdraw into themselves or attempt to go about usual
activities in an effort to avoid dealing with the pain of the loss.
Some teens exhibit acting-out behaviors, such as aggression
and deance. It is often easier for adolescents to discuss their
feelings with peers than with their parents or other adults.
Some adolescents may show regressive behaviors whereas oth-
ers react by trying to take care of their loved ones who are
also grieving. In general, individuals of this age group have an
attitude of immortality. Although they understand that their
own death is inevitable, the concept is so far-reaching as to be
imperceptible.
2506_Ch24_390-405.indd 0400 10/1/10 9:38:48 AM

Adults
The adults concept of death is inuenced by cultural and reli-
gious backgrounds (Murray, Zentner, & Yakimo, 2009). Behaviors
associated with grieving in the adult were discussed in the section
on Theoretical Perspectives on Loss and Bereavement.
Elderly Persons
Bateman (1999) has stated:
For the older adult, the later years have been described by philoso-
phers and poets as the season of loss. Loss of ones occupational
role upon retirement, loss of control and competence, loss in some
life experiences, loss of material possessions, and loss of dreams,
loved ones, and friends must be understood and accepted if the older
adult is to adapt effectively (p. 144).
By the time individuals reach their 60s and 70s, they have
experienced numerous losses, and mourning has become a life-
long process. Those who are most successful at adapting to
losses earlier in life will similarly cope better with the losses
and grief inherent in aging. Unfortunately, with the aging proc-
ess comes a convergence of losses, the timing of which makes it
impossible for the aging individual to complete the grief process
in response to one loss before another occurs. Because grief is
cumulative, this can result in bereavement overload; the person
is less able to adapt and reintegrate, and mental and physical
health is jeopardized (Halstead, 2005). Bereavement overload
has been implicated as a predisposing factor in the development
of depressive disorder in the elderly person.
Depression is a common symptom in the grief response to
signicant losses. It is important to understand the difference
between the depression of normal grieving and the disorder of
clinical depression. Some of these differences are presented in
Table 24-1.

Interventions for the Individual
Who Is Grieving
RISK FOR COMPLICATED GRIEVING

De nition: At risk for a disorder that occurs after the death of a
significant other [or any other loss of significance to the individual],
in which the experience of distress accompanying bereavement
fails to follow normative expectations and manifests in functional
impairment.
2506_Ch24_390-405.indd 0401 10/1/10 9:38:48 AM

TABLE 2 4 1 Normal Grief Reactions versus Symptoms

of Clinical Depression
Normal Grief Clinical Depression
Self-esteem intact Self-esteem disturbed

May openly express anger Usually does not directly express anger
Experiences a mixture of good Persistent state of dysphoria
and bad days
Able to experience moments of Anhedonia prevalent
pleasure
Accepts comfort and support Does not respond to social interaction
from others and support from others
Maintains feeling of hope Feelings of hopelessness prevail
May express guilt feelings over Has generalized feelings of guilt
some aspect of the loss
Relates feelings of depression to Does not relate feelings to a particular
specic loss experienced experience
May experience transient Expresses chronic physical complaints
physical symptoms
Sources: Cheong, Herkov, and Goodman (2009); Corr, Nabe, and Corr (2008);
and Sadock and Sadock (2007).
Risk Factors (related to)

[Actual or perceived object loss (e.g., people, pets, possessions,
job, status, home, ideals, parts and process of the body)]
[Denial of loss]
[Interference with life functioning]
[Reliving of past experiences with little or no reduction
(diminishment) of intensity of the grief]
Lack of social support
Emotional instability
Goals/Objectives
Short-term Goals
1. Client will acknowledge awareness of the loss.
2. Client will express feelings about the loss.
3. Client will verbalize own position in the grief process.
Long-term Goal
Client will progress through the grief process in a healthful
manner toward resolution.
1. Assess clients stage in the grief process. Accurate baseline
data are required to provide appropriate assistance.
2506_Ch24_390-405.indd 0402 10/1/10 9:38:48 AM

2. Develop trust. Show empathy, concern, and unconditional

positive regard. Developing trust provides the basis for a
therapeutic relationship.
3. Help the client actualize the loss by talking about it. When
did it happen? How did it happen? and so forth. Reviewing
the events of the loss can help the client come to full aware-
ness of the loss.
4. Help the client identify and express feelings. Until client can
recognize and accept personal feelings regarding the loss,
grief work cannot progress. Some of the more problematic
feelings include:
a. Anger. The anger may be directed at the deceased, at God,
displaced on others, or retroected inward on the self.
Encourage the client to examine this anger and validate
the appropriateness of this feeling. Many people will not
admit to angry feelings, believing it is inappropriate and
unjustified. Expression of this emotion is necessary to
prevent fi xation in this stage of grief.
b. Guilt. The client may feel that he or she did not do enough
to prevent the loss. Help the client by reviewing the cir-
cumstances of the loss and the reality that it could not
be prevented. Feelings of guilt prolong resolution of the
grief process.
c. Anxiety and helplessness. Help the client to recognize the way
that life was managed before the loss. Help the client to put
the feelings of helplessness into perspective by pointing out
ways that he or she managed situations effectively without
help from others. Role-play life events and assist with deci-
sion-making situations. The client may have fears that he
or she may not be able to carry on alone.
5. Interpret normal behaviors associated with grieving and
provide client with adequate time to grieve. Understanding
of the grief process will help prevent feelings of guilt gen-
erated by these responses. Individuals need adequate time
to accommodate to the loss and all its ramifications. This
involves getting past birthdays and anniversaries of which
the deceased was a part.
6. Provide continuing support. If this is not possible by the
nurse, then offer referrals to support groups. Support groups
of individuals going through the same experiences can be
very helpful for the grieving individual. The availability of
emotional support systems facilitates the grief process.
7. Identify pathological defenses that the client may be using
(e.g., drug/alcohol use, somatic complaints, social isolation).
Assist the client in understanding why these are not healthy
defenses and how they delay the process of grieving. The
2506_Ch24_390-405.indd 0403 10/1/10 9:38:49 AM

bereavement process is impaired by behaviors that mask the

pain of the loss.
8. Encourage the client to make an honest review of the rela-
tionship with what has been lost. Journal keeping is a facilita-
tive tool with this intervention. Only when the client is able
to see both positive and negative aspects related to the loss
will the grieving process be complete.
Outcome Criteria
1. Client is able to express feelings about the loss.
2. Client verbalizes stages of the grief process and behaviors
associated with each stage.
3. Client acknowledges own position in the grief process and
recognizes the appropriateness of the associated feelings and
behaviors.
RISK FOR SPIRITUAL DISTRESS

De nition: At risk for an impaired ability to experience and inte-
grate meaning and purpose in life through a persons connected-
ness with self, others, art, music, literature, nature, and/or a power
greater than oneself.
Risk Factors (related to)

Loss [of any concept of value to the individual]
Low self-esteem
Natural disasters
Physical illness
Depression; anxiety; stress
Separated from support systems
Life change
Goals/Objectives
Short-term Goal
Client will identify meaning and purpose in life, moving forward
with hope for the future.
Long-term Goal
Client will express achievement of support and personal satisfac-
tion from spiritual practices.

1. Be accepting and nonjudgmental when client expresses an-
ger and bitterness toward God. Stay with client. The nurses
presence and nonjudgmental attitude increase the clients
feelings of self-worth and promote trust in the relationship.
2506_Ch24_390-405.indd 0404 10/1/10 9:38:49 AM

2. Encourage client to ventilate feelings related to meaning of

own existence in the face of current loss. Client may be-
lieve he or she cannot go on living without the lost entity.
Catharsis can provide relief and put life back into realistic
perspective.
3. Encourage client as part of grief work to reach out to previ-
ously used religious practices for support. Encourage client
to discuss these practices and how they provided support in
the past. Client may find comfort in religious rituals with
which he or she is familiar.
4. Ensure client that he or she is not alone when feeling inad-
equate in the search for lifes answers. Validation of clients
feelings and assurance that they are shared by others offer
reassurance and an affirmation of acceptability.
5. Contact spiritual leader of clients choice, if he or she requests.
These individuals serve to provide relief from spiritual
distress and often can do so when other support persons
cannot.
Outcome Criteria
1. Client verbalizes increased sense of self-concept and hope for
the future.
2. Client verbalizes meaning and purpose in life that reinforces
hope, peace, and contentment.
3. Client expresses personal satisfaction and support from
spiritual practices.
INTERNET REFERENCES
Additional references related to bereavement may be located
a. http://www.journeyofhearts.org
b. http://www.nhpco.org
c. http://www.aarp.org/family/lifeafterloss/
d. http://www.hospicefoundation.org
e. http://www.bereavement.org
f. http://www.caringinfo.org/
g. http://www.aahpm.org/
h. http://www.hpna.org/
2506_Ch24_390-405.indd 0405 10/1/10 9:38:50 AM

UNIT FOUR
PSYCHOTROPIC
MEDICATIONS
C H A P T E R
25
Antianxiety Agents
CHEMICAL CLASS: ANTIHISTAMINES
Examples
Generic Half-life Pregnancy Available Forms

Name Trade Name (hr) Category (mg)
Hydroxyzine Vistaril 3 C Caps: 10, 25, 50, 100

Oral susp: 25/5 mL
Syrup: 10/5 mL
Inj: 25/mL, 50/mL
Indications
Anxiety disorders
Temporary relief of anxiety symptoms
Allergic reactions producing pruritic conditions
Antiemetic
Reduction of narcotic requirement, alleviation of anxiety, and
control of emesis in preoperative/postoperative clients (paren-
teral only)
Action
Exerts central nervous system (CNS)-depressant activity at
the subcortical level of the CNS
Has anticholinergic, antihistaminic, and antiemetic properties
406
2506_Ch25_406-416.indd Sec2:406 10/1/10 9:39:00 AM

Contraindications and Precautions:

Contraindicated in: Hypersensitivity Pregnancy and
lactation
Use Cautiously in: Elderly or debilitated patients (dos-
age reduction recommended) Hepatic or renal dysfunction
Concomitant use of other CNS depressants
Adverse Reactions and Side Effects

Dry mouth
Drowsiness
Pain at intramuscular site
Interactions
Additive CNS depression with other CNS depressants (e.g.,
alcohol, other anxiolytics, opioid analgesics, and sedative/
hypnotics) and with herbal depressants (e.g., kava, valerian)
Additive anticholinergic effects with other drugs possessing
anticholinergic properties (e.g., antihistamines, antidepres-
sants, atropine, haloperidol, phenothiazines) and herbal
products such as angels trumpet, jimson weed, and scopolia
Can antagonize the vasopressor effects of epinephrine
Route and Dosage

INTRAMUSCULAR
Anxiety
Adults: 50 to 100 mg 4 times a day
Pruritis
Adults: 25 mg 3 or 4 times a day
Preoperative and Postoperative Sedative
Adults: 50 to 100 mg
Children: 0.6 mg/kg
Antiemetic/Adjunctive Therapy to Analgesia
Adults: 25 to 100 mg every 4 to 6 hours as needed
Children: 0.5 to 1 mg/kg every 4 to 6 hours as needed
ORAL
Anxiety
Adults: 50 to 100 mg 4 times a day
Children (>6 years): 50 to 100 mg/day in divided doses
Children (<6 years): 50 mg/day in divided doses
Pruritus
Adults: 25 mg 3 or 4 times a day
Children (>6 years): 50 to 100 mg/day in divided doses
Children (<6 years): 50 mg/day in divided doses
2506_Ch25_406-416.indd Sec2:407 10/1/10 9:39:01 AM

408 PSYCHOTROPIC MEDICATIONS
Preoperative and Postoperative Sedative

Adults: 50 to 100 mg
Children: 0.6 mg/kg
CHEMICAL CLASS: BENZODIAZEPINES

Examples
Generic Controlled/
(Trade) Pregnancy Half-life Available Forms
Name Categories (hr) Indications (mg)
Alprazolam C-IV/D 6.326.9

Anxiety disorders Tabs: 0.25, 0.5, 1.0,
(Xanax)
Anxiety symptoms 2.0

Anxiety associated Tabs ER: 0.5, 1.0,
with depression 2.0, 3.0

Panic disorder Tabs (orally
disintegrating):
0.25, 0.5, 1.0, 2.0
Oral solu: 1/mL
Chlordiazepoxide C-IV/D 530
Anxiety disorders Caps: 5, 10, 25
(Librium)
Anxiety symptoms

Acute alcohol
withdrawal

Preoperative
sedation
Clonazepam C-IV/C 1850
Petit mal, akinetic, Tabs: 0.5, 1.0, 2.0
(Klonopin) and myoclonic Tabs (orally
seizures disintegrating):

Panic disorder 0.125, 0.25, 0.5,
Unlabeled uses: 1.0, 2.0

Acute manic
episodes

Neuralgias

Restless leg
syndrome

Adjunct therapy in
schizophrenia
Clorazepate C-IV/UK 4050
Anxiety disorders Tabs: 3.75, 7.5, 15
(Tranxene)
Anxiety symptoms Tabs (extended

Acute alcohol release): 11.25,
withdrawal 22.5

Partial seizures
Diazepam C-IV/D 2080
Anxiety disorders Tabs: 2, 5, 10
(Valium)
Anxiety symptoms Oral solu: 5/5 mL,

Skeletal muscle 5/mL
relaxant Inj: 5/mL

Acute alcohol Rectal gel: 2.5, 10, 20
withdrawal

Adjunct therapy in
convulsive disorders

Status epilepticus

Preoperative
sedation
2506_Ch25_406-416.indd Sec2:408 10/1/10 9:39:01 AM

Generic Controlled/
(Trade) Pregnancy Half-life Available Forms
Name Categories (hr) Indications (mg)
Lorazepam C-IV/D 1020

Anxiety disorders Tabs: 0.5, 1.0, 2.0
(Ativan)
Anxiety symptoms Oral solu: 2/mL

Status epilepticus Inj: 2/mL, 4/mL

Preoperative
sedation
Unlabeled uses:

Insomnia

Chemotherapy-
induced nausea
and vomiting
Oxazepam C-IV/D 520

Anxiety disorders Caps: 10, 15, 30

Anxiety symptoms

Acute alcohol
withdrawal
Unlabeled uses:

Management of
irritable bowel
syndrome
Action
Benzodiazepines are thought to potentiate the effects of
gamma-aminobutyric acid (GABA), a powerful inhibitory
neurotransmitter, thereby producing a calmative effect. The
activity may involve the spinal cord, brain stem, cerebellum,
limbic system, and cortical areas.

Contraindicated in: Hypersensitivity Psychoses Acute
narrow-angle glaucoma Preexisting CNS depression Preg-
nancy and lactation Shock Coma
Use Cautiously in: Elderly or debilitated patients (reduced
dosage recommended) Patients with hepatic/renal/pulmonary
impairment History of drug abuse/dependence Depressed/
suicidal patients Children
Drowsiness; dizziness, lethargy
Nausea and vomiting
Ataxia
Dry mouth
Blurred vision
Rash
Hypotension
Tolerance
Physical and psychological dependence
Paradoxical excitation
2506_Ch25_406-416.indd Sec2:409 10/1/10 9:39:02 AM

Interactions
Additive CNS depression with other CNS depressants
(e.g., alcohol, other anxiolytics, opioid analgesics, and
sedative/hypnotics) and with herbal depressants (e.g., kava,
valerian)
Cimetidine, oral contraceptives, disulfiram, fluoxetine, iso-
niazid, ketoconazole, metoprolol, propoxyphene, propran-
olol, or valproic acid may enhance effects of benzodiazepines
Benzodiazepines may decrease the efcacy of levodopa.
Sedative effects of benzodiazepines may be decreased by
theophylline.
Rifampin may decrease the efcacy of benzodiazepines.
Serum concentration of digoxin may be increased (and sub-
sequent toxicity can occur) with concurrent benzodiazepine
therapy.
Route and Dosage

ALPRAZOLAM (Xanax)
Anxiety Disorders and Anxiety Symptoms: PO: 0.25 to
0.5 mg 3 times a day. Maximum daily dose 4 mg in divided
doses.
In elderly or debilitated patients: 0.25 mg 2 or 3 times a day.
Gradually increase if needed and tolerated.
Panic Disorder: PO: Initial dose: 0.5 mg 3 times a day. Increase
dose at intervals of 3 to 4 days in increments of no more than
1 mg/day.
CHLORDIAZEPOXIDE (Librium)
Mild to Moderate Anxiety: PO: 5 or 10 mg 3 or 4 times
a day.
Severe Anxiety: PO: 20 or 25 mg 3 or 4 times a day.
Elderly or Debilitated Patients: PO: 5 mg 2 to 4 times
a day.
Preoperative Sedation: PO: 5 to 10 mg 3 or 4 times a day.
Acute Alcohol Withdrawal: PO: 50 to 100 mg; repeat as
needed up to 300 mg/day.
CLONAZEPAM (Klonopin)
Seizures: Adults: PO: 0.5 mg three times a day. May increase
by 0.5 to 1 mg every 3 days. Total daily maintenance dose not
to exceed 20 mg.
Children (10 years or 30 kg): PO: Initial daily dose 0.01 to
0.03 mg/kg/day (not to exceed 0.05 mg/kg/day) given in
2 or 3 equally divided doses; increase by no more than 0.25
to 0.5 mg every third day until a daily maintenance dose of
0.1 to 0.2 mg/kg has been reached. Therapeutic serum con-
centrations of clonazepam are 20 to 80 ng/ml.
2506_Ch25_406-416.indd Sec2:410 10/1/10 9:39:02 AM

Panic Disorder: PO: Initial dose: 0.25 mg 2 times a day.

Increase after 3 days toward target dose of 1 mg/day. Some
patients may require up to 4 mg/day, in which case the dose
may be increased in increments of 0.125 to 0.25 mg twice daily
every 3 days until symptoms are controlled.
Acute Manic Episode: PO: 1 to 6 mg/day.
Neuralgia: PO: 1.5 to 4 mg/day.
Restless Leg Syndrome: PO: 0.5 to 2 mg 30 minutes before
bedtime.
Adjunct Therapy in Schizophrenia: PO: 0.5 to 2 mg/day.
CLORAZEPATE (Tranxene)
Anxiety Disorders/Anxiety Symptoms: Adults: PO: 7.5 to
15 mg 2 to 4 times a day. Adjust gradually to dose within range
of 15 to 60 mg/day. May also be given in a single daily dose
at bedtime. The recommended initial dose is 15 mg. Adjust
subsequent dosages according to patient response.
Geriatric or debilitated patients: PO: 7.5 to 15 mg/day.
Acute Alcohol Withdrawal: PO: Day 1: 30 mg initially,
followed by 15 mg 2 to 4 times a day.
Day 2: 45 to 90 mg in divided doses.
Day 3: 22.5 to 45 mg in divided doses.
Day 4: 15 to 30 mg in divided doses.
Thereafter, gradually reduce the daily dose to 7.5 to 15 mg.
Discontinue drug as soon as patients condition is stable.
Partial Seizures: Adults: PO: 7.5 mg 3 times a day. Can
increase by no more than 7.5 mg/day at weekly intervals (daily
dose not to exceed 90 mg).
Children (9 to 12 years): PO: 7.5 mg 2 times a day initially; may
increase by 7.5 mg/week (not to exceed 60 mg/day).
DIAZEPAM (Valium)
Antianxiety/Adjunct Anticonvulsant: Adults: PO: 2 to 10 mg
2 to 4 times a day.
Children (6 months): PO: 1 to 2.5 mg 3 to 4 times a day.
Moderate to severe anxiety: Adults: IM or IV: 2 to 10 mg.
Repeat in 3 to 4 hours if necessary.
Skeletal Muscle Relaxant: Adults: PO: 2 to 10 mg 3 or
4 times a day.
Children (6 months): PO: 0.12 to 0.8 mg/kg/day divided into 3
or 4 equal doses.
Geriatric or debilitated patients: PO: 2 to 2.5 mg 1 to 2 times daily
initially. Increase gradually as needed and tolerated.
Acute Alcohol Withdrawal: PO: 10 mg 3 to 4 times a day in rst
24 hours; decrease to 5 mg 3 or 4 times a day as needed. IM or
IV: 10 mg initially, then 5 to 10 mg in 3 to 4 hours, if necessary.
2506_Ch25_406-416.indd Sec2:411 10/1/10 9:39:03 AM

Status Epilepticus/Acute Seizure Activity: Adults: IV (IM

route may be used if IV is unavailable): 5 to 10 mg; may repeat
every 10 to 15 minutes to a total of 30 mg; may repeat regimen
again in 2 to 4 hours.
Children (5 years): IM or IV: 1 mg every 2 to 5 minutes to a
maximum of 10 mg. May repeat in 2 to 4 hours if necessary.
Children (1 month to 5 years): IM or IV: 0.2 to 0.5 mg every 2 to
5 minutes to maximum of 5 mg.
Preoperative Sedation: Adults: IM: 10 mg.
LORAZEPAM (Ativan)
Anxiety Disorders/Anxiety Symptoms: PO: 2 to 6 mg/day
(varies from 1 to 10 mg/day) given in divided doses; take the
largest dose before bedtime.
Geriatric or debilitated patients: PO: 1 to 2 mg/day in divided
doses; adjust as needed and tolerated.
Insomnia: PO: 2 to 4 mg at bedtime.
Geriatric or debilitated patients: PO: 0.25 to 1 mg at bedtime.
Preoperative Sedation: IM: 0.05 mg/kg (maximum 4 mg)
2 hours before surgery.
IV: Initial dose is 2 mg or 0.044 mg/kg, whichever is smaller,
given 15 to 20 minutes before the procedure.
Status Epilepticus: IV: 4 mg given slowly (2 mg/min). May
be repeated after 10 to 15 minutes if seizures continue or
recur.
Antiemetic: IV: 2 mg 30 minutes prior to chemotherapy; may
be repeated every 4 hours as needed.
OXAZEPAM
Mild to Moderate Anxiety: PO: 10 to 15 mg 3 or 4 times
a day.
Severe Anxiety States: PO: 15 to 30 mg 3 or 4 times a day.
Geriatric patients: PO: Initial dosage: 10 mg 3 times a day. If
necessary, increase cautiously to 15 mg 3 or 4 times a day.
Acute alcohol withdrawal: PO: 15 to 30 mg 3 or 4 times
a day.
CHEMICAL CLASS: CARBAMATE

DERIVATIVE
Examples
Controlled/
Generic Pregnancy Half-life Available Forms
Name Categories (hr) (mg)
Meprobamate C-IV/D 617 Tabs: 200, 400
2506_Ch25_406-416.indd Sec2:412 10/1/10 9:39:03 AM

Indications
Anxiety disorders
Temporary relief of anxiety symptoms
Action
Depresses multiple sites in the CNS, including the thala-
mus and limbic system. May act by blocking the reuptake of
adenosine.

Contraindicated in: Hypersensitivity to the drug Com-
bination with other CNS depressants Children under age 6
Pregnancy and lactation Acute intermittent porphyria
Use Cautiously in: Elderly or debilitated clients Patients
with hepatic or renal dysfunction Individuals with a history of
drug abuse/addiction Clients with a history of seizure disor-
ders Depressed/suicidal clients
Palpitations, tachycardia
Drowsiness, dizziness, ataxia
Nausea, vomiting, diarrhea
Tolerance
Interactions
Additive CNS depression with other CNS depressants (e.g.,
alcohol, other anxiolytics, opioid analgesics, and sedative-
hypnotics) and with herbal depressants (e.g., kava, valerian).
Route and Dosage

Anxiety Disorders/Anxiety Symptoms: Adults and children:
>12 years: PO: 1200 to 1600 mg/day in 3 to 4 divided doses.
Maximum daily dose: 2400 mg.
Children (6 to 12 years): PO: 100 to 200 mg 2 or 3 times a day.
CHEMICAL CLASS:
AZASPIRODECANEDIONES
Examples
Generic Trade Pregnancy Half-life Available

Name Name Category (hr) Forms (mg)
Buspirone HCl BuSpar B 23 Tabs: 5, 7.5, 10,

15, 30
2506_Ch25_406-416.indd Sec2:413 10/1/10 9:39:03 AM

INDICATIONS
Generalized anxiety states
Unlabeled use:
Symptomatic management of premenstrual syndrome
Actions
Unknown
May produce desired effects through interactions with sero-
tonin, dopamine, and other neurotransmitter receptors
Delayed onset (a lag time of 7 to 10 days between onset of
therapy and subsiding of anxiety symptoms)
Cannot be used on a PRN basis

Contraindicated in: Hypersensitivity to the drug Severe
hepatic or renal impairment Concurrent use with monoamine
oxidase (MAO) inhibitors
Use Cautiously in: Elderly or debilitated clients Pregnancy
and lactation Children Clients with a history of chronic ben-
zodiazepine or other sedative/hypnotic use. Buspirone will not
block the withdrawal syndrome in these clients and they should
be withdrawn gradually from these medications before begin-
ning therapy with buspirone.

Drowsiness, dizziness
Excitement, nervousness
Fatigue, headache
Nausea, dry mouth
Incoordination, numbness
Palpitations, tachycardia
Interactions
Increased effects of buspirone with cimetidine, erythromycin,
itraconazole, nefazodone, ketoconazole, clarithromycin,
diltiazem, verapamil, fluvoxamine, and ritonavir
Decreased effects of buspirone with rifampin, rifabutin,
phenytoin, phenobarbital, carbamazepine, fluoxetine, and
dexamethasone
Increased serum concentrations of haloperidol when used
concomitantly with buspirone
Use of buspirone with an MAO inhibitor may result in
elevated blood pressure.
Increased risk of hepatic effects when used concomitantly with
trazodone
Additive effects when used with certain herbal products (e.g.,
kava, valerian)
2506_Ch25_406-416.indd Sec2:414 10/1/10 9:39:04 AM

Route and Dosage

Anxiety: Adults: PO: Initial dosage 7.5 mg 2 times a day.
Increase by 5 mg/day every 2 to 3 days as needed. Maximum
daily dosage: 60 mg.
NURSING DIAGNOSES RELATED
TO ALL ANTIANXIETY AGENTS
1. Risk for injury related to seizures, panic anxiety, acute
agitation from alcohol withdrawal (indications); abrupt
withdrawal from the medication after long-term use; effects
of medication intoxication or overdose
2. Anxiety (specify) related to threat to physical integrity or
self-concept
3. Risk for activity intolerance related to medication side effects
of sedation, confusion, lethargy
4. Disturbed sleep pattern related to situational crises, physical
condition, severe level of anxiety
5. Decient knowledge related to medication regimen
6. Risk for acute confusion related to action of the medication
on the CNS
NURSING IMPLICATIONS
FOR ANTIANXIETY AGENTS
1. Instruct client not to drive or operate dangerous machinery
while taking the medication.
2. Advise client receiving long-term therapy not to quit
taking the drug abruptly. Abrupt withdrawal can be life-
threatening (with the exception of buspirone). Symptoms
include depression, insomnia, increased anxiety, abdomi-
nal and muscle cramps, tremors, vomiting, sweating, con-
vulsions, and delirium.
3. Instruct client not to drink alcohol or take other medica-
tions that depress the CNS while taking this medication.
4. Assess mood daily. May aggravate symptoms in depressed
persons. Take necessary precautions for potential suicide.
5. Monitor lying and standing blood pressure and pulse every
shift. Instruct client to arise slowly from a lying or sitting
position.
6. Withhold drug and notify the physician should paradoxical
excitement occur.
7. Have client take frequent sips of water or ice chips, suck on
hard candy, or chew sugarless gum to relieve dry mouth.
8. Have client take drug with food or milk to prevent nausea
and vomiting.
9. Symptoms of sore throat, fever, malaise, easy bruising,
or unusual bleeding should be reported to the physician
immediately. They may be indications of blood dyscrasias.
2506_Ch25_406-416.indd Sec2:415 10/1/10 9:39:04 AM

10. Ensure that client taking buspirone (BuSpar) understands

there is a lag time of 7 to 10 days between onset of therapy
and subsiding of anxiety symptoms. Client should con-
tinue to take the medication during this time. (Note: This
medication is not recommended for PRN administration
because of this delayed therapeutic onset. There is no
evidence that buspirone creates tolerance or physical
dependence as do the CNS-depressant anxiolytics.)
CLIENT/FAMILY EDUCATION RELATED

TO ALL ANTIANXIETY AGENTS
Do not drive or operate dangerous machinery. Drowsiness
and dizziness can occur.
Do not stop taking the drug abruptly. This can produce
serious withdrawal symptoms, such as depression, insomnia,
anxiety, abdominal and muscle cramps, tremors, vomiting,
sweating, convulsions, and delirium.
(With buspirone only): Be aware of lag time between start
of therapy and subsiding of symptoms. Relief is usually evi-
dent within 7 to 10 days. Take the medication regularly, as
ordered, so that it has sufcient time to take effect.
Do not consume other CNS depressants (including alcohol).
Do not take nonprescription medication without approval
from physician.
Rise slowly from the sitting or lying position to prevent a sud-
den drop in blood pressure.
Report to physician immediately symptoms of sore throat,
fever, malaise, easy bruising, unusual bleeding, or motor rest-
lessness.
Be aware of risks of taking these drugs during pregnancy.
(Congenital malformations have been associated with use dur-
ing the rst trimester.) If pregnancy is suspected or planned,
the client should notify the physician of the desirability to
discontinue the drug.
Be aware of possible side effects. Refer to written materi-
als furnished by health-care providers regarding the correct
method of self-administration.
Carry a card or piece of paper at all times stating the names of
medications being taken.
INTERNET REFERENCES
a. http://www.mentalhealth.com/
b. http://w w w.nimh.nih.gov/health/publications/mental-
health-medications/complete-index.shtml
d. http://w w w.nlm.nih.gov/medlineplus/druginformation
.html
2506_Ch25_406-416.indd Sec2:416 10/1/10 9:39:04 AM

C H A P T E R
26
Antidepressants
CHEMICAL CLASS: TRICYCLICS AND
RELATED (Nonselective Reuptake Inhibitors)
Examples
Generic Pregnancy Therapeutic

(Trade) Categories/ Plasma Level Available
Name Half-life (hr) Indications Range (ng/ml) Forms (mg)
TRICYCLICS
Amitriptyline D/3146

Depression 110250 Tabs: 10, 25,
Unlabeled uses: (including 50, 75, 100,

Migraine prevention metabolite) 150

Fibromyalgia

Postherpetic neuralgia
Clomipramine C/1937
Obsessive-compulsive 80100 Caps: 25,
(Anafranil) disorder (OCD) 50, 75
Unlabeled uses:

Premenstrual
symptoms

Panic disorder
Desipramine C/1224 Depression 125300 Tabs: 10, 25,

(Norpramin) Unlabeled uses: 50, 75, 100,

Alcoholism 150

Attention-deficit/
hyperactivity disorder
(ADHD)

Bulimia nervosa

Diabetic neuropathy

Continued
417
2506_Ch26_417-446.indd 1417 10/1/10 9:39:17 AM


Name Half-life (hr) Indications Range (ng/ml) Forms (mg)
Doxepin C/824
Depression or anxiety 100200 Caps: 10, 25,
(Sinequan)
Depression or anxiety (including 50, 75, 100,
associated with metabolite) 150
alcoholism Oral conc:

Depression or anxiety 10/mL
associated with organic
disease

Psychotic depressive
disorders with anxiety
Unlabeled uses:

Migraine prevention
Imipramine D/1125
Depression 200350 HCl tabs: 10,
(Tofranil)
Childhood enuresis (including 25, 50
Unlabeled uses: metabolite) Pamoate

Alcoholism caps: 75,
100, 125,

ADHD
150

Bulimia nervosa

Migraine prevention

Urinary incontinence
Nortriptyline D/1844
Depression 50150 Caps: 10, 25,
(Aventyl; Unlabeled uses: 50, 75
Pamelor)
ADHD Oral Solution:

Postherpetic neuralgia 10/5 mL
Protriptyline C/6789
Depression 100200 Tabs: 5, 10
(Vivactil) Unlabeled uses:

Migraine prevention
Trimipramine C/730
Depression 180 (includes Caps: 25, 50,
(Surmontil) active 100
metabolite)
DIBENZOXAZEPINE
Amoxapine C/8

Depression with anxiety 100, 150
TETRACYCLIC
Maprotiline B/2125

Depression 200300 Tabs: 25,

Depression with anxiety (including 50, 75
Unlabeled uses: metabolite)

Action
Inhibit reuptake of norepinephrine or serotonin at the pre-
synaptic neuron
Contraindicated in: Hypersensitivity to any tricyclic
or related drug Concomitant use with monoamine oxidase
2506_Ch26_417-446.indd 1418 10/1/10 9:39:17 AM

Antidepressants 419
inhibitors (MAOIs) Acute recovery period following myo-

cardial infarction Narrow angle glaucoma Pregnancy and
lactation (safety not established) Known or suspected sei-
zure disorder (maprotiline)
Use Cautiously in: Patients with history of seizures
(maprotiline contraindicated) Patients with tendency to have
urinary retention Benign prostatic hypertrophy Cardio-
vascular disorders Hepatic or renal insufciency Psychotic
patients Elderly or debilitated patients

Drowsiness; fatigue
Dry mouth
Blurred vision
Orthostatic hypotension
Tachycardia; arrhythmias
Constipation
Urinary retention
Blood dyscrasias
Nausea and vomiting
Photosensitivity
Increased risk of suicidality in children and adolescents (black
box warning)
Interactions
Increased effects of tricyclic antidepressants with bupropion,
cimetidine, haloperidol, selective serotonin reuptake in-
hibitors (SSRIs), and valproic acid
Decreased effects of tricyclic antidepressants with carbam-
azepine, barbiturates, and rifamycins
Hyperpyretic crisis, convulsions, and death can occur with
MAOIs.
Coadministration with clonidine may produce hypertensive
crisis.
Decreased effects of levodopa and guanethidine with tricyclic
antidepressants
Potentiation of pressor response with direct-acting sympa-
thomimetics
Increased anticoagulation effects with dicumarol
Increased serum levels of carbamazepine occur with
concomitant use of tricyclics.
Increased risk of seizures with concomitant use of maprotiline
and phenothiazines
Potential for cardiovascular toxicity of maprotiline when
given concomitantly with thyroid hormones (e.g., levothy-
roxine)
2506_Ch26_417-446.indd 1419 10/1/10 9:39:18 AM

Route and Dosage

AMITRIPTYLINE
Depression: PO: 75 mg/day in divided doses. May gradually
increase to 150 mg/day.
Alternative dosing: May initiate at 50 to 100 mg at bedtime; in-
crease by 25 to 50 mg as necessary, to a total of 150 mg/day.
Hospitalized patients: may require up to 300 mg/day.
Adolescent and elderly patients: 10 mg 3 times a day and 20 mg at
bedtime.
Migraine Prevention: PO: Common dosage: 50 to 100 mg/
day in divided doses. Range: 10 to 300 mg/day.
Fibromyalgia: PO: 10 to 50 mg at bedtime
Postherpetic Neuralgia: PO: 65 to 100 mg/day for at least
3 weeks.
CLOMIPRAMINE (Anafranil)
Obsessive-Compulsive Disorder: PO: Adults: 25 mg/day.
Gradually increase to 100 mg/day during rst 2 weeks, given
in divided doses. May increase gradually over several weeks to
maximum of 250 mg/day.
Children and adolescents: 25 mg/day. Gradually increase during
rst 2 weeks to daily dose of 3 mg/kg or 100 mg, whichever is
smaller. Maximum daily dose: 3 mg/kg or 200 mg, whichever
is smaller.
Premenstrual Symptoms: PO: 25 to 75 mg/day for irritability
and dysphoria
Panic Disorder: PO: Initial dose: 10 mg. Increase to a
maximum dose of 150 mg given as multiple daily doses.
DESIPRAMINE (Norpramin)
Depression: PO: 100 to 200 mg/day in divided doses or as a single
daily dose. May increase to maximum dose of 300 mg/day.
Elderly and adolescents: 25 to 100 mg/day in divided doses or as a
single daily dose. Maximum dose: 150 mg/day.
Alcoholism: PO: 200 to 275 mg/day.
Attention-decit/Hyperactivity Disorder (ADHD): PO:
100 to 200 mg/day
Bulimia Nervosa: PO: Initial dose: 25 mg 3 times a day. Titrate
dosage up to 200 to 300 mg/day, depending on response and
adverse effects.
Diabetic Neuropathy: PO: 50 to 250 mg/day.
Postherpetic Neuralgia: PO: 94 to 167 mg/day for at least
6 weeks.
DOXEPIN (Sinequan)
Depression and/or Anxiety: PO: (Mild to moderate illness):
75 mg/day. May increase to maximum dose of 150 mg/day.
2506_Ch26_417-446.indd 1420 10/1/10 9:39:18 AM

Antidepressants 421
(Mild symptoms associated with organic illness): 25 to 50 mg/day.

(Severe symptoms): 50 mg 3 times a day; may gradually increase
to 300 mg/day.
Migraine Prevention: PO: 75 to 150 mg/day. Occasionally
dosages up to 300 mg/day may be required.
IMIPRAMINE (Tofranil)
Depression: PO: 75 mg/day. May increase to maximum of
200 mg/day. Hospitalized patients may require up to 300 mg/
day.
Adolescent and geriatric patients: 30 to 40 mg/day. May
increase to maximum of 100 mg/day.
Childhood Enuresis (children 6 years of age): PO:
25 mg/day 1 hour before bedtime. May increase after 1 week to
50 mg/night if <12 years of age; up to 75 mg/night if > 12 years
of age. Maximum dose 2.5 mg/kg/day
Alcoholism: PO: 50 mg/day titrated by 50 mg every 3 to 5 days
to a maximum daily dose of 300 mg.
ADHD: PO: 1 mg/kg/day titrated to a maximum dose of 4 mg/
kg/day or 200 mg/day, whichever is smaller.
Bulimia Nervosa: PO: 50 mg/day titrated to 100 mg 2 times
a day.
Migraine Prevention: PO: 10 to 25 mg 3 times a day.
Urinary Incontinence: PO: 25 mg 2 to 3 times a day.
NORTRIPTYLINE (Aventyl; Pamelor)
Depression: PO: 25 mg 3 or 4 times a day. The total daily dose
may be given at bedtime.
Elderly and adolescent patients: 30 to 50 mg daily in divided doses
or total daily dose may be given once a day.
ADHD: PO: Adults: 25 mg 3 to 4 times a day. Children and
adolescents: 0.5 mg/kg/day, titrated to a maximum dose of
2 mg/kg/day or 100 mg, whichever is less.
Postherpetic Neuralgia: PO: Dosage range: 58 to 89 mg/day
for at least 5 weeks.
PROTRIPTYLINE (Vivactil)
Depression: PO: 15 to 40 mg/day divided into 3 or 4 doses.
Adolescent and elderly patients: 5 mg 3 times a day.
TRIMIPRAMINE (Surmontil)
Depression: PO: 75 mg/day. Increase gradually to 150 to
200 mg/day. Adult hospitalized patients may require up to
300 mg/day.
Adolescent and elderly patients: Initially, 50 mg/day, with gradual
increments up to 100 mg/day.
2506_Ch26_417-446.indd 1421 10/1/10 9:39:18 AM

AMOXAPINE
Depression and Depression with Anxiety: PO: 50 mg 2 or
3 times a day. May increase to 100 mg 2 or 3 times a day by
end of rst week.
Elderly patients: 25 mg 2 or 3 times a day. May increase to 50 mg
2 or 3 times a day by end of rst week.
MAPROTILINE
Depression/Depression with Anxiety: PO: AdultsInitial
dose: 75 mg/day. After 2 weeks, may increase gradually in
25 mg increments. Maximum daily dose: 150 to 225 mg.
Elderly patients: Initiate dosage at 25 mg/day. 50 to 75 mg/day
may be sufcient for maintenance therapy in elderly patients.
Postherpetic Neuralgia: PO: 100 mg/day for 5 weeks.
CHEMICAL CLASS: SELECTIVE SEROTONIN

REUPTAKE INHIBITORS (SSRIs)
Examples

Name Half-life Indications Ranges Forms (mg)
Citalopram C/~35
Treatment of Not well Tabs: 10, 20, 40
(Celexa) depression established Oral Solution:
Unlabeled uses: 10/5 mL

Generalized
anxiety
disorder (GAD)

Obsessive-
compulsive
disorder (OCD)

Panic disorder

Premenstrual
dysphoric disorder
(PMDD)

Posttraumatic
stress disorder
(PTSD)
Escitalopram C/2732 hr
Major depressive Not well Tabs: 5, 10, 20
(Lexapro) disorder established Oral Solution:

GAD 1/mL
Unlabeled uses:

Post traumatic
stress disorder
2506_Ch26_417-446.indd 1422 10/1/10 9:39:19 AM

Antidepressants 423

Name Half-life Indications Ranges Forms (mg)
Fluoxetine C/1 to 16 days

Depression Not well Tabs: 10, 15, 20
(Prozac; (including
OCD established Caps: 10, 20, 40
Sarafem) metabolite)
Bulimia nervosa Caps, delayed-

Panic disorder release: 90
Oral solution:

PMDD
20/5 mL
Unlabeled uses:

Alcoholism

Borderline person-
ality disorder

Fibromyalgia

Hot flashes

PTSD

Migraine
prevention

Raynaud
phenomenon
Fluvoxamine C/13.615.6 hr
OCD Not well Tabs: 25, 50,
(Luvox)
Social anxiety established 100
disorder Caps (ER): 100,
Unlabeled uses: 150

Panic disorder

PTSD

Migraine
prevention
Paroxetine C/21 hr
Major depressive Not well Tabs: 10, 20,
(Paxil) (CR: 1520 hr) disorder established 30, 40

Panic disorder Oral Suspen-

OCD sion: 10/5 mL

Social anxiety Tabs (CR): 12.5,
disorder 25, 37.5

GAD

PTSD

PMDD
Unlabeled uses:

Hot flashes

Diabetic
neuropathy
Sertraline C/26104 hr
Major depressive Not well Tabs: 25, 50,
(Zoloft) (including disorder established 100
metabolite)
OCD Oral concen-

Panic disorder trate: 20/mL

PTSD

PMDD

Social anxiety
disorder
2506_Ch26_417-446.indd 1423 10/1/10 9:39:19 AM

Action
Selectively inhibit the central nervous system neuronal uptake
of serotonin (5-HT)
Contraindications and Precautions
Contraindicated in: Hypersensitivity to SSRIs Concomi-
tant use with, or within 14 days use of, MAOIs Fluoxetine:
concomitant use with thioridazine (or within 5 weeks after dis-
continuation of uoxetine) Fluvoxamine: concomitant use
with cisapride, thioridazine, or pimozide Paroxetine: con-
comitant use with thioridazine Sertraline: concomitant use
with pimozide Sertraline: coadministration of oral concen-
trate with disul ram
Use Cautiously in: Patients with history of seizures Un-
derweight or anorexic patients Patients with hepatic or renal
insufciency Elderly or debilitated patients Suicidal patients
Pregnancy and lactation
Headache
Insomnia
Nausea
Anorexia
Diarrhea
Constipation
Sexual dysfunction
Somnolence
Dry mouth
box warning)
Serotonin syndrome. Can occur if taken concurrently with
other medications that increase levels of serotonin (e.g.,
MAOIs, tryptophan, amphetamines, other antidepressants,
buspirone, lithium, dopamine agonists, or serotonin 5-HT1
receptor agonists [agents for migraine]). Symptoms of sero-
tonin syndrome include diarrhea, cramping, tachycardia,
labile blood pressure, diaphoresis, fever, tremor, shivering,
restlessness, confusion, disorientation, mania, myoclonus, hy-
perreexia, ataxia, seizures, cardiovascular shock, and death.
Interactions
Toxic, sometimes fatal, reactions have occurred with concom-
itant use of MAOIs.
Increased effects of SSRIs with cimetidine, L-tryptophan,
lithium, linezolid, and St. Johns wort.
Serotonin syndrome may occur with concomitant use of SSRIs
and metoclopramide, sibutramine, tramadol, serotonin
2506_Ch26_417-446.indd 1424 10/1/10 9:39:20 AM

Antidepressants 425
5-HT1 receptor agonists (agents for migraine), or any drug

that increases levels of serotonin.
Concomitant use of SSRIs may increase effects of hydanto-
ins, tricyclic antidepressants, cyclosporine, benzodiaze-
pines, beta blockers, methadone, carbamazepine, clozap-
ine, olanzapine, pimozide, haloperidol, phenothiazines,
St. Johns wort, sumatriptan, sympathomimetics, tacrine,
theophylline, and warfarin.
Concomitant use of SSRIs may decrease effects of buspirone
and digoxin.
Lithium levels may be increased or decreased by concomitant
use of SSRIs.
Decreased effects of SSRIs with concomitant use of carbam-
azepine or cyproheptadine
Route and Dosage

CITALOPRAM (Celexa)
Depression: PO: Initial dosage: 20 mg/day as a single
daily dose. May increase in increments of 20 mg at intervals
of no less than 1 week. Recommended maximum dose:
40 mg/day.
Elderly clients: 20 mg/day.
OCD: PO: Initial dosage: 20 mg/day. Titrate to a target dosage
of 40 to 60 mg/day. Maximum dosage: 80 mg.
ESCITALOPRAM (Lexapro)
Depression and GAD: PO: Initial dosage: 10 mg/day as a
single daily dose. May increase to 20 mg/day after 1 week.
Elderly clients: PO: 10 mg/day.
PTSD: PO: Initial dose: 10 mg/day. Increase to 20 mg/day after
4 weeks.
FLUOXETINE (Prozac; Sarafem)
Depression and OCD: PO: Adults: Initial dosage: 20 mg/day
in the morning. May increase dosage after several weeks if
clinical improvement is not observed. Maximum dose: 80 mg/
day. Children and adolescents: 10 to 20 mg/day.
Bulimia Nervosa: PO: 60 mg/day administered in the morning.
May need to titrate up to this target dose in some clients.
Panic Disorder: PO: Initial dose: 10 mg/day. After 1 week,
increase dose to 20 mg/day. If no improvement is seen
after several weeks, may consider dose increases up to
60 mg/day.
PMDD (Sarafem): PO: Initial dose: 20 mg/day. Maximum:
80 mg/day. May be given continuously throughout the cycle
or intermittently (only during the 14 days prior to anticipated
onset of menses).
2506_Ch26_417-446.indd 1425 10/1/10 9:39:20 AM

Alcoholism: PO: Initial dosage: 20 mg/day. Titrate to 40 mg/

day after 2 weeks, if needed.
Borderline Personality Disorder: PO: 20 to 80 mg/day.
Fibromyalgia: PO: 20 mg/day (in the morning) for up to
6 weeks.
Hot Flashes: PO: 20 mg/day.
PTSD: PO: Adults: 10 to 80 mg/day. Children: 10 to 20 mg/day.
Migraine Prevention: PO: 10 to 40 mg/day.
Raynaud Phenomenon: PO: 20 to 60 mg/day.
FLUVOXAMINE (Luvox)
OCD: PO: Adults: Initial dose: 50 mg at bedtime. May increase
dose in 50 mg increments every 4 to 7 days. Maximum dose:
300 mg. Administer daily doses >100 mg in 2 divided doses. If
unequal, give larger dose at bedtime.
Children 8 to 17 years: Initial dose: 25 mg single dose at bedtime.
May increase the dose in 25 mg increments every 4 to 7 days
to a maximum dose of 200 mg/day for children up to 11 years
of age. Maximum dose for adolescents: 300 mg/day. Divide
daily doses >50 mg into 2 doses. If unequal, give larger dose
at bedtime.
Social Anxiety Disorder: PO (extended release capsules): Initial
dose: 100 mg/day as a single daily dose at bedtime. Increase
in 50 mg increments every week, as tolerated, until maximum
therapeutic benet is achieved. Maximum dose: 300 mg/day.
Panic Disorder: PO: Initial dosage: 50 mg/day. Gradually
increase after several days to 150 mg/day. For clients who fail
to respond after several weeks of treatment, further increases
up to 300 mg/day may be considered.
PTSD: PO: Adults: Initial dosage: 50 mg/day. Increase gradually
to target dose of 100 to 250 mg/day in adults, and 100 mg/day
in older adults. Maximum recommended dosage: 300 mg/day.
Children and adolescents: Target dose: 50 mg/day.
Migraine Prevention: PO: 50 mg at bedtime for 12 weeks.
PAROXETINE (Paxil)
Depression: PO: Immediate release: Initial dose: 20 mg/day
in the morning. May increase dose in 10 mg increments at
intervals of at least 1 week to a maximum of 50 mg/day.
Controlled release: Initial dose: 25 mg/day in the morning. May
increase dose in 12.5 mg increments at intervals of at least
1 week to a maximum of 62.5 mg/day.
Panic Disorder: PO: Immediate release: Initial dose: 10 mg/
day in the morning. May increase dose in 10 mg increments
at intervals of at least 1 week to a target dose of 40 mg/
day. Maximum dose: 60 mg/day. Controlled release: Initial
2506_Ch26_417-446.indd 1426 10/1/10 9:39:20 AM

Antidepressants 427
dose: 12.5 mg/day. May increase dose in 12.5 mg/day

increments at intervals of at least 1 week to a maximum
dose of 75 mg/day.
OCD: PO: Immediate release: 20 mg/day. May increase dose
in 10 mg/day increments at intervals of at least 1 week.
Recommended dose: 40 mg/day. Maximum dose: 60 mg/day.
Social Anxiety Disorder: PO: Immediate release: 20 mg/day.
Usual range is 20 to 60 mg/day.
Controlled release: 12.5 mg/day. May increase dosage at intervals
of at least 1 week, in increments of 12.5 mg/day to a maximum
of 37.5 mg/day.
GAD and PTSD: PO: Immediate release: 20 mg/day. Usual
range is 20 to 50 mg/day. Change doses in increments of
10 mg/day at intervals of at least 1 week.
PMDD: PO: Controlled release: Initial dose: 12.5 mg/day. Usual
range: 12.5 to 25 mg/day. Change doses at intervals of at least
1 week. May be administered daily throughout the menstrual
cycle or limited to luteal phase of menstrual cycle.
Hot Flashes: PO: Immediate release: 20 mg/day.
Controlled release: 12.5 to 25 mg/day
Diabetic Neuropathy: PO: Initial dose: 10 mg/day. Titrate to
20 to 60 mg/day.
Elderly or Debilitated Patients: PO: Immediate release: Initial
dose: 10 mg/day. Maximum dose: 40 mg/day.
Controlled release: Initial dose: 12.5 mg/day. Maximum dose:
50 mg/day.
SERTRALINE (Zoloft)
Depression and OCD: PO: 50 mg/day (either morning
or evening). May increase dosage at 1 week intervals to a
Panic Disorder and PTSD: PO: Initial dose: 25 mg/day.
After 1 week, increase dose to 50 mg/day. For patients not
responding, may increase dosage at 1 week intervals to a
PMDD: PO: 50 mg/day given on each day of the menstrual cycle
or only during each day of the luteal phase of the menstrual
cycle. For patients not responding, may increase dosage in
50 mg increments per menstrual cycle up to 150 mg/day when
dosing throughout the cycle or 100 mg/day when dosing only
during the luteal phase. If 100 mg/day has been established
with luteal phase dosing, titrate at 50 mg/day for rst 3 days of
each luteal phase dosing period.
Social Anxiety Disorder: PO: Initial dose: 25 mg/day. After
1 week, increase dose to 50 mg/day. May increase gradually to
maximum dose of 200 mg/day.
2506_Ch26_417-446.indd 1427 10/1/10 9:39:21 AM

CHEMICAL CLASS: NOREPINEPHRINE-

DOPAMINE REUPTAKE INHIBITORS
(NDRIs)
Examples

Name Half-life (hr) Indications Range Forms (mg)
Bupropion C/824
Depression Not well Tabs: 75, 100
(Wellbutrin; (Wellbutrin) established Tabs (SR): 100,
Zyban)
Seasonal 150, 200
affective disorder Tabs (XL): 150,
(Wellbutrin XL) 300

Smoking
cessation
(Zyban)
Unlabeled uses:

ADHD
(Wellbutrin)
SR = 12-hour tablets; XL = 24-hour tablets.
Action
Action is unclear. Thought to inhibit the reuptake of norepi-
nephrine and dopamine into presynaptic neurons.

Contraindicated in: Hypersensitivity to the drug Con-
comitant use with, or within 2 weeks use of, MAOIs Known or
suspected seizure disorder Alcohol or benzodiazepine (or other
sedatives) withdrawal Current or prior diagnosis of bulimia or
anorexia nervosa Concomitant use of Wellbutrin (for depres-
sion or ADHD) and Zyban (for smoking cessation) Lactation
Use Cautiously in: Patients with urinary retention
Patients with hepatic or renal function impairment Patients
with suicidal ideation Patients with recent history of myocar-
dial infarction or unstable heart disease Pregnancy (safety not
established) Elderly and debilitated patients

Dry mouth
Blurred vision
Agitation
Insomnia
Tremor
Sedation; dizziness
Tachycardia
2506_Ch26_417-446.indd 1428 10/1/10 9:39:21 AM

Antidepressants 429
Excessive sweating
Headache
Nausea/vomiting
Anorexia; weight loss
Seizures
Constipation
box warning)
Interactions
Increased effects of bupropion with amantadine, levodopa,
clopidogrel, CYP2B6 inhibitors (e.g., cimetidine), guanfa-
cine, linezolid, and ticlopidine
Increased risk of acute toxicity with MAOIs. Coadministra-
tion is contraindicated.
Coadministration with a nicotine replacement agent may
cause hypertension.
Concomitant use with alcohol may produce adverse neuro-
psychiatric events (alcohol tolerance is reduced).
Decreased effects of bupropion with carbamazepine and
rifampin
Increased anticoagulant effect of warfarin with bupropion
Increased effects of drugs metabolized by CYP2D6 isoenzyme
(e.g., nortriptyline, imipramine, desipramine, paroxetine,
fluoxetine, sertraline, haloperidol, risperidone, thiorida-
zine, metoprolol, propafenone, and flecainide)
Route and Dosage

BUPROPION (Wellbutrin; Zyban)
Depression (Wellbutrin): PO: Adults (immediate release tabs):
100 mg 2 times a day. May increase after 3 days to 100 mg given
3 times a day. For patients who do not show improvement after
several weeks of dosing at 300 mg/day, an increase in dosage up
to 450 mg/day may be considered. No single dose of bupropion
should exceed 150 mg. To prevent the risk of seizures, administer
with an interval of 4 to 6 hours between doses.
Sustained release tabs: Give as a single 150 mg dose in the morn-
ing. May increase to twice a day (total 300 mg), with 8 hours
between doses.
Extended release tabs: Begin dosing at 150 mg/day, given as a
single daily dose in the morning. May increase after 3 days to
300 mg/day, given as a single daily dose in the morning.
Seasonal Affective Disorder (Wellbutrin XL): PO: 150 mg
administered each morning beginning in the autumn prior to
the onset of depressive symptoms. Dose may be uptitrated to
the target dose of 300 mg/day after 1 week. Therapy should
2506_Ch26_417-446.indd 1429 10/1/10 9:39:22 AM

continue through the winter season before being tapered to

150 mg/day for 2 weeks prior to discontinuation in early spring.
Smoking Cessation (Zyban): PO: Begin dosing at 150 mg
given once a day in the morning for 3 days. If tolerated
well, increase to target dose of 300 mg/day given in doses of
150 mg 2 times a day with an interval of 8 hours between
doses. Continue treatment for 7 to 12 weeks. Some patients
may need treatment for as long as 6 months.
ADHD: PO: Children: 3 mg/kg/day. Adults: 150 to 450 mg/day.
No single dose of bupropion should exceed 150 mg. To prevent
the risk of seizures, administer with an interval of 4 to 6 hours
between doses.
CHEMICAL CLASS: SEROTONIN-

NOREPINEPHRINE REUPTAKE
INHIBITORS (SNRIs)
Examples

(Trade) Category/ Plasma Level Available
Name Half-life (hr) Indications Ranges Forms (mg)
Desvenlafaxine C/11
Depression Not well Tabs ER: 50,
(Pristiq) established 100
Duloxetine C/817
Depression Not well Caps: 20,
(Cymbalta)
Diabetic established 30, 60
peripheral neuro-
pathic pain

Fibromyalgia

Generalized
anxiety disorder
(GAD)
Unlabeled uses:

Stress urinary
incontinence
Venlafaxine C/511 (incl.

Depression Not well Tabs: 25, 37.5,
(Effexor) metabolite)
GAD (extended established 50, 75, 100
release [ER] only) Caps XR: 37.5,

Social anxiety 75, 150
disorder (ER)

Panic disorder
(ER)
Unlabeled uses:

Hot flashes

PMDD

PTSD
2506_Ch26_417-446.indd 1430 10/1/10 9:39:22 AM

Antidepressants 431
Action
SNRIs are potent inhibitors of neuronal serotonin and nor-
epinephrine reuptake; weak inhibitors of dopamine reuptake.

Contraindicated in: Hypersensitivity to the drug
Children (safety not established) Concomitant (or within
14 days) use with MAOIs Severe renal or hepatic impairment
Pregnancy and lactation (safety not established) Uncon-
trolled narrow-angle glaucoma
Use Cautiously in: Patients with hepatic and renal insuf-
ciency Elderly and debilitated patients Patients with his-
tory of drug abuse Patients with suicidal ideation Patients
with history of or existing cardiovascular disease Patients with
history of mania Patients with history of seizures Children

Headache
Dry mouth
Nausea
Somnolence
Dizziness
Insomnia
Asthenia
Constipation
Diarrhea
Mydriasis (venlafaxine)
box warning)
Discontinuation syndrome. Abrupt withdrawal may result in
symptoms such as nausea, vomiting, nervousness, dizziness,
headache, insomnia, nightmares, paresthesias, and a return of
symptoms for which the medication was prescribed. A gradual
reduction in dosage is recommended.
Interactions
Concomitant use with MAOIs results in serious, sometimes
fatal, effects resembling neuroleptic malignant syndrome.
Coadministration is contraindicated.
Serotonin syndrome may occur when SNRIs are used con-
comitantly with St. Johns wort, sumatriptan, sibutramine,
trazodone, or other drugs that increase levels of serotonin.
Increased effects of haloperidol, clozapine, and desipra-
mine when used concomitantly with venlafaxine
Increased effects of venlafaxine with cimetidine and azole
antifungals
2506_Ch26_417-446.indd 1431 10/1/10 9:39:22 AM

Decreased effects of venlafaxine with cyproheptadine

Decreased effects of indinavir and metoprolol with venlafaxine
Increased effects of warfarin with SNRIs
Increased effects of duloxetine with CYP1A2 inhibitors (e.g.,
uvoxamine, quinolone antibiotics) and CYP2D6 inhibitors
(e.g., uoxetine, quinidine, paroxetine)
Increased risk of liver injury with concomitant use of alcohol
and duloxteine
Increased risk of toxicity or adverse effects from drugs exten-
sively metabolized by CYP2D6 (e.g., flecainide, phenothi-
azines, propafenone, tricyclic antidepressants, thiorida-
zine) when used concomitantly with duloxetine
Increased effects of desipramine with desvenlafaxine
Decreased effects of midazolam with desvenlafaxine
Route and Dosage

DESVENLAFAXINE (Pristiq)
Depression: PO: 50 mg once daily, with or without food.
(In clinical studies, doses of 50 to 400 mg/day were
shown to be effective, although no additional benet was
demonstrated at doses greater than 50 mg/day and adverse
events and discontinuations were more frequent at higher
doses.)
DULOXETINE (Cymbalta)
Depression: PO: 40 mg/day (given as 20 mg twice a day) to
60 mg/day (given either once a day or as 30 mg 2 times a day)
without regard to meals.
Diabetic Peripheral Neuropathic Pain: PO: 60 mg/day
given once daily without regard to meals.
Fibromyalgia: PO: 30 mg once daily for 1 week and then
increase to 60 mg once daily, if needed.
GAD: PO: 60 mg once daily. For some patients, it may be
desirable to start at 30 mg once daily for 1 week to allow the
patient to adjust to the medication before increasing to 60 mg
once daily.
VENLAFAXINE (Effexor)
Depression: PO: Immediate-release tabs: Initial dosage: 75 mg/
day in 2 or 3 divided doses, taken with food. May increase
in increments up to 75 mg/day at intervals of at least 4 days.
Maximum dosage: 225 mg/day.
Depression, GAD, and Social Anxiety Disorder: PO:
Extended-release caps: Initial dosage: 75 mg/day, administered
in a single dose. May increase dose in increments of up to
75 mg/day at intervals of at least 4 days to a maximum of
225 mg/day.
2506_Ch26_417-446.indd 1432 10/1/10 9:39:23 AM

Antidepressants 433
Panic Disorder: PO: Extended-release caps: Initial dosage:

37.5 mg/day for 7 days. After 7 days, increase dosage to
75 mg/day. May increase dose in increments of up to 75 mg/day
at intervals of at least 7 days to a maximum of 225 mg/day.
CHEMICAL CLASS: SEROTONIN-2

ANTAGONISTS/REUPTAKE INHIBITORS
(SARIs)
Examples
Pregnancy Therapeutic-
Generic Categories/ Plasma Level Available
Name Half-life (hr) Indications Ranges (ng/ml) Forms (mg)
Nefazodone* C/24
Depression Not well Tabs: 50, 100,
established 150, 200, 250
Trazodone C/49
Unlabeled uses: 150, 300

Aggressive
behavior

Panic disorder
and agorapho-
bia with panic
attacks

Insomnia

Migraine
prevention
* Bristol-Myers Squibb voluntarily removed their brand of nefazodone (Serzone)

from the market in 2004. The generic equivalent is currently available through
various other manufacturers.
Action
Trazodone inhibits neuronal reuptake of serotonin; nefazo-
done inhibits neuronal reuptake of serotonin and norepineph-
rine and acts as an antagonist at central 5-HT2 receptors.

Contraindicated in: Hypersensitivity Coadministration
with terfenadine, astemizole, cisapride, pimozide, carbamazepine,
or triazolam (nefazodone) Patients who were withdrawn because
of liver injury (nefazodone) Concomitant use with, or within
2 weeks of use of, MAOIs Acute phase of myocardial infarction
Use Cautiously in: Pregnancy and lactation (safety not
established) Children (safety not established) Patients with
suicidal ideation Patients with hepatic, renal, or cardiovascular
disease Elderly and debilitated patients
2506_Ch26_417-446.indd 1433 10/1/10 9:39:23 AM


Drowsiness; dizziness
Fatigue
Headache
Nervousness; insomnia
Dry mouth
Nausea
Somnolence
Constipation
Priapism
box warning)
Risk of hepatic failure (nefazodone) (black box warning)
Interactions
Increased effects of CNS depressants, carbamazepine,
digoxin, and phenytoin with trazodone
Increased effects of trazodone with phenothiazines, azole
antifungals, and protease inhibitors
Risk of serotonin syndrome with concomitant use of trazo-
done and SSRIs or SNRIs
Decreased effects of trazodone with carbamazepine
Increases or decreases in prothrombin time with concurrent
use of trazodone and warfarin
Symptoms of serotonin syndrome and those resembling
neuroleptic malignant syndrome may occur with concomitant
use of MAOIs and SARIs.
Risk of serotonin syndrome with concomitant use of nefazo-
done and sibutramine or sumatriptan
Increased effects of both drugs with concomitant use of
buspirone and nefazodone
Increased effects of benzodiazepines, carbamazepine,
cisapride, cyclosporine, digoxin, and St. Johns Wort with
nefazodone
Decreased effects of nefazodone with carbamazepine
Risk of rhabdomyolysis with concomitant use of nefazodone
and HMG-CoA reductase inhibitors (e.g., simvastatin,
atorvastatin, lovastatin)
Route and Dosage

NEFAZODONE
Depression: PO: Adults: Initial dosage: 200 mg/day, in
2 divided doses. Dose may be increased in increments of
100 to 200 mg/day (on a 2 times a day schedule) at intervals of
at least 1 week. Maximum dose: 600 mg/day.
2506_Ch26_417-446.indd 1434 10/1/10 9:39:24 AM

Antidepressants 435
Elderly and debilitated patients: PO: 100 mg/day, in 2 divided doses.

Increases should be titrated slowly and based on careful as-
sessment of the patients clinical response.
TRAZODONE
Depression: PO: Adults: Initial dosage: 150 mg/day in divided
doses. May be increased by 50 mg/day every 3 to 4 days to
maximum dose of 400 mg/day. Inpatients or severely depressed
patients may be given up to a maximum of 600 mg/day.
Drowsiness may require that largest dose of the medication
be taken at bedtime.
Aggressive Behavior: PO: 50 mg 2 times a day (along with
tryptophan 500 mg 2 times a day).
Panic Disorder or Agoraphobia with Panic Attacks: PO:
300 mg/day.
Insomnia: PO: 50 to 100 mg at bedtime.
Migraine Prevention: PO: 100 mg/day.
CHEMICAL CLASS: ALPHA-2 RECEPTOR

ANTAGONIST
Examples

Mirtazapine C/2040
Depression Not well Tabs: 7.5, 15, 30, 45
(Remeron) established Tabs (orally
disintegrating):
15, 30, 45
Action
Potent antagonist of 5-HT2 and 5-HT3 receptors. Acts as
antagonist at central presynaptic 2-adrenergic inhibitory
autoreceptors and heteroreceptors, resulting in an increase
in central noradrenergic and serotonergic activity. It is also a
potent antagonist of histamine (H1) receptors.

Contraindicated in: Patients with hypersensitivity to the
drug Patients with suicidal ideation Concurrent use with, or
within 14 days of therapy with, MAOIs
Use Cautiously in: History of seizures History of mania
or hypomania Elderly or debilitated patients Patients with he-
patic, renal, or cardiovascular disease Pregnancy and lactation
(safety not established) Children (safety not established)
2506_Ch26_417-446.indd 1435 10/1/10 9:39:24 AM


Somnolence
Dizziness
Dry mouth
Constipation
Increased appetite
Weight gain
Agranulocytosis
Increases in cholesterol and triglyceride levels
Interactions
Additive impairment in cognitive and motor skills with CNS
depressants (e.g., benzodiazepines, alcohol)
Life-threatening symptoms similar to neuroleptic malignant
syndrome with concurrent use, or within 14 days of use of,
MAOIs
Possible interaction with drugs that are metabolized by or
inhibit cytochrome P450 enzymes CYP2D6, CYP1A2, and
CYP3A4
Increased effects of mirtazapine with concomitant use of
SSRIs (e.g., fluoxetine, fluvoxamine)
Route and Dosage

MIRTAZAPINE (Remeron)
Depression: PO: Initial dosage: 15 mg/day, administered in a
single dose, preferably at bedtime. Dose may be increased at
intervals of 1 to 2 weeks, up to a maximum dose of 45 mg/day.
When switching to or from an MAOI: At least 14 days should
elapse between discontinuation of an MAOI and initiation of
therapy with mirtazapine. In addition, allow at least 14 days
after stopping mirtazapine before starting an MAOI.
CHEMICAL CLASS: MONOAMINE OXIDASE

INHIBITORS
Examples

Isocarboxazid C/Not
Depression Not well Tabs: 10
(Marplan) Established established
Phenelzine C/23
(Nardil) Unlabeled uses: established

PTSD

Migraine
prevention
2506_Ch26_417-446.indd 1436 10/1/10 9:39:24 AM

Antidepressants 437

Tranylcypromine C/2.42.8
(Parnate) Unlabeled uses: established

Migraine
prevention

Social anxiety
disorder

Panic disorder
Selegiline C/1825
Depression Not well Transdermal
transdermal (including established patches: 6,
system metabolites) 9, 12
(Emsam)
Action
Inhibition of the enzyme monoamine oxidase, which is respon-
sible for the decomposition of the biogenic amines, epineph-
rine, norepinephrine, dopamine, and serotonin. This action
results in an increase in the concentration of these endogenous
amines.

Contraindicated in: Hypersensitivity Pheochromo-
cytoma Hepatic or renal insufciency History of or exist-
ing cardiovascular disease Hypertension History of severe
or frequent headaches Concomitant use with other MAOIs,
tricyclic antidepressants, carbamazepine, cyclobenzaprine,
bupropion, SSRIs, SARIs, buspirone, sympathomimetics, me-
peridine, dextromethorphan, anesthetic agents, CNS depres-
sants, antihypertensives, caffeine, and food with high tyramine
content Children younger than 16 years Pregnancy and
lactation (safety not established)
Use Cautiously in: Patients with a history of seizures
Patients with diabetes mellitus Patients with suicidal ide-
ation Agitated or hypomanic patients Patients with a history
of angina pectoris or hyperthyroidism

Dizziness
Headache
Constipation
Nausea
Disturbances in cardiac rate and rhythm
Blurred vision
2506_Ch26_417-446.indd 1437 10/1/10 9:39:25 AM

Dry mouth
Weight gain
Hypomania
Site reactions (itching, irritation) (with selegiline transdermal
system)
box warning)
Interactions
Serious, potentially fatal adverse reactions may occur with
concurrent use of other antidepressants, carbamazepine,
cyclobenzaprine, bupropion, SSRIs, SARIs, buspirone,
sympathomimetics, tryptophan, dextromethorphan, an-
esthetic agents, CNS depressants, and amphetamines.
Avoid using within 2 weeks of each other (5 weeks after therapy
with fluoxetine).
Hypertensive crisis may occur with amphetamines, methyl-
dopa, levodopa, dopamine, epinephrine, norepinephrine,
guanethidine, methylphenidate, guanadrel, reserpine, or
vasoconstrictors.
Hypertension or hypotension, coma, convulsions, and death
may occur with opioids (avoid use of meperidine within 14 to
21 days of MAOI therapy).
Additive hypotension may occur with antihypertensives,
thiazide diuretics, or spinal anesthesia.
Additive hypoglycemia may occur with insulins or oral
hypoglycemic agents.
Doxapram may increase pressor response.
Serotonin syndrome may occur with concomitant use of
St. Johns wort.
Hypertensive crisis may occur with ingestion of foods or
other products containing high concentrations of tyramine
(see Nursing Implications).
Consumption of foods or beverages with high caffeine con-
tent increases the risk of hypertension and arrhythmias.
Bradycardia may occur with concurrent use of MAOIs and
beta blockers.
Route and Dosage

ISOCARBOXAZID (Marplan)
Depression: PO: Initial dose: 10 mg 2 times a day. May
increase dosage by 10 mg every 2 to 4 days to 40 mg by end
of rst week. If needed, may continue to increase dosage by
increments of up to 20 mg/week. Maximum dosage: 60 mg/
day divided into 2 to 4 doses. Gradually reduce to smallest
effective dose.
2506_Ch26_417-446.indd 1438 10/1/10 9:39:25 AM

Antidepressants 439
PHENELZINE (Nardil)
Depression: PO: Initial dose: 15 mg 3 times a day. Increase to
60 to 90 mg/day in divided doses until therapeutic response
is achieved. Then gradually reduce to smallest effective dose
(15 mg/day or every other day).
TRANYLCYPROMINE (Parnate)
Depression: PO: 30 mg/day in divided doses. After 2 weeks,
may increase by 10 mg/day, at 1- to 3-week intervals, up to
60 mg/day.
SELEGILINE TRANSDERMAL SYSTEM (Emsam)
Depression: Transdermal patch: Initial dose: 6 mg/24 hr. If
necessary, dosage may be increased in increments of 3 mg/24 hr
at intervals of no less than 2 weeks up to a maximum dose of
12 mg/24 hr.
Elderly clients: The recommended dosage is 6 mg/24 hr.
PSYCHOTHERAPEUTIC COMBINATIONS
Examples
Generic (Trade)
Name Indications Available Forms (mg)
Olanzapine/fluoxetine
For the acute treatment Caps: olanzapine 3/fluoxetine 25;
(Symbyax) of depressive episodes olanzapine 6/fluoxetine 25;
associated with bipolar olanzapine 6/fluoxetine 50;
I disorder in adults olanzapine 12/fluoxetine 25;

For the acute treatment olanzapine 12/fluoxetine 50
of treatment-resistant
depression
Chlordiazepoxide/
For the treatment of mod- Tabs: chlordiazepoxide 5/
amitriptyline erate to severe depression amitriptyline 12.5;
(Limbitrol) associated with moderate chlordiazepoxide 10/
to severe anxiety amitriptyline 25
Perphenazine/
For the treatment of Tabs: perphenazine 2/amitriptyline 10;
amitriptyline moderate to severe anxiety perphenazine 2/amitriptyline 25;
HCl (Etrafon) or agitation and depressed perphenazine 4/amitriptyline 10;
mood perphenazine 4/amitriptyline 25;

For the treatment of perphenazine 4/amitriptyline 50
patients with schizophre-
nia who have associated
symptoms of depression
* These medications are presented for general information only. For detailed
information, the reader is directed to the chapters that deal with each of the
specic drugs that make up these combinations.
2506_Ch26_417-446.indd 1439 10/1/10 9:39:26 AM

Route and Dosage

OLANZAPINE /FLUOXETINE (Symbyax)
Depression Associated with Bipolar I Disorder and
Treatment-resistant Depression: PO: Initial dosage:
olanzapine 6 mg/uoxetine 25 mg once daily in the evening.
Dosage adjustments, if indicated, can be made according to
efcacy and tolerability.
CHLORDIAZEPOXIDE /AMITRIPTYLINE (Limbitrol)
Moderate to Severe Depression Associated with Moderate
to Severe Anxiety: PO: Initial dose: chlordiazepoxide 10/
amitriptyline 25 given 3 or 4 times a day in divided doses. May
increase to 6 times a day, as required. Some patients respond
to smaller doses and can be maintained on 2 tablets daily.
PERPHENAZINE /AMITRIPTYLINE HCL (Etrafon)
Anxiety/Agitation/Depression: PO: Initial dose: perphe-
nazine 2 to 4 mg/amitriptyline 10 to 50 mg, 3 or 4 times/day.
Once a satisfactory response is achieved, reduce to smallest
amount necessary to obtain relief.

TO ALL ANTIDEPRESSANTS
1. Risk for suicide related to depressed mood.
2. Risk for injury related to side effects of sedation, lowered
seizure threshold, orthostatic hypotension, priapism, photo-
sensitivity, arrhythmias, and hypertensive crisis.
3. Social isolation related to depressed mood.
4. Risk for constipation related to side effects of the medication.
FOR ANTIDEPRESSANTS
The plan of care should include monitoring for the following
side effects from antidepressant medications. Nursing implica-
tions are designated by an asterisk (*).
1. May occur with all chemical classes:
a. Dry mouth
* Offer the client sugarless candy, ice, frequent sips of
water
* Strict oral hygiene is very important.
b. Sedation
* Request an order from the physician for the drug to be
given at bedtime.
* Request that the physician decrease the dosage or per-
haps order a less sedating drug.
* Instruct the client not to drive or use dangerous equip-
ment while experiencing sedation.
2506_Ch26_417-446.indd 1440 10/1/10 9:39:26 AM

Antidepressants 441
c. Nausea
* Medication may be taken with food to minimize GI
distress.
d. Discontinuation syndrome
* All classes of antidepressants have varying potentials to
cause discontinuation syndromes. Abrupt withdrawal
following long-term therapy with SSRIs and SNRIs
may result in dizziness, lethargy, headache, and nausea.
Fluoxetine is less likely to result in withdrawal symptoms
because of its long half-life. Abrupt withdrawal from
tricyclics may produce hypomania, akathisia, cardiac
arrhythmias, and panic attacks. The discontinuation
syndrome associated with MAOIs includes confusion,
hypomania, and worsening of depressive symptoms. All
antidepressant medication should be tapered gradually
to prevent withdrawal symptoms.
2. Most commonly occur with tricyclics and others, such as
the SARIs, bupropion, maprotiline, and mirtazapine:
a. Blurred vision
* Offer reassurance that this symptom should subside
after a few weeks
* Instruct the client not to drive until vision is clear.
* Clear small items from routine pathway to prevent
falls.
b. Constipation
* Order foods high in ber; increase uid intake if not
contraindicated; and encourage the client to increase
physical exercise, if possible.
c. Urinary retention
* Instruct the client to report hesitancy or inability to
urinate.
* Monitor intake and output.
* Try various methods to stimulate urination, such as
running water in the bathroom or pouring water over
the perineal area.
d. Orthostatic hypotension
* Instruct the client to rise slowly from a lying or sitting
position.
* Monitor blood pressure (lying and standing) frequently,
and document and report signicant changes.
* Instruct the client to avoid long hot showers or tub baths.
e. Reduction of seizure threshold
* Observe clients with history of seizures closely.
* Institute seizure precautions as specied in hospital pro-
cedure manual.
* Bupropion (Wellbutrin) should be administered in
doses of no more than 150 mg and should be given at
2506_Ch26_417-446.indd 1441 10/1/10 9:39:26 AM

least 4 hours apart. Bupropion has been associated with

a relatively high incidence of seizure activity in anorexic
and cachectic clients.
f. Tachycardia; arrhythmias
* Carefully monitor blood pressure and pulse rate
and rhythm, and report any signicant change to the
physician.
g. Photosensitivity
* Ensure that client wears sunblock lotion, protective
clothing, and sunglasses while outdoors.
h. Weight gain
* Provide instructions for reduced-calorie diet.
* Encourage increased level of activity, if appropriate.
3. Most commonly occur with SSRIs:
a. Insomnia; agitation
* Administer or instruct client to take dose early in
the day.
* Instruct client to avoid caffeinated food and drinks.
* Teach relaxation techniques to use before bedtime.
b. Headache
* Administer analgesics, as prescribed.
* If relief is not achieved, physician may order another
antidepressant.
c. Weight loss (may occur early in therapy)
* Ensure that client is provided with caloric intake
sufcient to maintain desired weight.
* Caution should be taken in prescribing these drugs for
anorexic clients.
* Weigh client daily or every other day, at the same time
and on the same scale if possible.
* After prolonged use, some clients may gain weight on
SSRIs.
d. Sexual dysfunction
* Men may report abnormal ejaculation or impotence.
* Women may experience delay or loss of orgasm.
* If side effect becomes intolerable, a switch to another
antidepressant may be necessary.
e. Serotonin syndrome (may occur when two drugs
that potentiate serotonergic neurotransmission are used
concurrently [see Interactions]).
* Most frequent symptoms include changes in mental
status, restlessness, myoclonus, hyperreexia, tachycar-
dia, labile blood pressure, diaphoresis, shivering, and
tremors.
* Discontinue offending agent immediately.
* The physician will prescribe medications to block
serotonin receptors, relieve hyperthermia and muscle
2506_Ch26_417-446.indd 1442 10/1/10 9:39:27 AM

Antidepressants 443
rigidity, and prevent seizures. In severe cases, articial

ventilation may be required. The histamine-1 receptor
antagonist cyproheptadine is commonly used to treat
the symptoms of serotonin syndrome.
* Supportive nursing measures include monitoring vital
signs, providing safety measures to prevent injury when
muscle rigidity and changes in mental status are present,
cooling blankets and tepid baths to assist with tem-
perature regulation, and monitoring intake and output
(Prator, 2006).
* The condition will usually resolve on its own once the
offending medication has been discontinued. However,
if the medication is not discontinued, the condition
may progress to life-threatening complications such as
seizures, coma, hypotension, ventricular arrhythmias,
disseminated intravascular coagulation, rhabdomyoly-
sis, metabolic acidosis, and renal failure (Prator, 2006).
4. Most commonly occur with MAOIs:
a. Hypertensive crisis
* Hypertensive crisis occurs if the individual consumes
foods or other substances containing tyramine while
receiving MAOI therapy. Foods that should be avoided
include aged cheeses, raisins, fava beans, red wines,
smoked and processed meats, caviar, pickled herring,
soy sauce, monosodium glutamate (MSG), beer, choco-
late, yogurt, and bananas. Drugs that should be avoided
include other antidepressants, sympathomimetics (in-
cluding over-the-counter cough and cold preparations),
stimulants (including over-the-counter diet drugs), an-
tihypertensives, meperidine and other opioid narcotics,
and antiparkinsonian agents, such as levodopa.
* Symptoms of hypertensive crisis include severe occipi-
tal headache, palpitations, nausea and vomiting, nuchal
rigidity, fever, sweating, marked increase in blood pres-
sure, chest pain, and coma.
* Treatment of hypertensive crisis: Discontinue drug im-
mediately; monitor vital signs; administer short-acting
antihypertensive medication, as ordered by physician;
use external cooling measures to control hyperpyrexia.
b. Application site reactions (with selegiline transdermal
system [Emsam])
* The most common reactions include rash, itching, ery-
thema, redness, irritation, swelling, or urticarial lesions.
Most reactions resolve spontaneously, requiring no
treatment. However, if reaction becomes problematic,
it should be reported to the physician. Topical corticos-
teroids have been used in treatment.
2506_Ch26_417-446.indd 1443 10/1/10 9:39:27 AM

5. Miscellaneous side effects:

a. Priapism (with trazodone)
* Priapism is a rare side effect, but it has occurred in some
men taking trazodone.
* If the client complains of prolonged or inappropriate
penile erection, withhold medication dosage and notify
the physician immediately.
* Priapism can become very problematic, requiring sur-
gical intervention, and, if not treated successfully, can
result in impotence.
b. Hepatic failure (with nefazodone)
* Cases of life-threatening hepatic failure have been
reported in clients treated with nefazodone.
* Advise clients to be alert for signs or symptoms sug-
gestive of liver dysfunction (e.g., jaundice, anorexia, GI
complaints, or malaise) and to report them to physician
immediately.

TO ALL ANTIDEPRESSANTS
Continue to take the medication even though the symptoms
have not subsided. The therapeutic effect may not be seen for
as long as 4 weeks. If after this length of time no improvement
is noted, the physician may prescribe a different medication.
Use caution when driving or operating dangerous machin-
ery. Drowsiness and dizziness can occur. If these side effects
become persistent or interfere with activities of daily living,
the client should report them to the physician. Dosage adjust-
ment may be necessary.
Do not stop taking the drug abruptly. To do so might pro-
duce withdrawal symptoms, such as nausea, vertigo, insomnia,
headache, malaise, nightmares, and a return of the symptoms
for which the medication was prescribed.
Use sunblock lotion and wear protective clothing when spend-
ing time outdoors. The skin may be sensitive to sunburn.
Report occurrence of any of the following symptoms to the
physician immediately: sore throat, fever, malaise, yellowish
skin, unusual bleeding, easy bruising, persistent nausea and
vomiting, severe headache, rapid heart rate, difculty urinat-
ing, anorexia or weight loss, seizure activity, stiff or sore neck,
and chest pain.
Rise slowly from a sitting or lying position to prevent a sudden
drop in blood pressure.
Take frequent sips of water, chew sugarless gum, or suck
on hard candy if dry mouth is a problem. Good oral care
(frequent brushing, ossing) is very important.
2506_Ch26_417-446.indd 1444 10/1/10 9:39:27 AM

Antidepressants 445
Do not consume the following foods or medications while

taking MAOIs: aged cheese, wine (especially Chianti), beer,
chocolate, colas, coffee, tea, sour cream, smoked and pro-
cessed meats, chicken or beef liver, soy sauce, pickled herring,
yogurt, raisins, caviar, broad beans, cold remedies, or diet
pills. To do so could cause a life-threatening hypertensive
crisis.
Follow the correct procedure for applying the selegiline trans-
dermal patch:
Apply to dry, intact skin on upper torso, upper thigh, or
outer surface of upper arm.

Apply approximately same time each day to new spot on
skin, after removing and discarding old patch.

Wash hands thoroughly after applying the patch.
Avoid exposing application site to direct heat (e.g., heating
pads, electric blankets, heat lamps, hot tub, or prolonged

direct sunlight).
If patch falls off, apply new patch to a new site and resume
previous schedule.
Avoid smoking while receiving tricyclic therapy. Smoking
increases the metabolism of tricyclics, requiring an adjust-
ment in dosage to achieve the therapeutic effect.
Do not drink alcohol while taking antidepressant therapy.
These drugs potentiate the effects of each other.
Do not consume other medications (including over-
the-counter medications) without the physicians approval
while receiving antidepressant therapy. Many medications
contain substances that, in combination with antidepressant
medication, could precipitate a life-threatening hyperten-
sive crisis.
Notify physician immediately if inappropriate or prolonged
penile erections occur while taking trazodone. If the erection
persists longer than 1 hour, seek emergency department treat-
ment. This condition is rare but has occurred in some men
who have taken trazodone. If measures are not instituted im-
mediately, impotence can result.
Do not double up on medication if a dose of bupropion
(Wellbutrin) is missed, unless advised to do so by the physi-
cian. Taking bupropion in divided doses will decrease the risk
of seizures and other adverse effects.
Be aware of possible risks of taking antidepressants during
pregnancy. Safe use during pregnancy and lactation has not
been fully established. These drugs are believed to readily
cross the placental barrier; if so, the fetus could experience
adverse effects of the drug. Inform the physician immediately
if pregnancy occurs, is suspected, or is planned.
2506_Ch26_417-446.indd 1445 10/1/10 9:39:27 AM

Be aware of the side effects of antidepressants. Refer to

written materials furnished by health care providers for safe
self-administration.
Carry a card or other identication at all times describing the
INTERNET REFERENCES
a. http://www.mentalhealth.com/
d. http://w w w.nlm.nih.gov/medlineplus/druginformation
.html
2506_Ch26_417-446.indd 1446 10/1/10 9:39:28 AM

C H A P T E R
27
Mood-Stabilizing Drugs
CHEMICAL CLASS: ANTIMANIC
Examples
Pregnancy
Generic Category/ Therapeutic
(Trade) Half-life Plasma Level Available
Name (hrs) Indications Range mEq/L Forms (mg)
Lithium D/2027
Manic episodes Acute mania: Caps: 150, 300,
carbonate associated with 1.01.5 600
(Eskalith; bipolar disorder Maintenance: Tabs: 300
Lithobid)
Maintenance therapy 0.61.2 Tabs (ER): 300,
Lithium citrate to prevent or diminish 450
intensity of subse- Syrup: 8 mEq
quent manic episodes (as citrate
Unlabeled uses: equivalent

Borderline personality to 300 mg
disorder lithium

Neutropenia carbonate)/

Cluster headaches 5 mL
(prophylaxis)

Alcohol dependence

Bulimia

Postpartum affective
psychosis

Corticosteroid-
induced psychosis
Action
Not fully understood, but lithium may have an inuence
on the reuptake of norepinephrine and serotonin. Effects on
other neurotransmitters have also been noted. Lithium also
alters sodium transport in nerve and muscle cells.

Contraindicated in: Hypersensitivity Severe cardio-
vascular or renal disease Dehydrated or debilitated patients
Sodium depletion Pregnancy and lactation
447
2506_Ch27_447-471.indd 0447 10/1/10 9:39:39 AM

Use Cautiously in: Elderly patients Any degree of cardiac,

renal, or thyroid disease Diabetes mellitus Urinary retention
Children younger than 12 years (safety not established)

Drowsiness, dizziness, headache
Seizures
Dry mouth, thirst
Indigestion, nausea, anorexia
Fine hand tremors
Hypotension, arrhythmias, electrocardiogram (ECG) changes
Polyuria, glycosuria
Weight gain
Hypothyroidism
Dehydration
Leukocytosis
Interactions
The effects of lithium (and potential for toxicity) are increased
with concurrent use of carbamazepine, fluoxetine, halo-
peridol, loop diuretics, methyldopa, nonsteroidal anti-
inflammatory drugs (NSAIDs), and thiazide diuretics.
The effects of lithium are decreased with concurrent use of
acetazolamide, osmotic diuretics, theophylline, and uri-
nary alkalinizers.
Increased effects of neuromuscular blocking agents and
tricyclic antidepressants are seen with concurrent use of
lithium.
Decreased pressor sensitivity of sympathomimetics with
lithium
Neurotoxicity may occur with concurrent use of lithium and
high-potency antipsychotics or calcium channel blockers.
Route and Dosage

Acute Mania: PO: 600 mg three times a day or 900 mg twice
daily for the slow release form. Serum levels should be taken
twice weekly at the initiation of therapy and until therapeutic
level has been achieved.
Long-Term (Maintenance) Use: PO: 300 mg three to four
times a day. Serum levels should be monitored in uncomplicated
cases during maintenance therapy every 1 to 2 months.
Borderline Personality Disorder: PO: 900 to 2400 mg/day
in 3 to 4 divided doses (or 900 to 1800 mg/day [ER tabs] in
2 divided doses). Titrate dosage to maintain serum levels of
0.8 to 1 mEq/L.
2506_Ch27_447-471.indd 0448 10/1/10 9:39:40 AM

CHEMICAL CLASS: ANTICONVULSANTS
Examples
2506_Ch27_447-471.indd 0449
Pregnancy
Generic (Trade) Categories/ Therapeutic Plasma
Name Half-life (hr) Indications Level Range Available Forms (mg)

Carbamazepine* D/2565 (initial) Epilepsy 412 mcg/mL Tabs: 100, 200

(Tegretol, Epitol, Carbatrol, 1217 (repeated Trigeminal neuralgia Tabs XR: 100, 200, 400
Equetro, Teril, Tegretol-XR) doses) Unlabeled uses: Caps XR: 100, 200, 300
Oral suspension: 100/5 mL
Bipolar disorder (FDA
approved: Equetro only)

Borderline personality disorder

Management of alcohol withdrawal

Restless legs syndrome


Clonazepam (C-IV) (Klonopin) C/1860 Petit mal, akinetic, and myoclonic 2080 ng/mL Tabs: 0.5, 1, 2
seizures

Panic disorder
Unlabeled uses:

Acute manic episodes

Restless leg syndrome

Neuralgias

Valproic acid* D/520 Epilepsy 50150 mcg/mL Caps: 250
(Depakene, Depakote, Unlabeled uses: Caps (DR): 125, 250, 500
Stavzor, Depacon) Syrup: 250/5 mL
Mood-Stabilizing Drugs
Manic episodes (FDA approved:

Stavzor only) Tabs (DR): 125, 250, 500

Tabs (ER): 250, 500

Migraine prophylaxis (FDA approved:
Stavzor only) Caps (sprinkle): 125
Injection: 100/mL in 5 mL vial
Borderline personality disorder
449
Continued
10/1/10 9:39:40 AM
Pregnancy
Generic (Trade) Categories/ Therapeutic Plasma
2506_Ch27_447-471.indd 0450
Name Half-life (hr) Indications Level Range Available Forms (mg)

Lamotrigine* C/~33 Epilepsy Not established Tabs: 25, 100, 150, 200

(Lamictal) Bipolar disorder Tabs (chewable): 2, 5, 25

Gabapentin* C/57 Epilepsy Not established Caps: 100, 300, 400

(Neurontin; Gabarone) Postherpetic neuralgia Tabs: 100, 300, 400, 600, 800
Unlabeled uses: Oral Solution: 250/5 mL

Bipolar disorder

Migraine prophylaxis

Neuropathic pain

Tremors associated with multiple sclerosis

Topiramate* C/21 Epilepsy Not established Tabs: 25, 50, 100, 200

(Topamax) Migraine prophylaxis Caps (sprinkle): 15, 25
Unlabeled uses:

Bipolar disorder

Cluster headaches

Bulimia

Weight loss in obesity

Oxcarbazepine* C/2 (metabolite 9) Epilepsy Not established Tabs: 150, 300, 600
(Trileptal) Unlabeled uses: Oral Susp: 60/mL

Alcohol withdrawal

Bipolar disorder

Diabetic neuropathy
* The FDA has issued a warning indicating reports of suicidal behavior or ideation associated with the use of these drugs (and other antiepileptic medica-
tions). The FDA now requires that all manufacturers of drugs in this class include a warning in their labeling to this effect. Results of a study published
in the December 2009 issue of Archives of General Psychiatry indicate that antiepileptic medications do not increase risk of suicide attempts in patients
with bipolar disorder (Gibbons et al., 2009).
10/1/10 9:39:41 AM
Action
Action in the treatment of bipolar disorder is unclear.
Carbamazepine
Contraindicated in hypersensitivity, with monoamine oxidase
inhibitors (MAOIs), lactation, history of previous bone mar-

row depression.
Use cautiously in elderly, liver/renal/cardiac disease, pregnancy.
Clonazepam
Contraindicated in hypersensitivity, acute narrow-angle
glaucoma, liver disease, lactation.
Use cautiously in elderly, liver/renal disease, pregnancy.
Valproic Acid
Contraindicated in hypersensitivity, liver disease.
Use cautiously in elderly, renal/cardiac diseases, pregnancy,
lactation.
Lamotrigine
Contraindicated in hypersensitivity.
Use cautiously in renal/hepatic/cardiac insufciency, preg-
nancy, lactation.
Gabapentin
Contraindicated in hypersensitivity, children <3 years of age.
Use cautiously in renal insufciency, pregnancy, lactation,
children, elderly.
Topiramate
Contraindicated in hypersensitivity.
Use cautiously in renal and hepatic impairment, pregnancy,
lactation, children, elderly.

Oxcarbazepine
Contraindicated in hypersensitivity (cross-sensitivity with
carbamazepine may occur), lactation.

Use cautiously in renal impairment, pregnancy, children
<4 years old.

Carbamazepine
Drowsiness, ataxia
Nausea, vomiting
Blood dyscrasias
Clonazepam
Drowsiness, ataxia
Dependence, tolerance
Blood dyscrasias
2506_Ch27_447-471.indd 0451 10/1/10 9:39:41 AM

Valproic Acid
Nausea, vomiting
Prolonged bleeding time
Tremor
Gabapentin
Drowsiness, dizziness, ataxia
Nystagmus
Tremor
Lamotrigine
Ataxia, dizziness, headache
Nausea, vomiting
Risk of severe rash
Photosensitivity
Topiramate
Drowsiness, dizziness, fatigue, ataxia
Impaired concentration, nervousness
Vision changes
Nausea, weight loss
Decreased efcacy with oral contraceptives
Oxcarbazepine
Dizziness, drowsiness
Headache
Nausea and vomiting
Abnormal vision, diplopia, nystagmus
Ataxia
Tremor
Interactions
The effects Are increased Are decreased Concurrent use may

of: by: by: result in:
Carbamazepine Verapamil, Cisplatin, Decreased levels of

diltiazem, doxorubicin, corticosteroids,
propoxyphene, felbamate, doxycycline, felbamate,
erythromycin, rifampin, quinidine, warfarin,
clarithromycin, barbiturates, estrogen-containing
SSRIs, tricyclic hydantoins, contraceptives, cyclo-
antidepressants, primidone, sporine, benzodiazepines,
cimetidine, theophylline theophylline, lamotrigine,
isoniazid, danazol, valproic acid, bupropion,
lamotrigine, haloperidol, olanzapine,
niacin, tiagabine, topiramate,
acetazolamide, voriconazole, ziprasidone.
dalfopristin, felbamate, levothyroxine,
valproate, antidepressants Increased
nefazodone levels of lithium Life-
threatening hypertensive
reaction with MAOIs
2506_Ch27_447-471.indd 0452 10/1/10 9:39:42 AM


Clonazepam CNS depressants, Rifampin, Increased phenytoin

cimetidine, hormonal theophylline levels; decreased efficacy
contraceptives, ( sedative of levodopa
disulfiram, fluoxetine, effects),
isoniazid, ketocon- phenytoin
azole, metoprolol,
propoxyphene,
propranol, valproic
acid, probenecid
Valproic acid Chlorpromazine, Rifampin, Increased effects of
cimetidine, carbamazepine, tricyclic antidepres-
erythromycin, cholestyramine, sants, carbamazepine,
felbamate, lamotrigine, CNS depressants,
salicylates phenobarbital, ethosuximide,
ethosuximide, lamotrigine,
hydantoins phenobarbital,
hydantoins, warfarin,
zidovudine, hydantoins
Gabapentin Cimetidine, Antacids Decreased effects of
hydrocodone, hydrocodone
morphine, naproxin
Lamotrigine Valproic acid Primidone, Decreased levels of
phenobarbital, valproic acid;
phenytoin, Increased levels of
rifamycin, suc- carbamazepine and
cinimides, oral topiramate
contraceptives,
oxcarbazepine,
carbamazepine,
acetaminophen
Topiramate Metformin; Phenytoin, Increased risk of CNS
hydrochlorothiazide carbamazepine, depression with
valproic acid, alcohol or other CNS
lamotrigine depressants.Increased
risk of kidney stones with
carbonic anhydrase
inhibitors. Increased
effects of phenytoin,
metformin, amitripty-
line. Decreased effects
of oral contraceptives,
digoxin, lithium,
riseridone, and
valproic acid.
Oxcarbazepine Carbamazepine, Increased concentrations
phenobarbital, of phenobarbital and
phenytoin, phenytoin; decreased
valproic acid, effects of oral
verapamil contraceptives,
felodipine, and
lamotrigine
2506_Ch27_447-471.indd 0453 10/1/10 9:39:42 AM

Route and Dosage

CARBAMAZEPINE (Tegretol)
Seizure Disorders: Adults and children > 12 years: PO: Initial
dosage: Either 200 mg 2 times a day for tablets and extended-
release (ER) tablets/capsules, or 5 mL (100 mg) 4 times a day
for suspension. Increase by 200 mg/day every 7 days until
therapeutic levels are achieved. Maximum dose: 1000 mg/day
in children 12 to 15 years; 1200 mg/day in patients >15 years.
Children 6 to 12 years: PO: 100 mg 2 times a day (50 mg 4 times
a day of suspension). Increase by 100 mg weekly until thera-
peutic levels are obtained. (Usual range: 400 to 800 mg/day.)
Children <6 years: PO: 10 to 20 mg/kg/day in 2 to 3 divided doses.
May increase weekly to achieve optimal clinical response admin-
istered 3 or 4 times a day. Maximum daily dose: 35 mg/kg/day.
Trigeminal Neuralgia: PO: Initial dose 100 mg 2 times a day.
May increase by up to 200 mg/day using 100 mg increments
every 12 hours. Maximum daily dose: 1200 mg.
Bipolar Disorder, Mania: (Equetro only) PO: Initial dose:
200 mg 2 times a day. Dosage may be adjusted in 200 mg daily
increments to achieve optimal clinical response. Doses higher
than 1600 mg/day have not been studied.
Borderline Personality Disorder: PO: 400 mg/day in
2 divided doses. May increase dose in increments of 200 mg/day
depending on response, tolerability, and plasma concentrations.
Maximum dosage: 1600 mg/day.
Management of Alcohol Withdrawal: PO: Dosage on day
1: 600 to 1200 mg. Dosage is then tapered over 5 to 10 days
to 0 mg.
Restless Leg Syndrome: PO: 100 to 600 mg daily for up to
5 weeks.
Postherpetic Neuralgia: PO: 100 to 200 mg/day, slowly
increased to a maximum of 1200 mg/day.
CLONAZEPAM (Klonopin)
Seizures: Adults: PO: 0.5 mg 3 times a day; may increase by
0.5 to 1 mg every third day. Maximum daily dose 20 mg.
Children <10 years or 30 kg: PO: Initial daily dose 0.01 to
0.03 mg/kg/day (not to exceed 0.05 mg/kg/day) given in 2 to
3 divided doses; increase by no more than 0.25 to 0.5 mg every
third day until a daily maintenance dose of 0.1 to 0.2 mg/kg
has been reached, unless seizures are controlled or side effects
preclude further increase.
Panic Disorder: PO: Initial dose: 0.25 mg 2 times a day.
Increase after 3 days toward target dose of 1 mg/day. Some
2506_Ch27_447-471.indd 0454 10/1/10 9:39:42 AM

patients may require up to 4 mg/day, in which case the dose

may be increased in increments of 0.125 to 0.25 mg twice daily
every 3 days until symptoms are controlled.
Bipolar Disorder, Mania: PO: 1 to 6 mg/day.
Restless Leg Syndrome: PO: 0.5 to 2 mg/night.
Neuralgias: PO: 1.5 to 4 mg/day.
VALPROIC ACID (Depakene; Depakote)
Epilepsy: PO: Adults and children 10 years old: Initial dose:
5 to 15 mg/kg/day. Increase by 5 to 10 mg/kg/week until
therapeutic levels are reached. Maximum recommended
dosage: 60 mg/kg/day. When daily dosage exceeds 250 mg,
give in 2 divided doses.
Manic Episodes: PO (Stavzor only): Initial dose: 750 mg/day
in divided doses. Titrate rapidly to desired clinical effect
or trough plasma levels of 50 to 125 mcg/mL. Maximum
recommended dose: 60/mg/kg/day.
Migraine Prophylaxis: PO (Stavzor only): 250 mg twice daily.
Some patients may require up to 1000 mg/day. No evidence
that higher doses lead to greater efcacy.
Borderline Personality Disorder: PO: 750 mg/day in divided
doses. Titrate to maintain a therapeutic plasma level of 50 to
100 mcg/mL.
LAMOTRIGINE (Lamictal)
Epilepsy Adults and children >12 years: Adjunctive therapy
with carbamazepine, phenobarbital, phenytoin, or primidone:
PO: 50 mg as a single daily dose for 2 weeks, then 50 mg
twice daily for next 2 weeks; then increase by 100 mg/day
on a weekly basis to maintenance dose of 300 to 500 mg/day
in 2 doses. If valproic acid is also being taken, the initial dose
should be 25 mg every other day for 2 weeks, then 25 mg
once daily for next 2 weeks; then increase by 25 to 50 mg/day
every 1 to 2 weeks to maintenance dose of 50 to 200 mg twice
a day.
Children 2 to 12 years: Refer to manufacturers dosing recom-
mendations.
Bipolar Disorder: Escalation regimen: For patients not taking
carbamazepine, valproic acid, or other enzyme-inducing drugs:
PO: Weeks 1 and 2: 25 mg/day; weeks 3 and 4: 50 mg/day;
week 5: 100 mg/day; then 200 mg/day.
For patients taking valproic acid: PO: Weeks 1 and 2: 25 mg every
other day; weeks 3 and 4: 25 mg/day; week 5: 50 mg/day; then
100 mg/day.
For patients taking carbamazepine or other enzyme-inducing drugs,
but not valproic acid: PO: Weeks 1 and 2: 50 mg/day; weeks 3
2506_Ch27_447-471.indd 0455 10/1/10 9:39:43 AM

and 4: 100 mg/day in divided doses; week 5: 200 mg/day in

divided doses; week 6: 300 mg/day in divided doses; then up
to 400 mg/day in divided doses.
GABAPENTIN (Neurontin)
Epilepsy: Adults and children >12 years: PO: Initial dose: 300 mg
3 times a day. Titration may be continued until desired results
have been achieved (range is 900 to 1800 mg/day in 3 divided
doses). Doses should not be more than 12 hours apart. Doses
of 2400 to 3600 mg have been well tolerated.
Children 5 to 12 years: PO: Initial dose: 10 to 15 mg/kg/day in
3 divided doses. Titrate dosage over a period of 3 days to
25 to 35 mg/kg/day in 3 divided doses. Dosage interval should
not exceed 12 hours. Dosages up to 50 mg/kg/day have been
used.
Children 3 to 4 years: PO: Initial dose: 10 to 15 mg/kg/day in
3 divided doses. Titrate dosage over a period of 3 days to
40 mg/kg/day in 3 divided doses. Dosage interval should
not exceed 12 hours. Dosages up to 50 mg/kg/day have been
used.
Bipolar Disorder: PO: 900 to 2400 mg/day in 2 or 3 divided
doses.
Postherpetic Neuralgia: PO: Adults: 300 mg once daily on
rst day; 300 mg twice daily on second day; then 300 mg three
times a day on day 3. May then be titrated upward as needed
up to 600 mg three times a day.
Migraine Prophylaxis: PO: Adults: 1200 to 2400 mg/day.
Tremors in Multiple Sclerosis: PO: 1200 to 1800 mg/day.
TOPIRAMATE (Topamax)
Epilepsy: Adults and children 17 years (adjunctive therapy):
PO: Initial dose: 25 to 50 mg/day. Gradually increase by 25 to
50 mg weekly up to 200 to 400 mg/day in 2 divided doses
(200 to 400 mg/day in 2 divided doses for partial seizures and
400 mg/day in 2 divided doses for primary generalized tonic/
clonic seizures).
Children 2 to 17 years (adjunctive therapy): PO: 5 to 9 mg/kg/day
in 2 divided doses; initiate with 25 mg (or less, based on 1 to
3 mg/kg) nightly for 7 days, then increase at 1- to 2-week
intervals in increments of 1 to 3 mg/kg/day in 2 divided doses.
Titration should be based on clinical outcome.
Adults and children 10 years (monotherapy): PO: 50 mg/day ini-
tially in 2 divided doses. Gradually increase over 6 weeks to
400 mg/day in 2 divided doses.
Migraine Prophylaxis: PO: Target dose of 100 mg/day in
2 divided doses, titrated weekly according to the following
2506_Ch27_447-471.indd 0456 10/1/10 9:39:43 AM

schedule: Week 1: 25 mg in the evening; Week 2: 25 mg in

the morning and 25 mg in the evening; Week 3: 25 mg in
the morning and 50 mg in the evening; Week 4: 50 mg in the
morning and 50 mg in the evening.
Bipolar Disorder: PO: Initial dose: 25 to 50 mg/day. Increase to
target range of 100 to 200 mg/day in divided doses. Maximum
dosage: 400 mg/day.
OXCARBAZEPINE (Trileptal)
Epilepsy: PO: Adults: (adjunctive therapy): 300 mg twice daily,
may be increased by up to 600 mg/day at weekly intervals
up to 1200 mg/day (up to 2400 mg/day may be needed).
Conversion to monotherapy: 300 mg twice daily; may be
increased by 600 mg/day at weekly intervals, whereas other
antiepileptic drugs are tapered over 3 to 6 weeks; dose of
oxcarbazepine should be increased up to 2400 mg/day over
a period of 2 to 4 weeks. Initiation of monotherapy: 300 mg
twice daily, increase by 300 mg/day every third day, up
to 1200 mg/day. Maximum maintenance dose should be
achieved over 2 to 4 weeks.
Children 2 to 16 years: (adjunctive therapy): 4 to 5 mg/kg twice
daily (up to 600 mg/day), increased over 2 weeks to achieve
900 mg/day in patients 20 to 29 kg, 1200 mg/day in patients
29.1 to 39 kg, and 1800 mg/day in patients >39 kg (range
6 to 51 mg/kg/day). In patients <20 kg, initial dose of 16 to
20 mg/kg/day may be used, not to exceed 60 mg/kg/day.
Conversion to monotherapy: 8 to 10 mg/kg/day given twice
daily; may be increased by 10 mg/kg/day at weekly inter-
vals, whereas other antiepileptic drugs are tapered over
3 to 6 weeks; dose of oxcarbazepine should be increased up
to 600 to 900 mg/day in patient 20 kg, 900 to 1200 mg/
day in patients 25 to 30 kg, 900 to 1500 mg/day in patients
35 to 40 kg, 1200 to 1500 mg/day in patients 45 kg, 1200 to
1800 mg/day in patients 50 to 55 kg, 1200 to 2100 mg/day
in patients 60 to 65 kg, and 1500 to 2100 mg/day in patients
70 kg. Maximum maintenance dose should be achieved over
2 to 4 weeks.
Alcohol Withdrawal: PO: 600 to 1800 mg in divided doses
for 6 weeks to 6 months.
Bipolar Disorder: PO: Adults: Initial dose: 300 mg/day. Titrate
to a maximum dose of 900 to 2400 mg/day.
Diabetic Neuropathy: PO: Initial dose: 150 to 300 mg/
day. Titrate to recommended dose of 900 to 1200 mg/day.
Maximum dose: 1800 mg/day.
2506_Ch27_447-471.indd 0457 10/1/10 9:39:44 AM

CHEMICAL CLASS: CALCIUM CHANNEL

BLOCKERS
Examples
Verapamil C/37 (initially)

Angina 80300 ng/ml Tabs: 40, 80, 120
(Calan; 4.512
Arrhythmias Tabs (XR; SR):
Isoptin) (repeated
Hypertension 120, 180, 240
dosing) Unlabeled uses: Caps XR: 100,
~12 (SR) 120, 180, 200,

Bipolar mania
25 (IV) 240, 300, 360

Migraine headache Injection: 2.5/mL
prophylaxis
Action
Action in the treatment of bipolar disorder is unclear.
Contraindicated in: Hypersensitivity Severe left ventric-
ular dysfunction Heart block Hypotension Cardiogenic
shock Congestive heart failure Patients with atrial utter or
atrial brillation and an accessory bypass tract
Use Cautiously in: Liver or renal disease Cardiomyopa-
thy Intracranial pressure Elderly patients Pregnancy and
lactation (safety not established)
Drowsiness
Dizziness
Headache
Hypotension
Bradycardia
Nausea
Constipation
Interactions
Effects of verapamil are increased with concomitant use of
amiodarone, beta-blockers, cimetidine, ranitidine, and
grapefruit juice.
Effects of verapamil are decreased with concomitant use of
barbiturates, calcium salts, hydantoins, rifampin, and
antineoplastics.
Effects of the following drugs are increased with concomi-
tant use of verapamil: beta-blockers, disopyramide, fle-
cainide, doxorubicin, benzodiazepines, buspirone, car-
bamazepine, digoxin, dofetilide, ethanol, imipramine,
2506_Ch27_447-471.indd 0458 10/1/10 9:39:44 AM

nondepolarizing muscle relaxants, prazosin, quinidine, siro-

limus, tacrolimus, theophylline, and HMG-CoA reductase
inhibitors.
Serum lithium levels may be altered when administered
concurrently with verapamil.
Route and Dosage
Angina: PO: 80 to 120 mg 3 times a day.
Arrhythmias: PO: 240 to 320 mg/day in 3 or 4 divided doses
Hypertension: PO: 40 to 80 mg 3 times a day. Maximum
recommended daily dose: 360 mg.
Bipolar Mania: PO: 80 to 320 mg/day in divided doses.
Migraine Prophylaxis: PO: 160 to 320 mg/day in 3 to
4 divided doses.
CHEMICAL CLASS: ANTIPSYCHOTICS
Examples
Generic Pregnancy
(Trade) Categories/ Available
Name Half-life (hr) Indications Forms (mg)
Olanzapine C/2154
Schizophrenia Tabs: 2.5, 5, 7.5, 10, 15, 20
(Zyprexa)
Bipolar disorder Tabs (Orally disintegrating):

Agitation associated 5, 10, 15, 20
with schizophrenia Powder for injection:
and mania (IM) 10 mg/vial
Olanzapine and
For the treatment of Caps: 3 olanzapine/25 fluoxetine;
fluoxetine depressive episodes 6 olanzapine/25 fluoxetine;
(Symbyax)1 associated with 6 olanzapine/50 fluoxetine;
bipolar disorder 12 olanzapine/25 fluoxetine;

Treatment- 12 olanzapine/50 fluoxetine
resistant depression
Aripiprazole C/7594
Bipolar mania Tabs: 2, 5, 10, 15, 20, 30
(Abilify) (including
Schizophrenia Tabs (orally disintegrating):
metabolite)
Major depressive 10, 15
disorder (adjunctive Oral solution: 1/mL
treatment) Injection: 7.5/mL
Chlorpromazine C/24
Bipolar mania Tabs: 10, 25, 50, 100, 200

Schizophrenia Injection: 25/mL

Emesis/hiccoughs

Acute intermittent
porphyria

Hyperexcitable,
combative behavior in
children

Preoperative
apprehension
Unlabeled uses:

Migraine headaches
Continued
2506_Ch27_447-471.indd 0459 10/1/10 9:39:45 AM

Generic Pregnancy
Quetiapine C/6
Schizophrenia Tabs: 25, 50, 100, 200, 300, 400
(Seroquel
Acute manic Tabs (XR): 200, 300, 400
episodes
Risperidone C/321
Bipolar mania Tabs: 0.25, 0.5, 1, 2, 3, 4
(Risperdal) (including
Schizophrenia Tabs (orally disintegrating):
metabolite)
Behavioral problems 0.5, 1, 2, 3, 4
associated with Oral solution: 1/mL
autism Powder for injection:
Unlabeled uses: 12.5/vial, 25/vial, 37.5/vial,
50/vial

Severe behavioral
problems in children

Obsessive-compulsive
disorder
Ziprasidone C/7 (oral);
Bipolar mania Caps: 20, 40, 60, 80
(Geodon) 25 (IM)
Schizophrenia Powder for injection: 20/vial

Acute agitation in
schizophrenia (IM)
Asenapine C/24
Schizophrenia Tabs (Sublingual): 5, 10
(Saphris)
Bipolar disorder
1
For information related to action, contraindications/precautions, adverse reac-
tions and side effects, and interactions, refer to the monographs for olanzapine
(see Chapters 27 and 28) and uoxetine (see Chapter 26).
Action
Efcacy in schizophrenia is achieved through a combination
of dopamine and serotonin type 2 (5-HT2) antagonism.
Mechanism of action in the treatment of acute manic episodes
is unknown.

Olanzapine
Contraindicated in hypersensitivity; lactation. Orally disin-
tegrating tablets only: Phenylketonuria (orally disintegrating

tablets contain aspartame).
Use cautiously in hepatic insufciency, elderly clients (reduce
dosage), pregnancy and children (safety not established), car-

diovascular or cerebrovascular disease, history of glaucoma,
history of seizures, history of attempted suicide, prostatic hy-
pertrophy, diabetes or risk factors for diabetes, narrow-angle
glaucoma, history of paralytic ileus; patients with preexisting
low white blood cell count and/or history of drug-induced leu-
kopenia/neutropenia; elderly patients with dementia-related
psychosis (black box warning).
2506_Ch27_447-471.indd 0460 10/1/10 9:39:45 AM

Aripiprazole
Contraindicated in hypersensitivity; lactation.
Use cautiously in cardiovascular or cerebrovascular dis-
ease; conditions that cause hypotension (dehydration, treat-

ment with antihypertensives or diuretics); elderly patients;
pregnancy, children, and adolescents (safety not established);
elderly patients with dementia-related psychosis (black box
warning).
Chlorpromazine
Contraindicated in hypersensitivity (cross-sensitivity with
other phenothiazines may occur); narrow-angle glaucoma;

bone marrow depression; severe liver or cardiovascular dis-
ease; concurrent pimozide use.
Use cautiously in elderly and debilitated patients; children
with acute illnesses, infections, gastroenteritis, or dehydration

(increased risk of extrapyramidal reactions); diabetes; respi-
ratory disease; prostatic hypertrophy; central nervous system
(CNS) tumors; epilepsy; intestinal obstruction; pregnancy or
lactation (safety not established); elderly patients with dementia-
related psychosis (black box warning).
Quetiapine
Use cautiously in cardiovascular or cerebrovascular disease;
dehydration or hypovolemia (increased risk of hypotension);

elderly patients; hepatic impairment; hypothyroidism; his-
tory of suicide attempt; pregnancy or children (safety not estab-
lished); elderly patients with dementia-related psychosis (black
box warning).
Risperidone
Use cautiously in elderly or debilitated patients; renal or
hepatic impairment; cardiovascular disease; history of sei-

zures; history of suicide attempt or drug abuse; diabetes or
risk factors for diabetes; pregnancy or children (safety not
established); elderly patients with dementia-related psychosis
(black box warning).
Ziprasidone
Contraindicated in hypersensitivity; history of QT prolon-
gation, arrhythmias, recent myocardial infarction (MI), or

uncompensated heart failure; concurrent use of other drugs
known to prolong QT interval; hypokalemia or hypomagne-
semia; lactation.
Use cautiously in concurrent diuretic therapy or diarrhea
(may increase the risk of hypotension, hypokalemia, or hypo-

magnesemia); hepatic impairment; cardiovascular or cerebro-
vascular disease; hypotension, concurrent antihypertensive
2506_Ch27_447-471.indd 0461 10/1/10 9:39:46 AM

therapy, dehydration, or hypovolemia (may increase risk of

orthostatic hypotension); elderly patients; patients at risk for
aspiration pneumonia; history of suicide attempt; pregnancy
and children (safety not established); patients with preexisting
low white blood cell count and/or history of drug-induced
leukopenia/neutropenia; elderly patients with dementia-
related psychosis (black box warning).
Asenapine
Contraindicated in hypersensitivity; lactation; history of QT
prolongation or arrhythmias; concurrent use of other drugs

known to prolong QT interval.
Use cautiously in patients with hepatic, renal, or cardio-
vascular insufciency; diabetes or risk factors for diabetes;

patients with preexisting low white blood cell count and/or
history of drug-induced leukopenia/neutropenia; history of
seizures; history of suicide attempt; patients at risk for aspi-
ration pneumonia; elderly patients; pregnancy and children
(safety not established); elderly patients with dementia-related

Olanzapine
Drowsiness, dizziness, weakness
Dry mouth, constipation, increased appetite
Nausea
Weight gain or loss
Orthostatic hypotension, tachycardia
Restlessness
Rhinitis
Tremor
Headache
Aripiprazole
Drowsiness, lightheadedness
Headache
Insomnia, restlessness
Constipation
Nausea
Weight gain
Chlorpromazine
Sedation
Blurred vision
Hypotension
Constipation
Dry mouth
Photosensitivity
Extrapyramidal symptoms
2506_Ch27_447-471.indd 0462 10/1/10 9:39:46 AM

Weight gain
Urinary retention
Quetiapine
Hypotension, tachycardia
Headache
Constipation
Dry mouth
Nausea
Weight gain
Risperidone
Agitation, anxiety
Headache
Insomnia
Constipation
Nausea/vomiting
Weight gain
Rhinitis
Sexual dysfunction
Diarrhea
Dry mouth
Ziprasidone
Restlessness
Headache
Constipation
Diarrhea
Dry mouth
Nausea
Weight gain
Prolonged QT interval
Asenapine
Constipation
Dry mouth
Nausea and vomiting
Weight gain
Restlessness
Insomnia
Headache
2506_Ch27_447-471.indd 0463 10/1/10 9:39:46 AM

Interactions
Concurrent use may
The effects of: Are increased by: Are decreased by: result in:
Olanzapine Fluvoxamine and other Carbamazepine and Decreased effects of
CYP-1A2 inhibitors, other CYP-1A2 levodopa and dopamine
fluoxetine inducers, agonists. Increased
omeprazole, hypotension with
rifampin antihypertensives.
Increased CNS depression
with alcohol or other CNS
depressants.
Aripiprazole Ketoconazole and Carbamazepine, Increased CNS depression
other CYP-3A4 famotidine, with alcohol or other CNS
inhibitors; quinidine, valproate depressants. Increased
fluoxetine, par- hypotension with
oxetine, or other antihypertensives.
potential CYP-2D6
inhibitors
Chlorproma- Beta-blockers, Centrally acting Increased effects of
zine paroxetine anticholinergics beta-blockers; excessive
sedation and hypoten-
sion with meperidine;
decreased hypotensive
effect of guanethidine;
decreased effect of
oral anticoagulants;
decreased or increased
phenytoin levels;
increased orthostatic
hypotension with thiazide
diuretics; Increased CNS
depression with alcohol
or other CNS depressants.
Increased hypotension
with antihypertensives.
Increased anticholinergic
effects with anticholiner-
gic agents.
Quetiapine Cimetidine; keto- Phenytoin, Decreased effects of
conazole, itracon- thioridazine levodopa and dopamine
azole, fluconazole, agonists. Increased
erythromycin, or CNS depression with
other CYP-3A4 alcohol or other CNS
inhibitors depressants. Increased
hypotension with
antihypertensives.
Risperidone Clozapine, fluoxetine, Carbamazepine Decreased effects of

paroxetine, or levodopa and dopamine
ritonavir agonists. Increased
effects of clozapine and
valproate. Increased CNS
depression with alcohol
Increased hypotension
with antihypertensives.
2506_Ch27_447-471.indd 0464 10/1/10 9:39:47 AM

Concurrent use may

Ziprasidone Ketoconazole and Carbamazepine Life-threatening prolonga-
other CYP-3A4 tion of QT interval with
inhibitors quinidine, dofetilide,
other class Ia and III
antiarrhythmics, pimozide,
sotalol, thioridazine,
chlorpromazine, floquine,
pentamidine, arsenic
trioxide, mefloquine,
dolasetron, tacrolimus,
droperidol, gatifloxacin,
or moxifloxacin. De-
creased effects of
levodopa and dopamine
agonists. Increased
CNS depression with
alcohol or other CNS
depressants. Increased
hypotension with
antihypertensives.
Asenapine Fluvoxamine, imipra- Carbamazepine, Increased effects of

mine, valproate cimetidine, paroxetine and dextro-
paroxetine methorphan; Increased
CNS depression with
alcohol or other CNS
depressants. Increased
hypotension with antihy-
pertensives; Additive
effects on QT interval
prolongation with
quinidine, dofetilide,
other Class Ia and III
antiarrhythmics, pimo-
zide, sotalol, thioridazine,
chlorpromazine, floquine,
pentamadine, arsenic
trioxide, mefloquine,
dolasetron, tacrolimus,
droperidol, gatifloxacin,
or moxifloxacin.
Route and Dosage

OLANZAPINE (Zyprexa)
Bipolar Disorder: Adults: PO: 10 to 15 mg/day initially;
may increase every 24 hours by 5 mg/day (not to exceed
20 mg/day).
Schizophrenia: Adults: PO: 5 to 10 mg/day initially; may increase
at weekly intervals by 5 mg/day (not to exceed 20 mg/day).
Agitation Associated with Schizophrenia or Mania: Adults:
IM: 2.5 to 10 mg, administered slowly, deep into muscle mass.
May repeat in 2 hours and again 4 hours later, if needed.
2506_Ch27_447-471.indd 0465 10/1/10 9:39:47 AM

OLANZAPINE AND FLUOXETINE (Symbyax)

Depressive Episodes Associated with Bipolar Disorder:
Adults: PO: Initial dosage: 6/25 given once daily in the
evening. Adjust dosage according to efcacy and tolerability
to within a range of 6 to 12 olanzapine/25 to 50 uoxetine.
ARIPIPRAZOLE (Abilify)
Bipolar Mania: Adults: PO: Usual starting dose: 15 mg/day.
Dosage may be increased to 30 mg/day based on clinical
response. The safety of dosages higher than 30 mg have not
been evaluated.
Major Depressive Disorder (adjunctive treatment): Adults:
PO: Initial dosage: 2 to 5 mg/day for patients already taking
another antidepressant. May increase dosage by up to 5 mg/
day at intervals of at least a week. Maintenance dosage range:
2 to 15 mg/day.
Schizophrenia: Adults: PO: Initial dosage: 10 or 15 mg/day
as a single dose. Doses up to 30 mg have been used. Dosage
increases should not be made before 2 weeks, the time required
to achieve steady state.
CHLORPROMAZINE (Thorazine)
Psychotic Disorders: Adults: PO: 10 mg 3 or 4 times a day or
25 mg 2 or 3 times a day. Increase by 20 to 50 mg every 3 to
4 days until effective dose is reached, usually 200 to 400 mg/
day. IM: Initial dose: 25 mg. May give additional 25 to 50 mg
in 1 hour. Increase gradually over several days (up to 400 mg
every 4 to 6 hours in severe cases).
Pediatric Behavioral Disorders: Children >6 months:
PO: 0.5 mg/kg every 4 to 6 hours as needed. IM: 0.5 mg/
kg every 6 to 8 hours (not to exceed 40 mg/day in children
6 months to 5 years or 75 mg/day in children 6 to 12 years).
Nausea and Vomiting: Adults: PO: 10 to 25 mg every 4 to
6 hours. IM: 25 mg initially, may repeat 25-50 mg every 3 to
4 hours.
Children >6 months: PO: 0.55 mg/kg every 4 to 6 hours.
IM: 0.55 mg/kg every 6 to 8 hours (not to exceed 40 mg/day in
children up to 5 years or 75 mg/day in children 5 to 12 years).
Intractable Hiccoughs: Adults: PO: 25 to 50 mg 3 or 4 times
daily. If symptoms persist for 2 or 3 days, give 25 to 50 mg IM.
Preoperative Sedation: Adults: PO: 25 to 50 mg 2 or 3 hours
before surgery, or IM: 12.5 to 25 mg 1 to 2 hours before
surgery.
Children: PO: 0.5 mg/kg 2 or 3 hours before surgery, or IM:
0.5 mg/kg 1 to 2 hours before surgery.
2506_Ch27_447-471.indd 0466 10/1/10 9:39:47 AM

Acute Intermittent Porphyria: Adults: PO: 25 to 50 mg 3 or

4 times a day, or IM: 25 mg 3 or 4 times a day until patient
can take PO.
QUETIAPINE (Seroquel)
Schizophrenia: Adults: PO: 25 mg twice daily initially,
increased by 25 to 50 mg 2 or 3 times daily over 3 days, up to
300 to 400 mg/day in 2 or 3 divided doses by the fourth day
(not to exceed 800 mg/day).
Bipolar Mania: Adults: PO: 100 mg/day in 2 divided doses
on day 1; increase dose by 100 mg/day up to 400 mg/day
by day 4 given in twice daily divided doses. May increase in
200 mg/day increments up to 800 mg/day by day 6 if
required.
RISPERIDONE (Risperdal)
Bipolar mania: Adults: PO: 2 or 3 mg/day as a single daily
dose; dose may be increased at 24-hour intervals by 1 mg
(range 1 to 6 mg/day).
Schizophrenia: Adults: PO: Initial dosage: 2 mg/day
administered as a single dose or in two divided doses. May
increase dose at 24-hour intervals in increments of 1 to 2 mg/day
to a recommended dose of 4 to 8 mg/day.
IM: Adults: 25 mg every 2 weeks; some patients may require
larger dose of 37.5 or 50 mg every 2 weeks.
Adolescents (13 to 17 years): PO: 0.5 mg once daily, increased by
0.5 to 1.0 mg no more frequently than every 24 hours to 3 mg
daily. May administer half the daily dose twice daily if drowsi-
ness persists.
Behavioral Problems Associated with Autistic Disorder:
Children and adolescents 5 to 16 years weighing <20 kg:
PO: 0.25 mg/day initially. After at least 4 days of therapy,
may increase to 0.5 mg/day. Dose increases in increments of
0.25 mg/day may be considered at 2-week or longer intervals.
May be given as a single dose or in divided doses.
Children and adolescents 5 to 16 years weighing >20 kg: PO: 0.5 mg/
day initially. After at least 4 days of therapy, may increase to
1.0 mg/day. Dose increases in increments of 0.5 mg/day may
be considered at 2-week or longer intervals. May be given as a
single dose or in divided doses.
ZIPRASIDONE (Geodon)
Bipolar Mania: Adults: PO: 40 mg twice daily with food.
Increase dose to 60 or 80 mg twice/day on the second day of
treatment. Adjust dose on the basis of toleration and efcacy
within the range of 40 to 80 mg twice/day.
2506_Ch27_447-471.indd 0467 10/1/10 9:39:48 AM

Schizophrenia: Adults: PO: Initial dose: 20 mg twice daily

with food. Dose increments may be made at 2-day intervals
up to 80 mg twice daily.
Acute Agitation in Schizophrenia: Adults: IM: 10 to 20 mg
as needed up to 40 mg/day. May be given as 10 mg every
2 hours or 20 mg every 4 hours. Maximum dosage: 40 mg/day.
ASENAPINE (Saphris)
Schizophrenia: Adults: PO: Usual starting and target dose:
5 mg twice daily. The safety of doses above 10 mg twice daily
has not been evaluated in clinical trials.
Bipolar Disorder: Adults: PO: Recommended initial dose:
10 mg twice daily. The dose can be decreased to 5 mg twice
daily if there are adverse effects. The safety of doses above
10 mg twice daily has not been evaluated in clinical trials.

TO ALL MOOD-STABILIZING DRUGS
1. Risk for injury related to manic hyperactivity.
2. Risk for self-directed or other-directed violence related to
unresolved anger turned inward on the self or outward on the
environment.
3. Risk for injury related to lithium toxicity.
4. Risk for injury related to adverse effects of mood-stabilizing
drugs.
5. Risk for activity intolerance related to side effects of
drowsiness and dizziness.
NURSING IMPLICATIONS FOR

MOOD-STABILIZING DRUGS
side effects from mood-stabilizing drugs. Nursing implications
are designated by an asterisk (*).
1. May occur with lithium:
a. Drowsiness, dizziness, headache
* Ensure that client does not participate in activities that
require alertness, or operate dangerous machinery.
b. Dry mouth; thirst
* Provide sugarless candy, ice, frequent sips of water.
Ensure that strict oral hygiene is maintained.
c. GI upset; nausea/vomiting
* Administer medications with meals to minimize GI
upset.
d. Fine hand tremors
* Report to physician, who may decrease dosage. Some
physicians prescribe a small dose of beta-blocker pro-
pranolol to counteract this effect.
2506_Ch27_447-471.indd 0468 10/1/10 9:39:48 AM

e. Hypotension; arrhythmias; pulse irregularities

* Monitor vital signs two or three times a day. Physician
may decrease dose of medication.
f. Polyuria; dehydration
* May subside after initial week or two. Monitor daily
intake and output and weight. Monitor skin turgor
daily.
g. Weight gain
* Provide instructions for reduced calorie diet. Emphasize
importance of maintaining adequate intake of sodium.
2. May occur with anticonvulsants:
a. Nausea/vomiting
* May give with food or milk to minimize GI upset.
b. Drowsiness; dizziness
* Ensure that client does not operate dangerous machin-
ery or participate in activities that require alertness.
c. Blood dyscrasias
* Ensure that client understands the importance of
regular blood tests while receiving anticonvulsant
therapy.
d. Prolonged bleeding time (with valproic acid)
* Ensure that platelet counts and bleed time are deter-
mined before initiation of therapy with valproic acid.
Monitor for spontaneous bleeding or bruising.
e. Risk of severe rash (with lamotrigine)
* Ensure that client is informed that he or she must report
evidence of skin rash to physician immediately.
f. Decreased efficacy of oral contraceptives (with
topiramate)
* Ensure that client is aware of decreased efcacy of oral
contraceptives with concomitant use.
g. Risk of suicide with all antiepileptic drugs (warning by
FDA, December 2008)
* Monitor for worsening of depression, suicidal thoughts or
behavior, or any unusual changes in mood or behavior.
3. May occur with calcium channel blockers:
a. Drowsiness; dizziness
b. Hypotension; bradycardia
* Take vital signs just before initiation of therapy and
before daily administration of the medication. Physician
will provide acceptable parameters for administration.
Report marked changes immediately.
c. Nausea
* May give with food to minimize GI upset.
2506_Ch27_447-471.indd 0469 10/1/10 9:39:49 AM

d. Constipation
* Encourage increased uid (if not contraindicated) and
ber in the diet.
4. May occur with antipsychotics:
a. Drowsiness; dizziness
b. Dry mouth; constipation
* Provide sugarless candy or gum, ice, and frequent sips
of water. Provide foods high in ber; encourage physical
activity and uid if not contraindicated.
c. Increased appetite; weight gain
* Provide calorie-controlled diet. Provide opportunity for
physical exercise. Provide diet and exercise instruction.
d. ECG changes
* Monitor vital signs. Observe for symptoms of dizziness,
palpitations, syncope, or weakness.
e. Extrapyramidal symptoms
* Monitor for symptoms. Administer prn medication at
rst sign.
f. Hyperglycemia and diabetes
* Monitor blood glucose regularly. Observe for the appear-
ance of symptoms of polydipsia, polyuria, polyphagia,
and weakness at any time during therapy.

TO MOOD-STABILIZING DRUGS
Do not drive or operate dangerous machinery. Drowsiness or
dizziness can occur.
Do not stop taking the drug abruptly. Can produce serious
withdrawal symptoms. The physician will administer orders
for tapering the drug when therapy is to be discontinued.
Report the following symptoms to the physician immediately:
Client taking anticonvulsant: unusual bleeding, sponta-
neous bruising, sore throat, fever, malaise, skin rash, dark

urine, and yellow skin or eyes.
Client taking calcium channel blocker: irregular heart-
beat, shortness of breath, swelling of the hands and feet,

pronounced dizziness, chest pain, profound mood swings,
severe and persistent headache.
Client taking lithium: ataxia, blurred vision, severe diar-
rhea, persistent nausea and vomiting, tinnitus, excessive

urine output, increasing tremors, or mental confusion.
Client taking antipsychotic: sore throat, fever, malaise, un-
usual bleeding, easy bruising, persistent nausea and vomit-

ing, severe headache, rapid heart rate, difculty urinating,
2506_Ch27_447-471.indd 0470 10/1/10 9:39:49 AM

muscle twitching, tremors, dark urine, excessive urination,

excessive thirst, excessive hunger, weakness, pale stools,
yellow skin or eyes, muscular incoordination, or skin
rash.
For the client on lithium: ensure that the diet contains ad-
equate sodium. Drink 6 to 8 glasses of water each day. Avoid
drinks that contain caffeine (that have a diuretic effect). Have
serum lithium level checked every 1 to 2 months, or as advised
by physician.
For the client on asenapine: Place the tablet under the tongue
and allow to dissolve completely. Do not chew or swallow
tablet. Do not eat or drink for 10 minutes.
Avoid consuming alcoholic beverages and nonprescription
medications without approval from physician.
Carry card at all times identifying the name of medications
being taken.
INTERNET REFERENCES
a. http://www.rxlist.com
e. http://www.nlm.nih.gov/medlineplus/druginformation
.html
2506_Ch27_447-471.indd 0471 10/1/10 9:39:49 AM

C H A P T E R
28
Antipsychotic Agents
CHEMICAL CLASS: PHENOTHIAZINES
Examples
Generic Pregnancy
Name Half-life Indications Forms (mg)
Chlorpromazine C/24 hr
Bipolar mania Tabs: 10, 25, 50,

Schizophrenia 100, 200

Emesis/hiccoughs Injection: 25/mL

Acute intermittent
porphyria

Hyperexcitable, combat-
ive behavior in children

Preoperative
apprehension
Unlabeled uses:

Migraine headaches
Fluphenazine C/HCl: 18 hr
Psychotic Tabs: 1, 2.5, 5, 10
Decanoate: disorders Elixir: 2.5/5 mL
6.89.6 days Conc: 5/mL
Inj: 2.5/mL
Inj (Decanoate): 25/mL
Perphenazine C/912 hr
Psychotic disorders Tabs: 2, 4, 8, 16

Nausea and vomiting Conc: 16/5 mL
Prochlorperazine C/35 hr (oral)

Schizophrenia Tabs: 5, 10
6.9 hr (IV)
Nonpsychotic anxiety Supp: 25

Nausea and vomiting Inj: 5/mL
Unlabeled uses:

Migraine headache
Thioridazine C/24 hr
Management of schizo- Tabs: 10, 15, 25, 50,
phrenia in patients who 100, 150, 200
do not have an accept-
able response to other
antipsychotic therapy
Trifluoperazine C/18 hr
Schizophrenia Tabs: 1, 2, 5, 10

Nonpsychotic anxiety
472
2506_Ch28_472-501.indd 1472 10/1/10 9:40:03 AM

Action
These drugs are thought to work by blocking postsynaptic
dopamine receptors in the basal ganglia, hypothalamus,
limbic system, brainstem, and medulla.
They also demonstrate varying af nity for cholinergic,
alpha1-adrenergic, and histaminic receptors.
Antipsychotic effects may also be related to inhibition of
dopamine-mediated transmission of neural impulses at the
synapses.

Contraindicated in: Hypersensitivity (cross-sensitivity
may exist among phenothiazines) In comatose or severely cen-
tral nervous system (CNS)-depressed clients Poorly controlled
seizure disorders Clients with blood dyscrasias Narrow
angle glaucoma Clients with liver, renal, or cardiac insufciency
Bone marrow depression Concurrent pemozide use Co-
administration with other drugs that prolong QT interval, or in
patients with long-QT syndrome or history of cardiac arrhyth-
mias
Use Cautiously in: Elderly and debilitated patients Children
with acute illnesses, infections, gastroenteritis, or dehydration
(increased risk of extrapyramidal reactions) Diabetes Respira-
tory disease Prostatic hypertrophy CNS tumors Epilepsy
Intestinal obstruction Pregnancy or lactation (safety not estab-
lished) Elderly patients with dementia-related psychosis (black
box warning)

Dry mouth
Blurred vision
Constipation
Urinary retention
Nausea
Skin rash
Sedation
Photosensitivity
Decreased libido
Amenorrhea
Retrograde ejaculation
Gynecomastia
Weight gain
Reduction of seizure threshold
Agranulocytosis
2506_Ch28_472-501.indd 1473 10/1/10 9:40:04 AM

Tardive dyskinesia
Neuroleptic malignant syndrome
Prolongation of QT interval (thioridazine)
Interactions
Coadministration of phenothiazines and beta-blockers may
increase effects from either or both drugs.
Increased effects of phenothiazines with paroxetine
Concurrent administration with meperidine may produce
excessive sedation and hypotension.
Therapeutic effects of phenothiazines may be decreased by
centrally acting anticholinergics. Anticholinergic effects
are increased.
Concurrent use may result in decreased hypotensive effect of
guanethidine.
Phenothiazines may reduce effectiveness of oral anticoag-
ulants.
Concurrent use with phenothiazines may increase or decrease
phenytoin levels.
Increased orthostatic hypotension with thiazide diuretics
Increased CNS depression with alcohol or other CNS
depressants
Increased hypotension with antihypertensives
Concurrent use with epinephrine or dopamine may result in
severe hypotension.
Route and Dosage
CHLORPROMAZINE
Psychotic Disorders: Adults: PO: 10 mg 3 or 4 times a day or
25 mg 2 or 3 times a day. Increase by 20 to 50 mg every 3 to
4 days until effective dose is reached, usually 200 to 400 mg/
day. IM: Initial dose: 25 mg. May give additional 25 to 50 mg
in 1 hour. Increase gradually over several days (up to 400 mg
every 4 to 6 hours in severe cases).
Pediatric Behavioral Disorders: Children >6 months:
PO: 0.5 mg/kg every 4 to 6 hours as needed.
IM: 0.5 mg/kg every 6 to 8 hours (not to exceed 40 mg/day
in children 6 months to 5 years or 75 mg/day in children 6 to
12 years).
Nausea and Vomiting: Adults: PO: 10 to 25 mg every 4 to
6 hours. IM: 25 mg initially, may repeat 25 to 50 mg every
3 to 4 hours.
Children >6 months: PO: 0.55 mg/kg every 4 to 6 hours.
IM: 0.55 mg/kg every 6 to 8 hours (not to exceed 40 mg/day in
children up to 5 years or 75 mg/day in children 5 to 12 years).
Intractable Hiccoughs: Adults: PO: 25 to 50 mg 3 or 4 times
daily. If symptoms persist for 2 to 3 days, give 25 to 50 mg IM.
2506_Ch28_472-501.indd 1474 10/1/10 9:40:04 AM

Preoperative Sedation: Adults: PO: 25 to 50 mg 2 to 3 hours

before surgery, or IM: 12.5 to 25 mg 1 to 2 hours before
surgery.
Children: PO: 0.5 mg/kg 2 to 3 hours before surgery or
IM: 0.5 mg/kg 1 to 2 hours before surgery.
Acute Intermittent Porphyria: Adults: PO: 25 to 50 mg 3 or
4 times a day or IM: 25 mg 3 or 4 times a day until patient
can take PO.
FLUPHENAZINE
Psychotic Disorders: Adults: PO: Initial dose: 2.5 to 10 mg/day
in divided doses every 6 to 8 hours. Maintenance dose: 1 to
5 mg/day. IM: 1.25 to 2.5 mg every 6 to 8 hours.
Elderly or debilitated patients: PO: 1 to 2.5 mg/day initially. Adjust
dosage according to response.
Decanoate Formulation: Adults: IM, SC: Initial dose: 12.5
to 25 mg. May be repeated every 3 to 4 weeks. Dosage may
be slowly increased in 12.5 mg increments as needed (not to
exceed 100 mg/dose).
PERPHENAZINE
Psychotic Disorders: Adults: PO: Outpatients: 4 to 8 mg
3 times a day initially. Reduce as soon as possible to minimum
effective dose.
Hospitalized patients with schizophrenia: 8 to 16 mg 2 to 4 times a
day, not to exceed 64 mg/day.
Nausea and Vomiting: Adults: PO: 8 to 16 mg daily in divided
doses, up to 24 mg, if necessary.
PROCHLORPERAZINE
Schizophrenia: Adults (mild conditions): PO: 5 to 10 mg 3 or
4 times a day. (Moderate conditions): 10 mg 3 or 4 times a day.
Gradually increase dosage by small increments over 2 or
3 days to 50 to 75 mg/day. (Severe conditions): 100 to 150 mg/
day. IM: 10 to 20 mg every 2 to 4 hours for up to 4 doses, then
10 to 20 mg every 4 to 6 hours, if needed. When control is
achieved, switch to oral dosage.
Children 12 years: PO: 5 to 10 mg 3 to 4 times a day.
Children 2 to 12 years: PO: 2.5 mg 2 to 3 times a day.
Nonpsychotic Anxiety: Adults: PO: 5 mg 3 to 4 times a day,
not to exceed 20 mg/day or longer than 12 weeks.
Nausea and Vomiting: Adults: PO: 5 to 10 mg 3 or 4 times a
day. SR caps: 15 mg once daily or 10 mg 2 times a day. Rectal:
25 mg 2 times a day. IM: 5 to 10 mg. May repeat every 3 or
4 hours, not to exceed 40 mg/day.
Children 20 to 29 lb: PO/Rectal: 2.5 mg 1 or 2 times a day, not
to exceed 7.5 mg/day.
2506_Ch28_472-501.indd 1475 10/1/10 9:40:04 AM

Children 30 to 39 lb: PO/Rectal: 2.5 mg 2 or 3 times a day, not

to exceed 10 mg/day.
Children 40 to 85 lb: PO/Rectal: 2.5 mg 3 times a day or 5 mg
2 times a day, not to exceed 15 mg/day.
Children >20 lb or 2 years of age: IM: 0.132 mg/kg. Usually only
1 dose is required.
THIORIDAZINE
Schizophrenia (Intractable to Other Antipsychotics):
Adults: PO: Initial dose: 50 to 100 mg 3 times a day. May
increase gradually to maximum dosage of 800 mg/day. Once
effective response has been achieved, may reduce gradually
to determine the minimum maintenance dose. Usual daily
dosage range: 200 to 800 mg, divided into 2 to 4 doses.
Children: PO: Initial dose: 0.5 mg/kg/day given in divided doses.
Increase gradually until therapeutic effect has been achieved
or maximum dose of 3 mg/kg/day has been reached.
TRIFLUOPERAZINE
Schizophrenia: Adults: PO: 2 to 5 mg 2 times a day. Usual
optimum dosage range: 15 to 20 mg/day, although a few may
require 40 mg/day or more.
Children 6 to 12 years: PO: Initial dose: 1 mg once or 2 times a day.
May increase dose gradually to a maximum of 15 mg/day.
Nonpsychotic Anxiety: Adults: PO: 1 or 2 mg 2 times a day.
Do not administer more than 6 mg/day or for longer than
12 weeks.
CHEMICAL CLASS: THIOXANTHENES

Examples
Pregnancy
Generic (Trade) Categories/ Available
Thiothixene C/34
Schizophrenia Caps: 1, 2, 5, 10, 20
(Navane)
Action
Blocks postsynaptic dopamine receptors in the basal ganglia,
hypothalamus, limbic system, brainstem, and medulla
Demonstrates varying afnity for cholinergic, alpha1-adrenergic,
and histaminic receptors

Contraindicated in: Hypersensitivity Comatose or
severely CNS-depressed patients Bone marrow depression or
2506_Ch28_472-501.indd 1476 10/1/10 9:40:05 AM

blood dyscrasias Parkinsons disease Severe hypotension or

hypertension Circulatory collapse Children <12 years old
Pregnancy and lactation (safety not established)
Use Cautiously in: Patients with history of seizures

Respiratory, renal, hepatic, thyroid, or cardiovascular dis-
orders Elderly or debilitated patients Patients exposed to
extreme environmental heat Patients taking atropine or
atropine-like drugs Elderly patients with dementia-related
psychosis (black box warning)

Refer to this section under Phenothiazines.
Interactions
Additive CNS depression with alcohol and other CNS
depressants
Additive anticholinergic effects with other drugs that have
anticholinergic properties
Possible additive hypotension with antihypertensive agents
severe hypotension.
Route and Dosage

Schizophrenia: Adults and children 12 years: PO: (Mild
conditions): Initial dosage: 2 mg three times a day. May increase
to 15 mg/day. (Severe conditions): Initial dosage: 5 mg 2 times a
day. Optimal dose is 20 to 30 mg/day. If needed, may increase
gradually, not to exceed 60 mg/day.
CHEMICAL CLASS:
PHENYLBUTYLPIPERADINES
Examples
Generic Pregnancy
(Trade) Categories/
Name Half-life Indications Available Forms (mg)
Haloperidol C/~18 hr (oral); ~3 wk
Psychotic disorders Tabs: 0.5, 1, 2, 5, 10, 20
(Haldol) (IM decanoate)
Tourettes disorder Conc: 2/mL

Pediatric behavior Inj (lactate): 5/mL
problems and Inj (decanoate): 50/mL;
hyperactivity 100/mL
Unlabeled uses:

Intractable
hiccoughs

Nausea and
vomiting
Continued
2506_Ch28_472-501.indd 1477 10/1/10 9:40:05 AM

Generic Pregnancy
(Trade) Categories/
Name Half-life Indications Available Forms (mg)
Pimozide C/~55 hr
Tourettes disorder Tabs: 1, 2
(Orap) Unlabeled uses:

Schizophrenia
Action
Blocks postsynaptic dopamine receptors in the hypothalamus,
limbic system, and reticular formation
Demonstrates varying afnity for cholinergic, alpha1-adrenergic,
and histaminic receptors

Contraindicated in: Hypersensitivity to the drug
Coadministration with other drugs that prolong the QT inter-
val Coadministration with drugs that inhibit CYP3A enzymes
(pimozide) Treatment of tics other than those associated with
Tourettes disorder (pimozide) Coadministration with other
drugs that may cause tics (e.g., pemoline, methylphenidate,
amphetamines) until it has been determined whether the tics
are caused by the medications or Tourettes disorder (pimozide)
Parkinson disease (haloperidol) In comatose or severely
CNS-depressed clients Clients with blood dyscrasias or bone
marrow depression Narrow-angle glaucoma Clients with
liver, renal, or cardiac insufciency Pregnancy and lactation
(safety not established)
Use Cautiously in: Elderly and debilitated clients Diabetic
clients Depressed clients Clients with history of seizures
Clients with respiratory insufciency Prostatic hypertrophy
Children Elderly patients with dementia-related psychosis
(black box warning)
Dry mouth
Blurred vision
Constipation
Urinary retention
Nausea
Skin rash
Sedation
Photosensitivity
Decreased libido
Amenorrhea
Retrograde ejaculation
2506_Ch28_472-501.indd 1478 10/1/10 9:40:06 AM

Gynecomastia
Weight gain
Reduction of seizure threshold
Agranulocytosis
Tardive dyskinesia
Prolongation of QT interval
Interactions
Decreased serum concentrations of haloperidol, worsening
schizophrenic symptoms, and tardive dyskinesia with con-
comitant use of anticholinergic agents
Increased plasma concentrations when administered with
drugs that inhibit CYP3A enzymes (azole antifungal agents;
macrolide antibiotics) and CYP1A2 enzymes (fluoxetine;
fluvoxamine)
Decreased therapeutic effects of haloperidol with carbam-
azepine; increased effects of carbamazepine
Additive hypotension with antihypertensives
Additive CNS depression with alcohol or other CNS
depressants
Coadministration of haloperidol and lithium may result in
alterations in consciousness, encephalopathy, extrapyramidal
effects, fever, leukocytosis, and increased serum enzymes.
Decreased therapeutic effects of haloperidol with rifamycins
severe hypotension.
Additive effects with other drugs that prolong QT interval
(e.g., phenothiazines, tricyclic antidepressants, antiar-
rhythmic agents)
Route and Dosage

HALOPERIDOL (Haldol)
Psychotic Disorders: Adults: PO: (Moderate symptoms or
geriatric or debilitated patients): 0.5 to 2 mg 2 or 3 times a day.
(Severe symptoms or chronic or resistant patients): 3 to 5 mg
2 or 3 times a day. Some patients may require dosages up to
100 mg/day.
Children (3 to 12 years; weight range 15 to 40 kg): Initial dose:
0.5 mg/day (25 to 50 mcg/kg/day). May increase in 0.5 mg incre-
ments at 5- to 7-day intervals up to 0.15 mg/kg/day or until ther-
apeutic effect is obtained. Administer in 2 or 3 divided doses.
Control of Acutely Agitated Schizophrenic Patient: Adults:
IM (lactate): 2 to 5 mg. May be repeated every 1 to 8 hours,
not to exceed 100 mg/day.
2506_Ch28_472-501.indd 1479 10/1/10 9:40:06 AM

Chronic Psychosis Requiring Prolonged Antipsychotic

Therapy: Adults: IM (decanoate): 10 to 15 times the
previous daily oral dose, not to exceed 100 mg initially.
Repeat every 4 weeks, or adjust interval to patient response.
For maintenance, titrate dosage upward or downward based
on therapeutic response.
Tourettes Disorder: Adults: PO: Initial dosage: 0.5 to 1.5 mg
3 times a day. Increase dose gradually as determined by patient
response. Up to 10 mg/day may be required.
Children (3 to 12 years; 15 to 40 kg): PO: 0.05 to 0.075 mg/
kg/day.
Behavioral Disorders/Hyperactivity: Children (3 to 12 years;
15 to 40 kg): PO: 0.05 to 0.075 mg/kg/day.
PIMOZIDE (Orap)
Tourettes Disorder: Adults: PO: Initial dose: 1 to 2 mg/day
in divided doses. Thereafter, increase dose every other day.
Maintenance dose: Less than 0.2 mg/kg/day or 10 mg/day,
whichever is less. Doses greater than 0.2 mg/kg/day or 10 mg/
day are not recommended.
Children (12 years and older): Initial dose: 0.05 mg/kg, preferably
taken once at bedtime. The dose may be increased every third
day to a maximum of 0.2 mg/kg, not to exceed 10 mg/day.
CHEMICAL CLASS: DIHYDROINDOLONES

Examples
Pregnancy
Molindone C/12
Schizophrenia Caps: 5, 10, 25, 50
(Moban)
Action
The exact mechanism of action is not fully understood.
It is thought that molindone exerts its effect on the ascending
reticular activating system.

Contraindicated in hypersensitivity, comatose or severely
CNS-depressed patients, children under 12 (safety not estab-
lished), lactation
Use cautiously in patients with history of seizures; respiratory,
renal, hepatic, thyroid, or cardiovascular disorders; elderly or
debilitated patients, pregnancy.
2506_Ch28_472-501.indd 1480 10/1/10 9:40:07 AM


Drowsiness
Depression
Hyperactivity/euphoria
Blurred vision
Tachycardia
Nausea
Dry mouth
Salivation
Urinary retention
Constipation
Interactions
Additive hypotension with antihypertensive agents
Additive CNS effects with CNS depressants
Additive anticholinergic effects with drugs that have anticho-
linergic properties
Route and Dosage

MOLINDONE (Moban)
Schizophremna: Adults: PO: Initial dosage: 50 to 75 mg/day.
May increase to 100 mg in 3 or 4 days, up to 225 mg/day if
required.
Maintenance Therapy: Adults (mild symptoms): PO: 5 to 15 mg
3 or 4 times a day. (Moderate symptoms): PO: 10 to 25 mg 3 or
4 times a day. (Severe symptoms): PO: Up to 225 mg/day may be
required.
CHEMICAL CLASS: DIBENZEPINES

Examples
Generic Pregnancy
Loxapine C/8
(Loxitane)
Clozapine B/8 (single dose);

Treatment-resistant Tabs: 12.5, 25, 50,
(Clozaril) 12 (at steady schizophrenia 100, 200
state)
Recurrent suicidal behavior Tabs (orally
Unlabeled uses: disintegrating):

Acute manic episodes 12.5, 25, 50, 100
associated with bipolar
disorder
Continued
2506_Ch28_472-501.indd 1481 10/1/10 9:40:07 AM

Generic Pregnancy
Olanzapine C/2154
Schizophrenia Tabs: 2.5, 5, 7.5, 10,
(Zyprexa)
Bipolar mania 15, 20

Acute agitation in schizo- Tabs (orally
phrenia (IM) disintegrating): 5,

Acute agitation associated 10, 15, 20
with bipolar mania (IM) Inj: 10/vial
Unlabeled uses:

Obsessive-compulsive dis-
order (refractory to SSRIs)
Quetiapine C/~6
Schizophrenia Tabs: 25, 50, 100,
(Seroquel)
Bipolar mania 200, 300, 400
Tabs (XR): 200, 300,
400
Action
Loxapine
Mechanism of action has not been fully established.
Exerts strong antagonistic effects on dopamine D and D and

2 4
serotonin 5-HT2 receptors
Clozapine
Exerts an antagonistic effect on dopamine receptors, with a
particularly high af nity for the D4 receptor

It appears to be more active at limbic than at striatal dopamine
receptors.
Also acts as an antagonist at adrenergic, cholinergic, hista-
minergic, and serotonergic receptors

Olanzapine
Efcacy in schizophrenia is mediated through a combination
of dopamine and 5-HT2 antagonism.

Also shows antagonism for muscarinic, histaminic, and adren-
ergic receptors
The mechanism of action of olanzapine in the treatment of
bipolar mania is unknown.

Quetiapine
Antipsychotic activity is thought to be mediated through
a combination of dopamine type 2 (D2) and serotonin type

2 (5-HT 2) antagonism. Other effects may be due to an-
tagonism of histamine H1 receptors and alpha1-adrenergic
receptors.
2506_Ch28_472-501.indd 1482 10/1/10 9:40:07 AM


Loxapine
Contraindicated in: hypersensitivity; comatose or severe
drug-induced depressed states; clients with blood dyscrasias;

hepatic, renal, or cardiac insufciency; severe hypotension or
hypertension; children, pregnancy, and lactation (safety not
established)
Use cautiously in: patients with epilepsy or history of sei-
zures; glaucoma; urinary retention; respiratory insufciency;

prostatic hypertrophy; elderly patients with dementia-related
Clozapine
Contraindicated in: hypersensitivity; myeloproliferative dis-
orders; history of clozapine-induced agranulocytosis or severe

granulocytopenia; concomitant use with other drugs that have
the potential to suppress bone marrow function; severe CNS
depression or comatose states; uncontrolled epilepsy; lacta-
tion; children (safety not established)
Use cautiously in: patients with hepatic, renal, respiratory, or
cardiac insufciency; diabetes mellitus or risk factors for dia-

betes; prostatic enlargement; narrow-angle glaucoma; preg-
nancy; elderly patients with dementia-related psychosis (black
box warning).
Olanzapine
Contraindicated in: hypersensitivity; lactation. Orally dis-
integrating tablets only: Phenylketonuria (orally disintegrating

tablets contain aspartame)
Use cautiously in: hepatic insufciency, elderly clients (reduce
dosage), pregnancy and children (safety not established), car-

diovascular or cerebrovascular disease, history of glaucoma,
history of seizures, history of attempted suicide, prostatic
hypertrophy, diabetes or risk factors for diabetes, narrow an-
gle glaucoma, history of paralytic ileus; elderly patients with
dementia-related psychosis (black box warning).
Quetiapine
Contraindicated in: hypersensitivity; lactation
Use cautiously in: cardiovascular or cerebrovascular dis-
ease; dehydration or hypovolemia (increased risk of hypoten-

sion); hepatic impairment; hypothyroidism; history of suicide
attempt; pregnancy or children (safety not established);
patients with diabetes or risk factors for diabetes; elderly pa-
tients with dementia-related psychosis (black box warning).
2506_Ch28_472-501.indd 1483 10/1/10 9:40:08 AM


Loxapine
Anticholinergic effects (dry mouth, blurred vision, urinary
retention, constipation, paralytic ileus)

Nausea and vomiting
Seizures
Hypotension; hypertension; tachycardia
Blood dyscrasias
Clozapine
Drowsiness, dizziness, sedation
Nausea and vomiting
Dry mouth; blurred vision
Agranulocytosis
Seizures (appear to be dose-related)
Salivation
Myocarditis; cardiomyopathy
Tachycardia
Constipation
Fever
Weight gain
Hyperglycemia
Olanzapine
Drowsiness, dizziness, weakness
Dry mouth, constipation, increased appetite
Nausea; weight gain
Orthostatic hypotension, tachycardia
Restlessness; insomnia
Rhinitis
Tremor
Headache
Hyperglycemia
Quetiapine
Hypotension, tachycardia
Headache
Nausea, dry mouth, constipation
Weight gain
Hyperglycemia
2506_Ch28_472-501.indd 1484 10/1/10 9:40:08 AM

Interactions
Loxapine Additive CNS depression with

alcohol or other CNS depres-
sants. Increased hypotension
with antihypertensive agents.
Additive anticholinergic
effects with anticholinergic
agents. Concomitant use
with lorazepam (and possibly
other benzodiazepines) may
result in respiratory depres-
sion, stupor, hypotension,
and/or respiratory or cardiac
arrest.
Clozapine Caffeine, CYP1A2 inducers Additive CNS depression with

citalopram, (e.g., carbamaze- alcohol or other CNS depres-
cimetidine, pine, omeprazole, sants. Increased hypotension
fluoxetine, rifampin), with antihypertensive agents.
fluvoxamine, phenobarbital, Additive anticholinergic
sertraline, phenytoin, effects with anticholinergic
CYP3A4- nicotine agents. Concomitant use
inhibiting with benzodiazepines may
drugs (e.g., result in respiratory depres-
ketoconazole), sion, stupor, hypotension,
risperidone, and/or respiratory or cardiac
ritonavir arrest. Increased effects
of risperidone with chronic
coadministration.
Olanzapine Fluvoxamine, Carbamazepine, Decreased effects of levodopa

fluoxetine omeprazole, and dopamine agonists.
rifampin Increased hypotension with
antihypertensives. Increased
CNS depression with alcohol
Increased anticholinergic
agents.
Quetiapine Cimetidine; Phenytoin, Decreased effects of levodopa

ketoconazole, thioridazine and dopamine agonists. In-
itraconazole, creased CNS depression with
fluconazole, alcohol or other CNS depres-
erythromycin, or sants. Increased hypotension
other CYP3A4 with antihypertensives.
inhibitors Additive anticholinergic
agents.
2506_Ch28_472-501.indd 1485 10/1/10 9:40:09 AM

Route and Dosage

LOXAPINE (Loxitane)
Schizophrenia: Adults: PO: Initial dosage: 10 mg 2 times a
day, although some severely disturbed patients may require up
to 50 mg/day. Increase dosage fairly rapidly over the rst 7 to
10 days until symptoms are controlled. The usual therapeutic
and maintenance dosage range is 60 mg to 100 mg/day. Doses
higher than 250 mg/day are not recommended. Dosage should
be maintained at the lowest level effective for controlling
symptoms.
CLOZAPINE (Clozaril)
Schizophrenia and Recurrent Suicidal Behavior: Adults:
PO: Initial dose: 12.5 mg once or 2 times a day. May
increase dosage by 25 to 50 mg/day over a period of 2 weeks
to a target dose of 300 to 450 mg/day. If required, make
additional increases in increments of 100 mg not more than
once or twice weekly to a maximum dosage of 900 mg/day in
3 divided doses. The mean and median doses are approximately
600 mg/day for schizophrenia and 300 mg/day for reducing
recurrent suicidal behavior. Titrate dosage slowly to observe
for possible seizures and agranulocytosis.
NOTE: A baseline white blood cell (WBC) count and ab-
solute neutrophil count (ANC) must be taken before ini-
tiation of treatment with clozapine and weekly for the rst
6 months of treatment. Because of the risk of agranulocytosis,
clozapine is available only in a 1-week supply through the
Clozaril Patient Management System, which combines WBC
testing, patient monitoring, and controlled distribution
through participating pharmacies. If the counts remain with-
in the acceptable levels (i.e., WBC at least 3,500/mm3 and the
AMC at least 2,000/mm3) during the 6-month period, blood
counts may be monitored biweekly, and a 2-week supply of
medication may then be dispensed. If for a 6-month period
the counts remain within the acceptable level for the biweekly
period, counts may then be monitored every 4 weeks there-
after. When the medication is discontinued, weekly WBC
counts are continued for an additional 4 weeks.
OLANZAPINE (Zyprexa)
Schizophrenia: Adults: PO: 5 to 10 mg/day initially; may increase
at weekly intervals by 5 mg/day (not to exceed 20 mg/day).
Bipolar Disorder: Adults: PO: 10 to 15 mg/day initially; may
increase every 24 hours by 5 mg/day (not to exceed 20 mg/day).
Agitation Associated with Schizophrenia or Mania: Adults:
IM: 2.5 to 10 mg, administered slowly, deep into muscle mass.
May repeat in 2 hours and again 4 hours later, if needed.
2506_Ch28_472-501.indd 1486 10/1/10 9:40:09 AM

QUETIAPINE (Seroquel)
Schizophrenia: Adults: PO: 25 mg 2 times a day initially,
increased by 25 to 50 mg 2 to 3 times daily over 3 days, up to
300 to 400 mg/day in 2 to 3 divided doses by the fourth day
(not to exceed 800 mg/day).
Bipolar Mania: Adults: PO: 100 mg/day in 2 divided doses
on day 1; increase dose by 100 mg/day up to 400 mg/day by
day 4 given in 2 divided doses. May increase in 200 mg/day
increments up to 800 mg/day on day 6 if required.
CHEMICAL CLASS: BENZISOXAZOLE

Examples
Generic Pregnancy
Risperidone C/~320
Schizophrenia Tabs: 0.25, 0.5, 1, 2, 3, 4
(Risperdal)
Bipolar mania Tabs (orally disintegrating):

Irritability associ- 0.5, 1, 2, 3, 4
ated with autistic Oral Solu: 1/mL
disorder in children Powder for injection:
Unlabeled uses: 12.5/vial, 25/vial, 37.5/vial,
50/vial

Obsessive-
compulsive
disorder
(refractory to SSRIs)
Paliperidone C/23
Schizophrenia Tabs (ER): 3, 6, 9
(Invega) Inj (ER): 39/0.25 mL,
78/0.5 mL, 117/0.75 mL,
156/mL, 234/1.5 mL
Iloperidone C/1833
Schizophrenia Tabs: 1, 2, 4, 6, 8, 10, 12
(Fanapt)
Ziprasidone C/~7 (oral)
(Geodon) 25 (IM)
Bipolar mania Powder for injection: 20/vial

Acute agitation in
schizophrenia (IM)
Action
Exerts antagonistic effects on dopamine type 2 (D2), serotonin
type 2 (5-HT2), alpha1- and alpha2-adrenergic, and H1 hista-
minergic receptors

Contraindicated in: Known hypersensitivity Comatose
or severely depressed patients Bradycardia, recent myocardial
infarction (MI), or uncompensated heart failure Lactation
2506_Ch28_472-501.indd 1487 10/1/10 9:40:09 AM

Patients with history of QT prolongation or cardiac arrhythmias

Concurrent use with drugs known to cause QT prolongation
Use Cautiously in: Clients with hepatic or renal impair-
ment Clients with history of seizures Clients with diabe-
tes or risk factors for diabetes Clients exposed to temperature
extremes Elderly or debilitated clients Clients with history
of suicide attempt Pregnancy and children (safety not estab-
lished) Elderly patients with dementia-related psychosis (black
box warning) Conditions that increase risk of hypotension
(e.g., dehydration [including from diuretic therapy or diarrhea],
hypovolemia, concurrent antihypertensive therapy).

Anxiety
Agitation
Dry mouth
Weight gain
Insomnia
Sedation
Dizziness
Headache
Constipation
Diarrhea
Nausea
Rhinitis
Rash
Tachycardia
Hyperglycemia
Prolonged QT interval
Interactions
Increased effects of risperidone with clozapine, fluoxetine,
paroxetine, or ritonavir
Decreased effects of levodopa and other dopamine agonists
with risperidone, paliperidone, and ziprasidone
Decreased effectiveness of risperidone with carbamazepine
Additive CNS depression with CNS depressants, such as
alcohol, antihistamines, sedative/hypnotics, or opioid
analgesics
Increased effects of clozapine and valproate with risperidone
Additive hypotension with antihypertensive agents
Additive orthostatic hypotension with coadministration of
other drugs that result in this adverse reaction
Additive anticholinergic effects with anticholinergic agents
2506_Ch28_472-501.indd 1488 10/1/10 9:40:10 AM

Serious life-threatening arrhythmias with drugs known to

prolong QT interval (e.g., antiarrhythmics [e.g., quinidine,
procainamide, amiodarone, sotalol], chlorpromazine,
thiroidazine, gatifloxacin, moxifloxacin, pentamidine,
levomethadyl)
Route and Dosage

RISPERIDONE (Risperdal)
Bipolar Mania: Adults: PO: 2 to 3 mg/day as a single daily dose;
dose may be increased at 24-hour intervals by 1 mg (range
1 to 6 mg/day).
Children: Initial dose: 0.5 mg once daily as a single daily dose.
May increase at 24-hour intervals by 0.5 or 1 mg/day, to a
recommended dose of 2.5 mg/day.
Schizophrenia: Adults: PO: Initial dose: 2 mg/day administered
in a single dose or in 2 divided doses. May increase in
increments of 1 to 2 mg/day at intervals of 24 hours to a
recommended dose of 4 to 8 mg/day.
Adolescents (13 to 17 years): Initial dose: 0.5 mg once daily as a
single dose. May increase in increments of 0.5 or 1 mg/day
at intervals of 24 hours to a recommended dose of 3 mg/day.
IM: 25 mg every 2 weeks; some patients may require larger
dose of 37.5 or 50 mg every 2 weeks.
Irritability Associated with Autistic Disorder: PO: Children
and adolescents (5 to 16 years weighing <20 kg): 0.25 mg/day
initially. After at least 4 days of therapy, may increase to
be considered at 2 week or longer intervals. May be as a single
or divided dose.
Children and adolescents (5 to 16 years weighing >20 kg): 0.5 mg/day
initially. After at least 4 days of therapy, may increase to
be considered at 2-week or longer intervals. May be as a single
or divided dose.
PALIPERIDONE (Invega)
Schizophrenia: Adults: PO: 6 mg as a single daily dose. After
clinical assessment, dose increases may be made at intervals
of more than 5 days. When dose increases are indicated,
small increments of 3 mg/day are recommended. Maximum
recommended dose: 12 mg/day.
ILOPERIDONE (Fanapt)
Schizophrenia: Adults: PO: Initiate treatment with 1 mg 2 times
a day on the rst day, then 2 mg 2 times a day the second day,
then increase by 2 mg/day every day until a target dose of 12 to
24 mg/day given in two divided doses is reached.
2506_Ch28_472-501.indd 1489 10/1/10 9:40:10 AM

ZIPRASIDONE (Geodon)
Schizophrenia: Adults: PO: Initial dosage: 20 mg 2 times a day
with food. May increase dosage by intervals of at least 2 days
up to a dosage of 80 mg 2 times a day.
Bipolar Mania: Adults: PO: Initial dosage: 40 mg 2 times a day
with food. On the second day of treatment, increase dose to
60 or 80 mg 2 times a day. Adjust dosage on the basis of toleration
and efcacy within the range of 40 to 80 mg 2 times a day.
Acute Agitation in Schizophrenia: Adults: IM: 10 to 20 mg
as needed up to a maximum of 40 mg/day. May be given as
10 mg every 2 hours or 20 mg every 4 hours.
CHEMICAL CLASS: QUINOLINONES

Example
Generic Pregnancy
Aripiprazole C/75 (aripiprazole);

Schizophrenia Tabs: 2, 5, 10, 15, 20, 30
(Abilify) 94 (metabolite)
Bipolar mania Tabs (orally disintegrating):

Major depression, 10, 15
adjunctive therapy Oral solution: 1/mL

Agitation associated Inj: 7.5 mL
with schizophrenia
or bipolar mania (IM)
Action
The efcacy of aripiprazole is thought to occur through a
combination of partial agonist activity at D2 and 5-HT1A recep-
tors and antagonist activity at 5-HT2A receptors.
Also exhibits antagonist activity at adrenergic 1 receptors.

Contraindicated in: Hypersensitivity Lactation
Use Cautiously in: History of seizures Hepatic or renal
impairment Known cardiovascular or cerebrovascular disease
Conditions that cause hypotension (dehydration, hypovole-
mia, treatment with antihypertensive medication) Conditions
that increase the core body temperature (excessive exercise, ex-
posure to extreme heat, dehydration) Patients with diabetes
or risk factors for diabetes Pregnancy (weigh benets of the
drug to potential risk to fetus) Children and adolescents (safety
and effectiveness not established) Elderly patients with dementia-
related psychosis (black box warning)
2506_Ch28_472-501.indd 1490 10/1/10 9:40:11 AM


Headache
Nausea and vomiting
Constipation
Anxiety, restlessness
Insomnia
Lightheadedness
Drowsiness, sedation, somnolence
Weight gain
Blurred vision
Increased salivation
Hyperglycemia
Disruption in the bodys ability to reduce core body
temperature
Interactions
Decreased plasma levels of aripiprazole with carbamazepine
and other CYP3A4 inducers
Increased plasma levels and potential for aripiprazole toxicity
with CYP2D6 inhibitors, such as quinidine, fluoxetine, and
paroxetine
Decreased metabolism and increased effects of aripiprazole
with ketoconazole or other CYP3A4 inhibitors
Additive hypotensive effects with antihypertensive drugs
Additive CNS effects with alcohol and other CNS depressants
Route and Dosage

Bipolar Mania: Adults: PO: Initial dose: 15 mg once daily. May
increase to 30 mg/day based on clinical response. Maximum
dosage: 30 mg/day.
Children (10 to 17 years): PO: Initial dose: 2 mg/day. May in-
crease to 5 mg after 2 days and to 10 mg after 2 more days. If
required, additional dose increases may be made in 5 mg/day
increments. Maintenance dosage: 10 to 30 mg/day (maintain
at lowest effective dose for symptom remission).
Schizophrenia: Adults: PO: Initial dose: 10 or 15 mg/day as
a single dose. Doses up to 30 mg have been used. Dosage
increases should not be made before 2 weeks, the time required
to achieve steady state.
Children (13 to 17 years): PO: Initial dose: 2 mg/day. May in-
crease to 5 mg after 2 days and to 10 mg after 2 more days. If
required, additional dose increases may be made in 5 mg/day
increments. Maintenance dosage: 10 to 30 mg/day (maintain
at lowest effective dose for symptom remission).
2506_Ch28_472-501.indd 1491 10/1/10 9:40:11 AM

Major Depression, Adjunctive Therapy: Adults: PO: Initial

dose: 2 to 5 mg as adjunctive treatment for patients already
taking an antidepressant. May increase dosage in increments
of 5 mg/day at intervals of at least 1 week. Maintenance dosage:
2 to 15 mg/day.
Agitation Associated with Schizophrenia or Bipolar
Mania: Adults: IM: Usual dose: 9.75 mg. May use a dose of
5.25 mg, based on clinical situation. May give additional doses
up to a maximum of 30 mg/day if needed for agitation.
CHEMICAL CLASS: DIBENZO-OXEPINO

PYRROLE
Example
Generic Pregnancy
Asenapine C/24
Schizophrenia Tabs (Sublingual): 5,10
(Saphris)
Bipolar mania
Action
Efcacy in schizophrenia is achieved through a combination
of dopamine and serotonin type 2 (5-HT2) antagonism.
Mechanism of action in the treatment of acute manic episodes
is unknown.

Contraindicated in: Hypersensitivity Lactation History
of QT prolongation or arrhythmias Concurrent use of other
drugs known to prolong QT interval
Use Cautiously in: Patients with hepatic, renal, or car-
diovascular insufciency Diabetes or risk factors for diabe-
tes Patients with preexisting low WBC count and/or history
of drug-induced leukopenia/neutropenia History of seizures
History of suicide attempt Patients at risk for aspiration pneu-
monia Pregnancy and children (safety not established) Elderly
patients with dementia-related psychosis (black box warning)

Constipation
Dry mouth
Nausea and vomiting
Weight gain
2506_Ch28_472-501.indd 1492 10/1/10 9:40:11 AM

Restlessness
Insomnia
Headache
Interactions
Increased effects of asenapine with fluvoxamine, imipra-
mine, or valproate
Decreased effects of asenapine with carbamazepine, cimeti-
dine, or paroxetine
Increased effects of paroxetine or dextromethorphan with
asenapine
Increased CNS depression with alcohol or other CNS
depressants
Increased hypotension with antihypertensives
Additive effects on QT interval prolongation with quinidine,
dofetilide, other Class Ia and III antiarrhythmics, pimozide,
sotalol, thioridazine, chlorpromazine, floquine, pentama-
dine, arsenic trioxide, mefloquine, dolasetron, tacrolimus,
droperidol, gatifloxacin, or moxifloxacin
Route and Dosage

ASENAPINE (Saphris)
Schizophrenia: Adults: PO: Usual starting and target dose:
5 mg 2 times a day. The safety of doses above 10 mg 2 times a
day has not been evaluated in clinical trials.
Bipolar Disorder: Adults: PO: Recommended initial dose:
10 mg 2 times a day. The dose can be decreased to 5 mg
2 times a day if there are adverse effects. The safety of doses
above 10 mg 2 times a day has not been evaluated in clinical
trials.
TO ALL ANTIPSYCHOTIC AGENTS
1. Risk for other-directed violence related to panic anxiety and
mistrust of others.
2. Risk for injury related to medication side effects of sedation,
photosensitivity, reduction of seizure threshold, agranulocy-
tosis, extrapyramidal symptoms, tardive dyskinesia, neuro-
leptic malignant syndrome, and/or QT prolongation.
3. Risk for activity intolerance related to medication side effects
of sedation, blurred vision, and/or weakness.
4. Noncompliance with medication regimen related to suspi-
ciousness and mistrust of others.
2506_Ch28_472-501.indd 1493 10/1/10 9:40:12 AM

FOR ANTIPSYCHOTIC AGENTS
side effects from antipsychotic medications. Nursing implica-
tions related to each side effect are designated by an asterisk (*).
A pro le of side effects comparing various antipsychotic medi-
cations is presented in Table 28-1.
1. Anticholinergic effects (see Table 28-1 for differences
between typicals and atypicals)
a. Dry mouth
* Provide the client with sugarless candy or gum, ice, and
frequent sips of water.
* Ensure that client practices strict oral hygiene.
b. Blurred vision
* Explain that this symptom will most likely subside after
a few weeks.
* Advise client not to drive a car until vision clears.
* Clear small items from pathway to prevent falls.
c. Constipation
* Order foods high in ber; encourage increase in physi-
cal activity and uid intake if not contraindicated.
d. Urinary retention
* Instruct client to report any difculty urinating; moni-
tor intake and output.
2. Nausea; gastrointestinal (GI) upset (may occur with all
classications)
* Tablets or capsules may be administered with food to mini-
mize GI upset.
* Concentrates may be diluted and administered with fruit
juice or other liquid; they should be mixed immediately
before administration.
3. Skin rash (may occur with all classications)
* Report appearance of any rash on skin to physician.
* Avoid spilling any of the liquid concentrate on skin; contact
dermatitis can occur.
4. Sedation (see Table 28-1 for differences between typicals
and atypicals)
* Discuss with physician possibility of administering drug at
bedtime.
* Discuss with physician possible decrease in dosage or order
for less sedating drug.
* Instruct client not to drive or operate dangerous equipment
while experiencing sedation.
5. Orthostatic hypotension (see Table 28-1 for differences
between typicals and atypicals)
* Instruct client to rise slowly from a lying or sitting position
2506_Ch28_472-501.indd 1494 10/1/10 9:40:12 AM

2506_Ch28_472-501.indd 1495
TABLE 28 1 Comparison of Side Effects Among Antipsychotic Agents
Generic (Trade) Orthostatic
Class Name EPS Sedation Anti-cholinergic Hypotension Weight Gain
Typicals Chlorpromazine 3 4 3 4 *
Fluphenazine 5 2 2 2
Haloperidol (Haldol) 5 2 2 2
Loxapine (Loxitane) 3 2 2 2 *
Molindone (Moban) 3 2 2 2 *
Perphenazine 4 2 2 2 *
Pimozide (Orap) 4 2 3 2 *
Prochlorperazine 3 2 2 2 *
Thioridazine 2 4 4 4 *
Thiothixene (Navane) 4 2 2 2 *
Triuoperazine 4 2 2 2 *
Continued
Antipsychotic Agents

495
10/1/10 9:40:13 AM
496
2506_Ch28_472-501.indd 1496
TABLE 28 1 Comparison of Side Effects Among Antipsychotic Agentscontd
Generic (Trade) Orthostatic
Class Name EPS Sedation Anti-cholinergic Hypotension Weight Gain
Atypicals Aripiprazole (Abilify) 1 2 1 3 2

Asenapine (Saphris) 1 3 1 3 4
Clozapine (Clozaril) 1 5 5 4 5
Iloperidone (Fanapt) 1 3 2 3 3
Olanzapine (Zyprexa) 1 3 2 2 5
Paliperidone (Invega) 1 2 1 3 2
Quetiapine (Seroquel) 1 3 1 3 4
Risperidone (Risperdal) 1 2 1 3 4
PSYCHOTROPIC MEDICATIONS
Ziprasidone (Geodon) 1 3 1 2 2
Key: 1=Very low; 2=Low; 3=Moderate; 4=High; 5=Very high

EPS=Extrapyramidal Symptoms
* Weight gain occurs, but incidence is unknown
SOURCE: Adapted from Black & Andreasen (2011); Drug Facts and Comparisons (2010); and Schatzberg, Cole, & DeBattista (2010).
10/1/10 9:40:13 AM
* Monitor blood pressure (lying and standing) each shift;

document and report signicant changes.
6. Photosensitivity (may occur with all classications)
* Ensure that client wears protective sunblock lotion, cloth-
ing, and sunglasses while spending time outdoors.
7. Hormonal effects (may occur with all classications, but
more common with typicals)
a. Decreased libido, retrograde ejaculation, gynecomastia
(men)
* Provide explanation of the effects and reassurance of re-
versibility. If necessary, discuss with physician possibil-
ity of ordering alternate medication.
b. Amenorrhea (women)
* Offer reassurance of reversibility; instruct client to con-
tinue use of contraception, because amenorrhea does
not indicate cessation of ovulation.
c. Weight gain (may occur with all classications; has been
problematic with the atypicals)
* Weigh client every other day; order calorie-controlled
diet; provide opportunity for physical exercise; provide
diet and exercise instruction.
8. ECG Changes. ECG changes, including prolongation of
the QT interval, are possible with most of the antipsychot-
ics. This is particularly true with ziprasidone, thioridazine,
pimozide, haloperidol, paliperidone, iloperidone, asenapine,
and clozapine. Caution is advised in prescribing these medica-
tions to individuals with history of arrhythmias. Conditions
that produce hypokalemia and/or hypomagnesemia, such as
diuretic therapy or diarrhea, should be taken into consider-
ation when prescribing. Routine ECG should be taken before
initiation of therapy and periodically during therapy. Clozap-
ine has also been associated with other cardiac events, such
as ischemic changes, arrhythmias, congestive heart failure,
myocarditis, and cardiomyopathy.
* Monitor vital signs every shift.
* Observe for symptoms of dizziness, palpitations, syncope,
weakness, dyspnea, and peripheral edema.
9. Reduction of seizure threshold (more common with typi-
cals than the atypicals, with the exception of clozapine)
* Closely observe clients with history of seizures.
* NOTE: This is particularly important with clients tak-
ing clozapine (Clozaril), with which seizures have been
frequently associated. Dose appears to be an important
predictor, with a greater likelihood of seizures occurring
at higher doses. Extreme caution is advised in prescribing
clozapine for clients with history of seizures.
2506_Ch28_472-501.indd 1497 10/1/10 9:40:13 AM

10. Agranulocytosis (more common with typicals than the

atypicals, with the exception of clozapine)
* It usually occurs within the rst 3 months of treatment.
Observe for symptoms of sore throat, fever, malaise.
A complete blood count should be monitored if these
symptoms appear.
* EXCEPTION: There is a signicant risk of agranulo-
cytosis with clozapine (Clozaril). Agranulocytosis is a
potentially fatal blood disorder in which the clients
white blood cell (WBC) count can drop to extremely low
levels. A baseline WBC count and absolute neutrophil
count (ANC) must be taken before initiation of treatment
with clozapine and weekly for the rst 6 months of treat-
ment. Only a 1-weeks supply of medication is dispensed
at a time. If the counts remain within the acceptable
levels (i.e., WBC at least 3,500/mm3 and the ANC at least
2,000/mm3) during the 6-month period, blood counts
may be monitored biweekly, and a 2-week supply of medi-
cation may then be dispensed. If for a 6-month period the
counts remain within the acceptable level for the biweekly
period, counts may then be monitored every 4 weeks
thereafter. When the medication is discontinued, weekly
WBC counts are continued for an additional 4 weeks.
11. Hypersalivation (most common with clozapine)
* A signicant number of clients receiving clozapine
(Clozaril) therapy experience extreme salivation. Offer
support to the client, as this may be an embarrassing
situation. It may even be a safety issue (e.g., risk of as-
piration), if the problem is very severe. Management has
included the use of sugar-free gum to increase the swal-
lowing rate, as well as the prescription of medications
such as an anticholinergic (e.g., scopolamine patch) or
alpha 2-adrenoceptor agonist (e.g., clonidine).
12. Extrapyramidal symptoms (EPS) (see Table 28-1 for dif-
ferences between typicals and atypicals)
* Observe for symptoms and report; administer an-
tiparkinsonian drugs, as ordered (see Chapter 29)
a. Pseudoparkinsonism (tremor, shuf ing gait, drooling,
rigidity)
* Symptoms may appear 1 to 5 days following initia-
tion of antipsychotic medication; occurs most often in
women, the elderly, and dehydrated clients.
b. Akinesia (muscular weakness)
* Same as pseudoparkinsonism.
c. Akathisia (continuous restlessness and dgeting)
* This occurs most frequently in women; symptoms may
occur 50 to 60 days following initiation of therapy.
2506_Ch28_472-501.indd 1498 10/1/10 9:40:14 AM

d. Dystonia (involuntary muscular movements [spasms] of

face, arms, legs, and neck)
* This occurs most often in men and in people younger
than 25 years.
e. Oculogyric crisis (uncontrolled rolling back of the eyes)
* This may appear as part of the syndrome described
as dystonia. It may be mistaken for seizure activity.
Dystonia and oculogyric crisis should be treated as
an emergency situation. The physician should be
contacted, and intravenous benztropine mesylate
(Cogentin) is commonly administered. Stay with
the client and offer reassurance and support during
this frightening time.
13. Tardive dyskinesia (bizarre facial and tongue movements,
stiff neck, and difculty swallowing) (may occur with all clas-
sications, but more common with typical antipsychotics)
* All clients receiving long-term (months or years) antipsy-
chotic therapy are at risk.
* Symptoms are potentially irreversible.
* Drug should be withdrawn at rst sign, which is usually
vermiform movements of the tongue; prompt action may
prevent irreversibility.
14. Neuroleptic malignant syndrome (NMS) (more common
with the typicals than the atypicals)
* This is a relatively rare, but potentially fatal, complication
of treatment with neuroleptic drugs. Routine assessments
should include temperature and observation for parkinso-
nian symptoms.
* Onset can occur within hours or even years after drug
initiation, and progression is rapid over the following 24
to 72 hours.
* Symptoms include severe parkinsonian muscle rigidity,
very high fever, tachycardia, tachypnea, uctuations in
blood pressure, diaphoresis, and rapid deterioration of
mental status to stupor and coma.
* Discontinue neuroleptic medication immediately.
* Monitor vital signs, degree of muscle rigidity, intake and
output, level of consciousness.
* The physician may order bromocriptine (Parlodel) or
dantrolene (Dantrium) to counteract the effects of NMS.
15. Hyperglycemia and diabetes (more common with atypicals)
* studies have suggested an increased risk of treatment-
emergent hyperglycemia-related adverse events in clients
using atypical antipsychotics (e.g., risperidone, clozap-
ine, olanzapine, quetiapine, ziprasidone, asenapine, and
aripiprazole). The FDA recommends that clients with dia-
betes starting on atypical antipsychotic drugs be monitored
2506_Ch28_472-501.indd 1499 10/1/10 9:40:14 AM

regularly for worsening of glucose control. Clients with risk

factors for diabetes should undergo fasting blood glucose
testing at the beginning of treatment and periodically there-
after. All clients taking these medications should be moni-
tored for symptoms of hyperglycemia (polydipsia, polyuria,
polyphagia, and weakness). If these symptoms appear during
treatment, the client should undergo fasting blood glucose
testing.
16. Increased risk of mortality in elderly patients with
dementia-related psychosis.
* Recent studies have indicated that elderly patients with
dementia-related psychosis who are treated with antipsy-
chotic drugs are at increased risk of death, compared with
placebo. Causes of death are most commonly related to
infections or cardiovascular problems. All antipsychotic
drugs now carry black box warnings to this effect. They
are not approved for treatment of elderly patients with
dementia-related psychosis.

TO ALL ANTIPSYCHOTICS
Use caution when driving or operating dangerous machinery.
Drowsiness and dizziness can occur.
Do not stop taking the drug abruptly after long-term use. To
do so might produce withdrawal symptoms, such as nausea,
vomiting, dizziness, gastritis, headache, tachycardia, insom-
nia, and tremulousness.
Use sunblock lotion and wear protective clothing when spend-
ing time outdoors. Skin is more susceptible to sunburn, which
can occur in as little as 30 minutes.
Report weekly (if receiving clozapine therapy) to have blood
levels drawn and to obtain a weekly supply of the drug.
physician immediately: sore throat, fever, malaise, unusual
bleeding, easy bruising, persistent nausea and vomiting, se-
vere headache, rapid heart rate, fainting, difculty urinating,
muscle twitching, tremors, darkly colored urine, excessive
urination, excessive thirst, excessive hunger, weakness, pale
stools, yellow skin or eyes, muscular incoordination, or skin
rash.
Take frequent sips of water, chew sugarless gum, or suck on
hard candy, if experiencing a problem with dry mouth. Good
oral care (frequent brushing, ossing) is very important.
2506_Ch28_472-501.indd 1500 10/1/10 9:40:14 AM

Consult the physician regarding smoking while taking this

medication. Smoking increases the metabolism of some anti-
psychotics, possibly requiring adjustment in dosage to achieve
therapeutic effect.
Dress warmly in cold weather and avoid extended exposure to
very high or low temperatures. Body temperature is harder to
maintain with this medication.
Do not drink alcohol while on antipsychotic therapy. These
drugs potentiate each others effects.
Do not consume other medications (including over-the-counter
products) without physicians approval. Many medications con-
tain substances that interact with antipsychotics in a way that
may be harmful.
Be aware of possible risks of taking antipsychotic medication
during pregnancy. Safe use during pregnancy and lactation
has not been established. Antipsychotics are thought to read-
ily cross the placental barrier; if so, a fetus could experience
adverse effects of the drug. Inform the physician immediately
if pregnancy occurs, is suspected, or is planned.
Be aware of side effects of antipsychotic drugs. Refer to writ-
ten materials furnished by health care providers for safe self-
administration.
Continue to take medication, even if feeling well and as
though it is not needed. Symptoms may return if medication
is discontinued.
Carry card or other identication at all times describing medi-
cations being taken.
INTERNET REFERENCES
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2506_Ch28_472-501.indd 1501 10/1/10 9:40:15 AM

C H A P T E R
29
Antiparkinsonian
Agents*
CHEMICAL CLASS: ANTICHOLINERGICS
Examples
Pregnancy
Name Half-life (hours) Indications Forms (mg)
Benztropine C/Unknown
Parkinsonism Tabs: 0.5, 1, 2
(Cogentin)
Drug-induced Inj: 1/mL
extrapyramidal
symptoms
Biperiden C/18.424.3
Parkinsonism Tabs: 2
(Akineton)
Drug-induced
extrapyramidal
symptoms
Trihexyphenidyl C/5.610.2
Parkinsonism Tabs: 2, 5

Drug-induced Elixir: 2/5 mL
extrapyramidal
symptoms
Diphenhydramine B/415
Parkinsonism Tabs and Caps: 25, 50
(Benadryl)
Drug-induced Tabs (orally
extrapyramidal disintegrating):
symptoms 12.5

Motion sickness Tabs, chewable:

Allergy reactions 12.5, 25

Nighttime sleep Strips (orally disinte-
aid grating): 12.5, 25

Cough suppressant Elixir/syrup/oral solu:
12.5/5 mL
Inj: 50/mL
* This chapter includes only those antiparkinsonian agents indicated

for the treatment of antipsychotic-induced extrapyramidal symptoms
or neuroleptic malignant syndrome (bromocriptine).
502
2506_Ch29_502-510.indd Sec1:502 10/1/10 9:40:24 AM

Action
Blocks acetylcholine receptors to diminish excess cholinergic
effects. May also inhibit the reuptake and storage of dopamine
at central dopamine receptors, thereby prolonging the action
of dopamine.
Diphenhydramine also blocks histamine release by compet-
ing with histamine for H1-receptor sites. Decreased allergic
response and somnolence are effected by diminished hista-
mine activity.

Contraindicated in: Hypersensitivity Angle-closure glau-
coma Pyloric or duodenal obstruction Peptic ulcers Pros-
tatic hypertrophy Bladder neck obstructions Megaesophagus
Megacolon Myasthenia gravis Lactation Children (except
diphenhydramine)
Use Cautiously in: Tachycardia Cardiac arrhythmias
Hypertension Hypotension Tendency toward urinary
retention Clients exposed to high environmental temperatures
Pregnancy

Dry mouth
Blurred vision
Constipation
Paralytic ileus
Urinary retention
Tachycardia
Agitation, nervousness
Decreased sweating
Elevated temperature
Nausea/vomiting
Sedation
Dizziness
Exacerbation of psychoses
Interactions
(Diphenhydramine): Additive sedative effects with central
nervous system (CNS) depressants
Increased effects of beta-blockers with diphenhydramine
Additive anticholinergic effects with other drugs that have
anticholinergic properties
Anticholinergic drugs counteract the cholinergic effects of
bethanechol.
Possible increased digoxin levels with anticholinergics
2506_Ch29_502-510.indd Sec1:503 10/1/10 9:40:25 AM

Concomitant use of anticholinergics with haloperidol may

result in worsening of psychotic symptoms, decreased halo-
peridol serum levels, and development of tardive dyskinesia.
Possible decreased efcacy of phenothiazines and in-
creased incidence of anticholinergic side effects with con-
comitant use
Decreased effects of levodopa with concomitant use
Route and Dosage

BENZTROPINE (Cogentin)
Parkinsonism: Adults: PO: 1 to 2 mg/day in 1 to 2 divided
doses (range 0.5 to 6 mg/day).
Drug-induced Extrapyramidal Symptoms: Adults: PO: 1 to
4 mg given 1 or 2 times a day.
Acute Dystonic Reactions: Adults: IM, IV: 1 to 2 mg, then 1
to 2 mg PO 2 times a day.
BIPERIDEN (Akineton)
Parkinsonism: Adults: PO: 2 mg 3 or 4 times a day, not to
exceed 16 mg/24 hours.
Drug-induced Extrapyramidal Symptoms: Adults: PO: 2 mg
1 to 3 times a day.
TRIHEXYPHENIDYL
Parkinsonism: Adults: PO: Initial dose: 1 mg on day 1; increase
by 2 mg increments at 3- to 5-day intervals, up to a daily dose
of 6 to 10 mg in 3 divided doses taken at mealtimes.
Drug-induced Extrapyramidal Symptoms: Adults: PO:
Initial dosage: 1 mg. Repeat dosage every few hours until
symptoms are controlled. Maintenance or prophylactic use:
5 to 15 mg/day.
DIPHENHYDRAMINE (Benadryl)
Parkinsonism and Drug-induced Extrapyramidal
Symptoms/Motion Sickness/Allergy Reactions: Adults
and children 12 years: PO: 25 to 50 mg every 4 to 6 hours.
Maximum dosage: 300 mg/day. IM/IV: Adults: 10 to 50 mg
IV or 100 mg IM. Maximum daily dose: 400 mg.
Children 6 to 12 years: PO: 12.5 to 25 mg every 4 to 6 hours, not
to exceed 150 mg/day.
Nighttime Sleep Aid: Adults and children 12 years: 50 mg at
bedtime.
Cough Suppressant: Adults and children 12 years: PO
Liquid: 25 to 50 mg every 4 hours, not to exceed 300 mg/day.
PO Syrup: 25 mg every 4 hours, not to exceed 150 mg/day.
Children 6 to 12 years: PO Liquid: 12.5 to 25 mg every 4 hours,
not to exceed 150 mg/day.
2506_Ch29_502-510.indd 504 10/1/10 9:40:25 AM

PO Syrup: 12.5 mg every 4 hours, not to exceed 75 mg/day.

Children 2 to 6 years: PO Syrup: 6.25 mg every 4 hours, not to
exceed 25 mg/day.
CHEMICAL CLASS: DOPAMINERGIC

AGONISTS
Examples
Pregnancy
Amantadine C/1025
Parkinsonism Tabs, Caps: 100
(Symmetrel)
Drug-induced extrapyramidal Syrup: 50/5 mL
symptoms

Prophylaxis and treatment of
Influenza A viral infection
Bromocriptine B/820
Parkinsonism Tabs: 2.5
(Parlodel)
Hyperprolactinemia- Caps: 5
associated dysfunctions

Acromegaly

Neuroleptic malignant
syndrome
Action
Amantadine increases dopamine at the receptor either by re-
leasing intact striatal dopamine stores or by blocking neuronal
dopamine reuptake. It also inhibits the replication of inuenza
A virus isolates from each of the subtypes.
Bromocriptine increases dopamine by direct stimulation of
dopamine receptors.
Contraindicated in:
Amantadine
Hypersensitivity to the drug
Pregnancy, lactation, and in children under 1 year (safety not
established)
Angle closure glaucoma
Bromocriptine
Hypersensitivity to this drug, other ergot alkaloids, or sultes
(contained in some preparations)

Uncontrolled hypertension
Pregnancy and lactation; children younger than 15 years
(safety not established)

Use Cautiously in: Hepatic or renal impairment Un-
controlled psychiatric disturbances History of congestive
2506_Ch29_502-510.indd 505 10/1/10 9:40:25 AM

heart failure, myocardial infarction, or ventricular arrhythmia

Elderly or debilitated clients Orthostatic hypotension
Amantadine
Clients with a history of seizures
Concurrent use of CNS stimulants
Bromocriptine
Clients with history of peptic ulcer or gastrointestinal
bleeding

Amantadine
Nausea
Dizziness
Insomnia; somnolence
Depression; anxiety
Hallucinations
Arrhythmia; tachycardia
Dry mouth
Blurred vision
Bromocriptine
Nausea and vomiting
Headache; dizziness; drowsiness
Confusion
Constipation; diarrhea
Skin mottling
Exacerbation of Raynaud syndrome
Ataxia
Interactions
Concurrent use may

Amantadine Quinidine, quinine, Potentiation of

triamterene, anticholinergic
thiazine diuretics, side effects with
trimethoprim/ anticholinergic
sulfamethoxazole, agents; increased
thioridazine effects of CNS
stimulants with
concurrent use.
Bromocriptine Erythromycin, Phenothiazines

sympathomimetics, (and other
isometheptene, antipsychotics),
phenylpropanolamine metoclopramide
2506_Ch29_502-510.indd 506 10/1/10 9:40:26 AM

Route and Dosage

AMANTADINE (Symmetrel)
Parkinsonism: Adults: PO: 100 mg 1 to 2 times/day (up to
400 mg/day).
Drug-induced Extrapyramidal Symptoms: Adults: PO:
100 mg 2 times a day (up to 300 mg/day in divided doses).
Inuenza A Viral Infection: Adults and children >12 years: PO:
200 mg/day as a single dose or 100 mg 2 times a day.
Children 9 to 12 years: PO: 200 mg as a single dose or 100 mg
2 times a day.
Children 1 to 9 years: PO: 4.4 to 8.8 mg/kg/day given once daily
or divided 2 times a day, not to exceed 150 mg/day.
BROMOCRIPTINE (Parlodel)
Parkinsonism: Adults: PO: Initial dose: 1.25 mg 2 times a
day with meals. May increase dosage every 2 to 4 weeks by
2.5 mg/day with meals. Usual range is 10 to 40 mg/day. If
adverse reactions necessitate reduction in dosage, reduce dose
gradually in 2.5 mg increments.
Hyperprolactinemia-associated Dysfunctions: Adults: PO:
Initial dose: 1.25 to 2.5 mg/day with meals. May increase by
2.5 mg every 2 to 7 days. Usual therapeutic dosage range: 2.5
to 15 mg/day.
Acromegaly: Adults: PO: Initial dose: 1.25 to 2.5 mg for
3 days (with food) at bedtime. May increase by 1.25 to 2.5 mg/
day every 3 to 7 days. Usual therapeutic dosage range: 20 to
30 mg/day. Maximum dosage: 100 mg/day.
Neuroleptic Malignant Syndrome: Adult: PO: 5 mg every
4 hours.
TO ANTIPARKINSONIAN AGENTS
1. Risk for injury related to symptoms of Parkinsons disease or
drug-induced EPS.
2. Hyperthermia related to anticholinergic effect of decreased
sweating.
3. Activity intolerance related to side effects of drowsiness, diz-
ziness, ataxia, weakness, confusion.
4. Decient knowledge related to medication regimen.
NURSING IMPLICATIONS FOR
ANTIPARKINSONIAN AGENTS
The plan of care should include monitoring for the follow-
ing side effects from antiparkinsonian medications. Nursing
implications related to each side effect are designated by an
asterisk (*).
2506_Ch29_502-510.indd 507 10/1/10 9:40:26 AM

1. Anticholinergic Effects. These side effects are identical to

those produced by antipsychotic drugs. Taking both medica-
tions compounds these effects. For this reason, the physician
may elect to prescribe an antiparkinsonian agent only at the
onset of EPS, rather than as routine adjunctive therapy.
a. Dry Mouth
* Offer sugarless candy or gum, ice, frequent sips of
water.
* Ensure that client practices strict oral hygiene.
b. Blurred Vision
* Explain that symptom will most likely subside after a
few weeks.
* Offer to assist with tasks requiring visual acuity.
c. Constipation
* Order foods high in ber; encourage increase in physi-
cal activity and uid intake, if not contraindicated.
d. Paralytic Ileus
* A rare, but potentially very serious side effect of anti-
cholinergic drugs. Monitor for abdominal distension,
absent bowel sounds, nausea, vomiting, epigastric pain.
* Report any of these symptoms to physician immediately.
e. Urinary Retention
* Instruct client to report any difculty urinating; moni-
tor intake and output.
f. Tachycardia, Decreased Sweating, Elevated Tem-
perature
* Assess vital signs each shift; document and report
signicant changes to physician.
* Ensure that client remains in cool environment, be-
cause the body is unable to cool itself naturally with
this medication.
2. Nausea, Gastrointestinal (GI) Upset
* May administer tablets or capsules with food to minimize
GI upset.
3. Sedation, Drowsiness, Dizziness
* Discuss with physician possibility of administering drug at
bedtime.
* Discuss with physician possible decrease in dosage or
order for less sedating drug.
* Instruct client not to drive or use dangerous equipment
while experiencing sedation or dizziness.
4. Exacerbation of Psychoses
* Assess for signs of loss of contact with reality.
* Intervene during a hallucination; talk about real people
and real events; reorient client to reality.
* Stay with client during period of agitation and delirium;
remain calm and reassure client of his or her safety.
2506_Ch29_502-510.indd 508 10/1/10 9:40:27 AM

* Discuss with physician possible decrease in dosage or

change in medication.
5. Orthostatic Hypotension
* Instruct client to rise slowly from a lying or sitting
position; monitor blood pressure (lying and standing) each
shift; document and report signicant changes.

TO ALL ANTIPARKINSONIAN AGENTS
Take the medication with food if GI upset occurs.
Use caution when driving or operating dangerous machinery.
Drowsiness and dizziness can occur.
Do not stop taking the drug abruptly. To do so might produce
unpleasant withdrawal symptoms.
physician immediately: pain or tenderness in area in front of
ear; extreme dryness of mouth; difculty urinating; abdomi-
nal pain; constipation; fast, pounding heart beat; rash; visual
disturbances; mental changes.
Stay inside in air-conditioned room when weather is very
hot. Perspiration is decreased with antiparkinsonian agents,
and the body cannot cool itself as well. There is greater sus-
ceptibility to heat stroke. Inform physician if air-conditioned
housing is not available.
Take frequent sips of water, chew sugarless gum, or suck
on hard candy if dry mouth is a problem. Good oral care
(frequent brushing, ossing) is very important.
Do not drink alcohol while on antiparkinsonian therapy.
Do not consume other medications (including over-the-
counter products) without physicians approval. Many medica-
tions contain substances that interact with antiparkinsonian
agents in a way that may be harmful.
Be aware of possible risks of taking antiparkinsonian agents
during pregnancy. Safe use during pregnancy and lactation
has not been fully established. It is thought that antiparkin-
sonian agents readily cross the placental barrier; if so, fetus
could experience adverse effects of the drug. Inform phy-
sician immediately if pregnancy occurs, is suspected, or is
planned.
Be aware of side effects of antiparkinsonian agents. Refer to
written materials furnished by health-care providers for safe
self-administration.
Continue to take medication, even if feeling well and as
though it is not needed. Symptoms may return if medication is
discontinued.
2506_Ch29_502-510.indd 509 10/1/10 9:40:27 AM

Carry card or other identication at all times describing

INTERNET REFERENCES
d. http://www.mentalhealth.com
.html
2506_Ch29_502-510.indd 510 10/1/10 9:40:27 AM

C H A P T E R
30
Sedative-Hypnotics
CHEMICAL CLASS: BENZODIAZEPINES
Examples
Generic Controlled/
(Trade) Pregnancy Half-life Available
Name Categories (hr) Indications Forms (mg)
Estazolam CIV/X 828

Insomnia Tabs: 1, 2
Flurazepam CIV/(Contraindicated 23 (active
Insomnia Caps: 15, 30
(Dalmane) in pregnancy) metabolite,
47100)
Quazepam CIV/X 41 (active
Insomnia Tabs: 7.5, 15
(Doral) metabolite,
47100)
Temazepam CIV/X 915
Insomnia Caps: 7.5, 15,
(Restoril) 22.5, 30
Triazolam CIV/X 1.55.5
Insomnia Tabs: 0.125, 0.25
(Halcion)
Action
Potentiate gamma-aminobutyric acid (GABA) neuronal
inhibition
The sedative effects involve GABA receptors in the limbic,
neocortical, and mesencephalic reticular systems.

Contraindicated in: Hypersensitivity to these or other ben-
zodiazepines Pregnancy and lactation Respiratory depression
and sleep apnea (Triazolam): concurrent use with ketoconazole,
itraconazole, or nefazodone, medications that impair the metabo-
lism of triazolam by cytochrome P450 3A (CYP3A) (Flurazepam):
Children younger than age 15 (Estazolam, quazepam, temazepam,
triazolam): Children younger than age 18
Use Cautiously in: Elderly and debilitated patients Hepatic
or renal dysfunction Patients with history of drug abuse and
dependence Depressed or suicidal patients
511
2506_Ch30_511-521.indd Sec2:511 10/1/10 9:40:37 AM


Drowsiness
Headache
Confusion
Lethargy
Tolerance
Potentiates the effects of other central nervous system (CNS)
depressants
May aggravate symptoms in depressed persons
Palpitations; tachycardia; hypotension
Paradoxical excitement
Dry mouth
Nausea and vomiting
Blood dyscrasias
Interactions
depressants
Decreased clearance and increased effects of benzodiazepines
with cimetidine, oral contraceptives, disulfiram, and
isoniazid
More rapid onset or more prolonged benzodiazepine effect
with probenecid
Increased clearance and decreased half-life of benzodiazepines
with rifampin
Increased benzodiazepine clearance with cigarette smoking
Decreased pharmacological effects of benzodiazepines with
theophylline
Increased bioavailability of triazolam with macrolides
Benzodiazepines may increase serum levels of digoxin and
phenytoin and increase risk of toxicity
Route and Dosage

ESTAZOLAM
Insomnia: Adults: PO: 1 to 2 mg at bedtime.
Healthy elderly: PO: 1 mg at bedtime. Increase with caution.
Debilitated or small elderly patients: PO: 0.5 mg at bedtime.
FLURAZEPAM (Dalmane)
Elderly or debilitated: PO: 15 mg at bedtime.
QUAZEPAM (Doral)
Insomnia: Adults: PO: 7.5 to 15 mg at bedtime.
Elderly or debilitated: PO: Initial dose: 7.5 mg at bedtime. If not
effective after 1 or 2 nights, may increase to 15 mg.
2506_Ch30_511-521.indd Sec2:512 10/1/10 9:40:38 AM

TEMAZEPAM (Restoril)
Insomnia: Adults: PO: 15 to 30 mg at bedtime. 7.5 mg may be
sufcient for some patients.
Elderly or debilitated: PO: 7.5 mg at bedtime.
TRIAZOLAM (Halcion)
Insomnia: Adults: PO: 0.125 to 0.5 mg at bedtime.
Elderly or debilitated: PO: 0.125 to 0.25 mg at bedtime.
CHEMICAL CLASS: BARBITURATES

Examples
Generic Controlled/
Amobarbital CII/D 1640

Sedation Injection: powder,

Insomnia 500/vial
Butabarbital CIII/D 66140

Sedation Tabs: 15, 30, 50
(Butisol)
Insomnia Elixir: 30/5 mL
Mephobarbital CIV/D 1167

Sedation Tabs: 32, 50, 100
(Mebaral)
Epilepsy
Pentobarbital CII/D 1550
Sedation Inj: 50/mL
(Nembutal)
Insomnia

Preanesthetic

Acute convulsive
episodes
Phenobarbital CIV/D 53118
Sedation Tabs: 15, 16, 30, 60,
(Solfoton;
Epilepsy 90, 100
Luminal) Caps: 16
Elixir: 15/5 mL;
20/5 mL
Inj (mg/mL): 30, 60,
65, 130
Secobarbital CII/D 1540
Preoperative Caps: 100
(Seconal) sedation

Insomnia
Action
Depress the sensory cortex, decrease motor activity, and alter
cerebellar function
All levels of CNS depression can occur, from mild sedation to
hypnosis to coma to death
Can induce anesthesia in sufciently high therapeutic doses
Contraindicated in: Hypersensitivity to barbiturates Severe
hepatic, renal, cardiac, or respiratory disease Individuals with
2506_Ch30_511-521.indd Sec2:513 10/1/10 9:40:39 AM

history of drug abuse or dependence Porphyria Uncontrolled

severe pain Intra-arterial or subcutaneous administration
Lactation
Use Cautiously in: Elderly and debilitated patients Patients
with hepatic, renal, cardiac, or respiratory impairment Depressed
or suicidal patients Pregnancy Children

Bradycardia
Hypotension
Somnolence
Agitation
Confusion
Nausea, vomiting
Constipation
Skin rashes
Respiratory depression
Interactions
depressants
Decreased effects of barbiturates with rifampin
Increased effects of barbiturates with monoamine oxidase
(MAO) inhibitors or valproic acid
Decreased effects of the following drugs with concurrent use of
barbiturates: anticoagulants, beta-blockers, carbamazepine,
clonazepam, oral contraceptives, corticosteroids, digi-
toxin, doxorubicin, doxycycline, felodipine, fenoprofen,
griseofulvin, metronidazole, phenylbutazone, quinidine,
theophylline, chloramphenicol, and verapamil
Concomitant use with methoxyflurane may enhance renal
toxicity.
Route and Dosage

AMOBARBITAL
Sedation: Adults: IM: 30 to 50 mg, 2 or 3 times a day.
Insomnia: Adults: IM: 65 to 200 mg at bedtime.
NOTE: Do not inject a volume >5 mL IM at any one site
regardless of drug concentration. Tissue irritation can occur.
2506_Ch30_511-521.indd Sec2:514 10/1/10 9:40:39 AM

BUTABARBITAL (Butisol)
Daytime Sedation: Adults: PO: 15 to 30 mg, 3 or 4 times a day.
Preoperative Sedation: Adults: PO: 50 to 100 mg, 60 to
90 minutes before surgery.
Children: PO: 2 to 6 mg/kg; maximum 100 mg.
MEPHOBARBITAL (Mebaral)
Sedation: Adults: PO: 32 to 100 mg 3 or 4 times a day. Optimum
dose: 50 mg 3 or 4 times a day.
Children: PO: 16 to 32 mg 3 or 4 times a day.
Epilepsy: Adults: PO: 400 to 600 mg daily.
Children <5 yr: PO: 16 to 32 mg 3 or 4 times a day.
Children >5 yr: PO: 32 to 64 mg 3 or 4 times a day.
PENTOBARBITAL (Nembutal)
Sedation, Insomnia, Preanesthetic: IM: Adults: Usual
dosage: 150 to 200 mg.
Children: 2 to 6 mg/kg as a single IM injection, not to exceed
100 mg.
NOTE: Inject deeply into large muscle mass. Do not exceed a vol-
ume of 5 mL at any one site because of possible tissue irritation.
PHENOBARBITAL (Luminal)
Sedation: Adults: PO or IM: 30 to 120 mg/day in 2 to 3 divided
doses not to exceed 400 mg/day
Children: PO: 2 mg/kg 3 times daily.
Preoperative Sedation: Adults: IM only: 100 to 200 mg, 60 to
90 minutes before the procedure
Children: PO, IM or IV: 1 to 3 mg/kg 60 to 90 minutes before
the procedure.
IM or IV: 100 to 320 mg.
Children: Route and dosage determined by age and weight.
Epilepsy: Adults: PO: 60 to 200 mg/day.
Children: PO: 3 to 6 mg/kg/day.
SECOBARBITAL (Seconal)
Preoperative Sedation: Adults: PO: 200 to 300 mg 1 to
2 hours before surgery.
Children: PO: 2 to 6 mg/kg, not to exceed 100 mg.
Insomnia: Adults: PO: 100 mg at bedtime.
2506_Ch30_511-521.indd Sec2:515 10/1/10 9:40:39 AM

CHEMICAL CLASS: MISCELLANEOUS

Examples
Generic Controlled/
Chloral hydrate CIV/C 710

Sedation Caps: 500

Insomnia Syrup: 250/5 mL;
500/5 mL
Eszopiclone CIV/C 6
Insomnia Tabs: 1, 2, 3
(Lunesta)
Ramelteon Not controlled/ 12.6

Insomnia Tabs: 8
(Rozerem) C
Zaleplon (Sonata) CIV/C 1

Insomnia Caps: 5, 10
Zolpidem CIV/B 23
Insomnia Tabs: 5, 10
(Ambien) Tabs CR: 6.25, 12.5
Tabs sublingual:
5, 10
Spray solution,
lingual: 5 per
actuation
Action
Zolpidem and Zaleplon
Bind to GABA receptors in the CNS. Appear to be selective
for the omega1-receptor subtype.

Eszopiclone
Action as a hypnotic is unclear but thought to interact with
GABA-receptor complexes near benzodiazepine receptors

Chloral Hydrate
Action unknown. Produces a calming effect through depres-
sion of the CNS.

Has generally been replaced by safer and more effective agents.
Ramelteon
Ramelteon is a melatonin receptor agonist with high af nity
for melatonin MT1 and MT2 receptors.

Contraindicated in: Hypersensitivity In combination
with other CNS depressants Pregnancy and lactation
Zolpidem, Zaleplon, Eszopiclone, Ramelteon
Children (safety not established)
Chloral Hydrate
Severe hepatic, renal, or cardiac impairment
Esophagitis, gastritis, or peptic ulcer disease
2506_Ch30_511-521.indd Sec2:516 10/1/10 9:40:40 AM

Ramelteon
Severe hepatic function impairment
Concomitantly with uvoxamine
Use Cautiously in: Elderly or debilitated patients De-

pressed or suicidal patients Patients with history of drug abuse
or dependence Patients with hepatic, renal, or respiratory dys-
function Patients susceptible to acute intermittent porphyria
(chloral hydrate)

Headache
Drowsiness
Dizziness
Lethargy
Amnesia
Nausea
Dry mouth
Rash
Paradoxical excitement
Physical and/or psychological dependence
Chloral hydrate, eszopiclone

Unpleasant taste
Interactions
The effects Concurrent use may
of: Are increased by: Are decreased by: result in:
Chloral Alcohol and other Increased effects of

hydrate CNS depressants oral anticoagulants;
including symptoms of sweating,
antihistamines, hot flashes, tachycardia,
antidepressants, hypertension, weakness,
opioids, sedative/ and nausea with IV
hypnotics, furosemide; decreased
antipsychotics effects of phenytoin
Eszopiclone Drugs that inhibit the Lorazepam; drugs Additive CNS depression
CYP3A4 enzyme that induce the with alcohol and other
system, including CYP3A4 enzyme CNS depressants, in-
ketoconazole, system, such as cluding antihistamines,
itraconazole, rifampin; taking antidepressants,
clarithromycin, eszopiclone with opioids, sedative/
nefazodone, or immediately hypnotics,
ritonavir, after a high-fat antipsychotics;
nelfi navir or heavy meal decreased effects
of lorazepam
Ramelteon Alcohol, azole Rifampin; taking

antifungals, ramelteon with or
fl uoxetine immediately after a
high-fat or heavy
meal
Continued
2506_Ch30_511-521.indd Sec2:517 10/1/10 9:40:40 AM

The effects Concurrent use may

of: Are increased by: Are decreased by: result in:
Zaleplon Cimetidine Drugs that induce the Additive CNS depression

CYP3A4, enzyme with alcohol and other
system, including CNS depressants, in-
rifampin, phenytoin, cluding antihistamines,
carbamazepine, antidepressants,
and phenobarbital; opioids, sedative/
taking zaleplon with hypnotics,
or immediately after antipsychotics
a high-fat or heavy
meal
Zolpidem Azole antifungals, Flumazenil; rifampin; Risk of life-threatening

ritonavir, SSRIs administration cardiac arrhythmias with
with food amiodarone; additive
CNS depression with
alcohol and other CNS
depressants, including
antihistamines, anti-
depressants, opioids,
sedative/hypnotics,
antipsychotics
Route and Dosage

CHLORAL HYDRATE
Sedation: Adults: PO: 250 mg 3 times a day after meals.
Maximum daily dose: 2 g.
Children: PO: 25 mg/kg/day, not to exceed 500 mg per single
dose. May be given in divided doses.
Insomnia: Adults: PO: 500 mg to 1 g 15 to 30 minutes before
bedtime.
Children: PO: 50 mg/kg/day, up to 1 g per single dose. May give
in divided doses.
ESZOPICLONE (Lunesta)
Insomnia: Adults: PO: 2 mg immediately before bedtime; may
be increased to 3 mg if needed (3 mg dose is more effective for
sleep maintenance).
Elderly patients: PO: 1 mg immediately before bedtime for
patients who have difculty falling asleep; 2 mg immediately
before bedtime for patients who have difculty staying asleep.
RAMELTEON (Rozerem)
Insomnia: Adults: PO: 8 mg within 30 minutes of bedtime.
It is recommended that ramelteon not be taken with or
immediately after a high-fat meal.
ZALEPLON (Sonata)
Insomnia: Adults: PO: 10 mg (range 5 to 20 mg) at bedtime.
Elderly and debilitated patients: PO: 5 mg at bedtime, not to
exceed 10 mg.
2506_Ch30_511-521.indd Sec2:518 10/1/10 9:40:41 AM

ZOLPIDEM (Ambien)
Insomnia: Adults: PO: 10 mg at bedtime. Extended-release
tablets: 12.5 mg at bedtime.
Elderly or debilitated patients and patients with hepatic impairment:
PO: 5 mg at bedtime. Extended-release tablets: 6.25 mg at
bedtime.
TO ALL SEDATIVE-HYPNOTICS
1. Risk for injury related to abrupt withdrawal from long-term
use or decreased mental alertness caused by residual sedation.
2. Disturbed sleep pattern related to situational crises, physical
condition, or severe level of anxiety.
3. Risk for activity intolerance related to side effects of lethargy,
drowsiness, and dizziness.
4. Risk for acute confusion related to action of the medication
on the central nervous system.
FOR SEDATIVE-HYPNOTICS
The nursing care plan should include monitoring for the follow-
ing side effects from sedative-hypnotics. Nursing implications
related to each side effect are designated by an asterisk (*):
1. Drowsiness, dizziness, lethargy (most common side
effects)
* Instruct client not to drive or operate dangerous machin-
ery while taking the medication.
2. Tolerance, physical and psychological dependence
* Instruct client to take the medication exactly as directed.
Do not take more than the amount prescribed because
of the habit-forming potential. Recommended for short-
term use only. Abrupt withdrawal after long-term use
may result in serious, even life-threatening, symptoms.
Exception: Ramelteon is not considered to be a drug of
abuse or dependence. It is not classied as a controlled
substance. It has, however, been associated with cases of
rebound insomnia after abrupt discontinuation following
long-term use.
3. Potentiates the effects of other CNS depressants
* Instruct client not to drink alcohol or take other medica-
tions that depress the CNS while taking this medication.
4. May aggravate symptoms in depressed persons
* Assess mood daily.
* Take necessary precautions for potential suicide.
5. Orthostatic hypotension, palpitations, tachycardia
* Monitor lying and standing blood pressure and pulse
every shift.
2506_Ch30_511-521.indd Sec2:519 10/1/10 9:40:41 AM

* Instruct client to arise slowly from a lying or sitting

position.
* Monitor pulse rate and rhythm and report any signicant
change to the physician.
6. Paradoxical excitement
* Withhold drug and notify the physician.
7. Dry mouth
* Have client take frequent sips of water or ice chips, suck on
hard candy, or chew sugarless gum.
8. Nausea and vomiting
* Have client take drug with food or milk (unless it is a drug
in which taking with food is not recommended).
9. Blood dyscrasias
* Symptoms of sore throat, fever, malaise, easy bruising,
or unusual bleeding should be reported to the physician
immediately.

TO ALL SEDATIVE-HYPNOTICS
Do not drive or operate dangerous machinery. Drowsiness
and dizziness can occur.
Do not stop taking the drug abruptly after prolonged use. Can
produce serious withdrawal symptoms, such as depression,
insomnia, anxiety, abdominal and muscle cramps, tremors,
vomiting, sweating, convulsions, and delirium.
Do not consume other CNS depressants (including alcohol).
Do not take nonprescription medication without approval
from physician.
Rise slowly from the sitting or lying position to prevent a sud-
den drop in blood pressure.
Report to physician immediately symptoms of sore throat,
fever, malaise, easy bruising, unusual bleeding, or motor
restlessness.
Be aware of risks of taking these drugs during pregnancy.
(Congenital malformations have been associated with use dur-
ing the rst trimester.) If pregnancy is suspected or planned,
notify the physician of the desirability to discontinue the
drug.
Be aware of possible side effects. Refer to written materi-
als furnished by health-care providers regarding the correct
method of self-administration.
Carry card or piece of paper at all times stating names of
2506_Ch30_511-521.indd Sec2:520 10/1/10 9:40:42 AM

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2506_Ch30_511-521.indd Sec2:521 10/1/10 9:40:42 AM

C H A P T E R
31
Agents Used to Treat
Attention-Decit/
Hyperactivity Disorder
CHEMICAL CLASS: CENTRAL
NERVOUS SYSTEM (CNS)
STIMULANTS (AMPHETAMINES)
Examples
Generic Controlled/
(Trade) Pregnancy Available
Name Categories Half-life (hr) Indications Forms (mg)
Amphetamine/ C-II/C 913

ADHD Tabs: 5, 7.5,
dextroam-
Narcolepsy 10, 12.5, 15,
phetamine 20, 30
mixtures Caps (XR): 5, 10,
(Adderall; 15, 20, 25, 30
Adderall XR)
Dextroamphet- C-II/C ~12

ADHD Tabs: 5, 10
amine sulfate
Narcolepsy Caps (ER): 5,
(Dexedrine; 10, 15
Dextrostat) Oral solu:
5 mg/5 mL
Metham- C-II/C 45
ADHD Tabs: 5
phetamine
Exogenous
(Desoxyn) obesity
Lisdexam- C-II/C <1

ADHD Caps: 20, 30, 40
fetamine 50, 60, 70
(Vyvanse)
Action
Central nervous system (CNS) stimulation is mediated by re-
lease of norepinephrine from central noradrenergic neurons
in cerebral cortex, reticular activating system, and brainstem.
522
2506_Ch31_522-537.indd 1522 10/1/10 9:40:53 AM

Agents Used to Treat Attention-Decit/Hyperactivity Disorder 523
At higher doses, dopamine may be released in the mesolimbic

system.
Action in the treatment of attention-decit/hyperactivity dis-
order (ADHD) is unclear.
Contraindicated in: Advanced arteriosclerosis Symptom-
atic cardiovascular disease Moderate to severe hypertension
Hyperthyroidism Hypersensitivity or idiosyncrasy to the
sympathomimetic amines Glaucoma Agitated states His-
tory of drug abuse During or within 14 days following admin-
istration of monoamine oxidase (MAO) inhibitors (hypertensive
crisis may occur) Children younger than 3 years (dextroam-
phetamine, lisdexamfetamine, and mixtures) Children
younger than 12 years (methamphetamine) Pregnancy and
lactation
Use Cautiously in: Patients with mild hypertension Chil-
dren with psychoses (may exacerbate symptoms) Tourettes
disorder (may exacerbate tics) Anorexia Insomnia Elderly,
debilitated, or asthenic patients Patients with suicidal or homi-
cidal tendencies

Overstimulation
Restlessness
Dizziness
Insomnia
Headache
Palpitations
Tachycardia
Elevation of blood pressure
Anorexia
Weight loss
Dry mouth
Tolerance
New or worsened psychiatric symptoms
Suppression of growth in children (with long-term use)
Interactions
Increased sensitivity to amphetamines with furazolidone
Use of amphetamines with MAO inhibitors can result in
hypertensive crisis.
Increased effects of amphetamines and risk of serotonin syn-
drome with selective serotonin reuptake inhibitors (SSRIs)
Prolonged effects of amphetamines with urinary alkalinizers
2506_Ch31_522-537.indd 1523 10/1/10 9:40:54 AM

Hastened elimination of amphetamines with urinary acidifiers

Amphetamines may reverse the hypotensive effects of gua-
nethidine and other antihypertensives.
Concomitant use of amphetamines and tricyclic antidepres-
sants may increase blood levels of both drugs.
Patients with diabetes mellitus who take amphetamines may
require insulin adjustment.
Route and Dosage

AMPHETAMINE /DEXTROAMPHETAMINE MIXTURES (Adderall;
Adderall XR)
ADHD: Adults and children 6 years: PO: Initial dose: 5 mg 1
or 2 times a day. May be increased in increments of 5 mg at
weekly intervals until optimal response is obtained. Maximum
dose: 40 mg/day. Extended-release caps: Initial dosage: 10 mg
once daily in the morning. May increase in increments of
10 mg at weekly intervals. Maximum dose: 30 mg/day.
Children 3 to 5 years: PO: Initial dose: 2.5 mg/day. May increase
in increments of 2.5 mg/day at weekly intervals.
Narcolepsy: Adults and children 12 years: PO: Initial dose:
10 mg/day; may increase in increments of 10 mg/day at weekly
intervals up to a maximum of 60 mg/day.
Children 6 to 12 years of age: PO: Narcolepsy is rare in children
younger than 12 years. When it does occur, initial dose is
5 mg/day. May increase in increments of 5 mg/day at weekly
intervals up to a maximum of 60 mg/day.
DEXTROAMPHETAMINE SULFATE (Dexedrine; Dextrostat)
ADHD: Adults and children 6 years: PO: Initial dosage: 5 mg
once or 2 times a day. May be increased in increments of 5 mg
at weekly intervals. More than 40 mg/day is seldom required.
(Sustained-release capsules should not be used as initial
therapy.)
Children 3 to 5 years: PO: Initial dose: 2.5 mg/day. May increase
in increments of 2.5 mg/day at weekly intervals until optimal
response is achieved.
Narcolepsy: Adults: PO: 5 to 60 mg/day in single or divided
doses. Sustained-release capsules should not be used as initial
therapy.
Children 12 years: PO: 10 mg/day. May increase by 10 mg/day
at weekly intervals until response is obtained or 60 mg is
reached.
Children 6 to 12 years: PO: 5 mg/day. May increase by 5 mg/
day at weekly intervals until response is obtained or 60 mg is
reached.
2506_Ch31_522-537.indd 1524 10/1/10 9:40:54 AM

METHAMPHETAMINE (Desoxyn)
ADHD: 5 mg once or 2 times a day. May increase in increments
of 5 mg at weekly intervals. Usual effective dose is 20 to
25 mg/day in divided doses.
Exogenous Obesity: 5 mg 1 to 3 times/day 30 minutes before
meals.
LISDEXAMFETAMINE (Vyvanse)
ADHD: Children 6 to 12 years of age: PO: 20 or 30 mg once
daily in the morning. Dosage may be increased in increments
of 10 or 20 mg/day at weekly intervals. Maximum dosage:
70 mg/day.
CHEMICAL CLASS: CNS STIMULANTS

(MISCELLANEOUS AGENTS)
Examples
Controlled/
Generic (Trade) Pregnancy Half-life Available
Dexmethylphenidate C-II/C 2.2

ADHD Tabs: 2.5, 5, 10
(Focalin; Focalin Caps (ER): 5, 10,
XR) 15, 20
Methylphenidate C-II/C 24
ADHD Immediate Release
(Ritalin; Ritalin-SR;
Narcolepsy Tabs (Methylin,
Ritalin LA; (except Ritalin): 5, 10, 20
Methylin; Concerta, Chewable tabs
Methylin ER; Metadate (Methylin): 2.5,
Metadate ER; CD, and 5, 10
Metadate CD; Ritalin LA) Metadate ER,
Concerta; Methylin ER: Tabs
Daytrana) 10, 20
Concerta: Tabs ER:
18, 27, 36, 54
Ritalin-SR: Tabs
SR: 20
Metadate CD, Ritalin
LA: Caps ER: 10,
20, 30, 40, (50,
60Metadate
CD only)
Oral Solu (Methylin):
5/5 mL, 10/5 mL
Transdermal Patch
(Daytrana): 10, 15,
20, 30
ER, CD, LA=extended release forms; SR=sustained release.
2506_Ch31_522-537.indd 1525 10/1/10 9:40:55 AM

Actions
Dexmethylphenidate blocks the reuptake of norepinephrine
and dopamine into the presynaptic neuron and increases the
release of these monoamines into the extraneuronal space.
Methylphenidate activates the brain stem arousal system and
cortex to produce its stimulant effect.
Action in the treatment of ADHD is unknown.

Contraindicated in: Hypersensitivity Pregnancy, lacta-
tion, and children younger than 6 years (safety has not been
established) Clients with marked anxiety, tension, or agita-
tion History of glaucoma Motor tics or family history or
diagnosis of Tourettes disorder During or within 14 days
of treatment with MAO inhibitors (hypertensive crisis can
occur) Clients with structural cardiac abnormalities, cardio-
myopathy, arrhythmias, recent myocardial infarction (MI), or
other serious cardiac problems
Use Cautiously in: Patients with history of seizure disorder
and/or electroencephalographic (EEG) abnormalities Hyper-
tension History of drug or alcohol dependence Emotionally
unstable patients Renal or hepatic insufciency Clients with
preexisting psychotic disorder

Headache
Nausea
Rhinitis
Fever
Anorexia
Insomnia
Tachycardia; palpitations; hypertension
Nervousness
Abdominal pain
Growth suppression in children (with long-term use)
Skin redness or itching at site of transdermal patch (Daytrana)
Interactions
Decreased effectiveness of antihypertensive agents
Increased serum levels of anticonvulsants (e.g., phenobarbi-
tal, phenytoin, and primidone), tricyclic antidepressants,
selective serotonin reuptake inhibitors [SSRIs], warfarin
Increased effects of vasopressor agents with concurrent use
Hypertensive crisis may occur with concurrent use (or within
2 weeks use) of MAO inhibitors
2506_Ch31_522-537.indd 1526 10/1/10 9:40:55 AM

Concurrent use with clonidine may result in serious electro-

cardiographic (ECG) abnormalities
Increased sympathomimetic effects with other adrenergics,
including vasoconstrictors and decongestants
Route and Dosage

DEXMETHYLPHENIDATE (Focalin; Focalin XR)
ADHD: (Immediate release tabs):
Adults and children 6 years: Patients not previously taking methyl-
phenidate: PO: 2.5 mg 2 times a day. May be increased weekly
as needed up to 10 mg 2 times a day. Patients currently taking
methylphenidate: Starting dose is 1 2 of the methylphenidate
dose, up to 10 mg 2 times a day.
(Extended-release capsules):
Adults: Patients not previously taking methylphenidate: PO: 10 mg
once daily. May be increased by 10 mg after 1 week to 20 mg/
day. Patients currently taking methylphenidate: Starting dose is
1
2 of the methylphenidate dose, up to 20 mg/day given as a
single daily dose. Patients currently taking dexmethylphenidate:
Give same daily dose as a single dose.
Children 6 years: PO: Patients not previously taking methylpheni-
date: 5 mg once daily. May be increased by 5 mg weekly up to
20 mg/day. Patients currently taking methylphenidate: Starting
dose is 1 2 of the methylphenidate dose, up to 20 mg/day, given
as a single daily dose. Patients currently taking dexmethylpheni-
date: Give same daily dose as a single dose.
METHYLPHENIDATE (Ritalin; Ritalin-SR; Ritalin LA;
Methylin; Methylin ER; Metadate ER; Metadate CD;
Concerta; Daytrana)
ADHD: (Immediate release forms):
Adults: PO: Range 10 to 60 mg/day, in divided doses 2 or 3 times/
day, preferably 30 to 45 minutes before meals. Average dose
is 20 to 30 mg/day. To prevent interruption of sleep, take last
dose of the day before 6 p.m.
Children 6 yr: PO: Individualize dosage. May start with low
dose of 5 mg 2 times a day before breakfast and lunch. May
increase dosage in 5 to 10 mg increments at weekly intervals.
Maximum daily dosage: 60 mg.
(Extended-release forms):
Ritalin-SR, Methylin ER, and Metadate ER: Adults and children
6 years: PO: May be used in place of the immediate-release
tablets when the 8-hour dosage corresponds to the titrated
8-hour dosage of the immediate-release tablets. Must be swal-
lowed whole.
Ritalin LA and Metadate CD: PO: Adults and children 6 years:
Initial dosage: 20 mg once daily in the morning. May increase
2506_Ch31_522-537.indd 1527 10/1/10 9:40:55 AM

dosage in 10 to 20 mg increments at weekly intervals to a max-

imum of 60 mg taken once daily in the morning. Capsules
may be swallowed whole with liquid or opened and contents
sprinkled on soft food (e.g., applesauce). Ensure that entire
contents of capsule are consumed when taken in this man-
ner. NOTE: Ritalin LA may be used in place of 2 times a day
regimen given once daily at same total dose, or in place of SR
product at same dose.
Concerta: Adults and children 6 years: PO: Should be taken
once daily in the morning. Must be swallowed whole and not
chewed, divided, or crushed.
Clients new to methylphenidate: 18 mg once daily in the morning.
May adjust dosage at weekly intervals to maximum of 54 mg/
day for children 6 to 12 years, and to a maximum of 72 mg/day
(not to exceed 2 mg/kg/day) for adolescents 13 to 17 years.
Clients currently using methylphenidate: Should use following con-
version table:
Previous Methylphenidate Dose Recommended Concerta Dose
5 mg 2 or 3 times/day or 20 mg (SR) 18 mg every morning

Daytrana (Transdermal Patch): Adults and children 6 years: Patch

should be applied to hip area 2 hours before an effect is needed
and should be removed 9 hours after application. Alternate
hips with additional doses. Dosage for patients new to meth-
ylphenidate should be titrated to desired effect according to
the following recommended schedule:
Week 1 Week 2 Week 3 Week 4
Nominal delivered 10 mg 15 mg 20 mg 30 mg
dose (mg/9 hr)
Delivery rate (based on 1.1 mg/hr 1.6 mg/hr 2.2 mg/hr 3.3 mg/hr
9-hr wear period)
Patients converting from another formulation of methylphenidate should follow

the above titration schedule due to differences in bioavailability of Daytrana
compared to other products.
Narcolepsy: Adults: PO: Ritalin, Methylin, Methylin ER, Ritalin-

SR, and Metadate ER indicated for this use. 10 mg 2 to 3 times/
day. Maximum dose 60 mg/day.
2506_Ch31_522-537.indd 1528 10/1/10 9:40:56 AM

CHEMICAL CLASS: ALPHA-ADRENERGIC

AGONISTS
Examples
Pregnancy
Clonidine (Catapres) C/1216

Hypertension Tabs: 0.1, 0.2, 0.3
Unlabeled use: Transdermal patches:

ADHD 0.1/24 hr, 0.2/24 hr,
0.3/24 hr
Guanfacine (Tenex; B/1618

Hypertension Tabs (Tenex): 1, 2
Intuniv) (Tenex) Tabs (ER) (Intuniv): 1,

ADHD (Intuniv) 2, 3, 4
Unlabeled use:

ADHD (Tenex)
Action
Stimulates alpha-adrenergic receptors in the brain, thereby
reducing sympathetic outow from the CNS resulting in de-
creases in peripheral vascular resistance, heart rate, and blood
pressure.
Mechanism of action in the treatment of ADHD is unknown.

Contraindicated in: Hypersensitivity to the drug or any of
its inactive ingredients
Use Cautiously in: Coronary insufciency Recent myo-
cardial infarction Cerebrovascular disease History of hy-
potension, bradycardia, or syncope Chronic renal or hepatic
failure Elderly Pregnancy and lactation

Bradycardia
Palpitations
Syncope
Dry mouth
Constipation
Nausea
Fatigue
Sedation
Rebound syndrome with abrupt withdrawal
2506_Ch31_522-537.indd 1529 10/1/10 9:40:56 AM

Interactions
Increased effects of clonidine with verapamil and beta-blockers
Decreased effects of clonidine with prazosin and tricyclic
antidepressants
Decreased effects of levodopa with clonidine
Additive CNS effects with CNS depressants, including
alcohol, antihistamines, opioid analgesics, and sedative/
hypnotics
Decreased effects of guanfacine with barbiturates, rifampin,
or phenytoin
Increased effects of guanfacine with ketoconazole
Increased effects of valproic acid with guanfacine
Route and Dosage
CLONIDINE (Catapres)
Hypertension: Adults: PO: Initial dosage: 0.1 mg 2 times a day.
May increase dosage in increments of 0.1 mg/day at weekly
intervals until desired response is achieved. Maximum dose:
2.4 mg/day. Transdermal system: Transdermal system delivering
0.1 mg to 0.3 mg/24 hr applied every 7 days. Initiate with
0.1 mg/24 hr system. Dosage increments may be made every 1
to 2 weeks when system is changed.
ADHD: Adults and children 12 years: PO: Initial dosage:
0.05 mg/day. May increase in increments of 0.05 mg at
intervals of 3 to 7 days to a maximum dose of 0.3 mg/day in
divided doses.
GUANFACINE (Tenex; Intuniv)
Hypertension (Tenex): Adults: PO: 1 mg daily at bedtime. If
satisfactory results are not achieved after 3 to 4 weeks, may
increase to 2 mg.
ADHD (Intuniv): Adults and children 6 years: PO: Initial
dosage: 1 mg once daily. May increase dose in increments
of 1 mg/day at weekly intervals until desired response is
achieved. Maximum dose: 4 mg/day. Tablets should not be
chewed, crushed, or broken before swallowing, and should not
be administered with high-fat meals.
CHEMICAL CLASS: MISCELLANEOUS
AGENTS FOR ADHD
Examples
Pregnancy
Atomoxatine C/5.2 hr (metabolites

ADHD Caps: 10, 18, 25, 40,
(Strattera) 68 hr) 60, 80, 100
2506_Ch31_522-537.indd 1530 10/1/10 9:40:57 AM

Pregnancy
Bupropion B/824 hr
Depression Tabs: 75, 100
(Wellbutrin; Unlabeled use : Tabs SR: 100, 150,
Wellbutrin SR;
ADHD 200
Wellbutrin XL) Tabs XL: 150, 300
SR = 12-hour tablets; XL = 24-hour tablets.
Action
Atomoxetine selectively inhibits the reuptake of the
neurotransmitter norepinephrine.
Bupropion is a weak inhibitor of the neuronal uptake of
norepinephrine, serotonin, and dopamine.
Action in the treatment of ADHD is unclear.

Contraindicated in: Hypersensitivity Coadministration
with or within 2 weeks after discontinuing an MAO inhibitor
Lactation
Atomoxetine
Narrow-angle glaucoma
Bupropion
Known or suspected seizure disorder
Acute phase of myocardial infarction
Clients with bulimia or anorexia nervosa
Clients undergoing abrupt discontinuation of alcohol or seda-
tives (increased risk of seizures)

Use Cautiously in: Clients with suicidal ideation Clients
with urinary retention Hypertension Hepatic, renal, or car-
diovascular insufciency Pregnancy (use only if benets outweigh
possible risks to fetus) Children and adolescents (may increase sui-
cidal risk) Elderly and debilitated patients
Atomoxetine
Children younger than 6 years (safety not established)

Dry mouth
Anorexia
Nausea and vomiting
Constipation
Urinary retention
Sexual dysfunction
Headache
Dizziness
Insomnia or sedation
2506_Ch31_522-537.indd 1531 10/1/10 9:40:57 AM

Palpitations; tachycardia
Weight loss
Abdominal pain
Increased sweating
Atomoxetine
Fatigue
Cough
New or worsened psychiatric symptoms
Severe liver damage
Bupropion
Weight gain
Tremor
Seizures
Blurred vision
Interactions

Atomoxetine Concomitant use of Increased risk of cardiovascu-

CYP2D6 inhibi- lar effects with albuterol
tors (paroxetine, or vasopressors; poten-
fl uoxetine, tially fatal reactions with
quinidine) concurrent use (or use
within 2 weeks of discontin-
uation) of MAO inhibitors;
increased cardiovascular
effects of albuterol with
concurrent use
Bupropion Amantadine, Carbamazepine Increased risk of acute toxicity

levodopa, with MAO inhibitors;
cimetidine, increased risk of hyperten-
triclopidine, sion with nicotine
guanfacine, replacement agent;
ritonavir adverse neuropsychiatric
events with alcohol
(alcohol tolerance is
reduced); increased antico-
agulant effect of warfarin;
increased effects of drugs
metabolized by CYP2D6
(e.g., nortriptyline, imip-
ramine, desipramine,
paroxetine, fluoxetine,
sertraline, haloperidol,
risperidone, thioridazine,
metoprolol, propafe-
none, and flecainide);
increased risk of seizures
with drugs that lower the
seizure threshold (antide-
pressants, antipsychotics,
theophylline, corticosteroids,
stimulants/anorectics)
2506_Ch31_522-537.indd 1532 10/1/10 9:40:58 AM

Route and Dosage

ATOMOXETINE (Strattera)
ADHD: Adults, adolescents, and children weighing more than 70 kg
(154 lb): PO: Initial dose: 40 mg/day. Increase after a minimum
of 3 days to a target total daily dose of 80 mg, as a single dose in
the morning or 2 evenly divided doses in the morning and late
afternoon or early evening. After 2 to 4 weeks, total dosage
may be increased to a maximum of 100 mg, if needed.
Children weighing 70 kg (154 lb) or less: PO: Initial dose: 0.5 mg/
kg/day. Increase after a minimum of 3 days to a target total
daily dose of about 1.2 mg/kg taken either as a single dose in
the morning or 2 evenly divided doses in the morning and late
afternoon or early evening. Maximum daily dose: 1.4 mg/kg
or 100 mg daily, whichever is less.
Adjusted Dosing: Hepatic impairment: In clients with moderate
hepatic impairment, reduce to 50% of usual dose. In clients
with severe hepatic impairment, reduce to 25% of usual dose.
Adjusted dosing: Coadministration with strong CYP2D6 inhibitors:
Adults, adolescents, and children weighing more than 70 kg:
Initiate dosage at 40 mg/day and only increase to the usual
target dose of 80 mg/day if symptoms fail to improve after
4 weeks and the initial dose is well tolerated.
Children and adolescents up to 70 kg: Initiate dosage at 0.5 mg/kg/day
and only increase to the usual target dose of 1.2 mg/kg/day if
symptoms fail to improve after 4 weeks and the initial dose is
well tolerated.
BUPROPION (Wellbutrin; Wellbutrin SR; Wellbutrin XL)
ADHD: Children and adolescents: PO: Initial dose: 3 mg/kg/
day. May titrate to a maximum dose of 6 mg/kg/day. Single
dose should not exceed 150 mg. Usually given daily in 2 or
3 divided doses.
Adults: 150 to 450 mg/day. No single dose of bupropion should
exceed 150 mg. To prevent the risk of seizures, administer
with 4 to 6 hours between doses.
Depression (Wellbutrin): PO: Adults (immediate release
tabs): 100 mg 2 times/day. May increase after 3 days to
100 mg given 3 times/day. For patients who do not show
improvement after several weeks of dosing at 300 mg/day,
an increase in dosage up to 450 mg/day may be considered.
No single dose of bupropion should exceed 150 mg. To
prevent the risk of seizures, administer with 4 to 6 hours
between doses.
Sustained release tabs: Give as a single 150 mg dose in the morn-
ing. May increase to twice a day (total 300 mg), with 8 hours
between doses.
2506_Ch31_522-537.indd 1533 10/1/10 9:40:58 AM

Extended release tabs: Begin dosing at 150 mg/day, given as a

single daily dose in the morning. May increase after 3 days to
300 mg/day, given as a single daily dose in the morning.
Seasonal Affective Disorder (Wellbutrin XL): PO: 150 mg
administered each morning beginning in the autumn prior to
the onset of depressive symptoms. Dose may be uptitrated to
the target dose of 300 mg/day after 1 week. Therapy should
continue through the winter season before being tapered to
150 mg/day for 2 weeks prior to discontinuation in early spring.

TO AGENTS FOR ADHD
1. Risk for injury related to overstimulation and hyperac-
tivity (CNS stimulants) or seizures (possible side effect of
bupropion).
2. Risk for suicide secondary to major depression related to
abrupt withdrawal after extended use (CNS stimulants).
3. Imbalanced nutrition, less than body requirements, related
to side effects of anorexia and weight loss (CNS stimulants).
4. Disturbed sleep pattern related to side effects of overstimula-
tion or insomnia.
5. Nausea related to side effects of atomoxetine or bupropion.
6. Pain related to side effect of abdominal pain (atomoxetine,
bupropion) or headache (all agents).
7. Risk for activity intolerance related to side effects of sedation
or dizziness (atomoxetine or bupropion)
NURSING IMPLICATIONS FOR ADHD

AGENTS
The plan of care should include monitoring for the follow-
ing side effects from agents for ADHD. Nursing implications
related to each side effect are designated by an asterisk (*).
1. Overstimulation, restlessness, insomnia (CNS stimulants)
* Assess mental status for changes in mood, level of activity,
degree of stimulation, and aggressiveness.
* Ensure that the client is protected from injury.
* Keep stimuli low and environment as quiet as possible to
discourage overstimulation.
* To prevent insomnia, administer the last dose at least
6 hours before bedtime. Administer sustained-release
forms in the morning.
2. Palpitations, tachycardia (CNS stimulants; atomoxetine;
bupropion; clonidine) or bradycardia (clonidine, guanfacine)
* Monitor and record vital signs at regular intervals (two or
three times a day) throughout therapy. Report signicant
changes to the physician immediately.
2506_Ch31_522-537.indd 1534 10/1/10 9:40:58 AM

NOTE: The U.S. Food and Drug Administration recently

issued warnings associated with CNS stimulants and
atomoxetine of the risk for sudden death in patients who
have cardiovascular disease. A careful personal and fam-
ily history of heart disease, heart defects, or hypertension
should be obtained before these medications are prescribed.
Careful monitoring of cardiovascular function during
administration must be ongoing.
3. Anorexia, weight loss (CNS stimulants; atomoxetine;
bupropion)
* To reduce anorexia, the medication may be administered
immediately after meals. The client should be weighed
regularly (at least weekly) when receiving therapy with
CNS stimulants, atomoxetine, or bupropion because of the
potential for anorexia and weight loss, and temporary in-
terruption of growth and development.
4. Tolerance, physical and psychological dependence (CNS
stimulants)
* Tolerance develops rapidly.
* In children with ADHD, a drug holiday should be
attempted periodically under direction of the physician to
determine the effectiveness of the medication and the need
for continuation.
* The drug should not be withdrawn abruptly. To do so
could initiate the following syndrome of symptoms: nau-
sea, vomiting, abdominal cramping, headache, fatigue,
weakness, mental depression, suicidal ideation, increased
dreaming, and psychotic behavior.
5. Nausea and vomiting (atomoxetine and bupropion)
* May be taken with food to minimize GI upset.
6. Constipation (atomoxetine, bupropion, clonidine, guanfacine)
* Increase ber and uid in diet, if not contraindicated.
7. Dry mouth (clonidine and guanfacine)
* Offer the client sugarless candy, ice, frequent sips of water
* Strict oral hygiene is very important.
8. Sedation (clonidine and guanfacine)
* Warn client that this effect is increased by concomitant use
of alcohol and other CNS drugs.
* Warn clients to refrain from driving or performing haz-
ardous tasks until response has been established.
9. Potential for seizures (bupropion)
* Protect client from injury if seizure should occur. Instruct
family and signicant others of clients on bupropion ther-
apy how to protect client during a seizure if one should
occur. Ensure that doses of the immediate release medica-
tion are administered 4 to 6 hours apart, and doses of the
sustained release medication at least 8 hours apart.
2506_Ch31_522-537.indd 1535 10/1/10 9:40:59 AM

10. Severe liver damage (with atomoxetine)

* Monitor for the following side effects and report to physi-
cian immediately: itching, dark urine, right upper quad-
rant pain, yellow skin or eyes, sore throat, fever, malaise.
11. New or worsened psychiatric symptoms (with CNS
stimulants and atomoxetine)
* Monitor for psychotic symptoms (e.g., hearing voices,
paranoid behaviors, delusions).
* Monitor for manic symptoms, including aggressive and
hostile behaviors.
12. Rebound syndrome (with clonidine and guanfacine)
* Client should be instructed not to discontinue therapy
abruptly. To do so may result in symptoms of nervous-
ness, agitation, headache, and tremor, and a rapid rise in
blood pressure. Dosage should be tapered gradually under
the supervision of the physician.

TO AGENTS FOR ADHD
Use caution in driving or operating dangerous machinery.
Drowsiness, dizziness, and blurred vision can occur.
Do not stop taking CNS stimulants abruptly. To do so could
produce serious withdrawal symptoms.
Avoid taking CNS stimulants late in the day to prevent insomnia.
Take no later than 6 hours before bedtime.
Do not take other medications (including over-the-counter
drugs) without physicians approval. Many medications con-
tain substances that, in combination with agents for ADHD,
can be harmful.
Diabetic clients should monitor blood sugar 2 or 3 times a day
or as instructed by the physician. Be aware of the need for
possible alteration in insulin requirements because of changes
in food intake, weight, and activity.
Avoid consumption of large amounts of caffeinated products
(coffee, tea, colas, chocolate), as they may enhance the CNS
stimulant effect.
Notify physician if symptoms of restlessness, insomnia, an-
orexia, or dry mouth become severe or if rapid, pounding
heartbeat becomes evident. Report any of the following side
effects to the physician immediately: shortness of breath,
chest pain, jaw/left arm pain, fainting, seizures, sudden vision
changes, weakness on one side of the body, slurred speech,
confusion, itching, dark urine, right upper quadrant pain,
yellow skin or eyes, sore throat, fever, malaise, increased
hyperactivity, believing things that are not true, or hearing
voices.
2506_Ch31_522-537.indd 1536 10/1/10 9:40:59 AM

Be aware of possible risks of taking agents for ADHD during

pregnancy. Safe use during pregnancy and lactation has not
been established. Inform the physician immediately if preg-
nancy is suspected or planned.
Be aware of potential side effects of agents for ADHD. Refer
to written materials furnished by health-care providers for
safe self-administration.
Carry a card or other identication at all times describing
INTERNET REFERENCES
b. http://www.drugguide.com
d. http://www.fadavis.com/townsend
.html
2506_Ch31_522-537.indd 1537 10/1/10 9:40:59 AM

A P P E N D I X
A
Comparison of
Development Theories
Age Stage Major Developmental Tasks
FREUDS STAGES OF PSYCHOSEXUAL DEVELOPMENT
Birth18 months Oral Relief from anxiety through
oral gratication of needs
18 months Anal Learning independence and

3 years control, with focus on the
excretory function
36 years Phallic Identication with parent
of same gender; develop-
ment of sexual identity;
focus is on genital organs
612 years Latency Sexuality is repressed; focus
is on relationships with
same-gender peers
1320 years Genital Libido is reawakened as geni-
tal organs mature; focus
is on relationships with
members of the
opposite gender
538
2506_Appendix_A_538-544.indd 1538 10/1/10 9:29:49 AM

APPENDIX A 539
STAGES OF DEVELOPMENT IN H.S. SULLIVANS

INTERPERSONAL THEORY
Birth18 months Infancy Relief from anxi-
ety through oral
gratication of
needs
18 months Childhood Learning to experi-

6 years ence a delay in
personal grati-
cation without
undue anxiety
69 years Juvenile Learning to form
satisfactory peer
relationships
912 years Preadolescence Learning to form
satisfactory
relationships
with persons of
the same gender;
the initiation of
feelings of affec-
tion for another
person
1214 years Early adolescence Learning to form
satisfactory re-
lationships with
persons of the
opposite gender;
developing a
sense of identity
1421 years Late adolescence Establishing self-
identity; experi-
encing satisfying
relationships;
working to
develop a lasting,
intimate op-
posite-gender
relationship

540 APPENDIX A
STAGES OF DEVELOPMENT IN ERIC

ERIKSONS PSYCHOSOCIAL THEORY
Infancy Trust vs. To develop a basic trust in
(Birth18 mistrust the mothering gure and
months) be able to generalize it
to others
Early Autonomy vs. To gain some self-control

childhood shame and and independence within
(18 months doubt the environment
3 years)
Late Initiative vs. To develop a sense of pur-

childhood. guilt pose and the ability to
(36 years) initiate and direct own
activities
School age Industry vs. To achieve a sense of self-
(612 years) inferiority condence by learning,
competing, performing
successfully, and receiv-
ing recognition from
signicant others, peers,
and acquaintances
Adolescence Identity vs. To integrate the tasks
(1220 years) role mastered in the previous
confusion stages into a secure sense
of self
Young adult- Intimacy vs. To form an intense, lasting
hood isolation relationship or a commit-
(2030 years) ment to another person,
a cause, an institution, or
a creative effort
Adulthood Generativity To achieve the life goals
while vs. stagna- established for oneself,
(3065 years) tion also considering the
welfare of future
generations
Old age Ego integrity To review ones life and derive
(65 years vs. despair meaning from both posi-
death) tive and negative events,
while achieving a positive
sense of self-worth

APPENDIX A 541
STAGES OF DEVELOPMENT IN M. MAHLERS THEORY

OF OBJECT RELATIONS
Birth I. Normal autism Fulllment of basic
1 month needs for survival
and comfort
15 months II. Symbiosis Developing awareness

of external source
of need fulllment
III. Separation-
Individuation
510 months a. Differentiation Commencement of a
primary recogni-
tion of separateness
from the mothering
gure
1016 b. Practicing Increased independ-
months ence through loco-
motor functioning;
increased sense of
separateness of self
1624 c. Rapprochement Acute awareness of
months separateness of
self; learning to
seek emotional
refueling from
mothering gure to
maintain feeling of
security
2436 months d. Consolidation Sense of separate-
ness established; on
the way to object
constancy (i.e., able
to internalize a
sustained image of
loved object/person
when it is out of
sight); resolution of
separation anxiety

542 APPENDIX A
PIAGETS STAGES OF COGNITIVE DEVELOPMENT

Birth Sensorimotor With increased mobility and
2 years awareness, develops a sense
of self as separate from the
external environment; the
concept of object perma-
nence emerges as the abil-
ity to form mental images
evolves
26 years Preopera- Learning to express self with

tional language; develops under-
standing of symbolic ges-
tures; achievement of object
permanence
612 years Concrete Learning to apply logic to
operations thinking; development of
understanding of reversibil-
ity and spatiality; learning
to differentiate and classify;
increased socialization and
application of rules
1215+ years Formal Learning to think and reason in
operations abstract terms; making and
testing hypotheses; capabil-
ity of logical thinking and
reasoning expand and are
rened; cognitive maturity
achieved
KOHLBERGS STAGES OF MORAL DEVELOPMENT

I. Preconventional 1. Punishment and Behavior is moti-
(common from obedience vated by fear of
ages 4 to orientation punishment
10 years)
2. Instrumental Behavior is
relativist motivated by
orientation egocentrism and
concern for self

APPENDIX A 543
KOHLBERGS STAGES OF MORAL DEVELOPMENT

II. Conventional 3. Interpersonal Behavior is
(common from concordance motivated by
ages 10 to 13 orientation the expecta-
years and into tions of others;
adulthood) strong desire
for approval and
acceptance
4. Law and order Behavior is moti-

orientation vated by respect
for authority
III. Postconven- 5. Social contract Behavior is moti-
tional (can legalistic vated by respect
occur from orientation for universal
adolescence on) laws and moral
principles and
guided by an
internal set of
values
6. Universal Behavior is moti-
ethical principle vated by internal-
orientation ized principles
of honor, justice,
and respect for
human dignity
and guided by the
conscience
STAGES OF DEVELOPMENT IN H. PEPLAUS

Infancy Learning to count Learning to com-
on others municate in
various ways to
the primary care-
giver in order
to have comfort
needs fullled
Continued

544 APPENDIX A
STAGES OF DEVELOPMENT IN H. PEPLAUS

Toddlerhood Learning to delay Learning the
gratication satisfaction of
pleasing others
by delaying self-
gratication in
small ways
Early childhood Identifying oneself Learning appropri-

ate roles and
behaviors by ac-
quiring the abil-
ity to perceive
the expectations
of others
Late childhood Developing skills in Learning the skills
participation of compromise,
competition, and
cooperation with
others; establish-
ment of a more
realistic view of
the world and a
feeling of ones
place in it.
Source: Adapted from Townsend, M.C. (2009). Psychiatric/mental health

nursing: Concepts of care in evidence-based practice (6th ed.). Philadelphia:
FA Davis, pp. 33, 35, 36, 38, 40, 41, 43.

A P P E N D I X
B
Ego Defense
Mechanisms
Defense Defense
Mechanisms Example Mechanisms Example
Compensa- A physically Rationaliza- John tells

tion: handi- tion: the rehab
Covering up capped boy Attempting nurse,
a real or is unable to to make I drink
perceived participate excuses or because its
weakness in football, formulate the only
by empha- so he com- logical way I can
sizing a pensates reasons to deal with
trait one by becom- justify un- my bad
considers ing a great acceptable marriage
more desir- scholar. feelings or and my
able. behaviors. worse job.
Denial: A woman Reaction Jane hates

Refusing to who drinks Formation: nursing. She
acknowl- alcohol Preventing attended
edge the every day unaccept- nursing
existence and cannot able or school to
of a real stop fails to undesirable please her
situation or acknowl- thoughts or parents.
the feelings edge that behaviors During
associated she has a from being career day,
with it. problem. expressed she speaks
by exag- to prospec-
gerating tive students
opposite about the
thoughts excellence
or types of of nursing
behaviors as a career.
Continued
545
2506_Appendix_B_545-547.indd 545 10/1/10 9:30:00 AM

546 APPENDIX B
Defense Defense
Displace- A client is Regression: When 2-year-

ment: angry at his Retreating old Jay is
The transfer physician, in response hospitalized
of feelings does not to stress to for tonsil-
from one express an ear- litis he will
target to it, but lier level of drink only
another becomes develop- from a
that is con- verbally ment and bottle, even
sidered less abusive the comfort though his
threatening with the measures mom states
or that is nurse. associated he has been
neutral. with that drinking
level of from a
functioning. cup for
6 months.
Identifica- A teen- Repression: An accident
tion: ager who Involuntar- victim can
An attempt required ily blocking remember
to increase lengthy unpleasant nothing
self-worth rehabilita- feelings and about his
by acquir- tion after experiences accident.
ing certain an accident from ones
attributes decides to awareness.
and charac- become a
teristics of physical
an indi- therapist as
vidual one a result
admires. of his
experiences.
Intellectuali- Ss husband Sublimation: A mother
zation: is being Rechan- whose son
An attempt transferred neling of was killed
to avoid with his job drives or by a drunk
expressing to a city far impulses driver
actual emo- away from that are chan-
tions asso- her parents. personally nels her
ciated with She hides or socially anger and
a stressful anxiety by unaccept- energy into
situation by explain- able into being the
using ing to her activities president
parents the that are of the local
advantages construc- chapter of
tive.

APPENDIX B 547
Defense Defense
the intellectu- associated Mothers

al processes with the Against
of logic, move. Drunk
reasoning, Drivers.
and analysis.
Introjection: Children Suppression: Scarlett
Integrating integrate The OHara
the beliefs their par- voluntary says, I
and values ents value blocking of dont want
of another system unpleasant to think
individual into the feelings and about that
into ones process of experiences now. Ill
own ego conscience from ones think
structure. formation. awareness. about that
A child says tomorrow.
to friend,
Dont
cheat. Its
wrong.
Isolation: A young Undoing: Joe is nervous
Separating woman Symbolical- about his
a thought describes ly negating new job and
or memory being or cance- yells at his
from the attacked ling out an wife. On his
feeling tone and raped, experience way home
or emotion without that one he stops
associated showing nds intol- and buys
with it. any erable. her some
emotion. owers.
Projection Sue feels a
Attributing strong sexual
feelings or attraction
impulses to her track
unacceptable coach and
to ones self tells her
to another friend, Hes
person. coming on
to me!
Source: Townsend, M.C. (2009). Psychiatric/mental health nursing:

Concepts of care in evidence-based practice (6th ed.). Philadelphia:
FA Davis, p. 18.

A P P E N D I X
C
Levels of Anxiety
548
2506_Appendix_C_548-551.indd 548 10/1/10 9:30:09 AM

2506_Appendix_C_548-551.indd 549
Physical Emotional/Behavioral
Level Perceptual Field Ability to Learn Characteristics Characteristics
Mild Heightened perception Learning is Restlessness May remain supercial
(e.g., noises may seem enhanced. Irritability with others
louder; details within the Rarely experienced as
environment are clearer) distressful
Increased awareness Motivation is
Increased alertness increased.
Moderate Reduction in perceptual Learning still Increased restlessness A feeling of discontent

eld occurs, but not at Increased heart and May lead to a degree
Reduced alertness to envi- optimal ability. respiration rate of impairment in in-
ronmental events (e.g., Decreased attention Increased perspiration terpersonal relation-
someone talking may span Gastric discomfort ships as individual
not be heard; part of the Decreased ability to Increased muscular begins to focus on
room may not be noticed) concentrate tension self and the need
Increase in speech rate, to relieve personal
volume, and pitch discomfort
APPENDIX C
Continued

549
10/1/10 9:30:09 AM
550
APPENDIX C
Severe Greatly diminished. Only Extremely limited Headaches Feelings of dread,

extraneous details are attention span Dizziness loathing, horror
perceived, or xation on a Unable to concentrate Nausea Total focus on self and
single detail may occur. or problem-solve Trembling intense desire to
May not take notice of an Effective learning Insomnia relieve the anxiety
event even when at- cannot occur. Palpitations
tention is directed by Tachycardia
another Hyperventilation
Urinary frequency
Diarrhea
10/1/10 9:30:09 AM
Panic Unable to focus on even Learning cannot occur. Dilated pupils Sense of impending
one detail within the Unable to Labored breathing doom
environment concentrate Severe trembling Terror
Misperceptions of the Unable to comprehend Sleeplessness Bizarre behavior,
environment are common even simple directions Palpitations including shouting,
(e.g., a perceived detail Diaphoresis and pallor screaming, running
may be elaborated and out Muscular incoordination about wildly, clinging
of proportion). Immobility or purpose- to anyone or anything
less hyperactivity from which a sense of
Incoherence or inability safety and security is
to verbalize derived
Hallucinations; delusions
Extreme withdrawal
into self
Source: From Townsend, M.C. (2009). Psychiatric/mental health nurs-

APPENDIX C
ing: Concepts of care in evidence-based practice (6th ed.). Philadelphia:

FA Davis, p. 16.
551
10/1/10 9:30:10 AM
A P P E N D I X
D
Stages of Grief
552
2506_Appendix_D_552-556.indd 552 10/1/10 9:30:18 AM

A Comparison of Models by Elisabeth Kbler-Ross, John Bowlby, George Engel, and William Worden
2506_Appendix_D_552-556.indd 553
Stages/Tasks
Possible Time
Kbler-Ross Bowlby Engel Worden Dimension Behaviors
I. Denial I. Numbness/ I. Shock/disbelief I. Accepting the Occurs im- Individual refuses to

protest reality of the mediately on acknowledge that the loss
loss experienc- has occurred.
ing the loss.
Usually lasts
no more
than a few
weeks.
II. Anger II. Disequilibrium II. Developing In most cases Anger is directed toward self
awareness begins within or others. Ambivalence and
hours of the guilt may be felt toward the
loss; peaks lost object.
within a few
weeks.
APPENDIX D

III. Bargaining The individual fervently seeks

alternatives to improve
553
current situation.
Continued
10/1/10 9:30:18 AM
554
Stages/Tasks
Possible Time
APPENDIX D
III. Restitution Attends to various rituals as-

sociated with the culture in
which the loss has occurred.
IV. Depression III. Disorgani- IV. Resolution of II. Processing the Very individ- The actual work of grieving.
zation and the loss pain of grief ual. Com- Preoccupation with the lost
despair monly 6 to entity. Feelings of helpless-
12 months. ness and loneliness occur
Longer for in response to realization
some. of the loss. Feelings as-
sociated with the loss are
confronted.
10/1/10 9:30:18 AM
Stages/Tasks
Possible Time
III. Adjusting to Ongoing How the environment chang-

a world with- es depends on the roles the
out the lost lost entity played in the
entity. life of the bereaved person.
Adaptations will have to
be made as the changes are
presented in daily life. New
coping skills will have to be
developed.
Continued
APPENDIX D

555
10/1/10 9:30:19 AM
Stages/Tasks
556 APPENDIX D
Possible Time
V. Acceptance IV. Reorganization V. Recovery IV. Finding an Resolution is complete. The

enduring con- bereaved person experiences
nection with a reinvestment in new rela-
the lost entity tionships and new goals. The
in the midst of lost entity is not purged or
embarking on a replaced, but relocated in the
new life. life of the bereaved. At this
stage, terminally ill persons
express a readiness to die.
Source: Adapted from Townsend, M.C. (2009), Psychiatric/mental

health nursing: Concept of care in evidence-based practice (6rh ed.).
Philadelphia: FA Davis.
10/1/10 9:30:19 AM
A P P E N D I X
E
Relationship
Development
and Therapeutic
Communication
PHASES OF A THERAPEUTIC
NURSE-CLIENT RELATIONSHIP
Psychiatric nurses use interpersonal relationship development
as the primary intervention with clients in various psychiatric
and mental health settings. This is congruent with Peplaus
(1962) identication of counseling as the major subrole of nurs-
ing in psychiatry. If Sullivans (1953) belief is true, that is, that
all emotional problems stem from difculties with interpersonal
relationships, then this role of the nurse in psychiatry becomes
especially meaningful and purposeful. It becomes an integral
part of the total therapeutic regimen.
The therapeutic interpersonal relationship is the means by
which the nursing process is implemented. Through the rela-
tionship, problems are identied and resolution is sought. Tasks
of the relationship have been categorized into four phases: the
preinteraction phase, the orientation (introductory) phase, the
working phase, and the termination phase. Although each phase
is presented as specic and distinct from the others, there may
be some overlapping of tasks, particularly when the interaction
is limited.
The Preinteraction Phase

The preinteraction phase involves preparation for the rst
encounter with the client. Tasks include the following:
1. Obtaining available information about the client from the
chart, signicant others, or other health-team members.
From this information, the initial assessment is begun. From
557
2506_Appendix_E_557-569.indd 557 10/1/10 9:30:28 AM

558 APPENDIX E
this initial information, the nurse may also become aware of

personal responses to knowledge about the client.
2. Examining ones feelings, fears, and anxieties about work-
ing with a particular client. For example, the nurse may have
been reared in an alcoholic family and have ambivalent feel-
ings about caring for a client who is alcohol dependent. All
individuals bring attitudes and feelings from prior experi-
ences to the clinical setting. The nurse needs to be aware of
how these preconceptions may affect his or her ability to care
for individual clients.
The Orientation (Introductory) Phase

During the orientation phase, the nurse and client become
acquainted. Tasks include the following:
1. Creating an environment for the establishment of trust and
rapport
2. Establishing a contract for intervention that details the
expectations and responsibilities of both the nurse and client
3. Gathering assessment information to build a strong client
database
4. Identifying the clients strengths and limitations
5. Formulating nursing diagnoses
6. Setting goals that are mutually agreeable to the nurse and
client
7. Developing a plan of action that is realistic for meeting the
established goals
8. Exploring feelings of both the client and the nurse in terms
of the introductory phase. Introductions are often uncom-
fortable, and the participants may experience some anxiety
until a degree of rapport has been established. Interactions
may remain on a supercial level until the anxiety subsides.
Several interactions may be required to fulll the tasks
associated with this phase.
The Working Phase

The therapeutic work of the relationship is accomplished during
this phase. Tasks include the following:
1. Maintaining the trust and rapport that was established dur-
ing the orientation phase
2. Promoting the clients insight and perception of reality
3. Problem-solving in an effort to bring about change in the
clients life
4. Overcoming resistance behaviors on the part of the client as
the level of anxiety rises in response to discussion of painful
issues
5. Continuously evaluating progress toward goal attainment

APPENDIX E 559
The Termination Phase

Termination of the relationship may occur for a variety of rea-
sons: the mutually agreed-upon goals may have been reached,
the client may be discharged from the hospital, or in the case of
a student nurse, the clinical rotation may come to an end. Ter-
mination can be a difcult phase for both the client and nurse.
Tasks include the following:
1. Bringing a therapeutic conclusion to the relationship. This
occurs when:
a. Progress has been made toward attainment of mutually
set goals.
b. A plan for continuing care or for assistance during stress-
ful life experiences is mutually established by the nurse
and client.
c. Feelings about termination of the relationship are rec-
ognized and explored. Both the nurse and client may ex-
perience feelings of sadness and loss. The nurse should
share his or her feelings with the client. Through these
interactions, the client learns that it is acceptable to un-
dergo these feelings at a time of separation. Through this
knowledge, the client experiences growth during the pro-
cess of termination.
Note: When the client feels sadness and loss, behaviors to
delay termination may become evident. If the nurse experi-
ences the same feelings, he or she may allow the clients
behaviors to delay termination. For therapeutic closure, the
nurse must establish the reality of the separation and resist
being manipulated into repeated delays by the client.
THERAPEUTIC COMMUNICATION
TECHNIQUES
Explanation/
Technique Rationale Examples
Using Gives the client the
silence opportunity to
collect and organ-
ize thoughts, to
think through a
point, or to consider
introducing a topic
of greater concern
than the one being
discussed.
Continued

560 APPENDIX E
Explanation/
Accepting Conveys an attitude Yes, I understand what
of reception and you said. Eye contact;
regard. nodding.
Giving Acknowledging; Hello, Mr. J. I notice

recogni- indicating aware- that you made a ce-
tion ness; better than ramic ash tray in OT.
complimenting, I see you made your
which reects the bed.
nurses judgment.
Offering Making oneself Ill stay with you a
self available on an while.
unconditional We can eat our lunch
basis, increasing the together.
clients feelings of Im interested in you.
self-worth.
Giving Allows the client to What would you like to
broad take the initiative talk about today?
openings in introducing the Tell me what you are
topic; emphasizes thinking.
the importance
of the clients role
in the interaction.
Offering Offers the client Yes, I see. Go on.
general encouragement to And after that?
leads continue.
Placing the Claries the relation- What seemed to lead
event in ship of events in up to...?
time or time so that the Was this before or
sequence nurse and client after...?
can view them in When did this
perspective. happen?
Making Verbalizing what You seem tense.

observa- is observed or I notice you are
tions perceived. This en- pacing a lot.
courages the client You seem uncomfort-
to recognize specic able when you...
behaviors and com-
pare perceptions
with the nurse.

APPENDIX E 561
Explanation/
Encour- Asking the client to Tell me what is
aging verbalize what is happening now.
descrip- being perceived; Are you hearing the
tion of often used with voices again?
percep- clients experiencing What do the voices
tions hallucinations. seem to be saying?
Encourag- Asking the client to Was this something

ing com- compare similarities like...?
parison and differences in How does this
ideas, experiences, or compare with the
interpersonal rela- time when...?
tionships. Helps the What was your
client recognize life response the last
experiences that tend time this situation
to recur as well as occurred?
those aspects of life
that are changeable.
Restating The main idea of Cl: I cant study.
what the client has My mind keeps wan-
said is repeated; dering.
lets the client Ns: You have difficulty
know whether an concentrating.
expressed statement Cl: I cant take that new
has been under- job. What if I cant
stood and gives him do it?
or her the chance Ns: Youre afraid you
to continue, or to will fail in this new
clarify if necessary. position.
Reecting Questions and feel- Cl: What do you think

ings are referred I should do about
back to the client my wifes drinking
so that they may problem?
be recognized and Ns: What do you think
accepted and so you should do?
that the client may Cl: My sister wont
recognize that his help a bit toward my
or her point of view mothers care. I have
has value. A good to do it all!
technique to use Ns: You feel angry when
when the client asks she doesnt help.
the nurse for advice.
Continued

562 APPENDIX E
Explanation/
Focusing Taking notice of a This point seems
single idea or even a worth looking at more
single word. Works closely. Perhaps you
especially well with and I can discuss it
a client who is mov- together.
ing rapidly from one
thought to another.
This technique is not
therapeutic, how-
ever, with the client
who is very anxious.
Focusing should
not be pursued until
the anxiety level has
subsided.
Exploring Delving further into a Please explain that

subject, idea, experi- situation in more
ence, or relation- detail.
ship. Especially Tell me more about
helpful with clients that particular
who tend to remain situation.
on a supercial level
of communication.
However, if the
client chooses not to
disclose further in-
formation, the nurse
should refrain from
pushing or prob-
ing in an area that
obviously creates
discomfort.
Seeking Striving to explain Im not sure that I un-
clarica- that which is vague derstand. Would you
tion and or incomprehensible please explain?
validation and searching for Tell me if my under-
mutual understand- standing agrees with
ing; clarifying the yours.
meaning of what has Do I understand
been said facilitates correctly that you
and increases under- said...?
standing for both
client and nurse.

APPENDIX E 563
Explanation/
Presenting When the client has I understand that the
reality a misperception of voices seem real to
the environment, you, but I do not hear
the nurse denes any voices.
reality or indicates There is no one else in
his or her perception the room but you and
of the situation for me.
the client.
Voicing Expressing uncer- I find that hard to

doubt tainty as to the believe (or accept).
reality of the clients That seems rather
perceptions. Often doubtful to me.
used with clients
experiencing delu-
sional thinking.
Verbal- Putting into words Cl: Its a waste of time
izing the what the client has to be here. I cant talk
implied only implied or said to you or anyone.
indirectly; can also Ns: Are you feeling that
be used with the no one understands?
client who is mute Cl: (Mute)
or is otherwise ex- Ns: It must have been
periencing impaired very difficult for you
verbal communica- when your husband
tion. This claries died in the fire.
that which is implicit
rather than explicit.
Attempting When feelings are Cl: Im way out in the
to trans- expressed indirectly, ocean.
late words the nurse tries to Ns: You must be
into desymbolize what feeling very lonely
feelings has been said and now.
to nd clues to the
underlying true
feelings.
Continued

564 APPENDIX E
Explanation/
Formulating When a client has a What could you do
a plan of plan in mind for to let your anger out
action dealing with what is harmlessly?
considered to be a Next time this comes
stressful situation, it up, what might you
may serve to prevent do to handle it more
anger or anxiety appropriately?
from escalating to an
unmanageable level.
Source: Adapted from Hays, J.S., and Larson, K.H. (1963). Interacting
with patients. New York: Holt, Rinehart, and Winston.
NONTHERAPEUTIC COMMUNICATION
TECHNIQUES
Explanation/
Giving Indicates to the client I wouldnt worry
reassurance that there is no cause for about that if I
anxiety, thereby devalu- were you.
ing the clients feelings. Everything will be
May discourage the client all right.
from further expression Better to say: We
of feelings if he or she will work on that
believes they will only be together.
downplayed or ridiculed.
Rejecting Refusing to consider or Lets not discuss...

showing contempt for I dont want to
the clients ideas or be- hear about...
havior. This may cause Better to say: Lets
the client to discontin- look at that a little
ue interaction with the closer.
nurse for fear of further
rejection.

APPENDIX E 565
Explanation/
Giving Sanctioning or denounc- Thats good. Im
approval ing the clients ideas glad that you...
or disap- or behavior. Implies Thats bad. Id
proval that the nurse has the rather you
right to pass judgment wouldnt...
on whether the clients Better to say: Lets
ideas or behaviors talk about how
are good or bad, your behavior
and that the client is invoked anger in
expected to please the the other clients at
nurse. The nurses ac- dinner.
ceptance of the client
is then seen as condi-
tional depending on the
clients behavior.
Agreeing/ Indicating accord with or Thats right. I

disagreeing opposition to the clients agree.
ideas or opinions. Im- Thats wrong. I
plies that the nurse has disagree.
the right to pass judg- I dont believe
ment on whether the that.
clients ideas or opinions Better to say: Lets
are right or wrong. discuss what
Agreement prevents the you feel is unfair
client from later modi- about the new
fying his or her point of community rules.
view without admitting
error. Disagreement
implies inaccuracy,
provoking the need for
defensiveness on the
part of the client.
Giving Telling the client what to I think you
advice do or how to behave should...
implies that the nurse Why dont you...
knows what is best and Better to say: What
that the client is incapa- do you think you
ble of any self-direction. should do? or
It nurtures the client What do you
in the dependent role think would be
by discouraging best for you?
independent thinking.
Continued

566 APPENDIX E
Explanation/
Probing Persistent questioning of Tell me how your

the client. Pushing for mother abused
answers to issues the you when you
client does not wish to were a child.
discuss. This causes the Tell me how you
client to feel used and feel toward your
valued only for what is mother now that
shared with the nurse, she is dead.
and places the client on Now tell me
the defensive. about...
Better technique:
The nurse should
be aware of the
clients response
and discontinue
the interaction at
the first sign of
discomfort.
Defending Attempting to protect No one here would
someone or something lie to you.
from verbal attack. You have a very
To defend what the capable physician.
client has criticized is Im sure he only
to imply that he or she has your best in-
has no right to express terests in mind.
ideas, opinions, or feel- Better to say: I
ings. Defending does will try to answer
not change the clients your questions
feelings and may cause and clarify some
the client to think the issues regarding
nurse is taking sides your treatment.
with those being criti-
cized and against the
client.

APPENDIX E 567
Explanation/
Requesting Asking the client to Why do you think

an expla- provide the reasons that?
nation for thoughts, feelings, Why do you feel
behavior, and events. this way?
Asking why a client Why did you do
did something or feels that?
a certain way can be Better to say:
very intimidating, and Describe what
implies that the client you were feeling
must defend his or her just before that
behavior or feelings. happened.
Indicating Attributing the source of What makes you

the exist- thoughts, feelings, and say that?
ence of an behavior to others or What made you do
external to outside inuences. that?
source of This encourages the What made you so
power client to project blame angry last night?
for his or her thoughts Better to say:
or behaviors on others You became
rather than accept- angry when your
ing the responsibility brother insulted
personally. your wife.
Belittling When the nurse mis- Cl: I have nothing

feelings judges the degree of to live for. I wish I
expressed the clients discomfort, were dead.
a lack of empathy and Ns: Everybody
understanding may be gets down in the
conveyed. The nurse dumps at times.
may tell the client to I feel that way my-
perk up or snap out self sometimes.
of it. This causes the Better to say: You
client to feel insigni- must be very up-
cant or unimportant. set. Tell me what
When one is experienc- you are feeling
ing discomfort, it is right now.
no relief to hear that
others are or have been
in similar situations.
Continued

568 APPENDIX E
Explanation/
Making Cliches and trite expres- Im fine, and how

stereo- sions are meaning- are you?
typed less in a nurse-client Hang in there.
comments relationship. For the Its for your own
nurse to make empty good.
conversation is to en- Keep your chin
courage a like response up.
from the client. Better to say: The
therapy must be
difficult for you
at times. How do
you feel about your
progress at this
point?
Using denial When the nurse denies Cl: Im nothing.
that a problem exists, Ns: Of course
he or she blocks discus- youre something.
sion with the client and Everybody is
avoids helping the cli- somebody.
ent identify and explore Better to say:
areas of difculty. Youre feeling
like no one cares
about you right
now.
Interpreting With this technique the What you really
therapist seeks to make mean is...
conscious that which is Unconsciously
unconscious, to tell the youre saying...
client the meaning of Better to say: The
his or her experience. nurse must leave
interpretation
of the clients
behavior to the
psychiatrist. The
nurse has not
been prepared
to perform this
technique and, in
attempting to do
so, may endanger
other nursing roles
with the client.

APPENDIX E 569
Explanation/
Introducing Changing the subject Cl: I dont have any-

an unre- causes the nurse to take thing to live for.
lated topic over the direction of the Ns: Did you have
discussion. This may visitors this
occur in order to get to weekend?
something that the nurse Better technique:
wants to discuss with The nurse must re-
the client or to get away main open and free
from a topic that he or to hear the client,
she would prefer not to to take in all that
discuss. is being conveyed,
both verbally and
nonverbally.
Source: Adapted from Hays, J.S., and Larson, K.H. (1963). Interacting
with patients. New York: Holt, Rinehart, and Winston.

A P P E N D I X
F
Psychosocial
Therapies
GROUP THERAPY
Group therapy is a type of psychosocial therapy with a number
of clients at one time. The group is founded in a specic theo-
retical framework, with the goal being to encourage improve-
ment in interpersonal functioning.
Nurses often lead therapeutic groups, which are based to a
lesser degree in theory. The focus of therapeutic groups is more
on group relations, interactions among group members, and the
consideration of a selected issue.
Types of groups include task groups, in which the function
is to accomplish a specic outcome or task; teaching groups, in
which knowledge or information is conveyed to a number of
individuals; supportive-therapeutic groups, which help prevent
future upsets by teaching participants effective ways of dealing
with emotional stress arising from situational or developmental
crises; and self-help groups of individuals with similar problems
who meet to help each other with emotional distress associated
with those problems.
Yalom (2005) identied 11 curative factors that individu-
als can achieve through interpersonal interactions within the
group. They include the following:
1. The instillation of hope
2. Universality (individuals come to understand that they are
not alone in the problems they experience)
3. The imparting of information
4. Altruism (mutual sharing and concern for each other)
5. The corrective recapitulation of the primary family group
6. The development of socializing techniques
7. Imitative behavior
8. Interpersonal learning
9. Group cohesiveness
10. Catharsis (open expression of feelings)
570
2506_Appendix_F_570-579.indd 570 10/1/10 9:30:40 AM

APPENDIX F 571
11. Existential factors (the group is able to help individual mem-

bers take direction of their own lives and to accept respon-
sibility for the quality of their existence)
PSYCHODRAMA
Psychodrama is a specialized type of therapeutic group that em-
ploys a dramatic approach in which clients become actors in
life-situation scenarios.
The group leader is called the director, group members are the
audience, and the set, or stage, may be specially designed or may
just be any room or part of a room selected for this purpose. Ac-
tors are members from the audience who agree to take part in
the drama by role-playing a situation about which they have
been informed by the director. Usually the situation is an issue
with which one individual client has been struggling. The client
plays the role of himself or herself and is called the protagonist.
In this role, the client is able to express true feelings toward in-
dividuals (represented by group members) with whom he or she
has unresolved con icts.
In some instances, the group leader may ask for a client to
volunteer to be the protagonist for that session. The client may
choose a situation he or she wishes to enact and select the audi-
ence members to portray the roles of others in the life situation.
The psychodrama setting provides the client with a safer and
less threatening atmosphere than the real situation in which
to express true feelings. Resolution of interpersonal con icts is
facilitated.
When the drama has been completed, group members from
the audience discuss the situation they have observed, offer feed-
back, express their feelings, and relate their own similar experi-
ences. In this way, all group members benet from the session,
either directly or indirectly.
Nurses often serve as actors, or role players, in psychodra-
ma sessions. Leaders of psychodrama have graduate degrees in
psychology, social work, nursing, or medicine with additional
training in group therapy and specialty preparation to become
a psychodramatist.
FAMILY THERAPY
In family therapy, the nurse-therapist works with the family as
a group to improve communication and interaction patterns.
Areas of assessment include communication, manner of self-
concept reinforcement, family members expectations, handling
differences, family interaction patterns, and the climate of the
family (a blend of feelings and experiences that are the result of
sharing and interacting).

572 APPENDIX F
The Family as a System

General systems theory is a way of organizing thought accord-
ing to the holistic perspective. A system is considered greater
than the sum of its parts. A family can be viewed as a system
composed of various subsystems. The systems approach to fam-
ily therapy is composed of eight major concepts: (1) differentia-
tion of self, (2) triangles, (3) nuclear family emotional process,
(4) family projection process, (5) multigenerational transmission
process, (6) sibling position pro les, (7) emotional cutoff, and
(8) societal regression. The goal is to increase the level of dif-
ferentiation of self, while remaining in touch with the family
system.
The Structural Model

In this model, the family is viewed as a social system within which
the individual lives and to which the individual must adapt. The
individual both contributes to and responds to stresses within
the family. Major concepts include systems, subsystems, trans-
actional patterns, and boundaries. The goal of therapy is to
facilitate change in the family structure. The therapist does this
by joining the family, evaluating the family system, and restruc-
turing the family.
The Strategic Model

This model uses the interactional or communications approach.
Functional families are open systems where clear and precise
messages, congruent with the situation, are sent and received.
Healthy communication patterns promote nurturance and indi-
vidual self-worth. In dysfunctional families, viewed as partially
closed systems, communication is vague, and messages are often
inconsistent and incongruent with the situation. Destructive
patterns of communication tend to inhibit healthful nurtur-
ing and decrease individual feelings of self-worth. Concepts of
this model include double-bind communication, pseudomutual-
ity and pseudohostility, marital schism, and marital skew. The
goal of therapy is to create change in destructive behavior and
communication patterns among family members. This is ac-
complished by using paradoxical intervention (prescribing the
symptom) and reframing (changing the setting or viewpoint
in relation to which a situation is experienced and placing it in
another more positive frame of reference).
MILIEU THERAPY
In psychiatry, milieu therapy, or a therapeutic community, con-
stitutes a manipulation of the environment in an effort to create
behavioral changes and to improve the psychological health and

APPENDIX F 573
functioning of the individual. The goal of therapeutic commu-

nity is for the client to learn adaptive coping, interaction, and
relationship skills that can be generalized to other aspects of his
or her life. The community environment itself serves as the pri-
mary tool of therapy.
According to Skinner (1979), a therapeutic community is
based on seven basic assumptions:
1. The health in each individual is to be realized and encour-
aged to grow.
2. Every interaction is an opportunity for therapeutic
intervention.
3. The client owns his or her own environment.
4. Each client owns his or her behavior.
5. Peer pressure is a useful and a powerful tool.
6. Inappropriate behaviors are dealt with as they occur.
7. Restrictions and punishment are to be avoided.
Since the goals of milieu therapy relate to helping the client
learn to generalize that which is learned to other aspects of his
or her life, the conditions that promote a therapeutic commu-
nity in the hospital setting are similar to the types of conditions
that exist in real-life situations. They include the following:
1. The fulllment of basic physiological needs.
2. Physical facilities that are conducive to the achievement of
the goals of therapy.
3. The existence of a democratic form of self-government.
4. The assignment of unit responsibilities according to client
capabilities.
5. A structured program of social and work-related activities.
6. The inclusion of community and family in the program of
therapy in an effort to facilitate discharge from the hospital.
The program of therapy on the milieu unit is conducted by
the interdisciplinary treatment (IDT) team. The team includes
some, or all, of the following disciplines and may include oth-
ers that are not specied here: psychiatrist, clinical psychologist,
psychiatric clinical nurse specialist, psychiatric nurse, mental
health technician, psychiatric social worker, occupational thera-
pist, recreational therapist, art therapist, music therapist, psy-
chodramatist, dietitian, and chaplain.
Nurses play a crucial role in the management of a therapeutic
milieu. They are involved in the assessment, diagnosis, outcome
identication, planning, implementation, and evaluation of all
treatment programs. They have signicant input into the IDT
plans that are developed for all clients. They are responsible
for ensuring that clients basic needs are fullled, for continual
assessment of physical and psychosocial status, for medication
administration, for the development of trusting relationships,

574 APPENDIX F
for setting limits on unacceptable behaviors, for client educa-

tion, and ultimately, for helping clients, within the limits of
their capability, become productive members of society.
Milieu therapy came into its own during the 1960s through
the early 1980s. During this period, psychiatric inpatient treat-
ment provided sufcient time to implement programs of ther-
apy that were aimed at social rehabilitation. Currently, care in
inpatient psychiatric facilities is shorter and more biologically
based, limiting clients benet from the socialization that occurs
in a milieu as treatment program. Although strategies for mi-
lieu therapy are still used, they have been modied to conform
to the short-term approach to care or to outpatient treatment
programs.
CRISIS INTERVENTION
A crisis is a sudden event in ones life that disturbs homeo-
stasis, during which usual coping mechanisms cannot resolve
the problem (Lagerquist, 2006). All individuals experience
crises at one time or another. This does not necessarily indi-
cate psychopathology.
Crises are precipitated by specic, identiable events and are
determined by an individuals personal perception of the situa-
tion. They are acute, not chronic, and generally last no longer
than 4 to 6 weeks.
Crises occur when an individual is exposed to a stressor
and previous problem-solving techniques are ineffective. This
causes the level of anxiety to rise. Panic may ensue when new
techniques are employed and resolution fails to occur.
Six types of crises have been identied. They include disposi-
tional crises, crises of anticipated life transitions, crises resulting
from traumatic stress, maturational or developmental crises, cri-
ses reecting psychopathology, and psychiatric emergencies. The
type of crisis determines the method of intervention selected.
Crisis intervention is designed to provide rapid assistance for
individuals who have an urgent need. Aguilera (1998) suggests
that the focus is on the supportive, with the restoration of the
individual to his precrisis level of functioning or possibly to a
higher level of functioning.
Nurses regularly respond to individuals in crisis in all types
of settings. Nursing process is the vehicle by which nurses assist
individuals in crisis with a short-term problem-solving approach
to change. A four-phase technique is used: assessment/analysis,
planning of therapeutic intervention, intervention, and evalua-
tion of crisis resolution and anticipatory planning. Through this
structured method of assistance, nurses assist individuals in cri-
sis to develop more adaptive coping strategies for dealing with
stressful situations in the future.

APPENDIX F 575
RELAXATION THERAPY
Stress is a part of our everyday lives. It can be positive or nega-
tive, but it cannot be eliminated. Keeping stress at a manageable
level is a lifelong process.
Individuals under stress respond with a physiological arousal
that can be dangerous over long periods. Indeed, the stress re-
sponse has been shown to be a major contributor, either directly
or indirectly, to coronary heart disease, cancer, lung ailments,
accidental injuries, cirrhosis of the liver, and suicidesix of the
leading causes of death in the United States.
Relaxation therapy is an effective means of reducing the
stress response in some individuals. The degree of anxiety that
an individual experiences in response to stress is related to cer-
tain predisposing factors, such as characteristics of temperament
with which he or she was born, past experiences resulting in
learned patterns of responding, and existing conditions, such as
health status, coping strategies, and adequate support systems.
Deep relaxation can counteract the physiological and be-
havioral manifestations of stress. Various methods of relaxation
include the following:
Deep-Breathing Exercises: Tension is released when the
lungs are allowed to breathe in as much oxygen as pos-
sible. Deep-breathing exercises involve inhaling slowly
and deeply through the nose, holding the breath for a few
seconds, then exhaling slowly through the mouth, pursing
the lips as if trying to whistle.
Progressive Relaxation: This method of deep-muscle re-
laxation is based on the premise that the body responds
to anxiety-provoking thoughts and events with muscle
tension. Each muscle group is tensed for 5 to 7 seconds
and then relaxed for 20 to 30 seconds, during which time
the individual concentrates on the difference in sensa-
tions between the two conditions. Soft, slow background
music may facilitate relaxation. A modied version of this
technique (called passive progressive relaxation) involves re-
laxation of the muscles by concentrating on the feeling of
relaxation within the muscle, rather than the actual tens-
ing and relaxing of the muscle.
Meditation: The goal of meditation is to gain mastery over
attention. It brings on a special state of consciousness as
attention is concentrated solely on one thought or object.
During meditation, as the individual becomes totally pre-
occupied with the selected focus, the respiration rate, heart
rate, and blood pressure decrease. The overall metabolism
declines, and the need for oxygen consumption is reduced.

576 APPENDIX F
Mental Imagery: Mental imagery uses the imagination in an

effort to reduce the bodys response to stress. The frame of
reference is very personal, based on what each individual
considers to be a relaxing environment. The relaxing sce-
nario is most useful when taped and played back at a time
when the individual wishes to achieve relaxation.
Biofeedback: Biofeedback is the use of instrumentation to
become aware of processes in the body that usually go un-
noticed and to help bring them under voluntary control.
Biological conditions, such as muscle tension, skin surface
temperature, blood pressure, and heart rate, are monitored
by the biofeedback equipment. With special training, the
individual learns to use relaxation and voluntary control
to modify the biological condition, in turn indicating a
modication of the autonomic function it represents. Bio-
feedback is often used together with other relaxation tech-
niques such as deep breathing, progressive relaxation, and
mental imagery.
ASSERTIVENESS TRAINING
Assertive behavior helps individuals feel better about themselves
by encouraging them to stand up for their own basic human
rights. These rights have equal representation for all individu-
als. But along with rights comes an equal number of respon-
sibilities. Part of being assertive includes living up to these
responsibilities.
Assertive behavior increases self-esteem and the ability
to develop satisfying interpersonal relationships. This is ac-
complished through honesty, directness, appropriateness, and
respecting ones own rights, as well as the rights of others.
Individuals develop patterns of responding in various ways,
such as role modeling, by receiving positive or negative rein-
forcement, or by conscious choice. These patterns can take
the form of nonassertiveness, assertiveness, aggressiveness, or
passive-aggressiveness.
Nonassertive individuals seek to please others at the expense
of denying their own basic human rights. Assertive individuals
stand up for their own rights while protecting the rights of oth-
ers. Those who respond aggressively defend their own rights by
violating the basic rights of others. Individuals who respond in a
passive-aggressive manner defend their own rights by expressing
resistance to social and occupational demands.
Some important behavioral considerations of assertive be-
havior include eye contact, body posture, personal distance,
physical contact, gestures, facial expression, voice, uency, tim-
ing, listening, thoughts, and content. Various techniques have

APPENDIX F 577
been developed to assist individuals in the process of becoming

more assertive. Some of these include the following:
1. Standing up for ones basic human rights.
Example: I have the right to express my opinion.
2. Assuming responsibility for ones own statements.
Example: I dont want to go out with you tonight, instead of
I cant go out with you tonight. The latter implies a lack
of power or ability.
3. Responding as a broken record. Persistently repeating in
a calm voice what is wanted.
Example: Telephone salesperson: I want to help you save
money by changing long-distance services.
Assertive response: I dont want to change my long-
distance service.
Telephone salesperson: I cant believe you dont want to
save money!
Assertive response: I dont want to change my long-
distance service.
4. Agreeing assertively. Assertively accepting negative aspects
about oneself. Admitting when an error has been made.
Example:
Ms. Jones: You sure let that meeting get out of hand.
What a waste of time.
Ms. Smith: Yes, I didnt do a very good job of conduct-
ing the meeting today.
5. Inquiring assertively. Seeking additional information about
critical statements.
Example:
Male board member: You made a real fool of yourself at
the board meeting last night.
Female board member: Oh, really? Just what about my
behavior offended you?
Male board member: You were so damned pushy!
Female board member: Were you offended that I spoke up
for my beliefs, or was it because my
beliefs are in direct opposition to
yours?
6. Shifting from content to process. Changing the focus of
the communication from discussing the topic at hand to ana-
lyzing what is actually going on in the interaction.
Example:
Wife: Would you please call me if you will be late for
dinner?
Husband: Why dont you just get off my back! I always
have to account for every minute of my time
with you!

578 APPENDIX F
Wife: Sounds to me like we need to discuss some

other things here. What are you really angry
about?
7. Clouding/fogging. Concurring with the critics argu-
ment without becoming defensive and without agreeing to
change.
Example:
Nurse No. 1: You make so many mistakes. I dont know
how you ever got this job!
Nurse No. 2: Youre right. I have made some mistakes
since I started this job.
8. Defusing. Putting off further discussion with an angry in-
dividual until he or she is calmer.
Example:
You are very angry right now. I dont want to discuss this
matter with you while you are so upset. I will discuss it with
you in my ofce at 3 oclock this afternoon.
9. Delaying assertively. Putting off further discussion with
another individual until one is calmer.
Example:
Thats a very challenging position you have taken,
Mr. Brown. Ill need time to give it some thought. Ill call
you later this afternoon.
10. Responding assertively with irony.
Example:
Man: I bet youre one of them so-called womens
libbers, arent you?
Woman: Yes, thank you for noticing.
COGNITIVE THERAPY
Cognitive therapy, developed by Aaron Beck, is commonly used
in the treatment of mood disorders. In cognitive therapy, the in-
dividual is taught to control thought distortions that are consid-
ered to be a factor in the development and maintenance of mood
disorders. In the cognitive model, depression is characterized
by a triad of negative distortions related to expectations of the
environment, self, and future. The environment and activities
within it are viewed as unsatisfying, the self is unrealistically
devalued, and the future is perceived as hopeless. In the same
model, mania is characterized by a positive cognitive triadthe
self is seen as highly valued and powerful, experiences within the
environment are viewed as overly positive, and the future is seen
as one of unlimited opportunity.
The general goals in cognitive therapy are to obtain symp-
tom relief as quickly as possible, to assist the client in identifying

APPENDIX F 579
dysfunctional patterns of thinking and behaving, and to guide

the client to evidence and logic that effectively test the valid-
ity of the dysfunctional thinking. Therapy focuses on changing
automatic thoughts that occur spontaneously and contribute
to the distorted affect. Examples of automatic thoughts in
depression include the following:
1. Personalizing: Im the only one who failed.
2. All or nothing: Im a complete failure.
3. Mind reading: He thinks Im foolish.
4. Discounting positives: The other questions were so easy.
Any dummy could have gotten them right.
Examples of automatic thoughts in mania include the
following:
1. Personalizing: Shes this happy only when shes with me.
2. All or nothing: Everything I do is great.
3. Mind reading: She thinks Im wonderful.
4. Discounting negatives: None of those mistakes are really
important.
The client is asked to describe evidence that both supports
and disputes the automatic thought. The logic underlying the
inferences is then reviewed with the client. Another technique
involves evaluating what would most likely happen if the clients
automatic thoughts were true. Implications of the consequences
are then discussed.
Clients should not become discouraged if one technique
seems not to be working. There is no single technique that
works with all clients. He or she should be reassured that there
are a number of techniques that may be used, and both therapist
and client may explore these possibilities. Cognitive therapy
has been shown to be an effective treatment for mood disor-
ders, particularly in conjunction with psychopharmacological
intervention.

A P P E N D I X
G
Electroconvulsive
Therapy
DEFINED
Electroconvulsive therapy (ECT) is a type of somatic treatment
in which electric current is applied to the brain through elec-
trodes placed on the temples. The current is sufcient to induce
a grand mal seizure, from which the desired therapeutic effect
is achieved.
INDICATIONS
ECT is primarily used in the treatment of severe depression. It
is sometimes administered in conjunction with antidepressant
medication, but most physicians prefer to perform this treat-
ment only after an unsuccessful trial of drug therapy.
ECT may also be used as a fast-acting treatment for very
hyperactive manic clients in danger of physical exhaustion, and
with individuals who are extremely suicidal.
ECT was originally attempted in the treatment of schizo-
phrenia, but with little success in most instances. There has
been evidence, however, of its effectiveness in the treatment of
acute schizophrenia, particularly if it is accompanied by cata-
tonic or affective (depression or mania) symptomatology (Black
& Andreasen, 2011).
CONTRAINDICATIONS
ECT should not be used if there is increased intracranial pressure
(resulting from a brain tumor, recent cardiovascular accident, or
other cerebrovascular lesion). Other conditions, although not
considered absolute contraindications, may render clients at high
risk for the treatment. They are largely cardiovascular in nature
and include myocardial infarction or cerebrovascular accident
within the preceding 3 months, aortic or cerebral aneurysm,
severe underlying hypertension, and congestive heart failure.
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APPENDIX G 581
MECHANISM OF ACTION
The exact mechanism of action is unknown. However, it is
thought that ECT produces biochemical changes in the brain
an increase in the levels of norepinephrine, serotonin, and
dopaminesimilar to the effects of antidepressant medications.
SIDE EFFECTS AND NURSING

IMPLICATIONS
Temporary Memory Loss and Confusion
These are the most common side effects of ECT. It is impor-
tant for the nurse to be present when the client awakens, to
alleviate the fears that accompany this loss of memory.
Provide reassurance that memory loss is only temporary.
Describe to client what has occurred.
Reorient client to time and place.
Allow client to verbalize fears and anxieties related to receiv-
ing ECT.
To minimize confusion, provide a good deal of structure for
clients routine activities.
RISKS ASSOCIATED WITH ECT

1. Death. The mortality rate from ECT is about 2 per 100,000
treatments (Marangell et al., 2003; Sadock & Sadock, 2007).
The major cause is cardiovascular complications, such as
acute myocardial infarction or cardiac arrest.
2. Brain Damage. Brain damage is considered to be a risk, but
evidence is largely unsubstantiated.
3. Permanent Memory Loss. Most individuals report no
problems with their memory, aside from the time imme-
diately surrounding the ECT treatments. However, some
clients have reported retrograde amnesia extending back to
months before treatment. In rare instances, more extensive
amnesia has occurred, resulting in memory gaps dating back
years (Joska & Stein, 2008), Black and Andreasen (2011) sug-
gest that all clients receiving ECT should be informed of the
possibility of permanent memory loss.
Although the potential for these effects appears to be mini-
mal, the client must be made aware of the risks involved before
consenting to treatment.
POTENTIAL NURSING DIAGNOSES

ASSOCIATED WITH ECT
1. Risk for injury related to certain risks associated with ECT.
2. Risk for aspiration related to altered level of consciousness
immediately following treatment.

582 APPENDIX G
3. Decreased cardiac output related to vagal stimulation occur-

ring during the ECT.
4. Disturbed thought processes related to side effects of tempo-
rary memory loss and confusion.
5. Decient knowledge related to necessity for, and side effects
and risks of, ECT.
6. Anxiety (moderate to severe) related to impending therapy.
7. Self-care decit related to incapacitation during postictal
stage.
8. Risk for activity intolerance related to post-ECT confusion
and memory loss.
NURSING INTERVENTIONS FOR CLIENT

RECEIVING ECT
1. Ensure that physician has obtained informed consent and
that a signed permission form is on the chart.
2. Ensure that most recent laboratory reports (complete blood
count [CBC], urinalysis) and results of ECG and x-ray
examination are available.
3. Client should receive nothing by mouth (NPO) on the
morning of the treatment.
4. Prior to the treatment, client should void, dress in night
clothes (or other loose clothing), and remove dentures and
eyeglasses or contact lenses. Bedrails should be raised.
5. Take baseline vital signs and blood pressure.
6. Administer cholinergic blocking agent (e.g., atropine sul-
fate, glycopyrrolate) approximately 30 minutes before treat-
ment, as ordered by the physician, to decrease secretions
and increase heart rate (which is suppressed in response to
vagal stimulation caused by the ECT).
7. Assist physician and/or anesthesiologist as necessary in the
administration of intravenous medications. A short-acting
anesthetic, such as methohexital sodium (Brevital sodium),
is given along with the muscle relaxant succinylcholine
chloride (Anectine).
8. Administer oxygen and provide suctioning as required.
9. After the procedure, take vital signs and blood pressure
every 15 minutes for the rst hour. Position client on side to
prevent aspiration.
10. Stay with client until he or she is fully awake.
11. Allow client to verbalize fears and anxieties associated with
the treatment.
12. Reassure client that memory loss and confusion are only
temporary.

A P P E N D I X
H
Medication Assessment
Tool
583
2506_Appendix_H_583-587.indd 583 10/1/10 9:31:01 AM

584
Date Clients Name Age
2506_Appendix_H_583-587.indd 584
Marital Status Children
Occupation
Presenting Symptoms (subjective & objective)

APPENDIX H
Diagnosis (DSM-IV-TR)
Current Vital Signs: Blood Pressure: Sitting / ; Standing / ; Pulse ; Respirations
CURRENT/PAST USE OF PRESCRIPTION DRUGS (Indicate with c or p beside name of drug whether current or past use):
Name Dosage How Long Used Why Prescribed By Whom Side Effects/Results
10/1/10 9:31:01 AM
CURRENT/PAST USE OF OVER-THE-COUNTER DRUGS (Indicate with c or p beside name of drug whether current or past use):
Name Dosage How Long Used Why Prescribed By Whom Side Effects/Results
CURRENT/PAST USE OF STREET DRUGS, ALCOHOL, NICOTINE, AND/OR CAFFEINE (Indicate with c or p beside name of drug
whether current or past use):
Name Amount Used How Often Used When Last Used Effects/Produced
Any allergies to food or drugs?

APPENDIX H
Any special diet considerations?

585
10/1/10 9:31:02 AM
Do you have (or have you ever had) any of the following? If yes, provide explanation on the back of this sheet.
Yes No Yes No Yes No
1. Difculty swallowing 13. Blood clots/pain in legs 24. Lumps in your breasts
2. Delayed wound healing 14. Fainting spells 25. Blurred or double vision
3. Constipation problems 15. Swollen ankles/legs/hands 26. Ringing in the ears
586 APPENDIX H
4. Urination problems 16. Asthma 27. Insomnia

5. Recent change in elimination 17. Varicose veins 28. Skin rashes
patterns 18. Numbness/tingling 29. Diabetes
6. Weakness or tremors (location?) 30. Hepatitis (or other
7. Seizures 19. Ulcers liver disease)
8. Headaches 20. Nausea/vomiting 31. Kidney disease
9. Dizziness 21. Problems with diarrhea 32. Glaucoma
10. High blood pressure 22. Shortness of breath
11. Palpitations 23. Sexual dysfunction
12. Chest pain
10/1/10 9:31:02 AM
Are you pregnant or breast feeding? Date of last menses Type of contraception used
Describe any restrictions/limitations that might interfere with your use of medication for your current problem.
Prescription orders: Patient teaching related to medications prescribed:
Lab work ordered:
Nurses Signature Clients Signature

APPENDIX H

587
10/1/10 9:31:02 AM
A P P E N D I X
I
Cultural Assessment
Tool
Clients Name Ethnic Origin
Address Birth Date
Name of Signicant Other Relationship
Primary Language Spoken
Second Language Spoken
How does client usually communicate with people who speak a
different language?
Is an interpreter required?
Available?
Highest level of education achieved
Occupation
Presenting Problem
Has this problem ever occurred before?
If so, in what manner was it handled previously?
What is clients usual manner of coping with stress?
Who is(are) the clients main support system(s)?
Describe the family living arrangements
Who is the major decision maker in the family?
Describe clients/family members roles within the
family
Describe religious beliefs and practices
Are there any religious requirements or restrictions that place
limitations on the clients care?
If so, describe
Who in the family takes responsibility for health concerns?
588
2506_Appendix_I_588-589.indd 588 10/1/10 9:31:10 AM

APPENDIX I 589
Describe any special health beliefs and practices that may

vary from the conventional
From whom does family usually seek medical assistance in time
of need?
Describe clients usual emotional/behavioral response to:
Anxiety
Anger
Loss/change/failure
Pain
Fear
Describe any topics that are particularly sensitive or that the
client is unwilling to discuss (because of cultural taboos)
Describe any activities in which the client is unwilling to par-

ticipate (because of cultural customs or taboos)
What are the clients personal feelings regarding touch?
What are the clients personal feelings regarding eye contact?
What is the clients personal orientation to time? (past, present,

future)
Describe any particular illnesses to which the client may be bio-
culturally susceptible (e.g., hypertension and sickle cell anemia
in African Americans)
Describe any nutritional deciencies to which the client may be
bioculturally susceptible (e.g., lactose intolerance in Native and
Asian Americans)
Describe clients favorite foods
Are there any foods the client requests or refuses because of
cultural beliefs related to this illness? (e.g., hot and cold
foods for Hispanic and Asian Americans). If so, please describe
Describe clients perception of the problem and expectations of

health care
2506_Appendix_I_588-589.indd 589 10/1/10 9:31:11 AM

A P P E N D I X
J
The DSM-IV-TR
Multiaxial Evaluation
System
The American Psychiatric Association (APA, 2000) endorses
case evaluation on a multiaxial system, to facilitate comprehen-
sive and systematic evaluation with attention to the various men-
tal disorders and general medical conditions, psychosocial and
environmental problems, and level of functioning that might
be overlooked if the focus were on assessing a single presenting
problem. Each individual is evaluated on ve axes. They are
de ned by the Diagnostic and Statistical Manual of Mental Disor-
ders, Fourth Edition, Text Revision (DSM-IV-TR) in the following
manner:
Axis IClinical Disorders and Other Conditions That May
Be a Focus of Clinical Attention
These include all mental disorders (except personality disor-
ders and mental retardation).
Axis IIPersonality Disorders and Mental Retardation
These disorders usually begin in childhood or adolescence
and persist in a stable form into adult life.
Axis IIIGeneral Medical Conditions
These include any current general medical condition that is
potentially relevant to the understanding or management
of the individuals mental disorder.
Axis IVPsychosocial and Environmental Problems
These are problems that may affect the diagnosis, treatment,
and prognosis of mental disorders named on axes I and II.
Examples include: problems related to primary support
group, social environment, education, occupation, housing,
economics, access to health care services, interaction with
the legal system or crime, and other types of psychosocial
and environmental problems.
590
2506_Appendix_J_590-591.indd 590 10/1/10 9:31:19 AM

APPENDIX J 591
Axis VGlobal Assessment of Functioning

This allows the clinician to rate the individuals overall function-
ing on the Global Assessment of Functioning (GAF) Scale.
This scale represents in global terms a single measure of the
individuals psychological, social, and occupational function-
ing. A copy of the GAF Scale appears in Appendix K.
Source: From the Diagnostic and Statistical Manual of Mental Disorders,

4th Edition, Text Revision, 2000. Used with permission from the American
Psychiatric Association.
Example of a psychiatric diagnosis using the

Multiaxial Evaluation System:
Axis I 300.4 Dysthymic Disorder
Axis II 301.6 Dependent Personality Disorder
Axis III 244.9 Hypothyroidism
Axis IV Unemployed
Axis V GAF = 65
(current)
2506_Appendix_J_590-591.indd 591 10/1/10 9:31:19 AM

A P P E N D I X
K
Global Assessment
of Functioning (GAF)
Scale
Consider psychological, social, and occupational functioning
on a hypothetical continuum of mental health-illness. Do not
include impairment in functioning due to physical (or environ-
mental) limitations.
Code (Note: Use intermediate codes when appropriate,

e.g., 45, 68, 72)
10091 Superior functioning in a wide range of activities,
lifes problems never seem to get out of hand, is
sought out by others because of his or her many
positive qualities. No symptoms.
9081 Absent or minimal symptoms (e.g., mild anxiety
before an exam), good functioning in all areas, in-
terested and involved in a wide range of activities,
socially effective, generally satised with life, no
more than everyday problems or concerns (e.g.,
an occasional argument with family members).
8071 If symptoms are present, they are transient and
expectable reactions to psychosocial stres-
sors (e.g., difculty concentrating after family
argument); no more than slight impairment in
social, occupational, or school functioning (e.g.,
temporarily falling behind in schoolwork).
592
2506_Appendix_K_592-594.indd 592 10/1/10 9:31:27 AM

APPENDIX K 593
7061 Some mild symptoms (e.g., depressed mood and

mild insomnia) OR some difculty in social, oc-
cupational, or school functioning (e.g., occasional
truancy, or theft within the household), but gen-
erally functioning pretty well, has some meaning-
ful interpersonal relationships.
6051 Moderate symptoms (e.g., at affect and circum-
stantial speech, occasional panic attacks) OR
moderate difculty in social, occupational, or
school functioning (e.g., few friends, conicts
with peers or co-workers).
5041 Serious symptoms (e.g., suicidal ideation, severe
obsessional rituals, frequent shoplifting) OR any
serious impairment in social, occupational, or
school functioning (e.g., no friends, unable to
keep a job).
4031 Some impairment in reality testing or communi-
cation (e.g., speech is at times illogical, obscure,
or irrelevant) OR major impairment in several
areas, such as work or school, family relations,
judgment, thinking, or mood (e.g., depressed
man avoids friends, neglects family, and is
unable to work; child frequently beats up
younger children, is deant at home, and is
failing at school).
3031 Behavior is considerably inuenced by delusions
or hallucinations OR serious impairment in
communication or judgment (e.g., sometimes
incoherent, acts grossly inappropriately, suicidal
preoccupation) OR inability to function in
almost all areas (e.g., stays in bed all day; no job,
home, or friends).
2011 Some degree of hurting self or others (e.g., suicide
attempts without clear expectation of death; fre-
quently violent; manic excitement) OR occasion-
ally fails to maintain minimal personal hygiene
(e.g., smears feces) OR gross impairment in com-
munication (e.g., largely incoherent or mute).
Continued

594 APPENDIX K
101 Persistent danger of severely hurting self or others

(e.g., recurrent violence) OR persistent inability
to maintain minimal personal hygiene OR seri-
ous suicidal act with clear expectation of death.
0 Inadequate information.
Source: Diagnostic and Statistical Manual of Mental Disorders (4th ed.).

Text Revision. Washington, DC: American Psychiatric Publishing (2000).
With permission.

A P P E N D I X
L
DSM-IV-TR
Classication: Axes
I and II Categories
and Codes
DISORDERS USUALLY FIRST
DIAGNOSED IN INFANCY, CHILDHOOD,
OR ADOLESCENCE
Mental Retardation
Note: These are coded on Axis II.
317 Mild Mental Retardation
318.0 Moderate Retardation
318.1 Severe Retardation
318.2 Profound Mental Retardation
319 Mental Retardation, Severity Unspecied
Learning Disorders
315.00 Reading Disorder
315.1 Mathematics Disorder
315.2 Disorder of Written Expression
315.9 Learning Disorder Not Otherwise Specied (NOS)
Motor Skills Disorder

315.4 Developmental Coordination Disorder
Reprinted with permission from the. Diagnostic and Statistical Manual

of Mental Disorders, Fourth Edition, Text Revision. Copyright 2000,
American Psychiatric Publishing.
595
2506_Appendix_L_595-609.indd 595 10/1/10 9:31:37 AM

596 APPENDIX L
Communication Disorders
315.31 Expressive Language Disorder
315.32 Mixed Receptive-Expressive Language Disorder
315.39 Phonological Disorder
307.0 Stuttering
307.9 Communication Disorder NOS
Pervasive Developmental Disorders

299.00 Autistic Disorder
299.80 Retts Disorder
299.10 Childhood Disintegrative Disorder
299.80 Aspergers Disorder
299.80 Pervasive Developmental Disorder NOS
Attention-Decit and Disruptive Behavior

Disorders
314.xx Attention-Decit/Hyperactivity Disorder
314.01 Combined Type
314.00 Predominantly Inattentive Type
314.01 Predominantly Hyperactive-Impulsive Type
314.9 Attention-Decit/Hyperactivity Disorder NOS
312.xx Conduct Disorder
.81 Childhood-Onset Type
.82 Adolescent-Onset Type
.89 Unspecied Onset
313.81 Oppositional Deant Disorder
312.9 Disruptive Behavior Disorder NOS
Feeding and Eating Disorders of Infancy

or Early Childhood
307.52 Pica
307.53 Rumination Disorder
307.59 Feeding Disorder of Infancy or Early Childhood
Tic Disorders
307.23 Tourettes Disorder
307.22 Chronic Motor or Vocal Tic Disorder
307.21 Transient Tic Disorder
307.20 Tic Disorder NOS
Elimination Disorders
Encopresis
787.6 With Constipation and Overow Incontinence
307.7 Without Constipation and Overow Incontinence
307.6 Enuresis (Not Due to a General Medical Condition)

APPENDIX L 597
Other Disorders of Infancy, Childhood,

or Adolescence
309.21 Separation Anxiety Disorder
313.23 Selective Mutism
313.89 Reactive Attachment Disorder of Infancy or Early
Childhood
307.3 Stereotypic Movement Disorder
313.9 Disorder of Infancy, Childhood, or Adolescence NOS
DELIRIUM, DEMENTIA, AND AMNESTIC

AND OTHER COGNITIVE DISORDERS
Delirium
293.0 Delirium Due to... (Indicate the General Medical Condition)
Substance Intoxication Delirium (refer to Substance-
Related Disorders for substance-specic codes)
Substance Withdrawal Delirium (refer to Substance-
Delirium Due to Multiple Etiologies (code each of the
specic etiologies)
780.09 Delirium NOS
Dementia
294.xx Dementia of the Alzheimers Type, With Early Onset
.10 Without Behavioral Disturbance
.11 With Behavioral Disturbance
294.xx Dementia of the Alzheimers Type, With Late Onset
.10 Without Behavioral Disturbance
.11 With Behavioral Disturbance
290.xx Vascular Dementia
.40 Uncomplicated
.41 With Delirium
.42 With Delusions
.43 With Depressed Mood
294.1x Dementia Due to HIV Disease
294.1x Dementia Due to Head Trauma
294.1x Dementia Due to Parkinsons Disease
294.1x Dementia Due to Huntingtons Disease
294.1x Dementia Due to Picks Disease
294.1x Dementia Due to Creutzfeldt-Jakob Disease
294.1x Dementia Due to (Indicate the General Medical
Condition not listed above)
Substance-Induced Persisting Dementia (refer to
Substance-Related Disorders for substance-specic codes)
Dementia Due to Multiple Etiologies (code each of the
specic etiologies)
294.8 Dementia NOS

598 APPENDIX L
Amnestic Disorders
294.0 Amnestic Disorder Due to (Indicate the General Medical
Condition)
Substance-Induced Persisting Amnestic Disorder (refer
to Substance-Related Disorders for substance-specic codes)
294.8 Amnestic Disorder NOS
Other Cognitive Disorders

294.9 Cognitive Disorder NOS
MENTAL DISORDERS DUE TO A GENERAL

MEDICAL CONDITION NOT ELSEWHERE
CLASSIFIED
293.89 Catatonic Disorder Due to (Indicate the General Medical
Condition)
310.1 Personality Change Due to (Indicate the General Medical
Condition)
293.9 Mental Disorder NOS Due to (Indicate the General
Medical Condition)
Alcohol-Related Disorders
Alcohol Use Disorders
303.90 Alcohol Dependence
305.00 Alcohol Abuse
Alcohol-Induced Disorders
303.00 Alcohol Intoxication
291.81 Alcohol Withdrawal
291.0 Alcohol Intoxication Delirium
291.0 Alcohol Withdrawal Delirium
291.2 Alcohol-Induced Persisting Dementia
291.1 Alcohol-Induced Persisting Amnestic Disorder
291.x Alcohol-Induced Psychotic Disorder
.5 With Delusions
.3 With Hallucinations
291.89 Alcohol-Induced Mood Disorder
291.89 Alcohol-Induced Anxiety Disorder
291.89 Alcohol-Induced Sexual Dysfunction
291.89 Alcohol-Induced Sleep Disorder
291.9 Alcohol Related Disorder NOS
Amphetamine (or Amphetamine-Like)-Related

Disorders
Amphetamine Use Disorders
304.40 Amphetamine Dependence
305.70 Amphetamine Abuse

APPENDIX L 599
Amphetamine-Induced Disorders
292.89 Amphetamine Intoxication
292.0 Amphetamine Withdrawal
292.81 Amphetamine Intoxication Delirium
292.xx Amphetamine-Induced Psychotic Disorder
.11 With Delusions
292.84 Amphetamine-Induced Mood Disorder
292.89 Amphetamine-Induced Anxiety Disorder
292.89 Amphetamine-Induced Sexual Dysfunction
292.89 Amphetamine-Induced Sleep Disorder
292.9 Amphetamine-Related Disorder NOS
Caffeine-Related Disorders
Caffeine-Induced Disorders
305.90 Caffeine Intoxication
292.89 Caffeine-Induced Anxiety Disorder
292.89 Caffeine-Induced Sleep Disorder
292.9 Caffeine-Related Disorder NOS
Cannabis-Related Disorders
Cannabis Use Disorders
304.30 Cannabis Dependence
305.20 Cannabis Abuse
Cannabis-Induced Disorders
292.89 Cannabis Intoxication
292.81 Cannabis Intoxication Delirium
292.xx Cannabis-Induced Psychotic Disorder
.11 With Delusions
292.89 Cannabis-Induced Anxiety Disorder
292.9 Cannabis-Related Disorder NOS
Cocaine-Related Disorders
Cocaine Use Disorders
304.20 Cocaine Dependence
305.60 Cocaine Abuse
Cocaine-Induced Disorders
292.89 Cocaine Intoxication
292.0 Cocaine Withdrawal
292.81 Cocaine Intoxication Delirium
292.xx Cocaine-Induced Psychotic Disorder
.11 With Delusions
292.84 Cocaine-Induced Mood Disorder

600 APPENDIX L
292.89 Cocaine-Induced Anxiety Disorder

292.89 Cocaine-Induced Sexual Dysfunction
292.89 Cocaine-Induced Sleep Disorder
292.9 Cocaine-Related Disorder NOS
Hallucinogen-Related Disorders
Hallucinogen Use Disorders
304.50 Hallucinogen Dependence
305.30 Hallucinogen Abuse
Hallucinogen-Induced Disorders
292.89 Hallucinogen Intoxication
292.89 Hallucinogen Persisting Perception Disorder
(Flashbacks)
292.81 Hallucinogen Intoxication Delirium
292.xx Hallucinogen-Induced Psychotic Disorder
.11 With Delusions
292.84 Hallucinogen-Induced Mood Disorder
292.89 Hallucinogen-Induced Anxiety Disorder
292.9 Hallucinogen-Related Disorder NOS
Inhalant-Related Disorders
Inhalant Use Disorders
304.60 Inhalant Dependence
305.90 Inhalant Abuse
Inhalant-Induced Disorders
292.89 Inhalant Intoxication
292.81 Inhalant Intoxication Delirium
292.82 Inhalant-Induced Persisting Dementia
292.xx Inhalant-Induced Psychotic Disorder
.11 With Delusions
292.84 Inhalant-Induced Mood Disorder
292.89 Inhalant-Induced Anxiety Disorder
292.9 Inhalant-Related Disorder NOS
Nicotine-Related Disorders
Nicotine Use Disorders
305.1 Nicotine Dependence
Nicotine-Induced Disorders
292.0 Nicotine Withdrawal
292.9 Nicotine-Related Disorder NOS

APPENDIX L 601
Opioid-Related Disorders
Opioid Use Disorders
304.00 Opioid Dependence
305.50 Opioid Abuse
Opioid-Induced Disorders
292.89 Opioid Intoxication
292.0 Opioid Withdrawal
292.81 Opioid Intoxication Delirium
292.xx Opioid-Induced Psychotic Disorder
.11 With Delusions
292.84 Opioid-Induced Mood Disorder
292.89 Opioid-Induced Sexual Dysfunction
292.89 Opioid-Induced Sleep Disorder
292.9 Opioid-Related Disorder NOS
Phencyclidine (or Phencyclidine-Like)-Related

Disorders
Phencyclidine Use Disorders
304.60 Phencyclidine Dependence
305.90 Phencyclidine Abuse
Phencyclidine-Induced Disorders
292.89 Phencyclidine Intoxication
292.81 Phencyclidine Intoxication Delirium
292.xx Phencyclidine-Induced Psychotic Disorder
.11 With Delusions
292.84 Phencyclidine-Induced Mood Disorder
292.89 Phencyclidine-Induced Anxiety Disorder
292.9 Phencyclidine-Related Disorder NOS
Sedative-, Hypnotic-, or Anxiolytic-Related

Disorders
Sedative, Hypnotic, or Anxiolytic Use Disorders
304.10 Sedative, Hypnotic, or Anxiolytic Dependence
305.40 Sedative, Hypnotic, or Anxiolytic Abuse
Sedative-, Hypnotic-, or Anxiolytic-Induced
Disorders
292.89 Sedative, Hypnotic, or Anxiolytic Intoxication
292.0 Sedative, Hypnotic, or Anxiolytic Withdrawal
292.81 Sedative, Hypnotic, or Anxiolytic Intoxication
Delirium

602 APPENDIX L
292.81 Sedative, Hypnotic, or Anxiolytic Withdrawal

Delirium
292.82 Sedative-, Hypnotic-, or Anxiolytic-Induced Persisting
Dementia
292.83 Sedative-, Hypnotic-, or Anxiolytic-Induced Persisting
Amnestic Disorder
292.xx Sedative-, Hypnotic-, or Anxiolytic-Induced Psychotic
Disorder
.11 With Delusions
292.84 Sedative-, Hypnotic-, or Anxiolytic-Induced Mood
Disorder
292.89 Sedative-, Hypnotic-, or Anxiolytic-Induced Anxiety
Disorder
292.89 Sedative-, Hypnotic-, or Anxiolytic-Induced Sexual
Dysfunction
292.89 Sedative-, Hypnotic-, or Anxiolytic-Induced Sleep
Disorder
292.9 Sedative-, Hypnotic-, or Anxiolytic-Related Disorder
NOS
Polysubstance-Related Disorder
304.80 Polysubstance Dependence
Other (or Unknown) Substance-Related

Disorders
Other (or Unknown) Substance Use Disorders
304.90 Other (or Unknown) Substance Dependence
305.90 Other (or Unknown) Substance Abuse
Other (or Unknown) Substance-Induced
Disorders
292.89 Other (or Unknown) Substance Intoxication
292.0 Other (or Unknown) Substance Withdrawal
292.81 Other (or Unknown) Substance-Induced Delirium
292.82 Other (or Unknown) Substance-Induced Persisting
Dementia
292.83 Other (or Unknown) Substance-Induced Persisting
Amnestic Disorder
292.xx Other (or Unknown) Substance-Induced Psychotic
Disorder
.11 With Delusions
292.84 Other (or Unknown) Substance-Induced Mood Disorder
292.89 Other (or Unknown) Substance-Induced Anxiety
Disorder

APPENDIX L 603
292.89 Other (or Unknown) Substance-Induced Sexual

Dysfunction
292.89 Other (or Unknown) Substance-Induced Sleep Disorder
292.9 Other (or Unknown) Substance-Related Disorder NOS
SCHIZOPHRENIA AND OTHER PSYCHOTIC

DISORDERS
295.xx Schizophrenia
.30 Paranoid type
.10 Disorganized type
.20 Catatonic type
.90 Undifferentiated type
.60 Residual type
295.40 Schizophreniform Disorder
295.70 Schizoaffective Disorder
297.1 Delusional Disorder
298.8 Brief Psychotic Disorder
297.3 Shared Psychotic Disorder
293.xx Psychotic Disorder Due to (Indicate the General Medical
Condition)
.81 With Delusions
Substance-Induced Psychotic Disorder (refer to
298.9 Psychotic Disorder NOS
MOOD DISORDERS
(Code current state of Major Depressive Disorder or Bipolar
I Disorder in fth digit: 0 = unspecied; 1 = mild; 2 = moderate;
3 = severe, without psychotic features; 4 = severe, with psychotic
features; 5 = in partial remission; 6 = in full remission.)
Depressive Disorders
296.xx Major Depressive Disorder
.2x Single episode
.3x Recurrent
300.4 Dysthymic Disorder
311 Depressive Disorder NOS
Bipolar Disorders
296.xx Bipolar I Disorder
.0x Single Manic Episode
.40 Most Recent Episode Hypomanic
.4x Most Recent Episode Manic
.6x Most Recent Episode Mixed
.5x Most Recent Episode Depressed

604 APPENDIX L
.7 Most Recent Episode Unspecied

296.89 Bipolar II Disorder (Specify current or most recent episode:
Hypomanic or Depressed)
301.13 Cyclothymic Disorder
296.80 Bipolar Disorder NOS
293.83 Mood Disorder Due to (Indicate the General Medical
Condition)
Substance-Induced Mood Disorder (refer to Substance-
296.90 Mood Disorder NOS
ANXIETY DISORDERS
300.01 Panic Disorder Without Agoraphobia
300.21 Panic Disorder With Agoraphobia
300.22 Agoraphobia Without History of Panic Disorder
300.29 Specic Phobia
300.23 Social Phobia
300.3 Obsessive-Compulsive Disorder
309.81 Posttraumatic Stress Disorder
308.3 Acute Stress Disorder
300.02 Generalized Anxiety Disorder
293.89 Anxiety Disorder Due to (Indicate the General Medical
Condition)
Substance-Induced Anxiety Disorder (refer to
300.00 Anxiety Disorder NOS
SOMATOFORM DISORDERS
300.81 Somatization Disorder
300.82 Undifferentiated Somatoform Disorder
300.11 Conversion Disorder
307.xx Pain Disorder
.80 Associated with Psychological Factors
.89 Associated with Both Psychological Factors and a
General Medical Condition
300.7 Hypochondriasis
300.7 Body Dysmorphic Disorder
300.82 Somatoform Disorder NOS
FACTITIOUS DISORDERS
300.xx Factitious Disorder
.16 With Predominantly Psychological Signs and
Symptoms
.19 With Predominantly Physical Signs and Symptoms
.19 With Combined Psychological and Physical Signs
and Symptoms
300.19 Factitious Disorder NOS

APPENDIX L 605
DISSOCIATIVE DISORDERS
300.12 Dissociative Amnesia
300.13 Dissociative Fugue
300.14 Dissociative Identity Disorder
300.6 Depersonalization Disorder
300.15 Dissociative Disorder NOS
SEXUAL AND GENDER IDENTITY

DISORDERS
Sexual Dysfunctions
Sexual Desire Disorders
302.71 Hypoactive Sexual Desire Disorder
302.79 Sexual Aversion Disorder
Sexual Arousal Disorders
302.72 Female Sexual Arousal Disorder
302.72 Male Erectile Disorder
Orgasmic Disorders
302.73 Female Orgasmic Disorder
302.74 Male Orgasmic Disorder
302.75 Premature Ejaculation
Sexual Pain Disorders
302.76 Dyspareunia (Not Due to a General Medical
Condition)
306.51 Vaginismus (Not Due to a General Medical
Condition)
Sexual Dysfunction Due to a General Medical
Condition
625.8 Female Hypoactive Sexual Desire Disorder Due to
(Indicate the General Medical Condition)
608.89 Male Hypoactive Sexual Desire Disorder Due to
(Indicate the General Medical Condition)
607.84 Male Erectile Disorder Due to (Indicate the General
Medical Condition)
625.0 Female Dyspareunia Due to (Indicate the General
Medical Condition)
608.89 Male Dyspareunia Due to (Indicate the General Medical
Condition)
625.8 Other Female Sexual Dysfunction Due to (Indicate the
General Medical Condition)
608.89 Other Male Sexual Dysfunction Due to (Indicate the
General Medical Condition)
Substance-Induced Sexual Dysfunction (refer to
302.70 Sexual Dysfunction NOS

606 APPENDIX L
Paraphilias
302.4 Exhibitionism
302.81 Fetishism
302.89 Frotteurism
302.2 Pedophilia
302.83 Sexual Masochism
302.84 Sexual Sadism
302.3 Transvestic Fetishism
302.82 Voyeurism
302.9 Paraphilia NOS
Gender Identity Disorders

302.xx Gender Identity Disorder
.6 In Children
.85 In Adolescents or Adults
302.6 Gender Identity Disorder NOS
302.9 Sexual Disorder NOS
EATING DISORDERS
307.1 Anorexia Nervosa
307.51 Bulimia Nervosa
307.50 Eating Disorder NOS
SLEEP DISORDERS
Primary Sleep Disorders
Dyssomnias
307.42 Primary Insomnia
307.44 Primary Hypersomnia
347 Narcolepsy
780.59 Breathing-Related Sleep Disorder
307.45 Circadian Rhythm Sleep Disorder
307.47 Dyssomnia NOS
Parasomnias
307.47 Nightmare Disorder
307.46 Sleep Terror Disorder
307.46 Sleepwalking Disorder
307.47 Parasomnia NOS
Sleep Disorders Related to Another Mental

Disorder
307.42 Insomnia Related to (Indicate the Axis I or Axis II
Disorder)
307.44 Hypersomnia Related to (Indicate the Axis I or Axis II
Disorder)

APPENDIX L 607
Other Sleep Disorders

780.xx Sleep Disorder Due to (Indicate the General Medical
Condition)
.52 Insomnia type
.54 Hypersomnia type
.59 Parasomnia type
.59 Mixed type
Substance-Induced Sleep Disorder (refer to Substance-
IMPULSE CONTROL DISORDERS NOT

ELSEWHERE CLASSIFIED
312.34 Intermittent Explosive Disorder
312.32 Kleptomania
312.33 Pyromania
312.31 Pathological Gambling
312.39 Trichotillomania
312.30 Impulse Control Disorder NOS
ADJUSTMENT DISORDERS
309.xx Adjustment Disorder
.0 With Depressed Mood
.24 With Anxiety
.28 With Mixed Anxiety and Depressed Mood
.3 With Disturbance of Conduct
.4 With Mixed Disturbance of Emotions and Conduct
.9 Unspecied
PERSONALITY DISORDERS
Note: These are coded on Axis II.
301.0 Paranoid Personality Disorder
301.20 Schizoid Personality Disorder
301.22 Schizotypal Personality Disorder
301.7 Antisocial Personality Disorder
301.83 Borderline Personality Disorder
301.50 Histrionic Personality Disorder
301.81 Narcissistic Personality Disorder
301.82 Avoidant Personality Disorder
301.6 Dependent Personality Disorder
301.4 Obsessive-Compulsive Personality Disorder
301.9 Personality Disorder NOS

608 APPENDIX L
OTHER CONDITIONS THAT MAY BE A

FOCUS OF CLINICAL ATTENTION
Psychological Factors Affecting Medical
Condition
316 Choose name based on nature of factors:
Mental Disorder Affecting Medical Condition
Psychological Symptoms Affecting Medical Condition
Personality Traits or Coping Style Affecting Medical
Condition
Maladaptive Health Behaviors Affecting Medical
Condition
Stress-Related Physiological Response Affecting Medical
Condition
Other or Unspecied Psychological Factors Affecting
Medical Condition
Medication-Induced Movement Disorders

332.1 Neuroleptic-Induced Parkinsonism
333.92 Neuroleptic Malignant Syndrome
333.7 Neuroleptic-Induced Acute Dystonia
333.99 Neuroleptic-Induced Acute Akathisia
333.82 Neuroleptic-Induced Tardive Dyskinesia
333.1 Medication-Induced Postural Tremor
333.90 Medication-Induced Movement Disorder NOS
Other Medication-Induced Disorder

995.2 Adverse Effects of Medication NOS
Relational Problems
V61.9 Relational Problem Related to a Mental Disorder or
General Medical Condition
V61.20 Parent-Child Relational Problem
V61.10 Partner Relational Problem
V61.8 Sibling Relational Problem
V62.81 Relational Problem NOS
Problems Related to Abuse or Neglect

V61.21 Physical Abuse of Child
V61.21 Sexual Abuse of Child
V61.21 Neglect of Child
Physical Abuse of Adult
V61.12 (if by partner)
V62.83 (if by person other than partner)
Sexual Abuse of Adult

APPENDIX L 609
V61.12 (if by partner)

V62.83 (if by person other than partner)
Additional Conditions That May Be a Focus

of Clinical Attention
V15.81 Noncompliance with Treatment
V65.2 Malingering
V71.01 Adult Antisocial Behavior
V71.02 Childhood or Adolescent Antisocial Behavior
V62.89 Borderline Intellectual Functioning (coded on Axis II)
780.9 Age-Related Cognitive Decline
V62.82 Bereavement
V62.3 Academic Problem
V62.2 Occupational Problem
313.82 Identity Problem
V62.89 Religious or Spiritual Problem
V62.4 Acculturation Problem
V62.89 Phase of Life Problem
ADDITIONAL CODES
300.9 Unspecied Mental Disorder (nonpsychotic)
V71.09 No Diagnosis or Condition on Axis I
799.9 Diagnosis or Condition Deferred on Axis I
V71.09 No Diagnosis on Axis II
799.9 Diagnosis Deferred on Axis II

A P P E N D I X
M
Mental Status
Assessment
Gathering the correct information about the clients mental sta-
tus is essential to the development of an appropriate plan of care.
The mental status examination is a description of all the areas of
the clients mental functioning. The following are the compo-
nents that are considered critical in the assessment of a clients
mental status. Examples of interview questions and criteria for
assessment are included.
IDENTIFYING DATA
1. Name
2. Gender
3. Age
a. How old are you?
b. When were you born?
4. Race/culture
a. What country did you (your ancestors) come from?
5. Occupational/ nancial status
a. How do you make your living?
b. How do you obtain money for your needs?
6. Educational level
a. What was the highest grade level you completed in
school?
7. Signicant other
a. Are you married?
b. Do you have a signicant relationship with another
person?
8. Living arrangements
a. Do you live alone?
b. With whom do you share your home?
9. Religious preference
a. Do you have a religious preference?
610
2506_Appendix_M_610-617.indd 610 10/1/10 9:31:49 AM

APPENDIX M 611
10. Allergies
a. Are you allergic to anything?
b. Foods? Medications?
11. Special diet considerations
a. Do you have any special diet requirements?
b. Diabetic? Low sodium?
12. Chief complaint
a. For what reason did you come for help today?
b. What seems to be the problem?
13. Medical diagnosis
GENERAL DESCRIPTION
Appearance
1. Grooming and dress
a. Note unusual modes of dress.
b. Evidence of soiled clothing?
c. Use of makeup
d. Neat; unkempt
2. Hygiene
a. Note evidence of body or breath odor.
b. Condition of skin, ngernails
3. Posture
a. Note if standing upright, rigid, slumped over.
4. Height and weight
a. Perform accurate measurements.
5. Level of eye contact
a. Intermittent?
b. Occasional and eeting?
c. Sustained and intense?
d. No eye contact?
6. Hair color and texture
a. Is hair clean and healthy-looking?
b. Greasy, matted, tangled?
7. Evidence of scars, tattoos, or other distinguishing skin
marks
a. Note any evidence of swelling or bruises.
b. Birth marks?
c. Rashes?
8. Evaluation of clients appearance compared with chronologi-
cal age.
Motor Activity
1. Tremors
a. Do hands or legs tremble?
Continuously?
At specic times?

612 APPENDIX M
2. Tics or other stereotypical movements

a. Any evidence of facial tics?
b. Jerking or spastic movements?
3. Mannerisms and gestures
a. Specic facial or body movements during conversation?
b. Nail biting?
c. Covering face with hands?
d. Grimacing?
4. Hyperactivity
a. Gets up and down out of chair
b. Paces
c. Unable to sit still
5. Restlessness or agitation
a. Lots of dgeting
b. Clenching hands
6. Aggressiveness
a. Overtly angry and hostile
b. Threatening
c. Uses sarcasm
7. Rigidity
a. Sits or stands in a rigid position
b. Arms and legs appear stiff and unyielding
8. Gait patterns
a. Any evidence of limping?
b. Limitation of range of motion?
c. Ataxia?
d. Shuf ing?
9. Echopraxia
a. Evidence of mimicking the actions of others?
10. Psychomotor retardation
a. Movements are very slow.
b. Thinking and speech are very slow.
c. Posture is slumped.
11. Freedom of movement (range of motion)
a. Note any limitation in ability to move.
Speech Patterns
1. Slowness or rapidity of speech
a. Note whether speech seems very rapid or slower than
normal.
2. Pressure of speech
a. Note whether speech seems frenzied.
b. Unable to be interrupted?
3. Intonation
a. Are words spoken with appropriate emphasis?
b. Are words spoken in monotone, without emphasis?

APPENDIX M 613
4. Volume
a. Is speech very loud? Soft?
b. Is speech low-pitched? High-pitched?
5. Stuttering or other speech impairments
a. Hoarseness?
b. Slurred speech?
6. Aphasia
a. Difculty forming words
b. Use of incorrect words
c. Difculty thinking of specic words
d. Making up words (neologisms)
General Attitude
1. Cooperative/uncooperative
a. Answers questions willingly
b. Refuses to answer questions
2. Friendly/hostile/defensive
a. Is sociable and responsive
b. Is sarcastic and irritable
3. Uninterested/apathetic
a. Refuses to participate in interview process
4. Attentive/interested
a. Actively participates in interview process
5. Guarded/suspicious
a. Continuously scans the environment
b. Questions motives of interviewer
c. Refuses to answer questions
EMOTIONS
Mood
1. Depressed; despairing
a. An overwhelming feeling of sadness
b. Loss of interest in regular activities
2. Irritable
a. Easily annoyed and provoked to anger
3. Anxious
a. Demonstrates or verbalizes feeling of apprehension
4. Elated
a. Expresses feelings of joy and intense pleasure
b. Is intensely optimistic
5. Euphoric
a. Demonstrates a heightened sense of elation
b. Expresses feelings of grandeur (Everything is wonderful!)
6. Fearful
a. Demonstrates or verbalizes feeling of apprehension asso-
ciated with real or perceived danger

614 APPENDIX M
7. Guilty
a. Expresses a feeling of discomfort associated with real or
perceived wrongdoing
b. May be associated with feelings of sadness and despair
8. Labile
a. Exhibits mood swings that range from euphoria to
depression or anxiety
Affect
1. Congruence with mood
a. Outward emotional expression is consistent with mood
(e.g., if depressed, emotional expression is sadness, eyes
downcast, may be crying)
2. Constricted or blunted
a. Minimal outward emotional expression is observed
3. Flat
a. There is an absence of outward emotional expression
4. Appropriate
a. The outward emotional expression is what would be
expected in a certain situation (e.g., crying upon hearing
of a death)
5. Inappropriate
a. The outward emotional expression is incompatible with
the situation (e.g., laughing upon hearing of a death)
THOUGHT PROCESSES
Form of Thought
1. Flight of ideas
a. Verbalizations are continuous and rapid, and ow from
one to another
2. Associative looseness
a. Verbalizations shift from one unrelated topic to another
3. Circumstantiality
a. Verbalizations are lengthy and tedious, and because of
numerous details, are delayed reaching the intended
point
4. Tangentiality
a. Verbalizations that are lengthy and tedious, and never
reach an intended point
5. Neologisms
a. The individual is making up nonsensical-sounding words,
which only have meaning to him or her
6. Concrete thinking
a. Thinking is literal; elemental
b. Absence of ability to think abstractly
c. Unable to translate simple proverbs

APPENDIX M 615
7. Clang associations
a. Speaking in puns or rhymes; using words that sound alike
but have different meanings
8. Word salad
a. Using a mixture of words that have no meaning together;
sounding incoherent
9. Perseveration
a. Persistently repeating the last word of a sentence spo-
ken to the client. (e.g., Nurse: George, its time to go to
lunch. George: lunch, lunch, lunch, lunch)
10. Echolalia
a. Persistently repeating what another person says
11. Mutism
a. Does not speak (either cannot or will not)
12. Poverty of speech
a. Speaks very little; may respond in monosyllables
13. Ability to concentrate and disturbance of attention
a. Does the person hold attention to the topic at hand?
b. Is the person easily distractible?
c. Is there selective attention (e.g., blocks out topics that
create anxiety)?
Content of Thought
1. Delusions (Does the person have unrealistic ideas or
beliefs?)
a. Persecutory: A belief that someone is out to get him or
her in some way (e.g., The FBI will be here at any time to
take me away.).
b. Grandiose: An idea that he or she is all-powerful or of
great importance (e.g., I am the king...and this is my
kingdom! I can do anything!).
c. Reference: An idea that whatever is happening in the en-
vironment is about him or her (e.g., Just watch the movie
on TV tonight. It is about my life.).
d. Control or inuence: A belief that his or her behavior and
thoughts are being controlled by external forces (e.g., I
get my orders from Channel 27. I do only what the forces
dictate.).
e. Somatic: A belief that he or she has a dysfunctional body
part (e.g., My heart is at a standstill. It is no longer beat-
ing.).
f. Nihilistic: A belief that he or she, or a part of the body, or
even the world does not exist or has been destroyed (e.g.,
I am no longer alive.).
2. Suicidal or homicidal ideas
a. Is the individual expressing ideas of harming self or others?

616 APPENDIX M
3. Obsessions
a. Is the person verbalizing about a persistent thought or
feeling that he or she is unable to eliminate from their
consciousness?
4. Paranoia/suspiciousness
a. Continuously scans the environment
b. Questions motives of interviewer
c. Refuses to answer questions
5. Magical thinking
a. Is the client speaking in a way that indicates his or her
words or actions have power? (e.g., If you step on a crack,
you break your mothers back!)
6. Religiosity
a. Is the individual demonstrating obsession with religious
ideas and behavior?
7. Phobias
a. Is there evidence of irrational fears (of a specic object, or
a social situation)?
8. Poverty of content
a. Is little information conveyed by the client because of
vagueness or stereotypical statements or clichs?
PERCEPTUAL DISTURBANCES
1. Hallucinations (Is the person experiencing unrealistic sen-
sory perceptions?)
a. Auditory (Is the individual hearing voices or other sounds
that do not exist?)
b. Visual (Is the individual seeing images that do not exist?)
c. Tactile (Does the individual feel unrealistic sensations on
the skin?)
d. Olfactory (Does the individual smell odors that do not
exist?)
e. Gustatory (Does the individual have a false perception of
an unpleasant taste?)
2. Illusions
a. Does the individual misperceive or misinterpret real
stimuli within the environment? (Sees something and
thinks it is something else?)
3. Depersonalization (altered perception of the self)
a. The individual verbalizes feeling outside the body; visu-
alizing him- or herself from afar.
4. Derealization (altered perception of the environment)
a. The individual verbalizes that the environment feels
strange or unreal. A feeling that the surroundings have
changed.

APPENDIX M 617
SENSORIUM AND COGNITIVE ABILITY

1. Level of alertness/consciousness
a. Is the individual clear-minded and attentive to the
environment?
b. Or is there disturbance in perception and awareness of the
surroundings?
2. Orientation. Is the person oriented to the following?
a. Time
b. Place
c. Person
d. Circumstances
3. Memory
a. Recent (Is the individual able to remember occurrences of
the past few days?)
b. Remote (Is the individual able to remember occurrences
of the distant past?)
c. Confabulation (Does the individual ll in memory gaps
with experiences that have no basis in fact?)
4. Capacity for abstract thought
a. Can the individual interpret proverbs correctly?
What does no use crying over spilled milk mean?
IMPULSE CONTROL
1. Ability to control impulses. (Does psychosocial history
reveal problems with any of the following?)
a. Aggression
b. Hostility
c. Fear
d. Guilt
e. Affection
f. Sexual feelings
JUDGMENT AND INSIGHT

1. Ability to solve problems and make decisions
a. What are your plans for the future?
b. What do you plan to do to reach your goals?
2. Knowledge about self
a. Awareness of limitations
b. Awareness of consequences of actions
c. Awareness of illness
Do you think you have a problem?
Do you think you need treatment?
3. Adaptive/maladaptive use of coping strategies and ego
defense mechanisms (e.g., rationalizing maladaptive behav-
iors, projection of blame, displacement of anger)

A P P E N D I X
N
Assigning Nursing
Diagnoses to Client
Behaviors
Following is a list of client behaviors and the NANDA nursing
diagnoses that correspond to the behaviors and that may be used
in planning care for the client exhibiting the specic behavioral
symptoms.
Behaviors NANDA Nursing Diagnoses

Aggression; hostility Risk for injury; Risk for other-
directed violence
Anorexia or refusal to eat Imbalanced nutrition: Less than

body requirements
Anxious behavior Anxiety (Specify level)
Confusion; memory loss Confusion, acute/chronic;
Disturbed thought processes;
Impaired memory
Delusions Disturbed thought processes
Denial of problems Ineffective denial
Depressed mood or anger Complicated grieving
turned inward
Detoxication; withdrawal Risk for injury
from substances
618
2506_Appendix_N_618-621.indd 618 10/1/10 9:31:59 AM

APPENDIX N 619
Difculty accepting new Risk-prone health behavior

diagnosis or recent
change in health status
Difculty making impor- Decisional conict (specify)
tant life decision
Difculty sleeping Insomnia; Disturbed sleep
pattern
Difculty with interper- Impaired social interaction
sonal relationships
Disruption in capability to Ineffective role performance
perform usual
responsibilities
Dissociative behaviors Disturbed sensory perception
(depersonalization; (kinesthetic)
derealization)
Expresses feelings of Disturbed body image
disgust about body or
body part
Expresses anger at God Spiritual distress
Expresses lack of control Powerlessness
over personal situation
Fails to follow prescribed Ineffective self-health manage-
therapy ment; Noncompliance
Flashbacks, nightmares, Posttrauma syndrome
obsession with traumatic
experience
Hallucinations Disturbed sensory perception
(auditory; visual)
Highly critical of self or Low self-esteem (chronic;
others situational)
HIV-positive; altered Ineffective protection
immunity
Continued

620 APPENDIX N
Inability to meet basic Self-care decit (feeding; bath-

needs ing; dressing; toileting)
Loose associations or ight Impaired verbal communication
of ideas
Loss of a valued entity, Risk for complicated grieving
recently experienced
Manic hyperactivity Risk for injury
Manipulative behavior Ineffective coping
Multiple personalities; gen- Disturbed personal identity
der identity disturbance
Orgasm, problems with; Sexual dysfunction
lack of sexual desire;
erectile dysfunction
Overeating, compulsive Risk for imbalanced nutrition:
More than body requirements
Phobias Fear
Physical symptoms as cop- Ineffective coping
ing behavior
Potential or anticipated Grieving
loss of signicant entity
Projection of blame; Defensive coping
rationalization of fail-
ures; denial of personal
responsibility
Ritualistic behaviors Anxiety (severe); Ineffective
coping
Seductive remarks; inap- Impaired social interaction
propriate sexual behav-
iors
Self-inicted injuries (non- Self-mutilation; Risk for
life-threatening) self-mutilation

APPENDIX N 621
Sexual behaviors (difculty, Ineffective sexuality pattern

limitations, or changes in;
reported dissatisfaction)
Stress from caring for Caregiver role strain
chronically ill person
Stress from locating to new Relocation stress syndrome
environment
Substance use as a coping Ineffective coping
behavior
Substance use (denies use is Ineffective denial
a problem)
Suicidal gestures/threats; Risk for suicide; Risk for
suicidal ideation self-directed violence
Suspiciousness Disturbed thought processes;
Ineffective coping
Vomiting, excessive, Risk for decient uid volume
self-induced
Withdrawn behavior Social isolation

A P P E N D I X
O
Brief Mental Status
Evaluation
Area of Mental Function

Evaluated Evaluation Activity
Orientation to time What year is it? What month is

it? What day is it? (3 points)
Orientation to place Where are you now? (1 point)
Attention and immediate Repeat these words now: bell,
recall book, & candle (3 points)
Remember these words and I
will ask you to repeat them in a
few minutes.
Abstract thinking What does this mean: No use
crying over spilled milk.
(3 points)
Recent memory Say the 3 words I asked you to
remember earlier. (3 points)
Naming objects Point to eyeglasses and ask,
What is this? Repeat with
1 other item (e.g., calendar,
watch, pencil). (2 points
possible)
Ability to follow simple Tear this piece of paper in half
verbal command and put it in the trash container.
(2 points)
622
2506_Appendix_O_622-623.indd 622 10/1/10 9:32:08 AM

APPENDIX O 623
Ability to follow simple Write a command on a piece of

written command paper (e.g., TOUCH YOUR
NOSE), give the paper to the
patient and say, Do what it
says on this paper. (1 point for
correct action)
Ability to use language Ask the patient to write a sen-
correctly tence. (3 points if sentence has a
subject and a verb, and has valid
meaning).
Ability to concentrate Say the months of the year in re-
verse, starting with December.
(1 point each for correct an-
swers from November through
August. 4 points possible.)
Understanding spatial Draw a clock; put in all the num-
relationships bers; and set the hands on
3 oclock. (clock circle = 1 point;
numbers in correct sequence =
1 point; numbers placed on clock
correctly = 1 point; two hands on
the clock = 1 point; hands set at
correct time = 1 point. 5 points
possible.)
Scoring: 30 to 21 = normal; 20 to 11 = mild cognitive impairment; 10 to 0 = severe
cognitive impairment (scores are not absolute and must be considered within
the comprehensive diagnostic assessment).
Sources: The Merck manual of health and aging (2005); Folstein, Folstein,
and McHugh (1975); Kaufman and Zun (1995); Kokman et al. (1991); and
Pfeiffer (1975).
2506_Appendix_O_622-623.indd 623 10/1/10 9:32:08 AM

A P P E N D I X
P
U.S. Food and Drug
Administration (FDA)
Pregnancy Categories
Category A Adequate, well-controlled studies in

pregnant women have not shown an
increased risk of fetal abnormalities.
Category B Animal studies have revealed no evi-
dence of harm to the fetus; however,
there are no adequate and well-
controlled studies in pregnant women.
OR Animal studies have shown an
adverse effect, but adequate and
well-controlled studies in pregnant
women have failed to demonstrate a
risk to the fetus.
Category C Animal studies have shown an adverse
effect and there are no adequate and
women.
OR No animal studies have been con-
ducted and there are no adequate and
women.
Category D Studies, adequate well-controlled or
observational, in pregnant women
have demonstrated a risk to the fetus.
However, the benets of therapy may
outweigh the potential risk.
624
2506_Appendix_P_624-625.indd 624 10/1/10 9:32:17 AM

APPENDIX P 625
Category X Studies, adequate well-controlled or

observational, in animals or pregnant
women have demonstrated positive
evidence of fetal abnormalities. The
use of the product is contraindicated
in women who are or may become
pregnant.
Source: From Deglin, J.H., & Vallerand, A.H. (2009). Daviss drug guide for
nurses (11th ed.). Philadelphia: F.D. Davis. With permission.
2506_Appendix_P_624-625.indd 625 10/1/10 9:32:17 AM

A P P E N D I X
Q
U.S. Drug Enforcement
Agency (DEA)
Controlled Substances
Schedules
Classes or schedules are determined by the DEA, an arm of
the U.S. Justice Department, and are based on the potential
for abuse and dependence liability (physical and psychological)
of the medication. Some states may have stricter prescription
regulations. Physicians, dentists, podiatrists, and veterinarians
may prescribe controlled substances. Nurse practitioners and
physicians assistants may prescribe controlled substances with
certain limitations.
Schedule I (C-I)
Potential for abuse is so high as to be unacceptable. May be used
for research with appropriate limitations. Examples are LSD
and heroin.
Schedule II (C-II)
High potential for abuse and extreme liability for physical and
psychological dependence (amphetamines, opioid analgesics,
dronabinol, certain barbiturates). Outpatient prescriptions must
be in writing. In emergencies, telephone orders may be accept-
able if a written prescription is provided within 72 hours. No
rells are allowed.
Schedule III (C-III)

Intermediate potential for abuse (less than C-II) and intermediate
liability for physical and psychological dependence (certain non-
barbiturate sedatives, certain nonamphetamine CNS stimulants,
and limited dosages of certain opioid analgesics). Outpatient
626
2506_Appendix_Q_626-627.indd 626 10/1/10 9:32:25 AM

APPENDIX Q 627
prescriptions can be relled 5 times within 6 months from

date of issue if authorized by prescriber. Telephone orders are
acceptable.
Schedule IV (C-IV)
Less abuse potential than Schedule III with minimal liability for
physical or psychological dependence (certain sedative/hypnotics,
certain antianxiety agents, some barbiturates, benzodiazepines,
chloral hydrate, pentazocine, and propoxyphene). Outpatient
prescriptions can be re lled 6 times within 6 months from
date of issue if authorized by prescriber. Telephone orders are
acceptable.
Schedule V (C-V)
Minimal abuse potential. Number of outpatient rells deter-
mined by prescriber. Some products (cough suppressants with
small amounts of codeine, antidiarrheals containing paregoric)
may be available without prescription to patients at least 18 years
of age.
Source: From Deglin, J.H., & Vallerand, A.H. (2009). Daviss drug guide
for nurses (11th ed.). Philadelphia: F.D. Davis. With permission.
2506_Appendix_Q_626-627.indd 627 10/1/10 9:32:25 AM

A P P E N D I X
R
Abnormal Involuntary
Movement Scale
(AIMS)
The AIMS rating scale is a 5- to 10-minute rating scale to assess
for tardive dyskinesia (TD). A baseline exam should be admin-
istered before instituting pharmacotherapy with antipsychotics,
and then every 3 to 6 months thereafter.
There are two parallel procedures, the Examination Procedure,
which tells the client what to do, and the Scoring Procedure, which
tells the clinician how to rate what he or she observes.
Examination Procedure
Either before or after completing the Examination Procedure,
observe the client unobtrusively, at rest (e.g., in waiting room).
The chair to be used in this examination should be a hard, rm
one without arms.
1. Ask client to remove shoes and socks.
2. Ask client whether there is anything in his/her mouth (i.e.,
gum, candy, etc.), and if there is, to remove it.
3. Ask client about the current condition of his/her teeth. Ask
client if he/she wears dentures. Do teeth or dentures bother
client now?
4. Ask client whether he/she notices any movements in mouth,
face, hands, or feet. If yes, ask him/her to describe and to what
extent they currently bother client or interfere with his/her
activities.
5. Have client sit in chair with both hands on knees, legs slightly
apart, and feet at on oor. (Look at entire body for move-
ments while in this position.)
6. Ask client to sit with hands hanging unsupported. If male,
between legs, if female and wearing a dress, hanging over
knees. (Observe hands and other body areas.)
7. Ask client to open mouth. (Observe tongue at rest within
mouth.) Do this twice.
628
2506_Appendix_R_628-630.indd 628 10/1/10 9:32:33 AM

APPENDIX R 629
8. Ask client to protrude tongue. (Observe abnormalities of

tongue movement.) Do this twice.
9. Ask client to tap thumb with each nger as rapidly as pos-
sible for 10 to 15 seconds; separately with right hand, then
with left hand. (Observe facial and leg movements.)
10. Flex and extend clients left and right arms (one at a time).
(Note any rigidity.)
11. Ask client to stand up. (Observe in pro le. Observe all body
areas again, hips included.)
12. Ask client to extend both arms outstretched in front with
palms down. (Observe trunk, legs, and mouth.)
13. Have client walk a few paces, turn, and walk back to chair.
(Observe hands and gait.) Do this twice.
Scoring Procedure
Instructions: Complete examination procedure before making
ratings.
Rate highest severity observed.
Code: 0 None
1 Minimal, may be extreme normal
2 Mild
3 Moderate
4 Severe
Facial and Oral Movements
1. Muscles of Facial Expression (e.g., movement of forehead,
eyebrows, periorbital area, cheeks; include frowning,
blinking, smiling, grimacing)
01234
2. Lips and Perioral Area (e.g., puckering, pouting, smacking)
01234
3. Jaws (e.g., biting, clenching, chewing, mouth opening, lat-
eral movement)
01234
4. Tongue (Rate only increase in movement both in and out
of mouth, NOT inability to sustain movement.)
01234
Extremity Movements
5. Upper (arms, wrists, hands, ngers). Include choreic
movements (i.e., rapid, objectively purposeless, irregular,
spontaneous), athetoid movements (i.e., slow, irregular,
complex, serpentine). Do NOT include tremor (i.e., re-
petitive, regular, rhythmic).
01234

630 APPENDIX R
6. Lower (legs, knees, ankles, toes) (e.g., lateral knee move-

ment, foot taping, heel dropping, foot squirming, inver-
sion and eversion of foot)
01234
Trunk Movements
7. Neck, shoulders, hips (e.g., rocking, twisting, squirming,
pelvic gyrations)
01234
Global Judgments
8. Severity of abnormal movements:
0 1 2 3 4 (Based on the highest single score on the above
items.)
9. Incapacitation due to abnormal movements:
0 None, normal
1 Minimal
2 Mild
3 Moderate
4 Severe
10. Clients awareness of abnormal movements (Rate only
clients report)
0 No awareness
1 Aware, no distress
2 Aware, mild distress
3 Aware, moderate distress
4 Aware, severe distress
Dental Status
11. Current problems with teeth and/or dentures
0 No
1 Yes
12. Does client usually wear dentures?
0 No
1 Yes
Interpretation of AIMS Score
Add client scores and note areas of difculty.
Score of:
0 to 1 = low risk
2 in only ONE of the areas assessed = borderline/observe
closely
2 in TWO or more of the areas assessed or 3 to 4 in ONLY
ONE area = indicative of TD
Source: U.S. Department of Health and Human Services. Available for use
in the public domain.

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2506_Bib_631-638.indd 1638 10/1/10 9:32:46 AM

Subject Index
Note: Page numbers followed by f indicate gures; those

followed by t indicate tabular material.
Abnormal Involuntary Movement Scale (AIMS), 628630

Abuse and neglect, 310319
categories of, 310311
DSM-IV-TR classication of, 608
Internet references on, 318319
movie(s) involving, 319
nursing diagnoses and interventions for
delayed growth and development, 317318
powerlessness, 315317
rape-trauma syndrome, 313315
predisposing factors in, 311312
symptomatology of, 312313
Acrophobia, 162
Acupressure, 376377
Acupuncture, 376377
Acute stress disorders, 162
Addiction. See Substance-related disorders
ADHD. See Attention-decit/hyperactivity disorder
Adjustment disorder, 236255
anxiety, 241243
complicated grieving, 247249
impaired social interaction, 251253
ineffective coping, 243245
low self-esteem, 249251
relocation stress syndrome, 253255
risk-prone health behavior, 245247
self-/other-directed violence risk, 238241
Adolescence
death concept in, 400
disorders rst diagnosed in, 1415
639
2506_Subject Index_639-682.indd 639 10/1/10 9:41:56 AM

640 SUBJECT INDEX
disruptive behavior disorders, 2642

DSM-IV-TR classication related to, 595597
separation anxiety disorder, 4853
Tourettes disorder, 4248
Adults
concepts of death in, 401
physical abuse of, 311
sexual abuse of, 311
forensic nursing for, 361
Affect, inappropriate, in psychotic disorders, 109
Agitation, antidepressant-related, 442
Agoraphobia, 161
AIDS/HIV disease, 329340
bloodborne transmission of, 331
dementia in, 56
early-stage, 329330
immune response to, 329
late-stage, 330331
middle-stage, 330
decient knowledge, 337339
ineffective protection, 332335
interrupted family processes, 335336
perinatal transmission of, 332
sexual transmission of, 331
stages and symptoms of, 329331
Akathisia, antipsychotic-related, 498
Akinesia, antipsychotic-related, 498
Alcohol use/abuse, 7273, 75t, 7879, 87t, 384385
DSM-IV-TR classication for, 598
dysfunctional family processes in, nursing diagnoses and
interventions for, 101104
intoxication with, 80, 87t
withdrawal from, 80, 87t, 9091
Alpha-adrenergic agonists, 529530
Alpha-2 receptor antagonists, 435436
Alternative medicine, 370. See also Complementary therapies
Alzheimers disease
caregiver role strain in, 6970
dementia of, 5556. See also Dementia

SUBJECT INDEX 641

Amenorrhea, antipsychotic-related, 497
American Nurses Association (ANA), 1
Amnesia, dissociative, 191
Amnestic disorders
denition of, 57
electroconvulsive therapy-induced, 581
caregiver role strain, 6870
chronic confusion, 6264
disturbed sensory perception, 6567
self-care decit, 6465
self-/other-directed violence, 6062
trauma risk, 5860
substance-induced, 58
Amphetamines, 522525
action of, 522523
adverse reactions and side effects of, 523
client/family education for, 536537
contraindications and precautions for, 523
DSM-IV-TR classication for, 598599
examples of, 522t
interactions of, 523524
intoxication with, 81
nursing diagnoses related to, 534
nursing implications of, 534535
route and dosage of, 524525
use/abuse of, 73, 75t, 80, 81
withdrawal from, 81, 91
ANA (American Nurses Association), 1
ANA standards of practice, 3
Anger notebook, 31
Anorexia
SSRI-related, 424
stimulant-related, 535
Anorexia nervosa
denition of, 218

642 SUBJECT INDEX

anxiety, 228229
decient uid volume, 224226
disturbed body image, 229231
imbalanced nutrition: less than body requirements, 222224
Anorgasmia, 204
Antianxiety agents, 406416
antihistamines, 406408
in antisocial personality disorder, 298
azaspirodecanediones, 413415
benzodiazepines, 408412
in borderline personality disorder, 284
carbamate derivative, 412413
in disruptive behavior disorders, 31
in eating disorders, 229
intoxication with, 89t
use/abuse of, 85, 89t
withdrawal from, 89t
Anticholinergic effects, antiparkinsonian agent-related, 508
Anticholinergics, 502505
action of, 503
examples of, 502t
route and dosage for, 504505
Anticonvulsants, 449457
action of, 451
examples of, 449t450t
interactions of, 452t453t
Antidepressants, 417446
alpha-2 receptor antagonists, 435436

SUBJECT INDEX 643

monoamine oxidase inhibitors, 437439
norepinephrine-dopamine reuptake inhibitors, 428430
psychotherapeutic combinations, 439440
serotonin-2 antagonists/reuptake inhibitors, 433435
serotonin-norepinephrine reuptake inhibitors, 430432
serotonin reuptake inhibitors, 422427
tricyclic antidepressants, 417422
Antihistamines, 406408
actions of, 406
examples of, 406t
indications for, 406
Antimanics, 447448
example of, 447t
Antiparkinsonian agents, 502510
anticholinergics, 502505
dopaminergic agonists, 505507
interactions, 506
Antipsychotics, 472501
action of, 460
benzisoxazole, 487489
client/family education for, 470471, 500501
dibenzepines, 481487
dibenzo-oxepino pyrrole, 492493
dihydroindolones, 480481
examples of, 459t460t, 472t, 476t, 477t488t, 480t,
481t482t, 487t, 490t
as mood-stabilizers, 459468
nursing diagnoses related to, 468, 493
nursing implications of, 468470, 494500

644 SUBJECT INDEX
phenothiazines, 472476
phenylbutylpiperadines, 477480
side effects of, 495t496t
thioxanthenes, 476477
in Tourettes disorder, 45
Antisocial personality disorder, 276, 294296
denition of, 294
defensive coping, 301303
other-directed violence risk, 297299
Anxiety. See also Anxiety disorders; Separation anxiety disorder
in adjustment disorder, 236
levels of, 549t551t
mild, 549t
moderate, 549t550t
moderate to severe
panic, in anxiety disorders, 165167
in psychiatric home nursing care, 354
severe, 550t
in separation anxiety disorder, 4951
severe to panic, in borderline personality disorder,
285286
in sexual assault, 362
Anxiety disorders, 161175
generalized, 162163
medical condition and, 163
anxiety (panic), 165167
fear, 167168
social isolation, 172173

SUBJECT INDEX 645

Anxiolytics. See Antianxiety agents
Arrhythmias, antidepressant-related, 442
Ascites, 79
Assertiveness training, 576578
Associative looseness, in psychotic disorders, 109
Attention-decit/hyperactivity disorder, 2627
denition of, 26
drug treatment for, 522537
DSM-IV-TR classication of, 26, 596
anxiety, 3940
noncompliance, 4042
Autism, in psychotic disorders, 108
Autistic disorder, 2025
denition of, 20
disturbed personal identity, 2425
impaired verbal communication, 2324
self-mutilation risk, 2122
Avoidant personality disorder, 277
Azaspirodecanediones, 413415
example of, 413t
Barbiturates, 73, 75t, 513515
action of, 513

646 SUBJECT INDEX
examples of, 513t

Behavior, disruptive. See Disruptive behavior disorders
Benzisoxazole, 487489
action of, 487
example of, 487t
Benzodiazepines, 408412
action of, 409
sedative-hypnotic use of, 511513, 511t
Bereavement. See Grief response; Grieving, complicated; Loss
and bereavement
Bereavement overload, 401
Beta-blockers, in premenstrual dysphoric disorder, 324t
Biochemical factors
in abuse and neglect, 311
in anxiety disorders, 163
in attention-decit/hyperactivity disorder, 26
in bipolar disorder, 146
in dysthymic disorder, 126
in pain disorder, 177
in premenstrual dysphoric disorder, 320
in substance-related disorders, 78
Biofeedback, 576
Biological factors, in paraphilias, 203
Bipolar disorder, mania, 146159
denition of, 145
disturbed thought processes, 153155
imbalanced nutrition: less than body requirements,
152153

SUBJECT INDEX 647

injury risk, 148149
insomnia, 158159
Birth temperament
in conduct disorder, 27
Black cohosh, 372t
Blood dyscrasias, sedative-hypnotic-related, 520
Blood transfusion, HIV disease with, 331
Body dysmorphic disorder, 177
Body image, disturbed, nursing diagnoses and interventions for
in obesity, 231233
in somatoform disorders, 183185
Body mass index, 221
Borderline personality disorder, 257294, 276
denition of, 278
anxiety, 285286
Bowlby model of grief response, 392393, 553t556t
Brain, alterations in
in psychotic disorders, 107
Brief mental status assessment, 622623
Brief psychotic disorders, 106
Bulimia nervosa
denition of, 219
anxiety, 228229

648 SUBJECT INDEX

222224
Caffeine, 73
use/abuse of, 87t
Calcium, 382t
Calcium channel blockers, 458459
example of, 458t
in premenstrual dysphoric disorder, 324t
Cancer, in HIV disease, 330331
Cannabinols, 77t
use/abuse of, 74, 81, 87t
withdrawal from, 87t, 90
Carbamate derivative, as antianxiety agents, 412413
Carbohydrates, intake of, 384
Cardiomyopathy, alcoholic, 79
Caregiver role strain, nursing diagnoses and interventions for
in delirium, dementia and amnestic disorders, 6870
Cascara sagrada, 372t
Catatonic schizophrenia, 105
Central nervous system depressants
withdrawal from, 91
Central nervous system stimulants. See Stimulants
Chamomile, 373t
Children
abuse and neglect of. See Abuse and neglect
assessment data, 1415
autistic disorder, 2025
disruptive behavior disorders, 2642
Internet references, 53

SUBJECT INDEX 649
mental retardation, 1520

separation anxiety disorder, 4853
physical abuse of, 310, 317318
sexual abuse of, 310311, 313
Chiropractic medicine, 385386
Cigarette smoking, 84, 88t
Circumstantiality, in psychotic disorders, 109
Cirrhosis, 79
Clang associations, in psychotic disorders, 109
Claustrophobia, 162
Client/family education
on amphetamines, 536537
on antianxiety agents, 416
on antidepressants, 444446
on mood-stabilizing drugs, 470471
for sedative-hypnotics, 520
on stimulants, 536537
Clinging behavior, in borderline personality disorder, 281
Clonidine (Catapres), in Tourettes disorder, 45
CNS stimulants. See Stimulants
Cocaine
use/abuse of, 73, 76t, 8182, 88t
withdrawal from, 82, 88t
Cognition
disorders of. See also Delirium; Dementia; Thought processes,
disturbed
impairment of, in dysthymic disorder, 127
Cognitive factors, in anxiety disorders, 164
Cognitive therapy, 578579
Communication techniques
nontherapeutic, 564t569t
therapeutic, 559t564t
Compensation (ego defense), 545t
Complementary therapies, 370389
acupressure, 376377
acupuncture, 376377
chiropractic medicine, 385386
diet and nutrition, 377379, 378t383t, 384385
herbal medicine, 371372, 372t376t
massage, 386387
pet therapy, 387388

650 SUBJECT INDEX
therapeutic touch, 386

yoga, 387
Concept mapping, 34
Concrete thinking, in psychotic disorders, 109
Conduct disorder, 2729
denition of, 27
anxiety, 3940
noncompliance, 4042
Confusion, chronic, in delirium, dementia, and amnestic
disorders, 6264
Confusion, sedative-hypnotic-related, 519
Constipation
antidepressant-related, 441
antiparkinsonian agent-related, 508
antipsychotic-related, 494
Conversion disorder, 177, 178
Coping. See Defensive coping; Ineffective coping
Correctional facilities, 362363
injury risk, 367369
Creutzfeldt-Jakob disease, dementia in, 56
Crisis intervention, 574
Cultural Assessment Tool, 588589
Cultural factors
Cyclothymic disorder, 145
Death
concepts of, 399401
in adolescents, 400
in adults, 401
in children, 399400
in elderly persons, 401
emergency room, 359360

SUBJECT INDEX 651
Deep-breathing exercises, 575

Defensive coping, nursing diagnoses and interventions for
in correctional facilities, 363365
Deinstitutionalization, in homelessness, 342
Delirium
alcohol withdrawal, 80
denition of, 54
trauma risk, 5860
Delusional disorder, 106
Delusion(s)
Dementia
denition of, 55
HIV-associated, 56
trauma risk, 5860
persisting, substance induced, 57
Denial
in grief response, 391
ineffective, nursing diagnoses and interventions for, in
substance-related disorders, 9293

652 SUBJECT INDEX
Denial (ego defense), 545t

Dependent personality disorder, 277
Depersonalization disorder, 192
Depression. See also Major depressive disorder
benzodiazepine effects on, 410, 415
chronic, in borderline personality disorder, 281
in grief response, 392
in HIV disease, 331
sedative-hypnotic effects on, 519
substance-induced, 126, 146
vs. grief response, 399, 402t
Depressive disorders, 125126. See also Major depressive disorder
Desensitization, for anxiety disorders, 168
Detoxication. See Withdrawal, substance
Development, impairment of, in adjustment disorder, 237
Developmental model, in adjustment disorder, 237
Development theory, 538544
Diabetes mellitus, antipsychotic-related, 499500
Dibenzepines, 481487
action of, 482
Dibenzo-oxepino pyrrole, 492493
Diet. See Nutrition
Dihydroindolones, 480481
action of, 480
examples of, 480t
Discontinuation syndrome, antidepressant-related, 441
Disorganized schizophrenia, 105
Displacement (ego defense), 545t
Disruptive behavior disorders, 2642
attention-decit/hyperactivity disorder, 2627
conduct disorder, 2729
anxiety, 3940

SUBJECT INDEX 653

noncompliance, 4042
oppositional deant disorder, 29
Dissociation, in borderline personality disorder, 282
Dissociative amnesia, 191
Dissociative disorders, 191200
predisposing factors for, 192193
Dissociative fugue, 191192
Dissociative identity disorder, 192
Distancing behavior, in borderline personality disorder, 281
Diuretics, in premenstrual dysphoric disorder, 324t
Dizziness
sedative-hypnotic-related, 519
Domestic violence. See also Abuse and neglect; Physical abuse
in homelessness, 342
Dopamine hypothesis, in psychotic disorders, 107108
Dopaminergic agonists, 505507
action of, 505
examples of, 505t
interactions of, 506t
Downward drift hypothesis, in psychotic disorders, 108
Drowsiness
Drugs. See also Substance-related disorders; specic classes of
drugs
amnestic disorders with, 58

654 SUBJECT INDEX
DEA controlled, 626627

delirium with, 5455
FDA pregnancy categories of, 624625
Dry mouth
DSM-IV-TR classication, 595609
DSM-IV-TR multiaxial evaluation system, 590591
Dyspareunia, 204
Dysthymic disorder, 126
disturbed sleep pattern, 142143
suicide risk, 129131
Dystonia, antipsychotic-related, 499
Eating disorders, 218235

denition of, 218, 219
anxiety, 228229
imbalanced nutrition: more than body requirements, 231233
Echinacea, 373t
Echolalia, in psychotic disorders, 109
Echopraxia, in psychotic disorders, 109
Education. See Client/family education
Ego defense mechanisms, 545t547t
Ejaculation
premature, 204
retarded, 204

SUBJECT INDEX 655
Elderly persons
home care for. See Psychiatric home nursing care
Electroconvulsive therapy, 580582
contraindications to, 580
denition of, 580
mechanism of action of, 581
nursing diagnoses for, 581582
nursing interventions for, 582
risks of, 581
side effects of, 581
Elimination disorders, DSM-IV-TR classication related to,
596
Emotional ambivalence, in psychotic disorders, 109
Emotional response pattern, in psychological factors affecting
medical condition, 265
Encephalopathy, hepatic, 79
Engel model of grief response, 393, 553t556t
Environmental factors
Epilepsy, anticonvulsants in, 454456
Erikson, E., psychosocial theory of, 540
Esophageal varices, alcohol-related, 79
Esophagitis, alcohol-related, 79
Evidence, preservation of, 359, 361, 362
Excitement, paradoxical, sedative-hypnotic-related, 520
Exhibitionism, 201
Extrapyramidal symptoms, antipsychotic-related, 499
Factitious disorders,. DSM-IV-TR classication of, 604

Failure, dysthymic disorder and, 127
Family dynamics
in alcoholism, 101104
in gender identity disorders, 212
in impulse control disorders, 258
in oppositional deant disorder, 29
in psychological factors affecting medical condition,
266

656 SUBJECT INDEX
Family processes
dysfunctional, in alcoholism, 101104
interrupted, in HIV disease, 335336
Family therapy, 572
Fats, intake of, 384
FDA pregnancy categories of drugs, 624625
Fear, nursing diagnoses and interventions for, 167168
Female orgasmic disorder, 204, 205
Female sexual arousal disorder, 204, 206
Fennel, 373t
Fetishism, 201202
Feverfew, 373t
Fire setting, 257
Flight of ideas, 147
Fluid volume, decient, in eating disorders, 224226
Folic acid, 382t
Folie deux, 106
Forensic nursing, 358360
correctional facilities, 362363
injury risk, 367369
denition of, 358
in posttrauma syndrome, 360363
in trauma care, 358360
Freud, S., psychosexual development theory of, 538
Frotteurism, 202
Fugue, dissociative, 191
GAF (Global Assessment of Functioning) Scale,

592594
Gambling, pathological, 257
Gastritis, alcohol-related, 79
Gastrointestinal upset
antipsychotic agent-related, 494
Gender identity disorders, 211213

SUBJECT INDEX 657

Genetic factors
in autistic disorder, 2021
in dissociative disorders, 192
in obesity, 221
Ginger, 374t
Ginkgo, 374t
Ginseng, 374t
Global Assessment of Functioning (GAF) Scale, 592594
Grandeur, delusions of, 147
Grief, denition of, 390
Grief response
anticipatory, 397
chronic/prolonged, 398399
denition of, 390
delayed/inhibited, 397398
distorted/exaggerated, 398
length of, 396397
models of
Bowlby, 392393, 553t556t
Engel, 393, 553t556t
Kbler-Ross, 391393, 553t556t
Worden, 393395, 553t556t
stages of, 391395
vs. depression, 399402t
Grieving, complicated, nursing diagnoses and interventions for,
247249
in loss and bereavement, 401404

658 SUBJECT INDEX
Group therapy, 570571

Growth and development, delayed, nursing diagnoses and
interventions for, in abuse and neglect, 317318
Hallucinations. See also Sensory perception, disturbed
Hallucinogens
use/abuse of, 7374, 77t, 8283
withdrawal from, 91
Headache, antidepressant-related, 442
Head injury, dementia after, 56
Health care availability, homelessness and, 342
Health maintenance, ineffective, in homelessness, 343345
Hepatic encephalopathy, 79
Hepatitis, alcoholic, 79
Herbal medicine, 371372, 372t376t
in premenstrual dysmorphic disorder, 324t325t
Hippocampus, in psychotic disorders, 107
Histrionic personality disorder, 276277
HIV disease. See AIDS/HIV disease
Homelessness, 341347
epidemiology of, 341
mental illness and, 341
ineffective health maintenance, 343345
Hops, 374t
Hormonal effects, antipsychotic-related, 497
Housing shortage, in homelessness, 342
Huntingtons disease, dementia in, 56
Hyperactivity. See Attention-decit/hyperactivity disorder
Hyperglycemia, antipsychotic-related, 499500
Hypertensive crisis, MAOI-related, 443
Hypnotics. See Sedative-hypnotics
Hypoactive sexual desire disorder, 204
Hypochondriasis, 177, 178
Hypotension, orthostatic
antipsychotic-related, 494, 497

SUBJECT INDEX 659
Identication (ego defense), 546t

Identity disorder. See also Gender identity disorders; Personal
identity, disturbed
dissociative, 192
Ileus, paralytic, antiparkinsonian agent-related, 508
Immune response, in AIDS/HIV disease, 329
Impulse control disorders
denition of, 256
other-directed violence risk, 258260
Impulsivity
Inattention. See Attention-decit/hyperactivity disorder
Ineffective coping, nursing diagnoses and interventions for
in psychological factors affecting the medical condition,
267269
Infancy. See also Newborns
mental retardation, 1520
feeding and eating disorders of, DSM-IV-TR classication of,
596
Infection, in HIV disease, 330
Inhalants
use/abuse of, 74, 77t, 83

660 SUBJECT INDEX
Injury risk. See also Violence, risk for, self-/other-directed

in mental retardation, 1617
in substance-related disorders, 86, 9092
Insomnia
Intellectualization (ego defense), 546t547t
Intelligence quotient, decit in. See Mental retardation
Intermittent explosive disorder, 256
Internet references
abuse and neglect, 318319
adjustment disorder, 255
alcohol use/abuse, 104
Alzheimers disease, 70
amphetamines, 537
anorexia nervosa, 234235
antianxiety agents, 416
antidepressants, 446
antiparkinsonian agents, 510
antipsychotics, 501
anxiety disorders, 175
attention-decit/hyperactivity disorder, 53
bulimia nervosa, 234235
complementary therapies, 389
depressive disorders, 144
disorders rst diagnosed in childhood, 53
dissociative disorders, 200
eating disorders, 234235
forensic nursing, 369
gender identity disorders, 217
HIV disease, 340
homelessness, 347
impulse control disorders, 263
loss and bereavement, 405
mood disorders, 159160
mood-stabilizing drugs, 471
nursing, 4
obesity, 234235
personality disorders, 309
psychiatric home nursing care, 357

SUBJECT INDEX 661
schizophrenia, 123
sedative-hypnotics, 520
sexual abuse, 318319
somatoform disorders, 190
stimulants, 537
substance-related disorders, 104
Intoxication. See Substance intoxication
Introjection (ego defense), 547t
Iodine, 383t
Iron, 383t
Isolation (ego defense), 547t
Kava-kava, 374t
Kleptomania, 257
Knowledge, decient, nursing diagnoses and interventions for
in HIV disease, 337339
272274
Kohlbergs stages of moral development, 542543
Kbler-Ross model of grief response, 391393, 553t556t
La belle indifference, 179

Learned helplessness, depression and, 127
Learning disorders, DSM-IV-TR classication of, 595
Learning theory
in psychological factors affecting medical condition, 266
Lethargy, sedative-hypnotic-related, 519
Lewy body disease, dementia due to, 56
Liver, nefazodone-related failure of, 444
Loneliness, in borderline personality disorder, 281
Loquaciousness, 147
Loss and bereavement, 390405. See also Grief response;
Grieving, complicated
forms of, 390
maladaptive response to, 397399
spiritual distress risk, 404405
Lymphadenopathy, in HIV disease, 330
Lysergic acid diethylamide (LSD), 74, 77t
Magnesium, 382t
Magnetic resonance imaging, in bipolar disorder, 146
Mahler, M., object relations theory of, 541

662 SUBJECT INDEX
Major depressive disorder

denition of, 125126
grieving, complicated, 131-133
nutrition, imbalanced: less than body requirements, 140-142
powerlessness, 137-139
self-esteem, low, 133-135
sleep pattern, disturbed, 142-143
suicide, risk for, 129-131
thought processes, disturbed, 127, 135, 139-140
Male erectile disorder, 204
Male orgasmic disorder, 204, 205
Mania. See also Bipolar disorder, mania, 146
Manipulation, in borderline personality disorder, 281282
MAOIs. See Monoamine oxidase inhibitors
Marijuana. See Cannabinols
Masochism, sexual, 202
Massage, 386387
Medical condition
amnestic disorder with, 5758
anxiety disorder with, 163
delirium with, 54
dementia with, 57
depressive disorder due to, 126
mood disorder with, 126, 146
psychological factors affecting, 264274
denition of, 265
deciency knowledge, 272274
ineffective role performance, 271272
psychotic disorder with, 107
Medication Assessment Tool, 583587
Medication-induced movement disorders, DSM-IV-TR
classication of, 608
Medications, depressive syndrome with, 127
Meditation, 575

SUBJECT INDEX 663
Melancholia, 127. See also Major depressive disorder

Memory, disorders of. See Amnestic disorders
Mental imagery, 576
Mental retardation, 1520
denition of, 15
injury risk, 1617
Mental state, in HIV disease, 331
Mental status assessment, 610617
brief, 622623
Milieu therapy, 572574
Minerals, 382t384t
Monoamine oxidase inhibitors, 437439
action of, 437
client/patient education for, 445
Mood, denition of, 125, 145
Mood disorders, 125127
bipolar disorders, 145146
152153
injury risk, 148149
insomnia, 158159
cyclothymic, 145
depressive disorders, 125126
denition of, 125126

664 SUBJECT INDEX

disturbed sleep pattern, 142143
140142
suicide risk, 129131
dysthymic, 126
substance-induced, 126, 146
Mood-stabilizing drugs, 447471
anticonvulsants, 449457
antimanic, 447448
antipsychotics, 459468
calcium channel blockers, 458459
client/family education on, 470471
nursing implications for, 468470
Motor skills disorder, DSM-IV-TR classication of, 595
Mourning, 390. See also Grief response; Grieving, complicated
Mutism, in psychotic disorders, 109
Narcissistic personality disorder, 277

Narcotics. See Opioids
National Center for Complementary Medicine and Alternative
Medicine, 370
Nausea
in HIV disease, 333
Needle stick, HIV disease with, 332
Neglect. See Abuse and neglect
Neologisms, in psychotic disorders, 109
Neuroendocrine disturbances
Neuroleptic malignant syndrome, antipsychotic-related,
499

SUBJECT INDEX 665
Neurological factors
in aggressive impulses, 311
Neuropathy, alcohol-related, 79
Neurotransmitters, in Tourettes disorder, 43
Newborns
HIV in, 332
temperament of
antisocial personality disorder and, 295
conduct disorder and, 27
separation anxiety disorder and, 48
Nicotine
dependence on, 8384
use/abuse of, 88t
Noncompliance, in disruptive behavior disorders, 4042
Nonsteroidal anti-inammatory drugs, in premenstrual
dysphoric disorder, 324t
Norepinephrine-dopamine reuptake inhibitors, 428430
action of, 428
example of, 428t
Nursing. See also Forensic nursing; Psychiatric home nursing care, 1
Nursing diagnosis, 2, 2f
client behavior assignment to, 618621
Nursing history and assessment tool, 413
Nursing process, 14, 2f
Nutrition, 348357
essential vitamins and minerals for, 380t384t
food groups for, 384385
imbalanced: less than body requirements, nursing diagnoses
and interventions for
imbalanced: more than body requirements, nursing diagnoses
and interventions for, in obesity, 231233

666 SUBJECT INDEX

USDA food guide for, 378t379t
Obesity
denition of, 221
imbalanced nutrition: more than body requirements,
231233
Object loss theory, 127
Object relations theory, 279280, 541
Obsessive-compulsive disorder, 162
Obsessive-compulsive personality disorder, 277
Oculogyric crisis, antipsychotic-related, 499
Opioids
use/abuse of, 73, 76t, 84, 89t
Oppositional deant disorder, 29
denition of, 29
anxiety, 3940
noncompliance, 4042
Orgasmic disorders, 205
denition of, 205
predisposing factors in, 205, 206
Other-directed violence, risk for. See Violence, risk for
Overstimulation, stimulant-related, 534
Pain
acute, in premenstrual dysphoric disorder, 321323, 324t,
325t
chronic, nursing diagnoses and interventions, in somatoform
disorders, 180181
Pain disorder, 176177. See also Sexual pain disorders
Palpitations

SUBJECT INDEX 667
Pancreatitis, alcohol-related, 79
Panic, 551t
Panic (anxiety), nursing diagnoses and interventions for,
165167
Panic disorder, 161
Paradoxical excitement, sedative-hypnotic-related, 520
Paralytic ileus
anticholinergic-related, 508
Paranoid personality disorder, 276
Paranoid schizophrenia, 105
Paraphilias
denition of, 201203
nursing diagnoses and interventions for, ineffective sexuality
patterns, 210211
Parkinsons disease, dementia in, 56
Passion ower, 375t
Passive-aggressive personality disorder, 277278
Pedophilia, 202
Peer relationships, in conduct disorder, 28
Peplau, H., interpersonal theory of, 543544
Peppermint, 375t
Perinatal factors, in attention-decit/hyperactivity disorder, 26
Peripheral neuropathy, alcohol-related, 79
Persecution, delusions of, 147
Perseveration, in psychotic disorders, 109
Personal identity, disturbed, nursing diagnoses and interventions for
Personality disorders, 275309
antisocial. See Antisocial personality disorder
borderline. See Borderline personality disorder
clusters of, 275278
Personality traits, in psychological factors affecting medical
condition, 265

668 SUBJECT INDEX
Pet therapy, 387388

Phencyclidine (PCP)
Phenothiazines, 472476
action of, 473
examples of, 472t
Phenylbutylpiperadines, 477480
action of, 478
Phobias, 161162
Phosphorus, 382t
Photosensitivity
Physical abuse
adult, 311
child, 310, 317318
Physical activity, 379, 384
Physical factors
in obesity, 221
Physiological factors

SUBJECT INDEX 669

in obesity, 221
in paraphilias, 203
in sexual dysfunction, 205206
Picks disease, dementia in, 56
Pigets, J., cognitive development theory, 542
Portal hypertension, 79
Postnatal factors, in attention-decit/hyperactivity disorder, 26
Posttrauma syndrome, forensic nursing for, 360363
Posttraumatic stress disorder, 162
Poverty, in homelessness, 342
Powerlessness, nursing diagnoses and interventions for
Pregnancy, sexual assault and, 361
Premature ejaculation, 204
Premenstrual dysphoric disorder, 320328
denition of, 320
acute pain, 321323, 324t, 325t
Prenatal factors, in attention-decit/hyperactivity disorder, 26
Priapism, trazodone-related, 444
Progressive relaxation, 575
Projection (ego defense), 547t
Protection, ineffective, nursing diagnoses and interventions for,
Pseudoparkinsonism, antipsychotic-related, 498
Psychiatric home nursing care, 348357
consultation for, 350, 352t
denition of, 348

670 SUBJECT INDEX

caregiver role strain risk, 356357
impaired adjustment, 352354
ineffective self-help management, 351352
reimbursement for, 349
symptomatology in, 349351
Psychoanalytical theory
in obesity, 222
in paraphilias, 203
Psychodrama, 571
Psychodynamic theory
Psychological factors affecting medical condition. See Medical
condition, psychological factors affecting
Psychological trauma, in dissociative disorders, 192193
Psychomotor retardation, in dysthymic disorder, 128
Psychosocial factors
in obesity, 222
in paraphilias, 203
in sexual dysfunction, 205206

SUBJECT INDEX 671
Psychosocial therapy, 570579

assertiveness training, 576578
cognitive therapy, 578579
crisis intervention, 574
family, 572
group, 570571
milieu, 572574
psychodrama, 571
relaxation, 575576
Psychotherapeutic combinations, 439440
Psychotic disorders, 105123
antiparkinsonian agent effects on, 508509
disturbed sensory perception: auditory/visual,
116117
insomnia, 122123
Psyllium, 375t
PTSD (posttraumatic stress disorder), 162
Pyridoxine (Vitamin B6), 381t
Pyromania, 257
Rage reaction, in borderline personality disorder, 282

Rape-trauma syndrome, nursing diagnoses and interventions for,
313315
Rationalization (ego defense), 545t
Reaction formation (ego defense), 545t
Regression, in psychotic disorders, 110
Regression (ego defense), 546t
Relaxation therapy, 575576
Religiosity, in psychotic disorders, 110
Relocation stress syndrome, nursing diagnoses and interventions
for, 253255
Repression (ego defense), 546t
Residual schizophrenia, 106
Restlessness, stimulant-related, 534
Restraints

672 SUBJECT INDEX

Retarded ejaculation, 204
Riboavin (Vitamin B2), 381t
Risk-prone health behavior, nursing diagnoses
and interventions for
Role performance, ineffective, nursing diagnoses and
interventions for, in psychological factors affecting the
medical condition, 271272
Sadism, sexual, 202

Salt, intake of, 384
Schizoaffective schizophrenia, 106
Schizoid personality disorder, 276
Schizophrenia
disturbed sensory perception: auditory/visual, 116117
insomnia, 122123
Schizophreniform disorder, 106
Schizotypal personality disorder, 276
Scullcap, 375t
Seasonal pattern, in major depressive disorder, 126
Sedation
Sedative-hypnotics, 511521
barbiturates, 513515
benzodiazepines, 511513

SUBJECT INDEX 673

interactions of, 517t518t
nursing diagnoses for, 519
Seizures
bupropion-related, 535
Selective serotonin reuptake inhibitors, 422427
action of, 424
in premenstrual dysphoric disorder, 324t
Selenium, 383t
Self-care decit, nursing diagnoses and interventions for
in delirium, dementia, and amnestic disorders, 6465
Self-directed violence, risk for. See Violence, risk for,
self-/other-directed
Self-esteem, low
chronic, in substance-related disorders, 9799
in obesity, 231233
267269
Self-health management, ineffective, in psychiatric home
nursing care, 351352
Self-mutilation

674 SUBJECT INDEX

risk for, nursing diagnoses and interventions for
Sensory perception
disturbed: auditory/visual, nursing diagnoses and
interventions for, in psychotic disorders, 116117
disturbed, nursing diagnoses and interventions for
in delirium, dementia, and amnestic disorders,
6567
Separation anxiety disorder, 4853
denition of, 48
anxiety, 4951
Serotonin-2 antagonists/reuptake inhibitors, 433435
action of, 433
examples of, 433t
Serotonin-norepinephrine reuptake inhibitors, 430432
action of, 431
examples of, 430t
Serotonin syndrome, 424, 442443
Sexual abuse
adult, 311
forensic nursing for, 361
child, 310311, 313

SUBJECT INDEX 675
Sexual arousal disorders, 204

Sexual aversion disorder, 204
Sexual desire disorders, 204, 205
Sexual dysfunctions, 204207
nursing diagnoses and interventions for, 207209
ineffective sexuality patterns, 209213
in paraphilias, 210211
types of, 204207
Sexual masochism, 202
Sexual pain disorders, 204, 205
Sexual sadism, 202
Shared psychotic disorder, 106
Skin rash, antipsychotic-related, 494
Sleep disorders
insomnia. See Insomnia
Sleep pattern, disturbed, in dysthymic disorder, 142143
Social interaction, impaired, nursing diagnoses and interventions
for
Social isolation, nursing diagnoses and interventions for
Social learning theory, and substance use/abuse, 78

676 SUBJECT INDEX
Social phobia, 161162

Sociocultural factors
in aggressive behavior, 312
Sodium chloride, intake of, 384
Somatization disorder, 176
Somatoform disorders, 176177
background assessment data, 176
chronic pain, 180181
predisposing factors for, 177179
Specic phobia, 162
Spiritual distress, risk for, nursing diagnoses and interventions
for, 404405
Splitting, 280, 281
SSRIs. See Selective serotonin reuptake inhibitors
St. Johns wort, 375t
Stimulants, 522525. See also Amphetamines
dexmethylphenidate, 525528
methylphenidate, 525528
use/abuse of, 73, 75t, 87t
withdrawal from, 87t, 91
Stress
acute, 162
posttraumatic, 162
relocation stress syndrome, nursing diagnoses and
interventions for, 253255
Stress-adaptation model, in adjustment disorder, 237238
Stressful events
Sublimation (ego defense), 546t547t
Substance abuse, 65

SUBJECT INDEX 677
Substance dependence, 7172

Substance-induced disorders, 72
depressed mood disorder, 126, 146
Substance intoxication
alcohol, 79
amphetamine, 81
anxiolytic, 85
cannabis, 81
cocaine, 82
denition of, 72
hallucinogen, 83
inhalant, 83
opioid, 84
PCP, 85
sedative-hypnotic, 85
Substance-related disorders, 71104. See also Withdrawal, substance
amnestic, 58
anxiety, 163
DEA substance schedule and, 626627
depressive, 146
manic, 147
chronic low self-esteem, 9799
dysfunctional family processes, 101104
imbalanced nutrition: less than body requirement, 9597
ineffective denial, 9293
injury risk, 86, 9092
patterns of use
alcohol, 7880, 87t
amphetamine, 81, 87t
anxiolytic, 85, 89t
caffeine, 87t
cannabis, 81, 88t
cocaine, 82, 88t
hallucinogen, 8283
hypnotic, 85, 89t
inhalant, 83, 88t
nicotine, 8384, 88t
opioid, 84, 89t
phencyclidine, 85, 89t
sedative, 85, 89t

678 SUBJECT INDEX

psychotic, 107
substance classication in, 7274
Substance-use disorders, 7172
Suicidal behavior/suicide
Sullivan, H.S., interpersonal theory of development theory of, 539
Suppression (ego defense), 547t
Tachycardia
Tangentiality, in psychotic disorders, 109
Tardive dyskinesia, antipsychotic-related, 499
Temperament
Therapeutic nurse-client relationship
communication techniques for, 559t564t
orientation (introductory) phase of, 558
preinteraction phase of, 557558
termination phase of, 559
working phase of, 558
Therapeutic touch, 386
Thiamine (Vitamin B1), 381t
Thioxanthenes, 476477, 476t
Thought processes, disturbed, nursing diagnoses and
interventions for
in dysthmic disorder, 139140
Tolerance
substance, 7172
Touch, therapeutic, 386
denition of, 43

SUBJECT INDEX 679

Trauma. See also Violence
childhood, in borderline personality disorder, 279
forensic nursing care in, 358360
risk for, nursing diagnoses and interventions for, in delirium,
dementia, and amnestic disorders, 5860
Trichotillomania, 257
Tricyclic antidepressants, 417422
action of, 418
Undifferentiated schizophrenia, 105

Undoing (ego defense), 547t
Urinary retention
Vaginismus, 204, 205

Valerian, 376t
Vascular dementia, 56
Verbal communication
impaired, nursing diagnoses and interventions for
nontherapeutic techniques of, 564t569t
therapeutic technqiues of, 559t564t
Violence
domestic. See also Abuse and neglect
risk for
other-directed, nursing diagnoses and interventions for
self-/other-directed, nursing diagnoses and interventions for

680 SUBJECT INDEX

Vision, blurred
Vitamin A, 380t
Vitamin B1, 381t
Vitamin B2, 381t
Vitamin B3, 381t
Vitamin B6, 381t
Vitamin B12, 381t
Vitamin C, 380t
Vitamin D, 380t
Vitamin E, 380t
Vitamin K, 380t
Vomiting
in bulimia nervosa, 219
in HIV disease, 333
Voyeurism, 202203
Wasting, in HIV disease, 330

Weight. See also Eating disorders; Obesity
gain of, antipsychotic-related, 497
loss of
management of, 379
Wernicke-Korsakoff syndrome, 79
Withdrawal, substance, 9091
alcohol, 80, 87t, 9091
amphetamine, 81, 87t, 90
anxiolytic, 86, 89t
cannabinols, 88t, 90
CNS depressant, 91
cocaine, 82, 88t
denition of, 72
delirium with, 55
hallucinogen, 91
hypnotic, 86, 89t

SUBJECT INDEX 681
inhalant, 88t
nicotine, 84, 88t
opioid, 84, 89t
phencyclidine, 89t
sedative, 86, 89t
Worden model of grief response, 393395, 553t556t
Word salad, in psychotic disorders, 109
Wound, trauma, examination of, 359
Yoga, 387
Zinc, 383t
Zoophobia, 162

Drug Index
Note: Page numbers followed by followed by t indicate tabular

material. Trade names appear in bold.
Abilify (aripiprazole), 459t, 461, 462, 464t, 466, 490491, 490t,

496t
Adderall/Adderal XR (amphetamine/dextroamphetamine
mixtures), 522t, 524
Advil (ibuprofen), 324t
Akineton (biperiden), 502t, 504
Alleve (naproxen), 324t
Almotriptan (Axert), 324t
Alprazolam (Xanax), 408t, 410
Amantadine (Symmetrel), 505t, 506, 506t, 507
Ambien (zolpidem), 516, 516t, 518, 519
Amerge (naratriptan), 324t
Amitriptyline, 417t, 420
Amitriptyline-chlordiazepoxide (Limbitrol), 439t
Amitriptyline HCI and perphenazine (Etrafon), 439t
Amobarbital (Amytal), 513t, 514
Amoxapine, 418t, 422
Amphetamine/dextroamphetamine mixtures (Adderall/Adderal
XR), 522t, 524
Amytal (amobarbital), 513t, 514
Anafranil (clomipramine), 417t, 420
Aripiprazole (Abilify), 459t, 461, 462, 464t, 466, 490491, 490t,
496t
Asenapine (Saphris), 460t, 463, 465t, 468, 492493, 492t, 496t
Ativan (lorazepam), 409t, 412
Atomoxetine (Strattera), 530534, 530t, 532t
Aventyl (nortriptyline), 418t, 421
Axert (almotriptan), 324t
Benadryl (diphenhydramine), 502t, 504505

Benztropine (Cogentin), 502t, 504
Biperiden (Akineton), 502t, 504
Black cohosh (Cimicifuga racemosa), 324t, 372t
Bromocriptine (Parlodel), 324t, 505t, 506, 506t
683
2506_Drug Index_683-690.indd 683 10/1/10 9:41:08 AM

684 DRUG INDEX
Bugleweed (Lycopus virginicus), 324t

Buprenorphine (Subutex), 91
Bupropion (Wellbutrin/Wellbutrin SR/Wellbutrin XL/
Zyban), 428430, 428t, 530534, 531t, 532t
BuSpar (buspirone HCl), 413415, 413t
Buspirone HC1 (BuSpar), 413415, 413t
Butabarbital (Butisol), 513t, 515
Butisol (butabarbital), 513t, 515
Calan (verapamil), 458459, 458t

Capsella bursa-pastoris (shepherds purse), 325t, 418t
Carbamazepine (Tegretol/Epitol/Carbatrol/Equetro/Teril/
Tegretol-XR), 449t, 451, 452t, 454
Carbatrol (carbamazepine), 449t, 451, 452t, 454
Cascara sagrada (Rhamnus purshiana), 372t
Catapres (clonidine), 45, 529t, 530
Celexa (citalopram), 422t, 425
Chamomile (Matricaria chamomilla), 373t
Chaste tree (Vitex agnus-castus), 324t
Chloral hydrate, 516, 516t, 518
Chlordiazepoxide-amitriptyline (Limbitrol), 439t
Chlordiazepoxide (Librium), 91, 408t, 410
Chlorpromazine (Thorazine), 149, 459t, 461, 462463, 464t,
466467, 472t, 474475, 495t
Cimicifuga racemosa (black cohosh), 324t, 372t
Citalopram (Celexa), 422t, 425
Clomipramine (Anafranil), 417t, 420
Clonazepam (Klonopin), 408t, 410411, 449t, 451, 453, 453t,
454455
Clonidine (Catapres), 45, 529t, 530
Clorazepate (Tranxene), 408t, 411
Clozapine (Clozaril), 481t, 482, 483, 484, 485t, 486, 496t
Clozaril (clozapine), 481t, 482, 483, 484, 485t, 486, 496t
Cogentin (benztropine), 502t, 504
Compazine (prochlorperazine), 472t, 475476, 495t
Concerta (methylphenidate), 525t, 527528
Cymbalta (duloxetine), 430t, 432
Dalmane (urazepam), 511t, 512

Darvon (propoxyphene), 91
Depakene (valproic acid), 449t, 451, 452, 453t, 455
Depakote (valproic acid), 449t, 451, 452, 453t, 455
Desipramine (Norpramin), 91, 417t, 420

DRUG INDEX 685
Desoxyn (methamphetamine), 522t, 525

Desvenlafaxine (Pristiq), 430t, 432
Desyrel (trazodone), 433t, 435
Dexmethylphenidate (Focalin/Focalin XR), 525t, 527
Dexedrine (dextroamphetamine sulfate), 522t, 524
Dextroamphetamine sulfate (Dexedrine/Dextrostat), 522t,
523, 524
Dextrostat (dextroamphetamine sulfate), 522t, 523, 524
Diazepam (Valium), 408t, 411412
Diphenhydramine (Benadryl), 502t, 504505
Dolophine (methadone), 91
Doral (quazepam), 511t, 512
Doxepin (Sinequan), 418t, 420421
Duloxetine (Cymbalta), 430t, 432
Echinacea (Echinacea angustifolia; Echniacea purpurea), 373t

Effexor (venlafaxine), 430t, 432
Eletriptan (Relpax), 324t
Emsam (selegiline transdermal system), 437t, 439
Epitol (carbamazepine), 449t, 451, 452t, 454
Equetro (carbamazepine), 449t, 451, 452t, 454
Escitalopram (Lexapro), 422t, 425
Eskalith (lithium carbonate), 447448, 447t
Estazolam (ProSom), 511t, 512
Eszopiclone (Lunesta), 516, 516t, 517t, 518
Etrafon (perphenazine-amitriptyline HCI), 439t
Evening primrose (Oenothera beinnis), 325t
Ezide (hydrochlorothiazide), 324t
Fanapt (iloperidone), 487t, 489, 496t

Fennel (Foeniculum vulgare; Foeniculum ofcinale), 373t
Feverfew (Tanacetum parthenium), 373t
Fluoxetine (Prozac/Sarafem), 324t, 423t, 425426
Fluphenazine (Prolixin), 472t, 475, 495t
Flurazepam (Dalmane), 511t, 512
Fluvoxamine (Luvox), 423t, 426
Focalin/Focalin XR (dexmethylphenidate), 525t, 527
Foeniculum vulgare; Foeniculum ofcinale (fennel), 373t
Frova (frovatriptan), 324t
Frovatriptan (Frova), 324t
Furosemide (Lasix), 324t

686 DRUG INDEX
Gabapentin (Neurontin/Gabarone), 450t, 451, 452, 453t, 456

Gabarone (gabapentin), 450t, 451, 452, 453t, 456
Geodon (ziprasidone), 45, 460t, 461462, 463, 465t, 467468,
487t, 490, 496t
Ginger (Zingiber ofcinale), 373t
Ginkgo (Ginkgo biloba), 374t
Ginseng (Panax ginseng), 374t
Guanfacine (Tenex, Intuniv), 529t, 530
Halcion (triazolam), 511t, 513

Haldol (haloperidol), 45, 91, 149, 477t, 479480, 495t
Haloperidol (Haldol), 45, 91, 149, 477t, 479480, 495t
Hops (Humulus lupulus), 374t
Hydrochlorothiazide (Ezide/Esidrix/HydroDIURIL), 324t
HydroDIURIL (hydrochlorothiazide), 324t
Hydroxyzine (Vistaril), 406408, 406t
Hypericum perforatum (St. Johns wort), 375t
Ibuprofen (Advil/ Motrin/ Nuprin), 324t

Iloperidone (Fanapt), 487t, 489, 496t
Imipramine (Tofranil), 418t, 421
Imitrex (sumatriptan), 324t
Inderal (propranolol), 324t
Intuniv (guanfacine), 529t, 530
Invega (paliperidone), 487t, 489, 496t
Isocarboxazid (Marplan), 436t, 438
Isoptin (verapamil), 324t, 458459, 458t
Kava-kava (Piper methylsticum), 374t

Klonopin (clonazepam), 408t, 410411, 449t, 451, 453, 453t,
454455
Lamictal (lamotrigine), 450t, 451, 452, 453t, 455456

Lamotrigine (Lamictal), 450t, 451, 452, 453t, 455456
Lasix (furosemide), 324t
Lexapro (escitalopram), 422t, 425
Librium (chlordiazepoxide), 91, 408t, 410
Limbitrol (chlordiazepoxide-amitriptyline), 439t
Lisdexamfetamine (Vyvanse) 472t, 522t, 523
Lithane (lithium carbonate), 447448, 447t
Lithium carbonate (Eskalith/Lithane/Lithobid), 447448, 447t
Lithium citrate, 447448, 447t
Lithobid (lithium carbonate), 447448, 447t

DRUG INDEX 687
Lorazepam (Ativan), 409t, 412

Loxapine (Loxitane), 481t, 482, 483, 484, 485t, 486, 495t
Loxitane (loxapine), 481t, 482, 483, 484, 485t, 486, 495t
Luminal (phenobarbital), 91, 513t, 515
Lunesta (eszopiclone), 516, 516t, 517t, 518
Luvox (uvoxamine), 423t, 426
Lycopus virginicus (bugleweed), 324t
Maprotiline, 418t, 422

Marplan (isocarboxazid), 436t, 438
Matricaria chamomilla (chamomile), 373t
Maxalt (rizatriptan), 324t
Mebaral (mephobarbital), 513t, 515
Mentha piperita (peppermint), 375t
Mephobarbital (Mebaral), 513t, 515
Meprobamate, 412t, 413
Metadate ER/Metadate CD (methylphenidate), 525t, 527528
Methadone (Dolophine), 91
Methamphetamine (Desoxyn), 522t, 525
Methylin/Methylin ER (methylphenidate), 525t, 527528
Methylphenidate (Ritalin/Ritalin-SR/Ritalin LA/Methylin/
Methylin ER/Metadate ER/Metadate CD/Concerta),
525t, 527528
Mirtazapine (Remeron), 435436, 435t
Moban (molindone), 480481, 480t, 495t
Molindone (Moban), 480481, 480t, 495t
Motrin (ibuprofen), 324t
Nalmefene (Revex), 91
Naloxone (Narcan), 91
Naltrexone (ReVia), 91
Naprosyn (naproxen), 324t
Naproxen (Naprosyn/Aleve), 324t
Naratriptan (Amerge), 324t
Narcan (naloxone), 91
Nardil (phenelzine), 436t, 439
Navane (thiothixene), 476477, 476t, 495t
Nefazodone, 433t, 434435
Nembutal (pentobarbital), 513t
Neurontin (gabapentin), 450t, 451, 452, 453t, 456
Norpramin (desipramine), 91, 417t, 420
Nortriptyline (Aventyl/Pamelor), 418t, 421
Nuprin (ibuprofen), 324t

688 DRUG INDEX
Oenothera beinnis (evening primrose), 325t

Olanzapine and uoxetine (Symbyax), 439t, 440, 459t, 466
Olanzapine (Zyprexa), 45, 149, 459t, 460, 462, 464t, 465, 482,
482t, 484, 485t, 486, 496t
Orap (pimozide), 45, 478t, 480, 495t
Oxazepam (Serax), 409t, 412
Oxcarbazepine (Trileptal), 450t, 453, 457
Paliperidone (Invega), 487t, 489, 496t

Pamelor (nortriptyline), 418t, 421
Panax ginseng (ginseng), 374t
Parlodel (bromocriptine), 324t, 505t, 506, 506t
Parnate (tranylcypromine), 437t, 439
Paroxetine (Paxil), 324t, 423t, 426427
Passion ower (Passiora incarnata), 375t
Paxil (paroxetine), 324t, 423t, 426427
Pentobarbital (Nembutal), 513t
Peppermint (Mentha piperita), 375t
Perphenazine, 472t, 475, 495t
Perphenazine-amitriptyline HCI (Etrafon), 439t
Phenelzine (Nardil), 436t, 439
Phenobarbital (Luminal), 91, 513t, 515
Pimozide (Orap), 45, 478t, 480, 495t
Piper methylsticum (kava-kava), 374t
Plantago ovata (psyllium), 375t
Potenilla (Potentilla anserine), 325t
Pristiq (desvenlafaxine), 430t, 432
Prochlorperazine (Compazine), 472t, 475476, 495t
Prolixin (uphenazine), 472t, 475, 495t
Propoxyphene (Darvon), 91
Propranolol (Inderal), 324t
ProSom (estazolam), 511t, 512
Protriptyline (Vivactil), 418t, 421
Prozac (uoxetine), 423t, 425426
Psyllium (Plantago ovata), 375t
Quazepam (Doral), 511t, 512

Quetiapine (Seroquel), 460t, 461, 463, 464t, 467, 482, 482t,
483, 484, 485t, 487, 496t
Ramelteon (Rozerem), 516, 516t, 518, 518t

Relpax (eletriptan), 324t
Remeron (mirtazapine), 435436, 435t
Restoril (temazepam), 511t, 513

DRUG INDEX 689
Revex (nalmefene), 91
ReVia (naltrexone), 91
Rhamnus purshiana (cascara sagrada), 372t
Risperdal (risperidone), 45, 460t, 461, 463, 464t, 467, 487489,
487t, 496t
Risperidone (Risperdal), 45, 460t, 461, 463, 464t, 467, 487489,
487t, 496t
Ritalin/Ritalin-SR/Ritalin LA (methylphenidate), 525t,
527528
Rizatriptan (Maxalt), 324t
Rozerem (ramelteon), 516, 516t, 518, 518t
Saphris (asenapine), 460t, 463, 465t, 468, 492493, 492t, 496t

Sarafem (uoxetine), 324t, 423t, 425426
Scullcap (Scutellaria lateriora), 375t
Scutellaria lateriora (scullcap), 375t
Secobarbital (Seconal), 513t, 515
Seconal (secobarbital), 513t, 515
Selegiline transdermal system (Emsan), 437t, 439
Serax (oxazepam), 409t, 412
Seroquel (quetiapine), 460t, 461, 463, 464t, 467, 482, 482t, 483,
484, 485t, 487, 496t
Sertraline (Zoloft), 324t, 423t, 427
Shepherds purse (Capsella bursa-pastoris), 325t, 418t
Sinequan (doxepin), 418t, 420421
Sonata (zaleplon), 516, 516t, 518, 518t
St. Johns wort (Hypericum perforatum), 375t
Stelazine (triuoperazine), 472t, 476, 495t
Strattera (atomoxetine), 530534, 530t, 532t
Subutex (buprenorphine), 91
Sumatriptan (Imitrex), 324t
Surmontil (trimipramine), 418t, 421
Symbyax (olanzapine and uoxetine), 439t, 440, 459t, 466
Symmetrel (amantadine), 505t, 506, 506t, 507
Tanacetum parthenium (feverfew), 373t

Tegretol/Tegretol-XR (carbamazepine), 449t, 451, 452t, 454
Temazepam (Restoril), 511t, 513
Tenex (guanfacine), 529t, 530
Teril (carbamazepine), 449t, 451, 452t, 454
Thioridazine, 472t, 476, 495t
Thiothixene (Navane), 476477, 476t, 495t
Thorazine (chlorpromazine), 149, 459t, 461, 462463, 464t,
466467, 472t, 474475, 495t

690 DRUG INDEX
Tofranil (imipramine), 418t, 421

Topamax (topriamate), 450t, 451, 453t, 456457
Topriamate (Topamax), 450t, 451, 453t, 456457
Tranxene (clorazepate), 408t, 411
Tranylcypromine (Parnate), 437t, 439
Trazodone (Desyrel), 433t, 435
Triazolam (Halcion), 511t, 513
Triuoperazine (Stelazine), 472t, 476, 495t
Trihexyphenidyl, 502t, 504
Trileptal (oxcarbazepine), 450t, 453, 457
Trimipramine (Surmontil), 418t, 421
Valerian (Valeriana ofcinalis), 325t

Valerian (Valeriana ofcinals), 375t
Valium (diazepam), 408t, 411412
Valproic acid (Depakene/Depakote), 449t, 451, 452, 453t, 455
Venlafaxine (Effexor), 430t, 432
Verapamil (Calan/Isoptin), 458459, 458t
Verapamil (Isoptin), 324t
Vistaril (hydroxyzine), 406408, 406t
Vitex agnus-castus (chaste tree), 324t
Vivactil (protriptyline), 418t, 421
Vyvanse (Lisdexamfetamine) 472t, 522t, 523
Wellbutrin (bupropion), 428430, 428t, 530534, 531t, 532t
Xanax (alprazolam), 408t, 410
Zaleplon (Sonata), 516, 516t, 518, 518t

Zingiber ofcinale (ginger), 373t
Ziprasidone (Geodon), 45, 460t, 461462, 463, 465t, 467468,
487t, 490, 496t
Zolmitriptan (Zomig), 324t
Zoloft (sertraline), 324t, 423t, 427
Zolpidem (Ambien), 516, 516t, 518, 519
Zomig (zolmitriptan), 324t
Zyban (bupropion), 428430, 428t
Zyprexa (olanzapine), 45, 149, 459t, 460, 462, 464t, 465, 482,
482t, 484, 485t, 486, 496t

Nursing Diagnoses
Index
Activity intolerance, risk for

antianxiety agents and, 415
antiparkinsonian agents and, 507
CNS stimulants and, 534
mood-stabilizing drugs and, 468
sedative-hypnotics and, 519
Anxiety
moderate to severe
client behavior leading to diagnosis of, 618
panic, in anxiety disorders, 165167
severe
client behavior leading to diagnosis of, 618, 620
severe to panic
borderline personality disorder, 285286
Body image, disturbed

in obesity, 233234
Caregiver role strain, risk for

in delirium, dementia and amnestic disorders, 6970
Confusion, risk for
Constipation, antidepressants and, 440
691
2506_Nursing Index_691-696.indd 691 10/1/10 9:41:46 AM

692 NURSING DIAGNOSES INDEX
Decisional conict, client behavior leading to diagnosis of, 619

Defensive coping
Denial, ineffective
Family processes
dysfunctional, in alcoholism, 101104
interrupted, in HIV disease, 335336
Fear
Fluid volume, decient
Grieving, complicated, 247249

in loss and bereavement, 401404
in major depressive disorder, 131133
Growth and development, delayed, in abuse and neglect, 317318
Health maintenance, ineffective, in homelessness, 343345

Hyperthermia, antiparkinsonian agents and, 507
Ineffective coping
in psychological factors affecting the medical condition, 267269

NURSING DIAGNOSES INDEX 693
Injury, risk for

antidepressants and, 440
antipsychotic agents and, 493
in substance-related disorders, 86, 9092
Insomnia
Knowledge, decient
in psychological factors affecting the medical condition, 272274
Nausea, CNS stimulants and, 534

Noncompliance
Nutrition
imbalanced: less than body requirements
imbalanced: more than body requirements
in obesity, 231233

Pain
acute, in premenstrual dysphoric disorder, 321323, 324t325t
chronic, in somatoform disorders, 180181
Personal identity, disturbed
Post-trauma syndrome
in forensic nursing, 360363
Powerlessness
Protection, ineffective
Rape-trauma syndrome, 313315

Relocation stress syndrome
Risk-prone health behavior
Role performance, ineffective
271272
Self-care decit
Self-esteem, low

NURSING DIAGNOSES INDEX 695
chronic, in substance-related disorders, 9799

in obesity, 233234
269270
in sexual and gender identity disorders, 216217
Self-health, ineffective management, in psychiatric home
nursing care, 351352
Self-mutilation, risk for
Sensory perception
disturbed
disturbed: auditory/visual
Sexual dysfunction
nursing interventions for, 207209
ineffective sexuality patterns, 209213
Sexuality patterns, ineffective
in paraphilias, 209213
Sleep pattern, disturbed, in major depressive disorder, 142143
Social interaction, impaired


Social isolation
Spiritual distress, risk for, in loss and bereavement, 404405
Suicide, risk for
Therapeutic regimen, ineffective management , client behavior

leading to diagnosis of, 619
Thought processes, disturbed
Trauma, risk of, in delirium, dementia, and amnestic disorders,
5860
Verbal communication, impaired

Violence, risk for, self-/other-directed

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2506_FM_i-xxxvi.

indd ii 10/4/10 3:53:18 PM

La belle indifference, 179, 185

Manic behavior, 125, 145, 620t

Noncompliance, 32, 4042, 189, 266, 364, 619t

Orgasmic problems, 204, 205, 208, 620t

Pain, 176177, 180181, 204, 205, 206, 321323

Regression/regressive behaviors, 110, 131, 141

Seductive remarks/inappropriate sexual behaviors, 28, 313, 620t

Thought processes, disturbed, 6264, 117119, 139140, 154155, 157

Verbal communication, impaired, 1819, 2324, 119120

2506_FM_i-xxxvi.indd i 10/4/10 3:53:17 PM

Care Plans and Psychotropic Medications

Mary C. Townsend, DSN, PMHCNS-BC

Former Assistant Professor and

2506_FM_i-xxxvi.indd iii 10/4/10 3:53:18 PM

Copyright 2011 by F. A. Davis Company

Printed in the United States of America

Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1

Publisher, Nursing: Robert G. Martone

As new scientic information becomes available through basic and clinical

Library of Congress Cataloging-in-Publication Data

Townsend, Mary C., 1941-

2506_FM_i-xxxvi.indd iv 10/4/10 3:53:19 PM

To my daughters, Kerry and Tina, my grandchildren, Meghan

To my faithful and beloved companions, Chiro, Angel, and Max,

And nally, to the memory of my father and mother, Francis and

2506_FM_i-xxxvi.indd v 10/4/10 3:53:19 PM

Maude H. Alston, RN, PhD

Betty J. Carmack, RN, EdD

Doris K. DeVincenzo, PhD

Mary Jo Gorney-Fadiman, RN, PhD

Mary E. Martucci, RN, PhD

Sheridan V. McCabe, BA, BSN, MSN, PhD

Elizabeth Anne Rankin, PhD

2506_FM_i-xxxvi.indd vii 10/4/10 3:53:19 PM

Judith M. Saunders, DNS, FAAN

Gail Stuart, RN, CS, PhD

2506_FM_i-xxxvi.indd viii 10/4/10 3:53:20 PM

Jaynee R. Boucher MS, RN

2506_FM_i-xxxvi.indd ix 10/4/10 3:53:20 PM

Jo Anne C. Jackson, EdD, RN

Florence Keane DNSc, MSN, BSN

Gayle Massie MSN, RN

Phyllis Rowe, DNP, RN, ANP

2506_FM_i-xxxvi.indd x 10/4/10 3:53:21 PM

Karen Tarnow, RN, PhD

2506_FM_i-xxxvi.indd xi 10/4/10 3:53:21 PM

My special thanks and appreciation:

2506_FM_i-xxxvi.indd xiii 10/4/10 3:53:21 PM

How to Use This Book xxvii

Index of DSM-IV-TR Psychiatric Diagnoses xix

THE FOUNDATION FOR PLANNING

2506_FM_i-xxxvi.indd xiv 10/4/10 3:53:21 PM

SPECIAL TOPICS IN PSYCHIATRIC/

2506_FM_i-xxxvi.indd xv 10/4/10 3:53:22 PM

2506_FM_i-xxxvi.indd xvi 10/4/10 3:53:22 PM

2506_FM_i-xxxvi.indd xvii 10/4/10 3:53:22 PM

Subject Index 639