Occupational Therapy 1

Liaquat University of Medical and Health Sciences Jamshoro Sindh
College of Nursing, JPMC Occupational Therapy ACN III Practical Scenario (Assignment # 1) Aster Ghulam
BScN Year II

Mrs. Munira A. Ali

Occupational Therapy 2 Professional with a baccalaureate degree in occupational therapy uses creative and manual techniques to assist client is working towards specific psychotherapeutic goals also may work with clients to develop independent living skill to smooth the transition between hospital and community. Definition Occupational Therapy is serves deliver to empower the client to advocate his own need with knowledge and a wide array of resource client controls or his life based on choices of acceptable options that minimized physical and psychological alliance on other in making decision and performing everyday activities. Goals The goal of occupation therapy is to enable individual to achieve competency and satisfaction in life’s chosen role and in the activities that support function of these roles. Assessing Task and Activities Occupational therapists use variety of assessment tools to measure baseline and discharge performance in tasks and activities of importance to client. Assessing role and community integration outlines taxonomy of three types of life roles. Self maintenance role is associated with the care of self and examples are of parent homemaker, caregiver and home maintainer, self enhancement role to contribute to a person’s accomplishment. They include friends, hobbyist reader, and participant in organization role that support the productive activities of person, self advancement role include activities of a person, self maintenance roles include self care, care of home and family, self enhancement role include play and leisure while the self advancement roles are close to the occupational function of one of work. Community integration refers to ability of person to line work and enjoy his or her free time within community setting. Several assessments can be used to assess community integration.

Occupational Therapy 3  The Craig handicap assessment and reporting technique reflect the language of international classification of impairment, disability and handicap.  The registration to normal living index is an easy to use. Items assessment that focuses on participation in community activities important to person.  The community integration measure uses ten items together information about the person qualitative experience of living in a community. This easy to use measure was developed for use of who have brachia injury. Many assessment of health related quality of life have been developed for use with people with chronic illness. Activities of Daily Living  It generally includes mobility at home feeding, dressing, bathing, grooming, toileting, basic communication and personal hygiene.  Observation of the activities identified by the client as problems should be done at the time of day. When these activities are normal done if possible.  Many people may have strong feeling of modesty regarding personal care. Those feelings should be respected. If many activities are evaluated by functional independence measurement. The Katz Index evaluated sex functions.  Functional Independence Measure uses a seven point’s scale to evaluate 18 items in the area of self care, sphincter control, mobility locomotion, communication and social cognition is function independence measure is intended to measure disability. It is effectiveness. Functional Independence Measure has good to excellent reliability also predict functional status at discharge and length of stay.  Klein Bell Activities Daily Living Scale – in 1982, is one of the most responsive assessment because of large number of items. It documents basic ADL skill including

Occupational Therapy 4 dressing, elimination, mobility, bathing, hygiene, eating and emergency telephone communication. Each area is broken down into task and task is broken down in step by step simple behavioral items.  Functional Status Index – Jette (1980) assessed level of performance, degree of difficulties and degree of pain in 5 areas; mobility hand activities, personal care, home chores, social and role activities. This assessment provides excellent overview of activities and daily living but may not be useful for treatment planning as assessment.  Safe and Safer – two assessment developed recently focus on evaluating functional performance and safety of activities of daily living concurrently. It is process of standardization assesses independence and required supervision in bathing, dressing, feeding bowel and bladder control. The safety assessment of function and the environment for rehabilitation.  Instrumental Activities of Daily Living – include meal planning preparation service and clean up, marketing for food and clothing and routine and seasonal care of the home and one’s clothing yard work and other maintenance task may have been responsibility of client evaluation are more complex and more attention is to basic activities of daily living takes in most rehabilitation programs.  Assessment of Motor and Process Skills – the assessment of motor and process skill (Fisher 1993-1995) is an innovative assessment through which the therapist can simultaneously assess performance of instrumental activities daily living takes and the motor and process performance component that contribute to completion of these task.

Occupational Therapy 5

Liaquat University of Medical and Health Sciences Jamshoro Sindh
College of Nursing, JPMC Occupational Therapy ACN III Major NCP (Assignment # 2) Aster Ghulam
BScN Year II

Mrs. Munira A. Ali

Occupational Therapy 6 Scenario Mrs. Iqbal is a 78 years old woman, recently admitted to Medical Ward Unit-III after a cerebral vascular accident. Now, she is only stable. Her medical course in acute care hospital is difficult. Her cerebral vascular accident right sided leaving her with hemiplegia. She lives alone having been widowed two years ago. Now she has continued to live with her son’s family, an hour away from hospital. Mrs. Iqbal interested in gardening, cooking, embroidering, etc. According to this situation, we will perform her functional instrument measures.  Self care           Eating Grooming Bathing Dressing upper body Dressing lower body Toileting She needs total assistance She needs helper and supervision.

Sphincter Control Bladder management Bowel management Transfer   Bed, chair, wheel chair Toilet Walk/Wheel chair Stairs Expression Needs helper Modified independence (device) Auditory + visual (Both) – Moderate Assistance Vocal + Nonvocal (Both) – Minimal assistance. Helper + maximum assistance

Locomotion  

Communication 

Social cognition   Social interaction Problem solving It is not testable due to risk.

Occupational Therapy 7  Memory

Occupational Therapy 8 NURSING CARE PLAN TITILE:
Date

Bathing/Hygiene Self-Care Deficit
Nursing Diagnosis Bathing/Hygiene self-care deficit.

Assessment (Data Statement) Subjective Data: Client verbalized that I am disturbed due to self initiated goal direct activities and poor personal hygiene. Inability to follow though with completion of daily tasks, apathy and unable to use energy productivity. Objective Data: A 78 years old client was admitted in Medical Unit-III after attack of CVA. She is looking untidy, uncombed hair. Chills and rashes, facial grimaces, restlessness and uncomfortable. Vital signs: Blood Pressure: 150/100 mmHg Pulse Rate: 100 beat/min Resp. Rate: 22 per min. Investigation Hb: 9 mg/dl Urine D/R: Normal CT Scan was done appeared normal.

Goal/Planning Short-term Goals:
The client will participate in self-care activity within one week.

Nursing Intervention  Provide time for a rest  period during the client’s daily schedule. Observe the client for signs  of fatigue and monitor his or her sleep patterns. Decrease stimuli before  bedtime (dim lights, turn off television). Use comfort measures or  sleeping medication if needed. Encourage the client to  follow a routine of sleeping at night rather than during the day, limit interaction with the client at night and allow only a short nap during the day.

Rationale

Evaluation

 Long-term Goals:  The client will adequate balanced of rest and sleep pattern.  The client will  demonstrate to initiate daily tasks with assistance.  The client will established normal nutritional eating pattern  till discharge.

The client’s increased The client has activity increases his or verbalized that I now participate in her need for rest. self-care activities The client may be and also estabunaware of fatigue or lished adequate may ignore the need for balance of rest, sleep and activity. rest. Limiting stimuli will The client was help encourage rest and taking her treatment effectively, sleep. maintaining Comfort measures and adequate nutrition medications can enhance and also meeting personal needs the ability to sleep. with assistance. Talking with the client during night hours will interfere with sleep by stimulating the client and giving attention for not sleeping. Sleeping excessively during the day may decrease the client’s ability to sleep at night. The client may be unaware of physical needs or may ignore feelings of thirst and hunger.

Monitor the client’s calorie,  protein and fluid intake. You may need to record intake and output.

Occupational Therapy 9

Occupational Therapy 10 Interventions      The client may need a high-calorie diet and supplemental feeding. Provide foods that the client can carry with him or her. Monitor the client’s elimination patterns    Rationales The client’s increased activity increases nutrition requirements. If the client is unable or unwilling to sit and eat, highly nutritious foods that require little effort to eat may be effective. The client may be unaware of or ignore the need to defecate. Constipation is a frequent adverse effect of antipsychotic medications. The client may be unaware of or lack interest in hygiene. Personal hygiene can foster feelings of well-being and self-esteem. The client must be encouraged to be as independent as possible to promote self-esteem.

If necessary, assist the client with personal hygiene, including mouth  care, bathing, dressing, and laundering clothes. Encourage the client to meet as many of his or her own needs as  possible.

References  Harber, Hoskins and Leach (1978). Comprehensive Psychiatric Nursing. 3rd Edition. USA.  Shives, L.R. and Isaacs, A. (2002). Basic Concepts of Psychiatric-Mental Health Nursing. 5th Edition. Lippincott Philadelphia.  Schultz, J.M. and Videbeek, S.L. (2004). Lippincott’s Manual of Psychiatric Nursing Care Plans.7th Edition. Lippincott Philadelphia.  Tromblhy, C.A. and Radomski, M.V. (2001). Occupational therapy for physical dysfunction. 5th Edition. Lippincott Philadelphia.

Liaquat University of Medical and Health Sciences Jamshoro Sindh
College of Nursing, JPMC Stress ACN III Aster Ghulam
BScN Year II

Mrs. Ruth K. Alam

Stress and anxiety are universal experiences that can be either catalysis for positive change or sources of discomfort and particularly nurses are involved with stress management from teaching perspective helping clients learn to cope with stress imposed by illness, injury, disability or treatment. Approaches caring for client who are experiencing high level of anxiety can be also provoking for nurse successful stress management is necessary for wellness of both client and nurses. Definition According to Hans Selye (1974), “stress is nonspecific response to any demand made on the body.” Selye termed such demands stressors, any situation, event or agent that produce stress is considered a stressor. Stressor s can be internal or external. A stressor is a stimulus that evokes the need to adopt. Factors Effecting Stress Responses The response of any individual to stress depends upon the following major factors.          Emotional factors – much stress occurs through emotions, such as: Aggression Impatient Anxiety Fear Anger Fight Loss of something valuable. Diet – contributes to physical stress Malnutrition and over nutrition. Imbalance diet.

              

Excessive smoking Excessive alcohol.

Financial Factors Unemployment. Poverty Price hike. Physiological Factors Adolescence Pregnancy. Overwork. Major Event in Life Marriage Death of close relative or friends. Divorce. Moving to new home/place. Frustration Fails to attain goals. Frustration is associated with motivation. The more motivated, more frustration we experienced when goal is blocked.

     

Conflict Physical Factors General illness Pain Disease Injury

         

Starvation Physical handicap. Medication Hospitalization Operation Chemical stress Individual perception Work related stress. Environmental Factors Maladjustment in family, poor working conditions, inadequate facilities, unreasonable demands of other downy, intolerable political situation and cultural values.

Most major cause is posttraumatic stress disorder.

Psychiatric Assessment Farzana, 17 years female, resident of Gulshan-e-Iqbal, Karachi admitted on 05-12-2006 in Psychiatric Ward and was allotted Bed No. 10. Presenting Problems  Physical dimension

Family health history Mother died two years ago with tuberculosis and diabetes. Father is alive with no active history of illness. Two sisters healthy and married. One brother health and unmarried. No history of any illness in the family and use of drugs.

Individual Health History No history of any other illness except, anger, guilt, sometimes weeping, lack of sleep and lack of appetite. No any physical illness.

Daily Activities Sitting ideally, most of times. Sometimes cleaning and off and on sleeping.

Sexuality Pattern Unmarried. Regular menstruation cycle. No any other significant.

Intellectual dimension

Difficult to express feelings.

Emotional dimension

Denial of feeling or emotional numbness.

Social dimension
• • •

Impaired social interaction. Decreased concentration. Difficulty with interpersonal problem.

Spiritual dimension
• •

Sometimes praying. Believe on remedies and hakeems.

Mental Status Examination (MSE)  Appearance

Young girl.

• • • •

Small height. Healthy. Wearing shalwar kameez Appropriate culture and clean clothing and appropriate hygienic condition.

Behavior
• • • •

Decrease concentration. Activities mild retarded. Rapid walking. Frustration and irritability.

Communication
• • •

Slow speaking. Low volume. Most of time silent.

Cognitive pattern
• •

Loose memory Remote

Mood and Affect

Disorganized.

Sensory perceptions

Thinking impaired.

Nursing Diagnosis   Posttraumatic stress disorder Risk for other directed violence.

Other Related Nursing Diagnosis

     

Dysfunctional grieving. Anxiety. Ineffective coping. Social isolation. Ineffective role performance. Risk for suicide.

Short-term Goals The client will:
• • • • • •

Identify the traumatic event. Demonstrate decreased physical symptoms. Verbalize need to grieve loss. Establish an adequate balance of rest, sleep and activity. Demonstrate decreased anxiety, fear, guilt and so forth. Participate in treatment program.

Long-term Goals The client will:
• • • • • •

Begin the grieving process. Express feelings directly and openly in nondestructive ways. Identify strengths and weaknesses realistically. Demonstrate an increased ability to cope with stress. Eliminate substance use. Verbalize knowledge of illness, treatment plan, or safe use of medications, if any.

Nursing Interventions and Rationales Interventions

Rationales The client’s fear may be triggered by authority figures or other characteristics. It is important not to reinforce blame that the client may have internalized related to the experience. Limiting the number of staff members who interact with the client at fist will facilitate familiarity and trust. The client may have strong feelings of fear or mistrust about working with staff members with certain characteristics. These feelings may have been reinforced in previous encounters with professionals and may interfere with the therapeutic relationship. Learning about the client’s experience will help prepare you for the client’s feelings and the details of his or her experience. Traumatic evens engender strong feelings in others and may be quite threatening. You may be reminded of a related experience or of your own vulnerability, or issues related to sexuality, morality, safety, or well-being. It is essential that you remain aware of your feelings so that you do not unconsciously project feelings, avoid issues, or be otherwise nontherapeutic with the client. The client may test limits or the therapeutic relationship. Problems with acceptance, trust, or authority often occur with posttraumatic behavior. Clients often use substances to help repress emotions.

When you approach the client, be • nonthreatening and professional. Remain nonjudgmental interactions with the client in you •

Initially, assign the same staff members • to the client if possible try to respect the client’s fears and feeling. Gradually increase the number and variety of staff members interacting with the client.

Educate yourself and other staff • members about the client’s experience and about posttraumatic behavior. Examine and remain aware of your own • feelings regarding both the client’s traumatic experience and his or her feelings and behavior. Talk with other staff members to ventilate and work through your feelings.

Be consistent with the client; convey • acceptance of him or her as a person while setting and maintaining limits regarding behaviors. Assess the client’s history of substance • use.

Interventions

Rationales Substance use undermines therapy and may endanger the client’s health. Allowing input from the client or group may minimize power struggles. Identification and expression of feelings are central to the grieving process. Knowledge about posttraumatic behavior may help alleviate anxiety or guilt and may increase hope for recovery. The client may feel that he/she is burdening others with his/her problems. It is important not to reinforce the client’s internalized blame. Guilt and forgiveness often are religious or spiritual issues for the client. Integrating traumatic experiences and making future plans are important resolution steps in the grief process. Social isolation and lack of interest in recreational activities are common problems following trauma. Problems with employment frequently occur in clients with posttraumatic behavior. Recovering from trauma may be a long-term process. Follow-up therapy can offer continuing support in the client’s recovery.

Be aware of the client’s use or abuse of • substances. Set limits and consequences for this behavior; it may be helpful to allow the client or group to have input into these decisions. Encourage the client to express his/her • feelings through talking, writing or in which the client is comfortable. Teach the client and the family or • significant others about posttraumatic behavior and treatment. Give the client positive feedback for • expressing feelings and sharing experiences. Remain nonjudgmental toward the client. If the client has a religious or spiritual • orientation, referral to a member of the clergy or a chaplain may be appropriate. Encourage the client to make realistic • plans for the future, integrating his or her traumatic experience. Provide social skills and leisure time • counseling, or refer the client to a recreational therapist as appropriate. Talk with the client about employment, • job-related stress, and so forth. Refer the client to vocational services as needed. Help the client arrange for follow-up • therapy as needed.

Evaluation    The client has expressed feeling directly and openly in nondestructive ways. The client has eliminated the substance use. The client has verbalized the knowledge of illness, treatment plan, and safe use of medications.  The client has identified support system in the community.

References   Alfred S (1998). Basics of Psychology for Nurses. 2nd Edition. Carson, V.B. (2000). Mental Health Nursing. The Nursing Patient Journey. 2nd Edition.   Johnson. (1989). Mental Health Nursing. 2nd Edition. Lippincott Philadelphia. Shives, L.R. and Isaacs, A. (2002). Basic Concepts of Psychiatric-Mental Health Nursing. 5th Edition. Lippincott Philadelphia.  Schultz, J.M. and Videbeek, S.L. (2004). Lippincott’s Manual of Psychiatric Nursing Care Plans.7th Edition. Lippincott Philadelphia.

Liaquat University of Medical and Health Sciences, Jamshoro Sindh College of Nursing, JPMC BScN Year-II, Session 2006-2008 Schizophrenia Advance Concept of Nursing

Abdul Hakeem Mrs. Mustaqima Begum January 18, 2008

Introduction Imran Ali, a 34 years old male has been admitted to Psychiatric Unit by his brothers. His brother stated that, he was alright six months back then he developed loosing interest in normal activities and started unrelated behavior and became unaware of his environment. He eats and drinks normally but speaks irrelevant words, phrases or sentences. He attends on calling but does not give proper answer to question. He also removes his clothes and does not feel any shame or guilt on to be naked. Sometimes he becomes aggressive and throws anything like stone, log, etc. on the person or any object in front of him. He awakes day and night without sleeping. He does not maintain personal hygiene and looks like bizarre person. He is unaware about his previous life.

NURSING CARE PLAN Patient’s Name: Mr. Imran Ali Age: 34 Years Medical Diagnosis: Schizophrenia Nursing Diagnosis: Risk for violence: Self directed or directed at others related to responding to delusional thoughts or hallucinations. Assessment Nursing Planning Interventions Rationales Diagnosis Subjective Data Immediate • Reassure the client that • The client is less likely to According to the client’s brother, The client will: the environment is safe feel threatened, if the “Mr. Imran Ali does not interest in • Be free from injury. by briefly and simply surroundings are known. normal living activities, unaware of explaining routines, • Not harm others or environment, does not feel shame or guilt procedures and so forth. destroy property. on to be naked, speaks continuously • Establish contact meaningless wording, does not maintain • Protect the client from • Client safety is a priority. with reality. hygienic condition and when aggressive harming himself or Self destructive ideas may • Demonstrate or throws any thing to any person or object others. come from hallucinations verbalize decreased present in front of him. or delusions. psychotic symptoms and feelings of Objective Data anxiety, agitation, • Remove the client from • The benefit of involving the A 34 years old male brought to the group, if his behavior client with the group is and so forth. Psychiatric Ward by his brothers with the becomes too bizarre, outweighed by the groups complaint of psychiatric problem. Client disturbing or dangerous need for safety and Stabilization is unaware of environment, bizarre facial to others. protection. The client will: expressions, disoriented feeling of • Take medications as agitation, disorganized, illogical • Help the client’s group • The client’s group benefits prescribed. thinking, having clothing but accept the client’s from awareness of others’ continuously trying to open or tear the • Express feelings in “strange” behavior. Give needs and can help the clothes. Aggressive behavior towards an acceptable simple explanations to the client by demonstrating others and property. manner. client’s group as needed empathy. (e.g., “[client] is very sick Vital Signs right now; he needs our Blood Pressure 100/70 mmHg understanding and Temperature 97 °F support”). Pulse 88 bpm Respiratory Rate 20 per min Risk for violence: Self directed or directed at others related to responding to delusional thoughts or hallucinations.

Evaluation Immediate The client: • Is free injury. • from

Does not harm others or property. Has established contact with reality. Participated therapeutic milieu. in

Stabilization Takes medication as prescribed. Expresses feelings in an acceptable manner. Community

Reflection Once, we reached at 08:30 AM at College, we found that a pre-clinical conference is arranged for us. In this pre-clinical conference, our Instructor gave us instruction about how to assess and deal the psychotic clients. Along with others psychotic diseases, we also discussed “Schizophrenia”. It is psychotic disorder in which client suffers from hallucination, delusion, illusion and thought disorders. All students gave their views and at last our Instructor summarized the disease. Then we went on clinical in Psychiatric Ward-20. We introduced ourselves with Head Nurse and other staff members of the ward and Doctors too. Their attitude was very supportive. They guide us, on the basis of their experiences to deal the psychiatric clients. Doctors gave lectures to differentiate between psychotic and neurotic disorders clients. Then I went to ward and selected my client. He was suffering with schizophrenia. The client was sitting on bed. He is looking angry, irritable with his attendant and asking him that he wants to kill him. I asked the attendant to leave the client alone for few minutes and try to built relationship and trust with client. I also started assessment and observed that the client is looking untidy, wearing dirty clothes. He is also looking miserable. Whenever, his relatives try to wake him, he starts verbalizing doubt about them and also blamed them. I gained his confidence and heard his point of view. I read the history and other health assessment milestone of psychiatric clients, then I discussed with attendant, who was in very problematic situation to deal with him. He told that “he is sick since last six months and have complaint of schizophrenia; sign was arising with hallucination, delusion and illusion.” I discussed the client’s condition with doctors and nurses of Ward to gain practical tips, to how to deal with this client. It was my first experience to deal with psychiatric client. I learned about the psychiatric diagnosis and difference between psychiatric and neurotic disorders. I also learned about different counseling techniques; how to deal the psychiatric clients. I share my experience with my classmates in past clinical experience and learn how to deal psychiatric clients in future.

References 
Carpenito, L.J. (1997). Nursing Diagnosis: Application to Clinical Practice, (7th ed.). Lippincott Philadelphia.

Schultz, J.M. and Videbeek, S.L. (2004). Lippincott’s Manual of Psychiatric Nursing Care Plans, (7th ed.). Philadelphia: Lippincott.

Shives, L.R. and Isaacs, A. (2002). Basic Concepts of Psychiatric-Mental Health Nursing, (5th ed.). Philadelphia: Lippincott.

http://www.google.com. Scott J (2001). Cognitive therapy for depression. B Med Bulletin; 57:101-113.

Liaquat University of Medical and Health Sciences, Jamshoro Sindh College of Nursing, JPMC, Karachi BScN Year-II, Session 2006-2008 Personality Disorders Advanced Concept of Nursing III Bushra Sultana

Mrs. Mustaqima Begum Dated: _______________

Personality is the totality of those aspects of behavior, which give meaning to an individual in society and differentiate him from other member in the community. One of the oldest methods of describing personality difference is to categorize people into different types on the basis of major characteristics. All individuals are roughly classified into type A and type B personalities. Type A Personality – people with this type of personality tend to be hard driving, competitive, ambitious, impatient and hostile.  They tend to talk rapidly and give single word immediate answers, with acceleration at the end of sentences; the volume of speech is loud.       They show a tense and hostile facial expression. They show tense posture and usually sit on the edge of the chair. The feel intense time urgency. They have a tendency to interrupt the speaker. They are constantly preoccupied with responsibilities. They are usually not satisfied with their job and want to move up. Type B Personality – people with this type of personality have a calm and relaxed attitude towards life. They are patience and easy going in their daily life.      The rate of speech is slow, with frequent pauses. The volume of speech is low. Facial expression is relaxed and friendly. They show a relaxed and comfortable posture. The rarely interrupt the speaker. They are usually satisfied with their job. A Personality Disorder is defined as “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive

and inflexible has an onset in adolescence or early adulthood is stable over time and leads to distress or impairment.” There are two classifications to classify the personality disorder. ICD-10 – used by WHO, deals with whole system and accounts for the course of disease. DSM-IV – used by Americans and measure problems quantitatively and is based on Axis. DSM-IV-TR classified the personality disorders as:  Cluster A Disorders – including paranoid, schizoid and schizocypal personality. Common traits – they often appear odd and eccentric.  Cluster B Disorders – including antisocial, borderline, histrionic and narcissistic personality disorder. Common traits – these are typical exhibit dramatic, emotional and erotic behavior.  Cluster C Disorders – including dependent, avoidant and obsessive compulsive personality disorder. Common traits – they characteristically display anxious and fearful behaviors. Cluster A Disorders A peculiar, fears social relationship, genetic, familial association with psychotic illness Personality Disorder Paranoid • • • Characteristics Distrustful. Suspicious Attributes responsibility for own problem to others Patient Snapshot A 45 years old female hospitalized aide says that she was laid off because she worked to hard and made her supervisor look lazy. She says that when the same things happened in a pervious job. She filed a law suit against that hospital.

Personality Disorder Schizoid

Characteristics

Patient Snapshot

Long standing pattern of The parents of a 26 years old man say that voluntary social withdrawal they are concerned about him because he without psychosis. has no friends and spends most of his time hiking in the woods. On examination, you find him contended with his solitary life and has no evidence of formal though disorder. Peculiar appearance magical An oddly dressed 32 years old lady says she thinking odd thought patterns likes to walk in the woods because the birds and have disorder. Cluster B Disorders behavior major without communicate with her. She never goes out depressive She has few friends. psychosis, most patient also on Thursday because this is dangerous day.

Schizotypal

Emotional, inconsistent or dramatic genetic or familial association with mood disorders Histrionic substance abuse and somato form disorder Theatrical, extroverted, 28 years old man comes to your office in a emotional, life of the party, black velvet beret and a cap by lined with cannot maintain intimate red satin. He reports that his mild sore throat felt like a hot poker. When he swallowed and says that he feels so warm Narcissistic that he must have a fever of at least 106. Pompous with a sense of A 38 years old man asks you to refer him to special entitlement; lacks a physician who attended a top medical school. He says that he knows you will not be offended because you understand that he is better than your other patients. empathy for others. relationships.

Personality Disorder Antisocial

Characteristics

Patient Snapshot

Refuses to confirm to social A 35 years old man brags that he has been norms shows no concern for sexually assaulting women ever since high others and does not learn school, but has never been caught. He has from experience associated often been unemployed and has been with conduct disorder in arrested for shoplifting several times. childhood and criminal behavior in adulthood. Erratic, unstable behavior A 20 years old female college student tells and mood boredom; feelings you that because she was afraid to be alone of aloneness i.e., feeling again. She tried to commit suicide after a alone in the world not merely man with whom she had two dates did not loneliness Suicide impulsiveness. call her again. After your interview, she attempts and tells you that all of the other doctors she has

Borderline

minipsychotic episodes i.e., seen were terrible and that you are the only brief periods of loss of doctor who ahs ever understood her contact with reality. Self problem (use of splitting as a defense mutilation burning comorbid disorders disorders. Cluster C Disorders Avoidant Fearful, anxious, genetic or familial association with anxiety disorders Timid, sensitive to rejection A 35 years old woman, who works as a and socially withdrawn laboratory assistant lives with her elderly mother and rarely socializes. She reports that when coworker ask her to join them for lunch. She refuses because she is afraid that they will not like her. feelings of inferiority. (cutting oneself). with and or mechanism). Often mood eating

Personality Disorder Obsessive compulsive

Characteristics Perfectionistic, of imperfection.

Patient Snapshot

orderly, A 33 years old man reports that each night activities for the next day. He tells you that his wife of six months recently moved out because she could not confirm to his rigid

stubborn, indecisive, feelings he creates a detailed schedule of his

Dependent

rules. Allows other people to make A 32 years old woman says that her decisions responsibility because of and for poor assume husband is angry because she calls him at them the office many times each day to ask him self to make trivial everyday decisions for her.

confidence may be abused by domestic partner. Each individual personality disorder affects approximately one percent of the population, although many patients have features of more than one personality disorders. Personality disorders have a genetic association with some psychiatric disorders. These are more common in relatives of patient with personality disorders than in general population. Psychological factors may be also implicated. Helgeland, et al. (2005) conducted a research and expected the following hypothesis to be confirmed.  Adolescent with disruptive behavior disorders would be more likely to have personality disorder as adult than would adolescent with emotional disorders.  Disruptive behavior disorders in adolescent would be associated with higher rates of cluster B personality disorders in adulthood than cluster A and cluster C personality disorders.  Emotional disorder in adolescent would be associated with development cluster C personality disorders in adulthood.

Method One hundred and thirty subjects, with age mean 43.2 years had been diagnosed with emotional and disruptive behavior disorder during adolescent age mean 14.6 years and rediagnosed based on hospital records. According to DSMIV, were interviewed with the structured interview for DSM IV personality to establish whether they suffered from personality disorder at 28 years follow up. Results Adolescent with disruptive behavior disorder were not more likely to have personality disorder in adulthood than ones with emotional disorders. They were significantly more likely to have cluster B personality disorder at follow up than adolescent with emotional disorder. Logistic regression analysis revealed that disruptive behavior disorders in females were significantly more strongly associated with a high risk of cluster B diagnosis at follow up than in men. Emotional disorders were significant and independent predictors of cluster C personality disorders in women but not in men. Disruptive behavior disorders were significant and independent predictor of antisocial personality in men. Conclusion In the conclusion it is said to be that these results support the view that personality disorders can be traced back to adolescent, emotional and disruptive behavior disorders. The moderating effect of gender in cluster B and cluster C personality disorders suggested that sociocultural and biological factors may contribute to different adult outcomes in men and women with similar adolescent psychiatry disorders.

References   Fadem, B., & Simring, S.S. (2003). High-yield psychiatry. USA. http/www.ajp.psychiatryonline.org. Retrieved on September 10, 2007.

Liaquat University of Medical & Health Sciences, Jamshoro Sindh College of Nursing, JPMC, Karachi

BScN Year-II, Session 2006-2008 Bipolar Disorder Advance Concept of Nursing Daisy Nasreen Mrs. Mustaqima Begum Dated: _______________

Happiness, sadness, excitement, and apathy are just a few of the many emotions we experience in everyday life. We all have our ups and downs, our "off" days and our "on" days. But if you're suffering from bipolar disorder, these peaks and valleys are more severe. Bipolar disorder—also known as manic depression or manic-depressive illness—involves dramatic shifts in mood from the highs of mania to the lows of major depression. What is Bipolar Disorder? Unlike ordinary mood

swings, the cycles of bipolar disorder are much more intense and disruptive to daily

functioning. More than just a fleeting good or bad mood, these episodes last for days, months, or sometimes even years. And your mood isn’t the only casualty of the disease. In addition to emotional well-being, bipolar disorder affects your energy, activity level, judgment, critical thinking skills, appetite, and sleep. While dealing with bipolar disorder isn’t always easy, it doesn’t have to run your life. With proper treatment and a solid support system, people with bipolar disorder are capable of leading rich and fulfilling lives. They can hold jobs, sustain loving marriages, raise children, and be productive members of society. But in order to successfully manage bipolar disorder, it is essential to fully understand the condition and its challenges.

Causes and Triggers Bipolar disorder has no single cause and none of the exact cause was found, yet. It appears that some people are genetically predisposed to have bipolar disorder and that the brain is the center of the illness. Yet not everyone with the genetic tendency displays bipolar disorder, so several other factors must be involved in producing the illness. These other environmental and psychological factors are called triggers. Although triggers may set off a bipolar episode in someone predisposed to the disorder, most bipolar episodes occur without an obvious trigger. Bipolar Disorder Causes and Risk Factors  Biological Causes Genetics - Bipolar disorder runs in families, with genetics believed to play a significant role. A person with this inherited vulnerability may develop bipolar disorder in response to environmental triggers such as a traumatic experience or drug abuse. Neurotransmitter Imbalance - serotonin, dopamine, and norepinephrine are three neurotransmitters—or chemical messengers in the brain—that help regulate our moods. It is believed that imbalances in these biochemicals are responsible for the mood swings of bipolar disorder. Brain Metabolism - brain imaging scans reveal significant differences between the metabolism of a normal brain and a bipolar brain. During normal mood, brain activity and blood flow across the two sides of the brain are basically equal. But in a manic or depressed state, different areas of the brain are more active than others. Hormonal Imbalances – have been found in many people with bipolar disorder. In particular, high levels of the stress hormone cortisol and abnormal levels of thyroid hormone are believed to contribute to manic and depressive mood episodes.

Biological Rhythms – disturbances in circadian rhythms have been implicated in bipolar disorder. Some researchers believe that the biological clock that regulates our sleepwake cycle is abnormally fast in people with bipolar disorder.  Bipolar Disorder Triggers Stress - Severe stress or emotional trauma can trigger either a depressive episode or a manic episode in an individual predisposed to bipolar disorder. Stress can also prolong a bipolar mood episode. Major Life Event - such as getting married, going away to college, or starting a new job can trigger a mood episode. Substance Abuse - While substance abuse doesn’t cause bipolar disorder, it can bring on manic or depressive episodes and worsen the course of the disease. Drugs such as cocaine, ecstasy, and amphetamines can trigger mania, while alcohol and tranquilizers can trigger depression. Medication-Induced Mania - Certain medications, most notably antidepressant drugs, can trigger a manic episode. If antidepressants are prescribed during the depressive phase of bipolar disorder, they must be taken with a mood stabilizer in order to avoid this complication. Other drugs that may induce mania include over-the-counter cold medicine, appetite suppressants, caffeine, corticosteroids, and thyroid medication. Seasonal Changes - Episodes of mania and depression often follow a seasonal pattern. Manic episodes are more common during the summer, and depressive episodes more common during the fall, winter, and spring. These patterns are believed to be tied to seasonal fluctuations in light. Sleep Deprivation - Sleep deprivation—even as little as skipping a few hours of sleep —can trigger an episode of mania.

Signs and Symptoms Bipolar disorder involves periods of elevated mood, or mania, alternating with periods of depression. A person with bipolar disorder typically cycles between these two extremes, often with periods of normal mood in between. The pattern of symptoms differs from person. Some people are more prone to either mania or depression, while others experience equal numbers of manic and depressive episodes. The frequency and duration of the mood episodes also varies widely. While a few individuals experience only one or two periods of mood disruption, most people with bipolar disorder suffer from multiple, recurring manic and depressive episodes. There are four types of mood episodes that can occur in bipolar disorder: mania, hypomania, depression, or a mixed episode.

Manic Phase - in this phase patient showed signs of:         Feeling of euphoria extreme, optimism and inflated self esteem. Rapid speech, racing thoughts. Agitations and increased physical activities. Poor judgments. Recklessness or taking chances not normally taken. Difficulty in sleeping. Inability to concentrate. Aggressive behavior. Depressive Phase - it includes:        Persistence feeling of sadness, anxiety, guild and hopelessness. Disturbance in sleep and appetite. Fatigue and loss of interest in daily activities. Problem in concentrating. Irritability. Chronic pain without unknown cause. Recurring thoughts of suicide.

Hypomania It is a less severe form of mania. People in a hypomanic state feel euphoric, energetic, and productive, but their symptoms are milder than those of mania and cause less impairment to functioning. Unlike manics, people with hypomania never suffer from delusions and hallucinations. They are able to carry on with their day-to-day lives. To others, it may seem as if the hypomanic individual is merely in an unusually good mood. But unfortunately, hypomania often escalates to full-blown mania or is followed by a major depressive episode.

Bipolar II Disorder – Hypomania and Depression In Bipolar II disorder, the person doesn’t experience full-blown manic episodes. Instead, the illness involves episodes of hypomania and severe depression. In order to be diagnosed with Bipolar II Disorder, you must have experienced at least one hypomanic episode and one major depressive episode in your lifetime. If you ever have a manic episode, your diagnosis would be changed to Bipolar I Disorder.

Cyclothymia – Hypomania and Mild Depression Cyclothymia, also known as cyclothymic disorder, is a milder form of bipolar disorder. Like bipolar disorder, cyclothymia consists of cyclical mood swings. However, the highs and lows are not severe enough to qualify as either mania or major depression. To be diagnosed with cyclothymia, you must experience numerous periods of hypomania and mild depression over at least a two-year time span. Because people with cyclothymia are at an increased risk of developing full-blown bipolar disorder, it is a condition that should be taken seriously and treated.

Rapid Cycling – Frequent episodes in Bipolar I or Bipolar II Disorder Rapid cycling is a subtype of bipolar disorder characterized by four or more manic, hypomanic, or depressive episodes within one year. The shifts from low to high can even occur over a matter of days or hours. People with Bipolar I and Bipolar II disorder can experience rapid cycling. According to the National Institute of Mental Health, rapid cycling usually develops later in the course of bipolar disorder. Diagnostic Criteria   Presence of a single major depressive episode. The major depressive episode is not better accounted for by Schizoafective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder or Psychotic Disorder.  There has never been a manic episode, a mixed episode or a hypomanic episode. This exclusion does not apply if all to the manic-like, mixed-like or hypomanic-like episodes are substance or treatment induced or due to the direct physiological effects of a general medical condition.  Severity/Psychotic/Remission specifiers chronic features include: With Catatonic features. With melancholic features With atypical features With postpartum onset.

Therapeutic Modalities  Pharmaceutical • Lithium Therapy: Carbamazepine and Lithonate Relief from neuroplastic conjunction. Effective regulating bipolar depression.

• • 

More effect in long-term treatment. Anti-Convulsant Therapy: Valproate or Depakote Effective for regulating mood and improve for indication for mania. Atypical Anti-Psychotic Drug: Clozopin This medication used to prevent manic episode.

Electroconvulsive Therapy (ECT) This therapy was discovered in the mid 1920s and at the time, it was the only treatment available and was frequently used and misused. DePaulo & Ablow, (1989) stated that it induces a seizure by applying electric current. It provides the most rapid relief of any treatment for severe depression. Most of the severely ill patients who fail to respond to medication respond to ECT. This form of treatment should be considered when drug therapy has failed, when the patient is at high risk for suicide or starvation, or when depression is judged to be overwhelmingly severe. It is also particularly useful when the depressed person is troubled by delusions or hallucinations. High success rates for treating both unipolar and bipolar depression and mania. Electroconvulsive therapy usually applied for all pharmaceutical treatment. It gives muscles relaxant to prevent convulsions.

Supportive Psychotherapy Supportive psychotherapy with medication treatment is most appropriate or patients with severe forms of depressive illness. Bachelor (1996) and Bloch (1979) stated the objectives for supportive psychotherapy, which are: • • Promote the patient’s best psychological and social functioning. Bolster self esteem and self confidence.

Make the patient aware of what can and cannot be achieved, both personal limitations and the limitations of treatment.

Prevent undue dependence on professional support and unnecessary hospitalizations.

Promote the best use of available support from family and friends.

Nursing Intervention  Maintain Safe Environment • • • • •  Decrease environmental stimuli,. Carefully observation of the patient. Setting boundaries. Explain the reason of limits. Focus on what they can do rather what they can not do.

Promote Physical Health • • • • • • • Assist patient in grooming and personal hygiene. Provide patient with portable food/finger food. Give high caloric and high protein diet. Ensure adequate water intake. Provide with sufficient sleep hours. Environment should be quite. Elimination pattern.

Communication • • Listen attentively. Use simple and clear sentences.

• • • 

Use firm, low pitch voice. Emphasize on here and now. Avoid loud demanding tone.

Reinforcement of Reality • • • • • Do not challenge the client/delusion. Do not encourage. Focus on reality. Reinforcement of reality. Observation for ‘carrying out’ behavior.

Nursing Diagnosis Major Depressive Disorder, recurrent.      Fear related to unfamiliar environment. Moderate4 anxiety related to anticipated transfer to nursing home. To assist the patient in meeting self care needs. Provide opportunities for the patient express feelings about self and illness. Observed for signs suicidal intent. Conclusion Bipolar disorder also known as ‘manic depression’ or ‘manic-depressive illness’ involves dramatic shifts in mood from the highs of mania to the lows of major depression. Unlike ordinary mood swings, the cycles of bipolar disorder are much more intense and disruptive to daily functioning. More than just a fleeting good or bad mood, these episodes last for days, months, or sometimes even years. It has no single cause and no exact cause was observed, yet. It may be due to genetic reason or due to neurotransmitter imbalance, brain

metabolism, hormonal imbalances, biological rhythms, stress, major life event, substance abuse, medication-induced mania, seasonal changes or sleep deprivation.

It can be treated by using various therapies; these include pharmaceutical therapy, Electroconvulsive Therapy (ECT) and supportive psychotherapy. Electroconvulsive therapy usually applied for all pharmaceutical treatment. It gives muscles relaxant to prevent convulsions. It provides the most rapid relief of any treatment for severe depression. Most of the severely ill patients who fail to respond to medication respond to ECT. This form of treatment should be considered when the patient is at high risk for suicide or starvation, or when depression is judged to be overwhelmingly severe. It is also particularly useful when the depressed person is troubled by delusions or hallucinations. On the other hand, supportive psychotherapy - with medication treatment is most appropriate for patients with severe forms of depressive illness.

References   Carson, V.B. (2000). Mental health nursing. 2nd Edition. USA. Bipolar Disorder. Article. Retrieved from http://www.healthline.com/glaecontent/ bipolar-7?utm-medium=yahoo&utm_source… on November 15, 2007.

Liaquat University of Medical and Health Sciences, Jamshoro Sindh College of Nursing, JPMC BScN Year-II, Session 2006-2008 Nursing Care Plan & Reflection Log Advance Concept of Nursing Daisy Nasreen Mrs. Mustaqima Begum January 24, 2008

Nursing Care Plan Introduction A 40 years old male named Khalid has been admitted to Psychiatric Ward at Bed No. 12 by his parents with complaint of hypermania. According to his mother, he was alright one week back. Suddenly, he developed a behavioral change and start shouting on others. He has no regard for eating, drinking, hygiene, grooming, resting or sleeping and have extremely poor judgment. Besides these he also developed psychotic symptoms like hallucination or delusions. His parents also added that sometimes he showed very depressive mood and during this he never eats and never sleep. Therefore, we brought him to the hospital for treatment.

NURSING CARE PLAN Mr. Khalid 40 Years Bipolar Disorder Risk for other directed violence related to risk of behaviors in which an individual demonstrates that he can be physically, emotionally, and/or sexually harmful to others. Assessment Nursing Planning Interventions Rationales Evaluation Diagnosis Subjective Data Immediate • Provide safe environment. • Physical safety of the client Immediate According to the client’s mother, The client will: and other is a priority. The The client demons“Mr. Khalid does not interest in decreased • Demonstrate decreased client may be used many trated normal living activities, unaware restlessness, hyperactivity, common items and restlessness, hyperof environment, does not maintain and agitation environmental situations in activity & agitation hygienic condition, restlessness, and also not harm a destructive manner. • Demonstrate decreased agitation, hyperactivity, hostile • Decrease environmental • The client’s ability to deal others or himself. hostility. behavior, threatened or actual stimuli whenever possible. with stimuli is impaired. • Not harm others and aggression towards self or others Stabilization Respond to cues of himself. and low self-esteem. The client be free agitation by removing of restlessness, stimuli and perhaps Stabilization Objective Data hyperactivity and isolating the client; a The client will: A 40 years old male brought to agitation. private room may be • Be free of restlessness, Psychiatric Ward by his parents beneficial hyperactivity and agitation. with the complaint of psychiatric • Provide a consistent, • Consistency and structure He also be free of • Be free of threatened or problem. Client is unaware of and structured environment. Let can reassure the client. The threatened environment, bizarre facial actual aggression toward actual aggression the client know what is client must know what is expressions, disoriented feeling of self or others. self or expected of him. Set goals expected before he can toward agitation, disorganized, others. with the client as soon as work toward meeting those restlessness, hostile behavior possible. expectations. towards others and self. • Give simple direct • The client is limited in the Vital Signs explanations. Do not argue ability to deal with complex Blood Pressure 100/80 mmHg with the client. stimuli. Stating a limit tells Temperature 99 °F the client what is expected. Pulse 100 bpm Arguing interjects doubt Respiratory Rate 28 per min and undermines limits. Patient’s Name: Age: Medical Diagnosis: Nursing Diagnosis: Risk for other directed violence related to risk of behaviors in which an individual demonstrates that he can be physically, emotionally, and/or sexually harmful to others.

Nursing Care Plan Interventions Encourage the client to verbalize feelings such as anxiety and anger. Explore ways to relieve tension with the client as soon as possible. Encourage supervised physical activity. Rationales Ventilation of feelings may help relieve anxiety, anger, and so forth. Physical activity can diminish tension and hyperactivity in a healthy, nondestructive manners. The client is limited in the ability to deal with complex stimuli. Stating a limit tells the client what is expected. Arguing interjects doubt and undermines limits. Positive feedback provides reinforcement for desired behaviors and can enhance selfesteem. It is essential that the client receive attention for positive behaviors, not only for unacceptable behaviors. Seeking staff assistance allows intervention before the client can no longer control his or her behavior and encourages the client to recognize feelings and seek help. Withdrawing attention can be more effective than negative reinforcement in decreasing unacceptable behaviors. The client may be seeking attention with this behavior. It is important to reinforce positive behaviors rather than unacceptable ones. Arguing with the client can reinforce adversarial attitudes and undermine limits. The client may fear loss of control and may be afraid of what he may do if he begins to express anger. Showing that you are in control without competing with the client can reassure the client without lowering his self-esteem.

• • • •

• • • •

Give the client positive feedback for controlling aggression, fulfilling responsibilities, and expressing feelings appropriately, especially angry feelings. Do not attempt to discuss feelings when the client is agitated.

• •

Encourage the client to seek a staff member when he is becoming upset or having strong feelings. Withdraw your attention (ignore the client) when the client is verbally abusive. Tell the client that you are doing this, but you will give attention for appropriate behavior. If the client and others, and then withdraw your attention from the client. Do not argue with the client.

• •

• •

Calmly and respectfully assure the client that you will provide control if he • cannot control himself, but do not threaten the client.

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Occupational therapy Reflection Introduction To fulfill my clinical requirements and to gain new experiences as a BSc Nursing student, I went to Psychiatric Ward. It was my second clinical week at Psychiatric unit. I wished staff members and with a permission of Head Nurse, I went to my client, which I selected last week. A 40 years old male was sitting on the bed uncomfortably and depressed mood. I wished to the client but he had not responded to me. I tried to draw his attention again. He looked at me and murmured, which I could not heard clearly. I asked him “why are you worried?” He told me, “I am worried about my family due to financial problems, as I am jobless. This is the main reason of worry.” He further verbalized that “I have four children and how being a jobless, I cannot cope with the situation to meet my expenses”. Analysis I analyzed the client’s problem. He was in critical condition and unable to manage the conditions. I suggested him to put his children in Government School, they will provide assistance to your children and they get good education. I also told him that now-a-days women are working at home and becoming a helping hand for the family. I also asked him that I will also help to obtain job. Similarly, I spend some more time with him and discuss various matters and also counsel, motivate and encourage him to cope with the situation, instead of becoming depressive. The Society for the Promotion of Occupational Therapy (1917) defined occupational therapy as “Occupational therapy is a health profession that helps people participate fully in life.” Occupational therapy also refers to the use of meaningful occupation to assist people who have difficulty in achieving healthy and balanced life, and to enable an inclusive society so that all people can participate to their potential in daily occupations of life (Elizabeth & Helene, 2007) Occupational Therapists and Occupational Therapy Assistants work with a variety of individuals who have difficulty accessing or performing meaningful occupations.

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Occupational therapy Learning I have learned from this situation that, if we listen attentively and spend time with the clients suffering from psychiatric disorders, we can motivate and encourage them to overcome their problems and to cope with the situation so that they can spend a successful independent life in society. Future Consideration If God provides me opportunity, I will solve the problems and give guidelines for living successful lives to all the clients suffering from psychiatric and disabled clients so that they can cope with the situation and become a useful citizen of their country, instead of becoming dependent on others.

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References 
Elizabeth, A., & Polatajko, H.J. (2007). Enabling Occupation II: Advancing an Occupational Therapy Vision for Health, Well-Being & Justice Through Occupation. Ottawa: CAOT Publications ACE.

Schultz, J.M. and Videbeek, S.L. (2004). Lippincott’s Manual of Psychiatric Nursing Care Plans, (7th ed.). Philadelphia: Lippincott.

Liaquat University of Medical and Health Sciences, Jamshoro Sindh College of Nursing, JPMC, Karachi BScN Year-II, Session 2006-2008 Depression Advanced Concept of Nursing III Farzana Gulzar Mrs. Mustaqima Begum Dated: ______________

Depression 55 The term ‘depression’ is used to define normal sadness and pain and with the illness of depression. Sadness is overwhelming and the person feel hopeless, helpless, there is noticeable change in eating habits and sleeping pattern, either sleeping too much or inability to feel rested after sleep. A person with depression loses energy and can describe recurring thought of death or suicide needs to be seen by a physician immediately. Depression carries with it disturbance in emotional, cognitive behavioral, somatic and spiritual dimensions of the individuals. World Health Organization has predicted that by 2020 depression will be the second most common cause of morbidity worldwide (WHO, 2000). The following are the risk factors for depression:

         

Prior episodes of depression. Family history of depressive disorder. Prior suicide attempts. Female gender. Age of onset under 40 years. Postpartum period. Medical comorbidity. Lack of social support. Stressful life situations. Current alcohol or substance abuse. The main two causes of depression are: The Biological cause of mood disorder includes altered neurotransmitter activity,

primarily decreased availability of serotonin and norepinephrene and abnormalities of the limbic-hypothalanie – pituitary adrenal axis.

Depression 56 The Psychological etiology of depression includes loss of a parent in childhood, social loss during adult life (loss of spouse), low self esteem, loss of hope and negative interpretation of life events, for example, taking a genuine compliment as insincere and undeserved. Drugs that may induce depression include:

        

Analgesics and non-steroidal anti-inflammatory agents. Antihypertensive. Antimicrobials. Anti-Parkinsonian drugs. Anti-Psychotic drugs. Cardiovascular agents. Sedatives and anti-anxiety drugs. Steroids and hormones. Stimulants and appetite suppressant. Characteristics of depression are:

   

Turned corners of mouth. Furrowed brow. Hunched, dejected posture. Decreased level of arousal. The principal symptoms of depression are:

  

Depressed mood. Loss of pleasure or interest in all or nearly all of one’s usual activities and past times. Insomnia or sometimes hypersomnia.

Depression 57

     

Anorexia and weight loss or sometimes hyperphagia and weight gain. Mental slowing and loss of concentration. Feeling of guilt. Worthlessness and helplessness. Thought of death and suicide. Overt suicidal behavior. Signs or depression include: Mnemonic S I G E C A P Sleep Interest Guilt Energy Concentration Appetite Psychomotor activity Signs Comments Insomnia and early awakening. Involvement in usual activities and motivation are decreased. Many patient feel excessive self-blame. Loss of vigor is common (hard to get though routine task). Cognitive problems (e.g., difficulty in paying attention and memory disturbance. Decreased desire for food and sex. Decreased physical activity, retardation, less common agitation occurs. psychomotor psychomotor

S

Suicidal ideation

Thoughts of self destruction are present in many patients.

The pathogenesis for depression included:

The etiology of major depression is undoubtedly complex and yet not known, because depressive episodes can be triggered by stressful life events in some people but not in others.

Greek believed that depression was caused by excessive amount of black bile.

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  

Current theory states that depression is associated with regional brain dysfunction. Observed symptoms and behaviors are related with disturbed chemistry. Two neurotransmitters are correlated with depression that are, Serotonin and norepinephrine.

  

The first function in thermoregulation feeding regulation of mood and emotion. It also involved in control of sleep, wakefulness, and sexual behavior. The second function is rather famous for its sympathetic nervous system control that includes regulation of blood pressure, fight or flight syndrome. It is also involved in sleep and wakefulness and hypothalamic function of thermoregulation, thirst and hunger. Depression is caused by a functional insufficiency of monoamine neurotransmitter in the brain. The diagnostic criteria for depression includes a self-rating depression scale (SDS) for

the quantitative measurement of depression as an emotional disorder based upon an operational definition was first published in 1965 (Zung, 1965). There are three approaches for treatments of depression. These are:

Pharmacological Treatment consists of:

• • •

Heterocyclic antidepressants. Selective serotonin reuptake inhibitors (SSR’s). Monoamine oxidase inhibiters (MAOIs). It is challenging to support people taking antidepressant beyond the initial

treatment period, and there is considerable noncompliance with drug treatment (Pevler, 1999).

Electroconvulsive Therapy consists of:

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• •

Safe and effective. Works quickly.

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Psychological Treatment

• •

Psychoanalytic, interpersonal family, behavioral and cognitive therapy. Psychological treatment in conjunction with medication is more effective than either type of treatment alone. Psychological therapies and counseling are widely acknowledged to have a

place in the treatment of depression and anxiety disorder (Simpson, 2000). Nursing diagnosis for depression includes:

  

Hopelessness related to long term stress. Loss of belief in God, evidenced by vegetative symptoms of depression. Verbalization of despair and abandonment by God.

Conclusion Depression is defined operationally as a syndrome comprised of co-existing signs and symptoms that signify the presence of pathologic disturbance or change in four areas; somatic, psychologic, psychomotor, and mood. The incidence of depression among people with chronic physical health problem has been shown to be much higher than was previously expected. Treating depression is problematic because of stigma attached to mental illness, difficulties in diagnosis and lack of awareness among the practitioners (Kisley & Goldberg, 1997). Patients need to be aware that they are unwell, that depression is treatable illness and that services are available. Great distribution of information among professionals is need, non-stigmatizing services, early diagnosis, proper assessment are important. Main obstacles in treatment are lack of time for proper assessment, lack of sources, fragmentation of services, absence of protocol and lack of training skills.

Depression 61 References    Clinical Research Education. Nursing Standard 2002; 16(26). Carson, V.B. (2000). Mental health nursing. 2nd Edition. USA. Fadem, B., & Simring, S.S. (2003). High-yield psychiatry. USA.

Liaquat University of Medical and Health Sciences Jamshoro Sindh
College of Nursing, JPMC Obsessive-Compulsive Disorder ACN III Practical Scenario (Assignment # 1) Farzana Kouser BScN Year II Mrs. Munira A. Ali

Depression 62 Obsess thoughts are persistent, intrusive thoughts that are troublesome to the client, producing significant anxiety. Compulsions are ritualistic behaviors, usually repetitive in nature, such as excessive hand-washing or checking and rechecking behavior. Obsessivecompulsive disorder, or OCD, is characterized by the presence of obsessions or compulsions that cause the client significant distress or impairment, and the adult client recognizes (at some time) as excessive and as produced by his or her own mind (APA, 2000). Etiology Compulsive behavior is thought to be a defense that is perceived by the client as necessary to protect him- or her-self from anxiety or impulses that are unacceptable. Specific obsessive thoughts and compulsive behaviors may be representative of the client’s anxiety. Many obsessive thoughts are religious or sexual in nature and may be destructive or delusional. For example, the client may be obsessed with the thought of killing his or her significant other or may be convinced that he or she has a terminal illness. The client also may place unrealistic standards on him- or her-self or others. Many people have some obsessive thoughts or compulsive behaviors but do not seek treatment unless the thoughts or behaviors impede their ability to function (Valente, 2002). Epidemiology Obsessive-compulsive disorder is equally common in adult men and women, thought more boys than girls have onset in childhood; there is also some evidence of a familial pattern. Up to 2.5% of the population may have OCD at some point in there lives. OCD can occur with other psychiatric problems, including depression, phobias, eating disorder, personality disorder, and overuse of alcohol or anxiolytic medications APA, 2000). Nursing Diagnoses Address in this Care Plan   Anxiety Ineffective coping

Depression 63 Related Nursing Diagnoses Addressed in the Manual     Ineffective Health Maintenance Risk for Injury Disturbed Thought Processes Impaired Social Interaction

General Interventions In early treatment, nursing care should be aimed primarily at safety concerns and reducing anxiety. Do not prevent the client from performing compulsive acts unless they are harmful. Initial nursing care should allow the client to be undisturbed in performing rituals (unless harm), as drawing undue attention to or attempting to forbid compulsive behaviors increases the client anxiety.

Liaquat University of Medical and Health Sciences, Jamshoro Sindh College of Nursing, JPMC BScN Year-II, Session 2006-2008 Depression

Depression 64

Advance Concept of Nursing Karim Bux Mrs. Mustaqima Begum January 18, 2008

Depression 65 Introduction Miss. Shumaila, a 24 years old lady admitted in Psychiatric Ward, Bed No. 7 with history of insomnia, anorexia and weight loss. She was social and enjoys parties and having a number of friends. Her past history revealed that she was all right before three months ago, when an incident changes her life i.e., her engagement was broken. Furthermore, she failed in her final examination. After these incidences, she become isolated and loss interest in life. She is single child of her parents. Her mother is working in an office and father is a businessman. Both are very busy, therefore, she becomes an isolated child.

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NURSING CARE PLAN

Patient’s Name: Age: Medical Diagnosis: Nursing Diagnosis:

Miss. Shumaila 24 Years Depression Impaired social interaction related to loss of intimate relationship
Nursing Diagnosis Impaired social interaction related to loss of intimate relationship Expected Outcome Short term goals The client will demonstrate increased involvement in social interaction with in one week. Interventions Introduction to the client. Rationales To establish a therapeutic relationship. It provides a baseline data for the management of situation. Assist client to examine social experience and verbalize feelings and encourage therapeutic relationship. Depressed clients have potential for suicide that may be change by pre effective interventions. Improve communication skills and interactive process. Evaluation Short term Goal The Client verbalized satisfaction with quantity and quality of social interaction. Client communicated and participated with others and community She reestablished or maintained relationships and a social life and also established support system.

Assessment Subjective Data According to the client’s parent, “she is feeling difficulty in falling asleep, anorexia and loss weight ,does not taking part in any activity and mostly lives alone, calm and quite, and complains headache, chest, back pain and indigestion after engagement broken and failed in BA examination,”. Objective Data

An adult girl of moderate build and with rough, unhygienic and inappropriate dressing and face. Looks pale, sad, with inappropriate eye contact, facial grimaces present, and malnourished. Delayed response with slow motor behavior, gait slow, restlessness, confused and tremors present communications with low volume, and slurred speech, Oriented and Poor in judgment and in decision making. Suicidal ideas, feeling of helplessness, and hopelessness

Assess the level of severity and condition of the patient. Encourage patient to express how she feels by scheduling at least 10 minutes, twice a day focus on client problem / topic. The client will Continually assess the client’s participate in daily potential for suicide. activities. Evaluate patient communiLong term goals cation skills and help her to The client will be find alternative during able to initiate interaction with patient. interaction with Help the client to obtain a others to maintain realistic perception of self by relationship and focusing on and enhancing social life. strength during conferences with patient. Allow client to choose social interactions for role play for 10 minutes twice a day time. Involve patient in daily care to help the patient in planning and decision making about own care. Initiate referrals to support groups prior to discharge.

Long term Help patient in achieving goal, and Client participated in improves self-concept. normal daily activities and normal routine life. Promote self-confidence and social interaction by allowing practice in a safe environment. Improve self-concept, and increase motivation. Decrease feelings of powerlessness. The client verbalized satisfaction with quality of interactions.

The client identified and demonstrated a number of measures that increase social Client’s contact with community interaction. group to interact to decrease social isolation.

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Assessment Vital Signs Blood Pressure Temperature Pulse 100/70 mmHg 97 °F 88 bpm Nursing Diagnosis Expected Outcome Interventions Assign one staff permanent for the care of the client. Rationales Limiting the number of new contacts will facilitate familiarity and trust among client and staffs. Evaluation

Use silence and active listening Your presence and use of active listening when interacting with the client. will communicate your interest and concern. Use simple, direct sentences and It will encourage the client to express her ask open ended questions. feelings. Encourage the client to express her feelings in comfortable way. Expressing of feelings may help to relieve despair, and hopelessness.

Interact with the client on the topic It establishes trust and encourages of her choice and don’t probe for communication on difficult topics. information. Educate the client about problem- Successful use of problem solving solving, selection and process facilitates the client’s confidence implementation of alternatives and in the use of coping skills. evaluation of results. Teach and encourage the client to It will increase the confidence and social practice social skills, and give interaction of the client and prevents feedback to the client regarding social isolation and depression. interactions. Encourage the client to pursue Recreational activities can help the personal interests, hobbies, and client’s social interaction and provide recreational activities enjoyment.

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Assessment Nursing Diagnosis Expected Outcome Interventions Rationales Evaluation

Help the client to participate in Increase social skills by providing social group interactions. contact. Include client in group activities and assign activities that will be easily accomplished and provide positive reinforcement. Discuss with support system ways in which they can facilitate client interaction. Involve client and family in planning, implementing and promoting in reduction or elimination of impaired social interaction. Encourage the client to participate in diversional activities, especially those involving groups, daily. Encourage the client to use assistive or corrective devices. Limit the amount of time client can spend alone in the room. Document all the procedure in the client’s file. Reinforcement encourages positive behavior and enhances self-esteem.

Support system understanding facilitates the maintenance of new behavior after discharge. Family involvement enhances effective ness of the interventions. the

Increases social contacts and interact -ional skills. It will increase self-esteem and selfconfidence. Provide opportunities for client to practice new role behavior in a safe and supportive environment. For continuation of nursing care in the next shift.

Reflection We reached at 08:30 AM at Ward # 20, and introduced ourselves with Head Nurse and other staff members of the ward and Doctors too. Their attitude was very supportive. They guide us, on the basis of their experiences to deal the psychiatric clients. One of the Doctors gave us lecture to differentiate between psychotic and neurotic disorders clients. Then I went to ward and selected my client. He was suffering with depression. With the assistance of 2nd Year Student Nurse, I took history and physical examination of the client. As the client had depression, I thought her attendant must have knowledge about her disease, cause of disease and most of all is about persistent low mood and feeling of hopelessness. I decided to give health talk to client and her attendant. Promotion of the human functioning and development with social group in accord with human potential know human limitation and human desire to be normal (Oren, 1995). I gave health talk about depression and its feeling of hopelessness and worthlessness. Help the client understanding how physical, intellectual, sociocultural, psychological, and spiritual health are related and can lead to overall sense of well being. Help and improve the client’s self esteem by suggesting simple success oriented task. Client cannot leave alone in suicidal condition and never leave some suicidal material near to client. Communicate using simple direct sentence, avoiding complex sentence of the direction. Provide positive feedback as the client achieves goals of treatment. Listen the client very attentively. Spend time with the client to provide support and reminder of the reality. Future Consideration A client suffering from depression requires long term management and follow up for good prognoses. The effectiveness of psychotherapy depends on the psychopathology of the family members. Therefore the family therapy may be provided in case of out patient.

The client will not leave alone and after discharge the relative may be educated for care of the client. References  Carpenito, L.J. (1997). Nursing Diagnosis: Application to Clinical Practice. 7th Edition. Lippincott Philadelphia.  Schultz, J.M. and Videbeek, S.L. (2004). Lippincott’s Manual of Psychiatric Nursing Care Plans.7th Edition. Philadelphia: Lippincott.  Shives, L.R. and Isaacs, A. (2002). Basic Concepts of Psychiatric-Mental Health Nursing. 5th Edition. Philadelphia: Lippincott.  http://www.google.com. Scott J (2001). Cognitive therapy for depression. British Medical Bulletin; 57:101-113.

Liaquat University of Medical and Health Sciences, Jamshoro Sindh College of Nursing, JPMC, Karachi BScN Year-II, Session 2006-2008 Therapeutic Communication

Advanced Concept of Nursing III Khar-un-nisa Mrs. Mustaqima Begum Dated: _______________

Introduction Sears (2004), reported that “to be an effective communication we must be willing to let go of judgment accept our own imperfection and have a desire to connect with others feeling and need. Michael Zychowicz introduced therapeutic communication as, “Nurses interact with many people daily and success depends upon effective interpersonal skills.” Communication is the modes of behavior that one individual employs, conscious or unconscious, to affect another: not only the spoken and written word, but also gestures, body movements, somatic signals, and symbolism in the arts.” It is necessary for nurses to have good skills. Ruesch (1972) stated that communication may be verbal or nonverbal. Therapeutic Communication is an interpersonal interaction between the nurse and client during which the nurse focuses on the client’s specific needs to promote an effective exchange of information (DeVito, 2004) Sears (2004), stated that, “if a nurse had use empathy, instead of judgment and advice, she would have learned what really was happening and would have the offered appropriate intervention to prevent such a tragedy from recurring if therapeutic communication had been used.” Factors influencing communication are the ways we taught to communicate in our society seems to be harmful to esteem and destroys intimacy (Sears, 2004). Similarly, Zychowicz, reported the factors influencing communication are: culture, perceptions and values, content of the message (toxic versus non-toxic words). Therapeutic communication skills depends upon facilitative questions and statements (encourage patients to answer in their own words and broad open ended questions), reflection (reflect content or feeling of message to patient, patient can hear and think about what they said, and can be over used easily), restatement (for example, patient: “I think I study as hard

as anyone else, but all my efforts seem to go down the tube. I don’t know what else to do.” Nurse: “It sounds as if you are frustrated because even when you think you try hard, you don’t get the result you want. Perhaps you also feel a little sorry for yourself.”), clarifying (clarify a point that the patient makes and ensure there is no miscommunication), conveying information (convey direct information for example, patient: “I feel nauseous and have diarrhea. Why do I feel so sick?” Nurse: “You may be having a side effect from the lithium you are taking. We should check your level.”), providing feedback, stating observations, connecting islands of information, confrontation, summarizing, silence (usually not comforting socially, conveys acceptance, support, and concern and allows patient to organize thoughts or reflect), and humor (can help pt diffuse emotionally charged situation, and be careful with whom you use humor). Nonviolent communication process is changing lives every day. It provides an easy to grasp, effective method to get the root of conflict, violence and pain peacefully. The nonviolent communication process is now being taught in corporations, classrooms, prisons and medication centers around the globe. Steps of nonviolent communication process include observing – what patients are seeing, hearing, thinking and smelling, understanding – how a patient feels when they observe the former, recognizing – the need or the unmet need of the patient, and learning – what the patient wants to fulfill their needs (Sears, 2004). Barriers to therapeutic communication include giving advice, giving false reassurance, changing the subject, being judgmental, giving directions, excessive questioning, using emotionally charged words, challenging, making stereotypical comments, self-focusing and behavior. Beside these barriers, one of the main barriers is patients with special needs like: (1) hearing impaired patient, (2) visually impaired, (3) speech impaired/Aphasic, (4) non English or Urdu speaking, (5) the emotional patient, (6) low IQ patient, and (7) the older patient.

To check patients with special needs including hearing impaired patient it is necessary to check and see the patient wears a hearing aid, be sure it is working, minimize background noise, always face the patient, speak with a normal tone and pace, observe that does the patient use sign language?, pay attention to non verbal communication from you and the patient and use a pen and paper if necessary. For visually impaired patients, use a normal tone and pace, look at and speak to the patient, tell the patient when you leave and enter the room, orient the patient to the immediate area, and ask for permission before touching the patient. Speech impaired/Aphasic patient should be assessed by how well the patient communicates, adapt to the patients ability for communication, allow time for the patient to respond, don’t answer questions for the patient, use closed questions when possible, repeat or rephrase questions when needed, and speak directly to the patient, not and intermediary For non-English speaking patients, use an interpreter, use pictures if needed, and try not to use colloquial phrases. Similarly, for the emotional patient, observe that emotions are neither good or bad, actions based on emotion can be good or bad, allow the patient or family member to express their emotion, let them know it is OK to express emotion, when a person is angry; recognize and acknowledge that anger and bring it to their attention, give permission. Low IQ patient requires time and patience, do not hurry, may need to interview family guardian for additional information, and direct questions toward the patient. Same procedure may be used for the older patient (Michael Zychowicz). Techniques to Facilitate Therapeutic Communication   Accepting – indicating reception. Broad openings – allow the client to take the initiative in introducing the topic.

Consensual validation – search for mutual understanding, for accord in the meaning of the word.

Encouraging expression – asking the client to appraise the quality of his or her experiences.

  

Exploring – delving further into a subject or idea. Focusing – concentrating on a single point. Formulating a plan of action – asking the client to consider kinds of behavior likely to be appropriate in future situations.

   

Giving information – making available the facts that the client needs. Presenting reality – offering for consideration that which is real. Reflecting – directing client actions, thoughts and feelings back to client. Suggesting collaboration – offering to share, to strive, to work with the client for his or her benefit.

Translating into feelings – seeking to verbalize client’s feelings that he or she expresses only indirectly.

       

Advising – telling the client what to do. Agreeing – indicating accord with the client. Belittling feelings expressed – misjudging the degree of the client’s discomfort. Challenging – demanding proof from the client. Defending – attempting to protect someone or something from verbal attack. Disagreeing – opposing the client’s ideas. Disapproving – denouncing the client’s behavior or ideas. Giving approval – sanctioning the client’s behavior or ideas.

Giving literal responses – responding to a figurative comment as though it were a statement of fact.

Indicating the existence of an external source – attributing the source of thoughts, feelings and behavior to others or to outside influences.

Interpreting – asking to make conscious that which is unconscious, telling the client the meaning of his or her experience.

    

Introducing an unrelated topic – changing the subject. Making stereotypes comments – offering meaningless clichés or trite comments. Probing – persistent questioning of the client. Reassuring – indicating there is no reason for anxiety or other feelings of discomfort. Rejecting – refusing to consider or showing contempt for the client’s ideas of behaviors.

Requesting an explanation – asking the client to provide reasons for thoughts, feeling, behaviors, events.

 

Testing – appraising the client’s degree of insight. Using denial – refusing to admit that a problem exists.

Points to Consider when Working on Therapeutic Communication Skills  Remember that nonverbal communication is just as important as the words you speak. Be mindful of your facial expression, body posture, and other non-verbal aspects of communication as you work with clients.  Ask colleagues for feedback about your communication style. Ask them how they communicate with clients in difficult or uncomfortable situations.  Examine your communication by asking questions such as “How do I relate to men? To women? To authority figures? To elderly persons? To people from cultures

different from my own?” “What types of clients or situations make me uncomfortable? Sad? Angry? Frustrated?” Use these self-assessment data to improve your communication skills. Conclusion Communication is the process people use to exchange information through verbal and nonverbal messages. To communicate effectively, the nurse must be skilled in the analysis of both content and process as, it includes establishing rapport, actively listening, gaining the client’s perspective, exploring client’s thoughts and feelings, and guiding the client in problem solving. Therapeutic communication is and interpersonal interaction between the nurse and client during which the nurse focuses on the needs of the client to promote an effect exchange of information between the nurse and client. Nurse should have knowledge about the crucial components of therapeutic communication that are: confidentiality, privacy, respect for bounding, self-disclosure, use of touch, and active listening and observation skills. Effective use and working knowledge of therapeutic communication techniques will enhance patient care and interactions with family and patients through the concept of “therapeutic use of communication”.

References  Carson, V.B. (2000). Mental Health Nursing: The Nurse patient journey. 2nd Edition. USA.  DeVito, J.A. (2004). The interpersonal communication handbook. (10th ed.) Boston: Pearson Education.  Sears, M. (2004). Using Therapeutic communication to connect with patients. Retrieved from http//www.nonviolent-communication.com/press/article_PDF/

Melanie_Sears/Therapeutic_Communication on September 15, 2007.  Summers, L.C. (2002). Mutual timing: An essential component of provider/patient communication. Journal of the American Academy of Nurse Practitioners. 14(1):19-25.

Liaquat University of Medical and Health Sciences, Jamshoro Sindh College of Nursing, JPMC, Karachi BScN Year-II, Session 2006-2008 Nursing Care Plan & Reflection Log

Advance Concept of Nursing Khar-un-nisa Mrs. Mustaqima Begum January 24, 2008

Nursing Care Plan Introduction A 30 year old female, Sultana has been admitted to Psychiatric Ward at Bed No. 11 by her parents with complaint of depression. According to her mother, she was alright one year back. She also stated that “the client has less abilities and strength in developing relationship with others and said that people will defeat me and criticize me; therefore, she has lack of involvement in job performance and seek of evaluation from others. She has depressed mood, feeling of worthlessness and looking pale.” Her mother also stated that signs and symptoms observed by her include depress mood, hopelessness, suicidal attempts, ideas of guilt or worthlessness, impaired concentration, loss of interest, sleeplessness, disturbed appetite, decreased sexual desires, feeling of tiredness, unknown fear, negative thinking, headache, persistent backache, chest pain, palpitation, hyperventilation and wiping episodes occurred. Therefore, we brought her to the hospital for treatment.

NURSING CARE PLAN
Patient’s Name: Medical Diagnosis: Nursing Diagnosis:
Date

Mrs. Sultana W/o Shahid Age: 30 Years Bed No. 11 Ward No.: 20 Date of Admission: 24-09-2007. Depression Chronic Low Self-Esteem related to long-standing negative self-evaluation/feelings about self or self-capabilities.
Nursing Diagnosis Goal/Planning Nursing Intervention Rationale Evaluation

Assessment (Data Statement)

Chronic Low Self-Esteem related to long-standing negative self-evaluation/feeling about self or self-capabilities

Subjective Data: The client’s mother verbalize that she has less abilities and strength to develop and self evaluation thinking about criticism of other as evidence by lack of job performance, hopelessness, suicidal attempts, self-depreciation, loss of selfconfidence, ideas of guilt or worthlessness, disturbed sleep pattern, decreased sexual desires, loss of energy and fatigue, appetite and weight changes, headache, persistent backache, chest pain, palpitation, hyperventilation and wiping episodes. Objective Data: A 30 years old client looked pale with depressed mood. She is having low self-esteem. Her communication is slow and irregular, loss of interest, insufficient thinking, worrying, and restlessness. Vital signs: Blood Pressure: 110/70 mmHg Pulse Rate: 70 beat/min Resp. Rate: 20 per min. Temp. 98° F

Short-term Goals:   The client will verbalize increased feelings of selfworth.  The client express feelings directly and  openly.  The client evaluate own strengths realistically.  Long-term Goals:  The client will demonstrate behavior consistent with increased self-esteem.   The client makes plans for the future consistent with personal strengths.  The client expresses satisfaction with self and personal qualities.

Encourage the client to  become involved with staff and other clients in the milieu through interactions and activities. Give the client positive  feedback for completing responsibilities and interacting with others. Involve the client in  activities that are pleasant or recreational as a break from self-examination. If negativism dominates the  client’s conversation, it may help to structure the content of interactions, for example, by making an agreement to listen to 10 minutes of “negative” interaction, after which the client will interact on a positive topic. Provide simple activities  that can be accomplished easily and quickly. Begin with a solitary project; progress to group occupational and recreational therapy sessions. Give the client positive feedback for participat6ion

When the client can focus on other people or interactions cyclic, negative thoughts are interrupted. Positive feedback increases the likelihood that the client will continue the behavior. The client needs to experience pleasurable activities that are not related to self and problems. The client will feel you are acknowledging his or her feelings yet will begin practicing the conscious interruption of negativistic thought and feeling patterns. The client may be limited in his or her ability to deal with complex tasks or stimuli. Any task that the client is able to complete provides in opportunity for positive feedback to the client.

The client has demonstrated behavior consistent with increased selfesteem. The client has made plans for the future consistent with personal strengths and expressed satisfaction with self and personal qualities.

Nursing Care Plan Interventions  Give the client honest praise for accomplishing small responsibilities by  acknowledging how difficult it can be for the client to perform these tasks. Gradually increase the number and complexity of activities expected of  the client; give positive feedback at each level of accomplishment. It may be necessary to stress to the client that he or she should begin  doing things to feel better, rather than waiting to feel better before doing things. Explore with the client his or her personal strengths. Making a written  list is sometimes helpful. Rationales Clients with low self-esteem do not benefit from flattery or undue praise. Positive feedback provides reinforcement for the client’s growth and can enhance self-esteem. As the client’s abilities increase, he or she can accomplish more complex activities and receive more feedback. The client will have the opportunity to recognize his or her own achievements and will receive positive feedback. Without this stimulus, the client may lack motivation to attempt activities. While you can help the client discover his or her strengths, it will not be useful for you to list the client’s strengths. The client needs to identify them but may benefit from your supportive expectation that he or she will do so.

Therapeutic Communication Reflection Introduction The day when I went to Psychiatric Ward as a clinical attachment as BSc Nursing student to gain new experiences, it was my second clinical week in Psychiatric unit. I wished to the staff members. With the permission of Head Nurse, I selected the patient, who was 30 years old female, lying on bed admitted in ward with complaint of depression with sign and symptoms of depress mood, hopelessness, suicidal attempts, ideas of guilt or worthlessness, impaired concentration, loss of interest, sleeplessness, disturbed appetite, decreased sexual desires, feeling of tiredness, unknown fear, negative thinking, headache, persistent backache, chest pain, palpitation, hyperventilation and wiping episodes occurred. I introduced myself to the selected client, but she didn’t talk to me. So I came back to staff room and thought, why she ignored me. Sometime later, I understand that, if I am interested in doing work that has emotional and spiritual impact on my client then the most powerful way of dealing with therapeutic communication. Analysis According to Sears (2004), “If a nurse had use empathy, instead of judgment and advice, she would have learned what really was happening and would have offered appropriate intervention to prevent such a tragedy from recurring if therapeutic communication had been used.” Devito (2004) defined therapeutic communication as an interpersonal interaction between the nurse and client during which the nurse focuses on the client’s specific needs to promote an effective exchange of information.

Therapeutic Communication I have analyzed that without having the skills of therapeutic communication most of the people cannot tell you what their request and often are out of touch with their feelings and needs. This is why as a Nurse, I need to identify what they are feeling and needing. I do this my translating their judgments and thoughts into feelings and needs. I again went to her and used therapeutic communication technique and encouraged her to talk with me. I spend some time with the client, and asked her small questions to build a trustworthy relationship between client and me. Now she is ready to answer my questions and give information about her feelings. I heard the client carefully and observed that if we spend more time with them and give opportunity to express their feelings and needs, they feel more relaxed and look better. One should get the feedback when a client state that “I feel better and relax, as you are the only one, I can talk about my feelings.” Learning I had learned that clients need to resolve whatever they are dealing with on an emotional level. I learned therapeutic communication technique to deal effectively to the clients having psychiatric disorders and others too and to say that therapeutic communication skill is one of the successful techniques to spend life with success. Assists and educates clients to select choices which will support positive changes in their effects, cognition, behavior and relationship (CAN, 1997b, p.68). Future Consideration Insha Allah! If Allah gives the opportunity, the trick to giving therapeutic communication is to practice and try using this technique in all areas where I connect such as staff members, clients, friends and also family members because: “God loves those who love mankind first”

References  Sears, M. (2004). Using therapeutic communication to connect with patients. Retrieved from http://www.nonviolentcommunication.com/press/article_PDF/

Melanie_Sears/Therapeutic_Communication.  Schultz, J.M., & Videbeek, S.L. (2004). Lippincott’s Manual of Psychiatric Nursing Care Plans.7th Edition. Philadelphia: Lippincott.

Liaquat University of Medical and Health Sciences, Jamshoro Sindh College of Nursing, JPMC, Karachi BScN Year-II, Session 2006-2008 Anger Advanced Concept of Nursing III Musarrat Begum Mrs. Mustaqima Begum

Dated ______________

Definitions Anger is a reaction to an inner emotion and not planned action. It is also stated that “It is phychophysiological response to pain, perceived suffering or distress, or threat. Anger is often a response to the perception of threat due to a physical conflict, injustice, negligence, humiliation or betrayal. There are two ways in which we express anger, they are: Actively – in the case of active emotion, the angry person “Lashes out” verbally or physically at a target. Passively – when anger is a passive emotion, it is often characterized by silent sulking, passive aggressive behavior, and tension. Human often experience anger empathetically, for example, after reading about other being treated unjustly, one may experience anger, even though he/she is not the victim. Common factors that predispose anger include: fatigue, hunger, pain, suffering, sexual frustration, stress, recovery from illness, puberty, use of certain drugs, hormonal changes associated with premenstrual or menopause. Physiological disorders includes: physical withdrawal, bipolar disorder, borderline personality disorder, other emotional disorder or situational behaviors also contribute. Genetic predisposition – at the end of 19th century, Signund Freud, the father of Psychology argued that one born with an innate loving instinct. However, anger and hostility arise when the individual’s need for love is unmet. In 1998, the American Psychologist Association concluded that people are not genetically predisposed to violence and that violence cannot be scientifically related to natural evolutionary process. At the beginning of 21st century, it is general censuses among psychologist that a combination of nature and nurture is involved in the manifestation of anger and therefore that neither should be ignored.

Physiological progression of anger – neuroscience has shown that emotions are generated by multiple structures in the brain, such as amygdala. Amygdala is responsible for identifying threat and reacting according to initiate action within the body. Jone (2003-2004) reported that left prefrontal cortex has also been identified involved in activating anger. The action of amygdale causes the body’s muscles tense up. Inside the brain, neurotransmitter chemical known as catecholamines are released causing an increase in energy that generally lasts several minutes. Heart rate increases, blood pressure rises, the rate of breathing increases, additional brain neurotransmitters and the hormones adrenaline and noradrenaline are released. The body will start to relax back toward its resting state when the target of anger is no longer accessible or an immediate threat. It is difficult to relax from an angry state within a short time. This is an account of the adrenaline caused arousal that occurs during anger. This invariably lasts as substantial time (many hours) potentially days during which time the anger threshold is lowered. Religious perspective on anger - in Islam, anger is seen as sign of weakness. Mohammad (Peace be Upon Him) said “The strong is not the one who overcomes the people by his strength, but the strong is one who control himself while in anger.” In Christianity, Bible warns, “Do not let the sun go down on your anger.” In Hindusim, “Anger is equated with sorrow as a form of unrequited desire. Anger is considered to be packed with more evil power than desire. Signs and symptoms of anger include: heightened blood pressure, increase of stress hormones (particularly catecholamines, as corticosteroids are more typical of fear), shortness of breath, trembling, heightened senses, animated and exaggerate body movement, stiffness of posture, constipation, dilated pupils, increase physical strength, speech and motion are

faster and more intense, tense muscles, criticism, irritation, hatred, passive-aggressive behavior, anxiety, apathy, and sleeplessness. Dealing with Anger – there are various strategies for dealing with anger; some address individual episodes of anger, and other address an ongoing tendency toward anger. Dealing with each instance of anger represents a choice. The basic alternatives are to respond with hostile action, including overt violence, respond with inaction, such as withdrawing or stonewalling, initiate a dominance contest, work to better understand and constructively resolve the issue and harbor resentment. Other strategies address ongoing tendencies toward anger In the 1960s and 1970s, theories about dealing with anger in a therapeutic process were based upon expressing the feeling through action. This ranged from pillow hitting strategies to radical and extreme therapies such as scream therapy. Scream therapy is a treatment in which patients stand in a room and simply scream for hours. On end, supposedly relieving the tension or feeling spawned from the initial anger. Cognitive behavioral therapy – research showed that people who suffer from excessive anger often harbor irrational thoughts and belief towards negatively. It has been shown that with therapy by a trained professional, individual can bring their anger to manageable level. In order for a cathartic affects to occur, the source of the anger must be damaged or destroyed by the aggrieved party. Conclusion Anger is a reaction to an inner emotion and not a planned action. We can express anger actively and passively. Common factors that predispose one to anger are physiological disorder and genetic predisposition, physiological progression of anger. Neuroscience has shown that emotions are generated by multiple structures in the brain, such as amygdale.

Religious perspective on anger in Islam, Christianity and Hindusim. Dealing with anger some address individual episodes of anger and others address on ongoing tendency toward anger.

References  Jones, H.E., et al. (2004). Contributions from research on anger and cognitive dissonance to understanding the motivation functions of asymmetrical frontal brain activity. Biological Psychology.

Liaquat University of Medical and Health Sciences, Jamshoro Sindh College of Nursing, JPMC, Karachi BScN Year-II, Session 2006-2008 Nursing Care Plan & Reflection Log Advance Concept of Nursing-III Musarrat Begum Mrs. Mustaqima Begum January 24, 2008

NURSING CARE PLAN
Name: Miss. Momal D/o Rushan Ali Age: 18 Years Sex: Female Psychiatric Diagnosis: Anger (The Client who will not eat) Nursing Diagnosis: Imbalanced Nutrition Less than Body Requirement
Date Assessment (Data Statement) Nursing Diagnosis Goal/Planning

Date of Admission: 24th September, 2007.
Nursing Intervention Rationale Evaluation

Imbalanced nutrition less than body requirement (Intake of nutrient insufficient to meet metabolic needs).

Subjective Data: According to attendant, the client may not eat for physical or psychological reasons. She is refusing to eat and unaware of the need or desire to eat, lack of appetite, lack of interest in eating, aversion to eat, weight loss (around 10 Kg), difficulty in eating, malnutrition, inadequate hydration, electrolyte imbalance, starvation, difficulty in swallowing, lack of awareness of need for food and fluids, delusion, anger and hostility, manic behavior, low self-esteem, gait and disturbance in elimination. Objective Data: 18 years old female client Momal lying on bed well oriented with time, place and person. She is looking:  Pale, irritable.  Aggressive behavior.  Refused from eating.  Dry mucus membrane  Dehydrated

Short-term Goals:   The client will establish adequate  nutrition, hydration and elimination. Long-term Goals:   The client will demonstrate weight gain, if appropriate.  The client will demonstrate in food  and fluid intake.

Reassure the client and their  family. Strictly monitor intake and  output in an unobtrusive way. Record the type and amount of food and the times of eating. Weight the client regularly, at  the same time of day and in a matter of fact manner. Provide nursing care and  facilitate medical treatment for physical problem related to client no eating. Provide fruit juice and food  high in fiber. Try to accommodate the client  normal or previous eating habits as much as possible. Make culturally or ethnically appropriate food available. The  client significant others may be able to provide guidance or food acceptable to the client. Gradually decrease the  frequency of suggestions and allow the client to take responsibility for eating, again, record change.

The client has able to eat and Information on intake and shown interest output is necessary the during eating. client’s nutrition state. She has better Being matter of fact about than before. weight measurement will help to separate issues of weight and eating from emotional issues. The client physical health is a priority many physical problems can contribute to result from the client not eating. Fruit, juice and foods high in fiber content promote adequate elimination. Reinforcing previous normal eating habit increases the likelihood that the client will eat. The client may be more apt to eat food that are culturally acceptable or provide by family members or significant others. The transition from feeding the client to independent eating is more likely to be successful if it is gradual. For cooperation.

Nursing Care Plan Date Assessment (Data Statement)
According to file documentation Weight: 38 Kg (previous weight 48 Kg), unhygienic condition, uncombed hair. Vital signs: Blood Pressure: 80/50 mmHg Pulse Rate: 136 beat/min Resp. Rate: 30 per min. Serum Electrolyte Na: 120 Ka: 3 Cl: 82 Urea: 48 Hb: 8 gm

Nursing Diagnosis

Goal/Planning

Nursing Intervention

Rationale

Evaluation

Communication Reflection Introduction The day when I was to go and join the Psychiatric Ward as a clinical attachment as BSc Nursing student was to become a door to new experiences. It was my first clinical week in Psychiatric Ward. I wished and introduced myself to staff. There was one Ward Manager, two Staff Nurses and one Student Nurse in the ward. It was basically a psychiatric ward but in those days my clinical attachment was there. It is my first day in this ward. I was very impressed with the ward management and communication skills of Head Nurse. She distributes all ward work equally and accordingly. She also communicates with each and every person of the ward in verbal and nonverbal ways and conveys right information and condition of the client to the doctor and possesses good communication with subordinates and assigned duties by herself and they were directly accountable to her. She also communicates each and every person who was related with her ward, her clients and her work. Even with the relatives of the client, she made conversation and convincing them by giving information about their patients. According to Huston & Marquis (2003), “Communication is a complex exchange of thoughts, ideas or information on at least two levels: verbal and nonverbal communication is so complex, many models exist to explain how organization and individual communicate. In all communication, there is at least one sender, one receiver and one message.” It is very necessary for a Nurse Manager rather for all nurses that they should be good in communication because a nurse is always in contact with many peoples at a time. Insha Allah, if Allah provide me opportunity to work as a manager then I try to follow good nurses and a good experiences, as I gained a good experience of communication from that Ward Manager.

Anxiety Disorder 95 References  Huston, C.J. and Marquis, B.L. (2003). Leadership Roles and Management Functions in Nursing Theory and Application. 4th Edition. New York: Lippincott Williams and Wilkins.

Liaquat University of Medical and Health Sciences, Jamshoro Sindh College of Nursing, JPMC, Karachi BScN Year-II Session 2006-2008 Anxiety Disorder Advance Concept of Nursing-III Mariam Fozia Mrs. Mustaqima Begum

Anxiety Disorder 96 Introduction Anxiety is a universal phenomenon and every body feels some degree of anxiety before and during stressful situation like examination, interview or stage performance. Grave situation like sudden onset of serious illness, death of a loved one, loss of job, or a critical accident also produces a certain level of anxiety. In all such situation this state of anxiety is a natural response of the body. Within limits, it enables the individual to cope with the stressful situation in a better way and hence is termed “normal anxiety”. It is a feeling of dread apprehension that is often accompanied by different physical and psychological signs and symptoms. Anxiety is a result of different physical, psychological, socio-cultural and environmental problems. Contrary to normal anxiety, anxiety disorder is not help to the individual instead it produces a severe state of inner tension and interferes with normal activities of the individual. Anxiety is defined as a “state in which an individual or group experiences feelings of uneasiness, apprehension and activation of the autonomic nervous system in response to a vague nonspecific threat. Anxiety is manifested by disturbances of mood, thinking and behavior.” It is debilitating and should not be taken lightly. Anxiety Disorders are possibly the most common and frequently occurring mental disorders. They include a group of conditions that share extreme anxiety as the principle disturbance of mood or emotional tone. Anxiety, which may be understood as the pathological counterpart of normal fear is manifest by disturbances of mood as well as of thinking behavior and physiological activity. Included in this category are panic disorders with or without a history of agoraphobia. Agoraphobia with or without a history of panic disorder generalized anxiety disorder specific phobia, social phobia obsessive compulsive disorders, acute stress disorder and post traumatic stress disorder. Physical and Psychological Symptoms

Anxiety Disorder 97   Physical Symptoms Gastrointestinal • • • • •  Dry mouth. Difficulty in swallowing. Epigastric discomfort. Aerophagy. Diarrhea (usually frequency).

Respiratory • • • Feeling of chest constriction. Difficulty in inhaling. Over breathing.

Cardiovascular • • • Palpitations. Awareness of missed beats. Feeling of pain over heart.

Genitorurinary • • • Increased frequency. Failure of erection. Lack of libido.

Nervous System Fatigue • • • Blurred vision. Dizziness. Headache.

Anxiety Disorder 98 •  Sleep disturbance.

Psychological Symptoms • • • • • • • • Apprehension and fear. Irritability. Difficulty in concentrating. Distractibility. Restlessness. Sensitivity to noise. Depersonalization. Derealization.

Anxiety Disorder 99 Causative Factors   No specific causative factor of anxiety disorders has been identified. A physiological or neurochemical predisposition is associated with the development of anxiety disorders.   A genetic factor. The anxiety disorder represents a conflict between two divergent drives or desires that have been repressed into the unconscious mind.   To potent developmental stressors. Environmental factors.

Treatment  Counseling and Psychotherapy Anxiety disorders are responsive to counseling and to a wide variety of psychotherapies. During the past several decades, there has been a increasing enthusiasm for focused time limited therapies that address ways of coping with anxiety symptoms directly rather than exploring unconscious conflict or other personal vulnerabilities.  Pharmacotherapy The medications typically used to treat clients with anxiety disorder benzodiazepines, antidepressants and newer compounds such as buspirone.  Combination Treatment Some clients with anxiety disorders may benefit both from psychotherapy and pharmacotherapy treatment either combined or used in sequence. It is likely that such combinations are not uniformly necessary and are probably more cost effective when reserved from patients with more complex complicated or severe disorders.

Anxiety Disorder 100 Panic disorders are extremely debilitating and common yet respond well to treatment, if started early enough in the course of the disease. It is not a condition to be taken lightly in view of its effect on the quality of the sufferer’s life. Anxiety Disorder and Dissociative Disorders Essentials of Diagnosis  Overt anxiety or an overt manifestation of a defense mechanism (such as a phobia) or both.   Not limited to an adjustment disorder. Somatic symptoms referable to the autonomic nervous system or to a specific organ system (e.g., dyspnea, palpitations, paresthesias).  Not a result of physical disorders. Psychiatric conditions (e.g., schizophrenia) or drug abuse (e.g., cocaine). Conclusion Stress, fear and anxiety all tend to be interactive. The principle components of anxiety are psychologic (tension, fears, difficulty in concentration, apprehension) and somatic tachycardia, hyperventilation, palpitations, tremor, and sweating. Other organ systems (gastrointestinal) may be involved in multiple system complaints, fatigue and sleep disturbances are common. Anxiety may be free floating resulting in acute anxiety attacks.

References  Schultz, J.M. and Videbeek, S.L. (2004). Lippincott’s Manual of Psychiatric Nursing Care Plans.7th Edition. Philadelphia: Lippincott.  Shives, L.R. and Isaacs, A. (2002). Basic Concepts of Psychiatric-Mental Health Nursing. 5th Edition. Philadelphia: Lippincott.  Taylor, C.M. Essentials of Psychiatric Nursing.

Liaquat University of Medical and Health Sciences, Jamshoro Sindh College of Nursing, JPMC, Karachi BScN Year-II Session 2006-2008 Nursing Care Plan & Reflection Log Advance Concept of Nursing-III Mariam Fozia Mrs. Mustaqima Begum

Nursing Care Plan Introduction A 40 years old lady was admitted to Psychiatric ward. Her attendant stated that she was fine a month ago. She suddenly developed signs and symptoms of lack of concentration, irritability, poor appetite, sleeplessness, hopelessness, fear, restlessness, increased motor movements, false beliefs and increased level of anxiety. Anxiety is the state in which an individual or group experiences feelings of uneasiness, apprehension and activation of the autonomic nervous system in response to a vague nonspecific threat.

NURSING CARE PLAN
Name: Shazia Age: 40 Years Sex: Female Psychiatric Diagnosis: Anxiety Nursing Diagnosis: Altered perception related Anxiety due to divorce.
Date Assessment (Data Statement) Nursing Diagnosis Goal/Planning Nursing Intervention Rationale Evaluation

Significant others anxiety due to divorce related to divorce

Subjective Data: The client’s attendant, she was fine a month ago, suddenly she develop sign and symptoms of lack of concentration, irritability, poor appetite, sleeplessness, hopelessness, fear, restlessness, increased motor movements, false beliefs and increased level of anxiety. Objective Data: A 40 years lady having history of anxiety due to divorce is lying on the bed uncomfortably. She is looking restlessness, pale, insomnia, loss of appetite and poor confidence. Vital Sign Blood Pressure: 120/70 mmHg Temperature: 99°F Pulse: 100 bpm Respiratory Rate: 24 per min.

Short-term Goals: • The client will feel relaxed with appropriate social behavior and cope to reduce • anxiety level and fear. Long-term Goals: • The client will make full attention. Discuss current events, and • oriented with the date and time. The client relates an increase in psychological and physiological comfort. •

Introduce yourself and try to • spend more time with the client. Assist the client to identify • anxious feelings. Encourage patient to • verbalize feelings of anxiety. Discuss relationship between • increased anxiety and behavior pattern. Note time and occasion. Teach relaxation techniques. •

To establish a trustworthy Short-term Goals: The client verbalized relationship. that she feel relax and comfortable and can To cope with anxiety and to call the nurse by name. Expressed reduce its level. reduce anxiety level Verbalizing feelings will and fear. Immobility dependence. reduce level of anxiety. To differentiate changes Long-term Goals: between anxiety and The client made behavior pattern. decision about reality, and feelings. Also cope with the anxiety Enables client to reduce level and pain. anxiety and fear levels Accurately described whenever occur. relationship between anxiety and behavior Family support can help to pattern. reduce anxiety and fear. To reduce side effects of medication and further follow up. To collect basic data for further follow up.

• •

Encourage the client to use • support system. Observe for side effects of • analgesic. Assess vital signs. •

Anxiety
Reflection

Introduction On clinical visit of Psychiatric unit (Ward 20), with the permission of the Head Nurse, I selected a client who was 40 years old lady. She was lying on the bed with complaint of anxiety due divorce. She was well one month age but suddenly appeared signs and symptom of dry mouth, excessive perspiration, increased restlessness, pounding of heart, change in urinary pattern, lack of concentration, loneliness, false beliefs, hopelessness, fear, sleeplessness and increased level of anxiety. Analysis I analyzed the client’s condition. She is looking restless, uncomfortable and pale. When I addressed her, she not responds. So I took interview of her attendant. The client’s attendant informed that, “after the incidence of divorce, she was fine a month age, she suddenly shows signs and symptoms of fear, hopelessness, low concentration, sleeplessness, etc. The condition of the client was disturbed, restless, sleeplessness and uncomfortable due to her disease. She also showed loss of appetite, weakness, fear of the people.” Conclusion The clients suffering for such psychiatric disorder not only need special nursing interventions, but also require full attention from the family members to spend more time to with the client, as altered perception related to anxiety can cause biochemical or psychological changes, which disturbed the coping pattern of the client, which can be improved through nursing interventions.

Anxiety Learning I had learned many thing though this clinical practice such as how to take a history of the client suffering from psychiatric disorder; how to diagnose and make nursing care plan, etc. I examined the client that was admitted in psychiatric ward with the complaint of increased level of anxiety due to divorce, fear and unable to cope with the situation. During my observation, I provided her comfortable bed, tried to spend more time with the client, encourage and motivate to express her feelings, which enables her to cope with the situation and reduce anxiety. Future Consideration In future, I will like to work with clients suffering with anxiety especially in elderly age. By spending more time with them, I will try to develop a trustworthy relationship and motivate them to cope with their present sufferings and encourage them to express their feelings, which in results enable me to provided necessary nursing care and intervention, to not only reduce mental disorder but also enable them to spend useful and independent lives.

Culture 106 References  Schultz, J.M. and Videbeek, S.L. (2004). Lippincott’s Manual of Psychiatric Nursing Care Plans.7th Edition. Philadelphia: Lippincott.  Shives, L.R. and Isaacs, A. (2002). Basic Concepts of Psychiatric-Mental Health Nursing. 5th Edition. Philadelphia: Lippincott.

Liaquat University of Medical and Health Sciences Jamshoro Sindh
College of Nursing, JPMC Culture ACN III Muhammad Farooq Saeed
BScN Year II

Mrs. Ruth K. Alam

Culture 107 Culture refers to dynamic and integrated structures of knowledge, beliefs, behaviors, ideas, attitudes, habits, languages, symbols, rituals, and practices that are unique to particular group of people. This structure provides the group of people a general design for living. Ethnicity is a cultural group’s perception of itself, identity, or is a sense of belongingness and a common social heritage that is passed from one generation to the next. Race is the grouping of people based on biological similarities. Members of a racial group have similar physical characteristics as blood group, facial features, and color of skin, hair and eyes. Culture diversity refers to the differences among people that result from racial, ethnic, and cultural variables. Cultural beliefs, values, customs, and behaviors are transmitted from one generation to another through interaction, daily activities, and celebrations. For instance, the birth of a child is celebrated according to the family’s cultural norms, which may includes prayers, blessings, special naming ceremonies, and religious rites. Grand parents, other elders, and parents teach children cultural expectation and norm through role modeling, demonstrations and discussion. Cultural messages are transmitted in a variety of setting such as homes, schools, religious organization, and communities. Media such as radio, TV, internet etc are powerful transmitters and shapers of culture. Culture is not static nor is it uniform among all members within a given cultural group. Culture is transmitted through crises and the way a family deal with crises. The crises may cause a family that is part of culture with a strong sense of responsibility to family and blood relatives to become closer, or conversely, the same situation may cause a family that is from a culture that values independence and individuality to withdraw and create distance among its members, which are rooted in the family’s cultural background and heritage.

Culture 108 Components of Culture According to Stewart there are five components of culture.   Activity – identify how people organize and values work. Social Relations – explains the importance and structure of friendships, gender roles and class.    Motivation – describes the values and methods of achievements, Perception of work – refers to the interpretation of life events and religious beliefs. Perception of self and the individual – refers to personal identity, value and respect for individuals. This model is helpful to the nurse in planning the care of another ethnic group. Work, social relationships, success, religion, and self identity influence cultural groups, attribute to health and illness and the cultural group response to health events. If a culture values relationships more than work, the culture may sanction on extended period of illness and a lengthy time away from employment site. However, if a culture measures achievement by output at work, illness may be intercepted in a negative manner. Members of the later culture may deny illness and delay seeking appropriate health care. Characteristics of Culture Spradley and Allender identified five characteristics of culture. According to them culture is:  Learned pattern of behaviors are acquired as children imitate adults and develop actions and attitudes acceptable by others in society.  Not inherited or innate, but, it is integrated throughout all the interrelated components. Activities, relationships, motivations, world views, and individuality are permeated with consistent patterns of behaviors to form a cohesive whole.

Culture 109  Shared by every one who belongs to the cultural group. Behavioral patterns are not individually defined, but, rather, are accepted and practical by all.  Tacit (unspoken), in that acceptable behavior is understood by everyone in the cultural group, regardless of whether beliefs are written down or spoken. Cultural beliefs are commonly known and adopted.  Dynamic and it is constantly changing.

Cultural Influences on Health Care Beliefs and Practices Each cultural group has a body of knowledge and beliefs health about diseases. Cultural practices can positively and negatively affect health and disease distribution, as in culture where raw foods are not consumed, the incidence of shigellosis may be lower than culture where consumption of meat and fish is common. Cultural taboo against protein during pregnancy has a harmful or destructive affect on fatal development.   Mental problems considered as magic effects or saya. According to African American diseases is caused by disharmony in relationships, evil spirits or it is sent by God as a punishment for a serious infraction against Him or another person.  Hispanic American believe that disease have natural cause as an act of God, as punishment for sin, or as the result of witchcraft or a curse by an enemy, imbalance between wet and dry or cold and hot forces.  Asian American believes that disease is due to Yin and Yong. They also view as disease caused by such power, as God, evil spirit or ancestral spirits.  Native American believes that illnesses are due to use of witchcraft can.

Culture 110 Peter Morley’s four views about origin of diseases  Supernatural traces diseases to metaphysical forces such as witchcraft, sorcery and voodoo. In this view, an individual might ascribe illness to evil spirits or to a curse by a powerful spiritual person.  Non supernatural traces disease to accepted cause and effect relationship, even though their relationship may lack scientific rationale. As people of many cultures relate the colic pain of infant to the breast milk of nursing mother impure by sexual relations because in this culture sexual relations are prohibited for nursing mother.  Immediate: according to them diseases is due to known pathogenic or other agents as depression caused by neurotransmitters imbalance.  Ultimate describes determinates for disease, as smoking resulting in lung cancer. Folk Medicine, Healers and Practices Cultural group European American African American Traditional healers Nurse Physician Elderly woman healers, Granny , voodoo healer Spiritualist, root doctor. Hispanic American Asian American Healing practices. Exercise, Medications, modified diets, amulets and religious healing rituals. Herbs, poultices, religious healing through rituals, talismans worm around the wrist or neck or carried in a pouch to ward off disease

Curandero, Espiritualist Hot and cold application, Herbal teas, Yerbero, Santiguadora. Prayers and religious medals, Brujo, and Sobadora. massage, Azabache and three bath. Herbalist Physician Hot and cold, Herbs and soups, Cupping, pinching and rubbing, Medication, Acupuncture, application of tiger balm or energy balancing. Plants and herbs, Blessed medicine, burned sweet grass, Estafiate (dried leaves), the blessing ceremony ritual and sand paintings.

Native American

Shaman Medicine man /woman

Culture 111 Cultural and Racial Influences on Client Care Client’s cultural backgrounds and preferences influence the manner whereby they interact with other people and with the world around them. All human beings are not share the same language. This culture differences can leads to misunderstanding and frustration, for which an interpreter may be needed for translation. In case of restricted communication the alternatives are gestures, flash cards translators, and family members. Orientation to space, the distance that a person prefers to maintain from another is determined different by deferent culture as the Arabic, Southern European and African origin frequently sit or stand relatively close to each other (0 to 18 inches), where as people from Asian, Northern European and north American origin are more comfortable with a larger personal space more tan 18 inches. Touch is perceived negatively or positively by different culture. Orientation to time, some people are very conscious about time and appointment thus the nurse must also be very attentive to the time schedule. Social organization refers to the ways whereby cultural groups determine rules of acceptable behavior and roles of individual members. It includes family structure, gender roles and religion. Family structure as nuclear and extended family, functional and dysfunctional family, the chief values of the family as responsibility, satisfaction and flexibility affect the psychiatric patient differently in different culture. Gender roles vary according to culture context as husband, father or head of the family is the chief authority. Spiritual and religious beliefs have important in life, and has a great significance at the time of illness. Biological variation distinguishes one culture or racial group from other include hair texture, skin color, thickness of lips, eye shape and body structure. Enzymatic differences and susceptibility to diseases varies from culture to culture.

Culture 112 Assessment Having examined culture and influences it may have had in developing personal beliefs about sickness and health, the next step to providing culturally appropriate care is to assess the client’s cultural background. Spradley and Allender identify six categories of information necessary for a comprehensive cultural assessment of the client.  Ethnic or racial background. Where did the client group originate, and how does that influence the status and identity of group members?  Language and communication patterns. What is the preferred language spoken, and what are the currently based communication patterns?  Cultural values and norms. What are the values, beliefs, and standards regarding things as roles of education, family functions, child rearing, work and leisure, aging, death and dying, and rites of passage?  Biological factors. Are there physical or genetic traits unique to the ethnic or racial groups that predispose group members to certain condition or illnesses?  Religious beliefs and practices. What are the group’s religious beliefs, and how do they influence life events, roles, health and illness?  Health beliefs and practices. What are the group’s beliefs and practices regarding prevention, causes, and treatment of illnesses?

Culture 113 Cultural Assessment Interview Guide Name:_______________________ Father / Husband name:______________________ Primary language: When speaking:_____________ When writing:_________________ Date of birth:_____________ Education level:_________________ Sex:____________ To which ethnic group do you have belong? __________________________________ To what extent do you identify with your cultural group?________________________ Who is the spokesperson for your family? ____________________________________ Describe some of the customs or beliefs that you have about the following: Health:__________________________________________________________ Life:____________________________________________________________ Illness:__________________________________________________________ Death:___________________________________________________________ How do you best learn information? Reading: __ Having some explain verbally: __ Having someone demonstrate: __ Describe some of your family’s dietary habits and your personal food preferences:____ ______________________________________________________________________ Are there any foods forbidden from your diet for religious or cultural reasons:________ ______________________________________________________________________ Describe your religious affiliation:__________________________________________ What role do your religious beliefs and practices play in your life during times of good health and bad health: _________________________________________________________ On whom do you rely on for health care services or healing:______________________ What type of cultural health practices have you been exposed:____________________ Are there any sanctions or restrictions in your culture about which the person taking care to you should know:_______________________________________________________ Describe your current living arrangement:____________________________________ Describe your strength:___________________________________________________ Who/what is your primary source of information about health?____________________ Is there any important thing else about your cultural beliefs that you want to tell me: _______________________________________________________________________

Culture 114 Nursing Diagnosis                   Coping individual ineffective. Coping, family, ineffective, compromised Social interaction. Impaired Anxiety Body image disturbance. Breast feeding ineffective Communication, verbal impaired. Decisional conflict Fear Grieving, anticipatory Health maintenance altered Health seeking behaviors Noncompliance Nutrition, altered. More than body requirements. Pain Role performance, altered Sleep pattern disturbed Spiritual distress.

Depression 115 Scenario Kulsoom is a 22 years old married young adult female admitted to psychiatric ward through emergency with the complains of headache, feeling of guilt, hopelessness and worthlessness, decreased sleep, restlessness, tension and anxiety. According to her husband, she was alright two months before, but after she married through court against the wishes of her parents in other ethnic group her parents and community opposed us and tried to arrest both of us through police. They were caused severe agony, tension and discouragement. Kulsoom took it very severely and tried once to kill herself by taking excessive oral pills, but on emergency care she was recovered and was admitted to psychiatric ward for further management. Her family and she were unable to cope with situation. Patient Assessment  Presenting Problem •  Severe depression.

Physical Dimension • Family history Mother and father alive, both alive, mother is house wife and father works in foreign country and both of them are healthy. No family mental illness history. • Father is cigarette smoker, and no drug user.

Individual Health Loss of appetite and history of constipation from one week with frequent urination. Limited social activities, disturbed sleeping pattern, restlessness, and no use of any drug. Doesn’t meet her relatives and friends and not take part in any activity.

Depression 116 • Sexuality Young adult female, married, regular menstrual cycle, ineffective coping, decreased desire for intercourse, no sexual abnormality.  Anxious about current problem

Emotional Dimension • She was very anxious about ignorance and negative behavior of other against them, worried about current problem and with depressed mood.

Intellectual Dimension • She is with depressed mood, feeling of hopelessness and helplessness regarding other. Delusion, auditory hallucination present and decreased decision making and problem solving ability. Low self-esteem.

Social Dimension • • • Low self concept and self esteem. Ignored by parents and relatives, house wife, mistrust. Dependent on family (husband) support.

Spiritual Dimension • • • Muslim, prays irregularly. Satisfied with his religious beliefs, activities and motivation, . Believes on faith, folk remedies, herbal medicines, religious healing, and rituals.

Mental Status Examination  Appearance • A 22 years old adult of moderate build and normal height, with rough, uncleaned and inappropriate dressing and face. Looks pale, anxious, sad, inappropriate eye contact, depressed facial grimaces present, and malnourished.

Depression 117  Behavior • Co-operative to health worker, delayed response with slow motor behavior, gait slow, restlessness, tremors present.  Communication •  Slow communications with low volume, interrupted and slurred and speech.

Cognitive • • Oriented to time, place and person. Poor in judgment and in decision making.

Thought Process • Suicidal ideas, idea of helplessness, thought blocking, delusion.

Mood and Affect • Verbalized displayed depressed, anxious and confused mood about current problem, and congruent mood expressions.

Sensory Perception • Auditory hallucination and delusion present.

Insight • Partial

Treatment • • • Tab: Diamecron 1 x OD Tab: Depex 40 mg BD Tab: Xanax 1 mg HS

The goals will be achieved after several teaching sessions with patient.

Depression 118 Nursing Diagnosis  Ineffective individual coping related to social stigma.

Planning  Short-term Goals

The client will verbalize increased adaptation to change in health status within a week.

The client will demonstrate measures necessary to increase independence within one week

The client will identify the stressor and learn the strategy to cope with them within five days.

Client will identify alternative ways of dealing with emotional problem and participate in the treatment program within five days.

Long-term Goals:
• •

The client and family will maintain open communication. The client will demonstrate the behavior and thinking according to develop effective coping mechanism and use it effectively till discharge

The client will demonstrate plan for using alternate ways of dealing with stress and emotional problems when they occur after discharge.

• •

The client will maintain satisfying relationship in the community and on job. The community leader will verbally express more positive thoughts regarding adaptation of other culture.

Depression 119 Nursing Interventions and Rationales Nursing Interventions
• •

Rationales

Introduction to the patient.

• •

Assess and determine the client • strength and weaknesses to develop the method and level of adaptation. Assess causative and contributing • factors as disapproval, inadequate support system and culture. Check vital signs. • Establish rapport by spending time, provision of support system, conveying of honesty and empathy. Encourage the client to ventilate her feelings. Convey your acceptance of the client’s feeling. Sit with the client many times to discuss the current concern, feelings, know her perception about stressor and help to realize and face reality. Involve the client as much as possible in her treatment. Provide with achievable task, goal and activities, and opportunity to make decision. Convey your interest in the client and approach her for interaction at least once per shift or allow visit to significant others. Provide the opportunity for the client to express emotion and fears to release tension and help the client identify the situation which would promote more comfortable feeling. Teach relaxation techniques such as exercise, deep breathing, imaginary to decrease physical tension. Assist the client to develop appropriate effective coping strategies Identify previous coping mechanisms, and assist patient to fined new one.

Establish a therapeutic relationship with client and relatives For baseline data for future planning to help the client in successful coping ability enhancement. To provide baseline data for planning, management and developing and enhancing coping ability of the client. To see the effectiveness of medication and severity of disease. Coping effectively requires successful management of task. Ventilating feeling can help the client to identify, and work through the feeling and to remain nonjudgmental. Communication of the concerns and supportive environment can facilitate development of the coping behavior. Assess the client and promote the sense of the control and responsibility

Your presence demonstrate interest and caring and convey the client your continued caring. Client need to develop skills and replace the behavior, create the supportive environment and develop coping ability in the client to pace this critical situation. Reduce the stress and provide alternative coping strategies. To overcome on the maladaptive condition. Determine the successful strategies, helps to have satisfaction in activities.

Depression120

Nursing Interventions

Rationales

• •

Help the client find alternatives or modification in previous lifestyle behavior by using assistive devices, participation in activities and learning new behavior. Encourage independence in self care activities by focusing on patient’s strengths rewarding small success. Assess the client with achievable task, goal, and opportunities to make decision. Teach the client social skills and encourage for practice with staff members and other clients. Give the client feedback regarding the social interaction. Provides the client familiar needed objects for activities. Encourage the client to identify and develop relationship with supportive people outside the hospital environment. Assist the client to identify and use available support system before the discharge from hospital and help to use the plan of care and in the community Provide social reinforcement and other behavioral rewards for demonstration of adaptation Assist the client in identifying and developing support system and plan for their use. Be alert to the client’s behaviors, as less talkative, comments about death, frustration, low tolerance, dependence, and disinterest in surrounding and concealing feelings. Do not joke about death, belittle the client’s wishes, feelings, or make insensitive remarks such as every body want to live to change behavior.

Helps client continue to have satisfaction in activities and provides a sense of control in lifestyle. Provides a sense of control and increase self-esteem and adjustment. To assist the client, promote positive self-esteem and sense of control. Client may lack skills and confidence in social interaction, and enhances coping ability. Promotes the client’s sense of control in meeting safety and security need. Increase the client support system may help decrease future suicidal behavior. Procedure to reach the short-term and long-term goal.

• •

Reinforcement encourages positive behavior and enhances self-esteem and coping mechanism. Support system can facilitate the client’s coping ability and strategies. These behaviors may indicate the client decision to commit suicide.

Client ability to understand and use obstruction

Depression121

Nursing Interventions

Rationales

Allow the client to develop solution that the best fit her concern. The nurse role is to provide assistance and feedback encourages creative approaches to problem solving. Encourage the client to pursue personal interest, hobbies and recreational activities. Provide client with an environment that will optimize sensory input. This includes hearing aids, eyeglasses, pencil and paper, decreased noise and appropriate lighting. Schedule a meeting with the identified support system to assist them in understanding alternatives in the client’s health. Provide client with group interaction 4-6 member for 15-30minutss.

To develop new behavior to solve her problem and improve the self-esteem.

Recreational activities can help increase the client social interaction and may provide social action. Appropriate level of sensory input decreases disorganization, confusion and maximizing the client coping ability. Promotes the development of a trusting relationship and provides the support system with the information that they utilize, be more effective. Assess the client to express personal importance to other while enhancing interpersonal relationship skills. This will help in coping, problem solving and decrease the conflict among the community members. Coping strategies to maintain healthy emotional and psychological health may be necessary. This is especially true for individual from a culture that discourages placing individual needs or emotion ahead of those of the family. Increases awareness of problems in the community and stimulates interest. Increases awareness in the targeted community and enhances adaptation of the other culture and importance of effective coping mechanisms. For continuation of the patient care in the next shift.

Develop trusting and respectful • relationship among client, family and community. Teach coping strategies for • managing tension and strain in the event of previous techniques losing their effectiveness.

Discuss examples with the family • and community of ineffective coping in order to begin problem solving. Educate the community about • cultural diversity, adaptation and coping mechanism through TV, radio, news papers, seminars, and internet. Document the procedure in the • patient file.

Depression122 Evaluation     The client has verbalized an increased adaptation to change in health status. The client has demonstrated measures necessary to increase independence. The client has identified the stressor and learnt the strategy to cope with them. The client has identified alternative ways of dealing with emotional problem and participated in the treatment program.  The client has demonstrated the behavior and thinking according to develop effective coping mechanism and use it effectively till discharge.   The client and family have maintained open communication. The client has demonstrated plan for using alternate ways of dealing with stress and emotional problems when they occur after discharge.   The client maintained satisfying relationship in the community and on job. The client was taking her treatment effectively and taking care of her mother and was using coping measures and planned strategy effectively.  The client and family verbally indicated a more positive adaptation and agreed to accept their marriage.  The community leader verbally expressed more positive thoughts regarding adaptation of other culture.

Depression123 References   Benner, C.V. Mental Health Nursing. 2nd Edition. USA. Carpenito, L.J. (1997). Nursing Diagnosis: Application to Clinical Practice. 7th Edition. Lippincott Philadelphia.  Cox, H. (1997). Clinical Applications of Nursing Diagnosis: Adult, Child, Women’s, Psychiatric, Gerontic, and Home Health Considerations. 3rd Edition. Davis, F.A. Company Philadelphia.  Harber, Hoskins and Leach (1978). Comprehensive Psychiatric Nursing. 3rd Edition. USA.  Schultz, J.M. and Videbeek, S.L. (2004). Lippincott’s Manual of Psychiatric Nursing Care Plans.7th Edition. Lippincott Philadelphia.  Shives, L.R. and Isaacs, A. (2002). Basic Concepts of Psychiatric-Mental Health Nursing. 5th Edition. Lippincott Philadelphia.  http://www.google.com. Scott J (2001). Cognitive therapy for depression. B Med Bulletin; 57:101-113.  White Lois (2001). Foundation of Nursing. 6th Edition. USA.

Depression124

Liaquat University of Medical and Health Sciences Jamshoro Sindh
College of Nursing, JPMC Depression ACN III Practical Scenario (Assignment # 1) Muhammad Farooq Saeed BScN Year II Mrs. Munira A. Ali

Depression125 Depression is a mood disorder in which a persistent feeling of sadness often accompanied by feeling of hopelessness, inadequacy and unworthiness. In depression, the client self seems worthless, world meaningless, hopeless and misery with high risk of suicide. The activities, voice and behavior become lower and client worry about the past failure and thinks that his/her future may be dark. According to WHO, it occurs in 20 – 30% of all clients. Etiology  Socioeconomic Causes          Separation of parents, failure in love or divorce.. Injustice. Unemployment. Poverty Death of a believed person. Stress. Family conflicts. Failure in exams.

Organic Causes   Genetic factors. Neurochemical factors: According to Biogenic Amine Theory, there is disturbance in the nonepinephrine, serotonin and dopamine. These will be decreased. According to Permissive Theory, serotonin and non-epinephrine are decreased in depression.     Infections attack like influenza, epilepsy, dementia, etc. Endocrine disorder. Separation of loss of any part of the body, as eye, hand, etc. Psychological factor (according to Frued):     Anal fixation and oral fixation Cognitive theory – lack of positive reinforcement. Drugs – antischezophrenic drugs. Oral contraceptive Antihypertensive.

Depression126 Clinical Features  Appearance           Improper dress and hair style. Improper eye contact. Skin rashes. Malaise, lethargic, fatigue. Self blaming with slow speech. Restlessness and dissatisfaction. Slow working with decreased motor activity. Decreased thinking process. Sadness, hopelessness and worthlessness.

Behavior                Anxious. Negative thinking. Dull emotions. Rigid Delirium. Over consciousness. Profound retardation of though. Nausea, vomiting. Difficulty in planning, Fearfulness. Loss of appetite. Self-accusation and even of death. Illusionary falsification are common (Colarel syndrome) Hallucination is occurring in one-third of the cases. Every task seems to burden.

Diagnostic Criteria for Major Depression Five or more symptoms from the following have been present during the same two week period and represent a change from previous functioning as in depressed mood and lost of interest or pleasure.

Depression127   Depressed mood most of the day, nearly everyday. Markedly diminished interest or pleasure in all or almost all activities most of the day nearly everyday.  Significant weight loss when not dieting or weight gain (change of more than 5% of the body weight) or decrease/increase in appetite nearly everyday.       Insomnia or hypersomnia nearly everyday. Psychomotor agitation or retardation nearly everyday. Fatigue or loss of energy everyday. Feeling so worthlessness or excessive or inappropriate guilt, nearly everyday. Diminished ability to think or concentrate indecisiveness nearly everyday. Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, suicidal attempts. Nursing Diagnosis          Social isolation. High risk for self-directed violence. Self-esteem disturbance. Powerlessness. Spiritual distress. Altered though processes. Altered nutrition, less than body requirements. Sleep pattern disturbance. Self-care deficit. Psychotherapy.  Cognitive-behavioral therapy – helps to change the negative thinking and unsatisfying behavior associated with depression.  Interpersonal therapy – focuses on improving troubled personal relationships and adapting to new life roles that may have been associated with person’s depression.  Medication  Tricyclic antidepressants – elevate mood in depressed individuals, reestablish their normal sleep, appetite and energy level.

Interventions 

Depression128  Selective serotonin reuptake inhibitors – they act specifically on the neurotransmitter serotonin.  Serotonin and Norepinephrine reuptake inhibitors – useful as first-line treatments in people taking an antidepressant for the first time and for people who have not responded to other medications.  Monoamine oxidase inhibitors – often effective in individuals who do not respond to other medications or who have “atypical” depressions with marked anxiety, excessive sleeping, irritability, hypochondria, or phobic characteristics.  Electroconvulsive therapy (ECT).  Electroconvulsive therapy is a treatment for sever mental illness in which a brief application of electric stimulus is used to produce a generalized seizure. It is a highly effective treatment for severe depressive episodes. Remarks In depression, the client seems self worthless, world meaningless, hopeless and misery with high risk of suicide. The activities, voice and behavior become lower and client worry about the past failure and thinks that his/her future may be dark. According to WHO, it occurs in 20 – 30% of all clients. Most of the patients recover and some of them advanced into bipolar disease. It requires long term management and follow up for good prognoses. The effectiveness of psychotherapy depends on the psychopathology of the family members. Therefore the family therapy may be provided in case of out patient. The client will not leave alone and after discharge the relative may be educated for care of the patient.

Depression129

Liaquat University of Medical and Health Sciences Jamshoro Sindh
College of Nursing, JPMC Depression ACN III Major NCP (Assignment # 2) Muhammad Farooq Saeed BScN Year II Mrs. Munira A. Ali

Depression130 Scenario Miss. Saima, a 20 years old girl admitted in Psychiatric unit with history of insomnia, anorexia and weight loss. She was social and enjoys parties and having a number of friends. Her past history revealed that she was all right before three months ago, when an incident changes her life i.e., her engagement was broken. Furthermore, she failed in her final examination. After this incident, she become isolated and loss interest in life. She is single child of her parents. Her mother is working in an office and father is a businessman. Both are very busy, therefore, she becomes an isolated child. Assessment   Presenting problem – severe depression. Physical Dimension • • • Family history Mother and father alive, both alive, mother is house wife and father works in foreign country and both of them are healthy. No family mental illness history. Father is cigarette smoker, and no drug user. Individual Health Loss of appetite and history of constipation from one week and frequent urination. Limited social activities, disturbed sleeping pattern, and restlessness. No use of any drug. Doesn’t meet her relatives and friends and not take part in any activity. Sexuality Young adult female, single, regular menstrual cycle. No sexual abnormality, anxious about current problem and ineffective social interaction.  Emotional Dimension • She is very anxious about failure, and broken engagement, worrying about future and with depressed mood. Look fearful, helpless, and feeling of insecurity and.  Intellectual Dimension • She is with depressed mood, feeling of hopelessness and helplessness regarding other. Delusion, auditory, hallucination present and decreased decision making and problem solving ability. Low self-esteem.  Social Dimension • Low self concept and self esteem.

Depression131 • • • •  Ignored by relatives, student, mistrust Dependent on family support with inability to develop relationship with relatives. She takes less part in occasions. She cannot cope with job current environment, so she isolated.

Spiritual Dimension • • Muslim, prays irregularly and satisfied with his religious beliefs, activities and motivation. Believes on faith, folk remedies, herbal medicines, religious healing, and rituals.

Mental Status Examination  Appearance • A 20 years old adult of moderate build and normal height, with rough, unclean and inappropriate dressing and face. Looks pale, anxious, sad, inappropriate eye contact, depressed facial grimaces present, and malnourished.  Behavior • Co-operative to health worker, delayed response with slow motor behavior, gait slow, restlessness, tremors present.  Communication •  Slow communications with low volume, interrupted and slurred speech.

Cognitive • • Oriented to time, place and person. Poor in judgment and in decision making.

Thought Process • Suicidal ideas, idea of helplessness, thought blocking, delusion.

Mood and Affect • Verbalized and displayed depressed, anxious and confused mood about current problem, and congruent mood expressions.

Sensory Perception:• Auditory hallucination and delusion present.

Insight • Partial

Treatment

Depression132    Tab: Diamecron 1 x OD Tab: Depex 40 mg BD Tab: Xanax 1 mg HS

Depression133
NURSING CARE PLAN

Title: Impaired social interaction related to loss of intimate relationship
Assessment Subjective Data According to the client’s parent, “she is feeling difficulty in falling asleep, anorexia and loss weight ,does not taking part in any activity and mostly lives alone, calm and quite, and complains headache, chest, back pain and indigestion after engagement broken and failed in BA examination,”. Objective Data Nursing Diagnosis Impaired social interaction related to loss of intimate relationship Expected Outcome Short term goals The client will demonstrate increased involvement in social interaction with in one week. Interventions Introduction to the client. Rationales To establish a therapeutic relationship. It provides a baseline data for the management of situation. Assist client to examine social experience and verbalize feelings and encourage therapeutic relationship. Depressed clients have potential for suicide that may be change by pre effective interventions. Improve communication skills and interactive process. Evaluation Short term Goal The Client verbalized satisfaction with quantity and quality of social interaction. Client communicated and participated with others and community She reestablished or maintained relationships and a social life and also established support system.

An adult girl of moderate build and with rough, uncleaned and inappropriate dressing and face. Looks pale, sad, with inappropriate eye contact, facial grimaces present, and malnourished. Delayed response with slow motor behavior, gait slow, restlessness, confused and tremors present communications with low volume, and slurred speech, Oriented and Poor in judgment and in decision making. Suicidal ideas, feeling of helplessness, and hopelessness
Vital Signs Blood Pressure Temperature Pulse 100/70 mmHg 97 °F 88 bpm

Assess the level of severity and condition of the patient. Encourage patient to express how she feels by scheduling at least 10 minutes, twice a day focus on client problem / topic. The client will Continually assess the client’s participate in daily potential for suicide. activities. Evaluate patient communiLong term goals cation skills and help her to The client will be find alternative during able to initiate interaction with patient. interaction with Help the client to obtain a others to maintain realistic perception of self by relationship and focusing on and enhancing social life. strength during conferences with patient. Allow client to choose social interactions for role play for 10 minutes twice a day time. Involve patient in daily care to help the patient in planning and decision making about own care. Initiate referrals to support groups prior to discharge.

Long term Help patient in achieving goal, and Client participated in improves self-concept. normal daily activities and normal routine life. Promote self-confidence and social interaction by allowing practice in a safe environment. Improve self-concept, and increase motivation. Decrease feelings of powerlessness. The client verbalized satisfaction with quality of interactions.

The client identified and demonstrated a number of measures that increase social Client’s contact with community interaction. group to interact to decrease social isolation.

Depression134
Assessment Nursing Diagnosis Expected Outcome Interventions Assign one staff permanent for the care of the client. Rationales Limiting the number of new contacts will facilitate familiarity and trust among client and staffs. Evaluation

Use silence and active listening Your presence and use of active listening when interacting with the client. will communicate your interest and concern. Use simple, direct sentences and It will encourage the client to express her ask open ended questions. feelings. Encourage the client to express her feelings in comfortable way. Expressing of feelings may help to relieve despair, and hopelessness.

Interact with the client on the topic It establishes trust and encourages of her choice and don’t probe for communication on difficult topics. information. Educate the client about problem- Successful use of problem solving solving, selection and process facilitates the client’s confidence implementation of alternatives and in the use of coping skills. evaluation of results. Teach and encourage the client to It will increase the confidence and social practice social skills, and give interaction of the client and prevents feedback to the client regarding social isolation and depression. interactions. Encourage the client to pursue Recreational activities can help the personal interests, hobbies, and client’s social interaction and provide recreational activities enjoyment.

Depression135
Assessment Nursing Diagnosis Expected Outcome Interventions Rationales Evaluation

Help the client to participate in Increase social skills by providing social group interactions. contact. Include client in group activities and assign activities that will be easily accomplished and provide positive reinforcement. Discuss with support system ways in which they can facilitate client interaction. Involve client and family in planning, implementing and promoting in reduction or elimination of impaired social interaction. Encourage the client to participate in diversional activities, especially those involving groups, daily. Encourage the client to use assistive or corrective devices. Limit the amount of time client can spend alone in the room. Document all the procedure in the client’s file. Reinforcement encourages positive behavior and enhances self-esteem.

Support system understanding facilitates the maintenance of new behavior after discharge. Family involvement enhances effective ness of the interventions. the

Increases social contacts and interact -ional skills. It will increase self-esteem and selfconfidence. Provide opportunities for client to practice new role behavior in a safe and supportive environment. For continuation of nursing care in the next shift.

Therapeutic Communication136 References   Benner, C.V. Mental Health Nursing. 2nd Edition. USA. Carpenito, L.J. (1997). Nursing Diagnosis: Application to Clinical Practice. 7th Edition. Lippincott Philadelphia.  Cox, H. (1997). Clinical Applications of Nursing Diagnosis: Adult, Child, Women’s, Psychiatric, Gerontic, and Home Health Considerations. 3rd Edition. Davis, F.A. Company Philadelphia.  Harber, Hoskins and Leach (1978). Comprehensive Psychiatric Nursing. 3rd Edition. USA.  Schultz, J.M. and Videbeek, S.L. (2004). Lippincott’s Manual of Psychiatric Nursing Care Plans.7th Edition. Lippincott Philadelphia.  Shives, L.R. and Isaacs, A. (2002). Basic Concepts of Psychiatric-Mental Health Nursing. 5th Edition. Lippincott Philadelphia.  http://www.google.com. Scott J (2001). Cognitive therapy for depression. B Med Bulletin; 57:101-113.  White Lois (2001). Foundation of Nursing. 6th Edition. USA.

Liaquat University of Medical and Health Sciences Jamshoro Sindh
College of Nursing, JPMC

Therapeutic Communication137

HIV AIDS ACN III Mukhtari Sardar
BScN Year II

Mrs. Ruth K. Alam

Therapeutic Communication138 HIV AIDS is the second leading cause of death. About half of all new HIV infections are among young people under age 25, with most being infected though sexual transmission. In women, ages 13 to 24, about 49% are infected heterosexually and 13% are infected via injecting drug use. As AIDS increases among people in the childbearing years, the number of children with HIV is expected to increase. HIV belongs to a group of viruses known as retroviruses, which indicates that the virus carries its genetic material in ribonucleic acid (RNA) rather than deoxyribonucleic acid (DNA). Manifestations of HIV infection range from mild abnormalities in the immune response without overt signs and symptoms to profound immunosuppression associated with various life-threatening infections and malignancies. Definition Acquired immunodeficiency syndrome (AIDS) is defined as the most severe form of a continuum of illnesses associated with human immunodeficiency virus (HIV) infection. General Transmission HIV is transmitted by way of body fluids that contain HIV-1 or CD4 + T lymphocytes. These fluids include serum, seminal fluid, vaginal secretions, amniotic fluid, and breast milk (i.e., HIV may be transmitted in utero from mother to child and later through breast milk). Some recent strains of HIV-1 have heightened virulence and infectious ability. Transmission to Health Care Providers The incidence of HIV for health care workers who are exposed to HIV through needle-stick injury is estimated to be about 0.3%. Large scale studies of exposed health care workers continue to be conducted by the Central Disease Control (CDC) and other groups. Prevention of Transmission Epidemiologic evidence indicates that HIV is transmitted only through intimate sexual contact, parenteral exposure to infected blood or blood products, and perinatal transmission from mother to neonate.

Therapeutic Communication139 Standard Precautions          Hand washing Gloves Mask, Eye protection, face shield Gown Patient care equipment Environmental control Linen Occupational health and blood-borne pathogens Patient placement. The three types of Transmission-Based Precautions are referred to as Airborne Precautions, Droplet Precautions, and Contact Precautions. They can be used singularity or in combination, but they are always to be used in addition to Standard Precautions. Clinical Manifestations The clinical manifestations of AIDS are widespread and may affect virtually any organ system. The following limited to the most common clinical manifestations and effects of severe HIV infection.  Respiratory Manifestations     Pneumocystis carinii Pneumonia. Mycobacterium avium Complex. Tuberculosis.

Gastrointestinal Manifestations   Oral Candidiasis. Wasting Syndrome

Therapeutic Communication140  Oncologic Manifestations    Kaposi’s Sarcoma. B-Cell Lymphomas.

Neurologic Manifestations    HIV Encephalopathy. Cryptococcus neoformans Progressive Multifocal Leukoencephalopathy

   

Depressive Manifestations Integumentary Manifestations Endocrine Manifestations. Manifestations Specific to Women

Psychiatric Assessment     Patient’s Name: Age: Sex Address: Zaibunisa 21 Years Female Quarter # 10, Street # 5, Hijrat Colony, Karachi.

Presenting Problems  Physical dimension

Family health history No any physical influences by emotional. She has 3 sisters and 2 brothers. Her parents are alive. No any drug habits and mental illness.

Therapeutic Communication141

Individual Health History No any physical illness. No mental illness present. No any history of hypertension or diabetic. She spend whole day with talking and walking here and there. Elimination pattern is normal. Sleep pattern is decrease. No use of tobacco, drugs or alcohol.

Sexual Pattern Sexual pattern is disturbed.

Intellectual dimension
• •

Less mental potential skill and self-esteem. Altered thought process.

Social dimension
• •

Poor interpersonal relationship, mistrust on others. Suspicious concept.

Emotional dimension
• • • •

Aggressive behavior. Anxiety. Fear Hopelessness and worthlessness.

Spiritual dimension
• •

Decrease religious practices due to mental illness. Believes on folk remedies and alternative healings by Hakeem.

Therapeutic Communication142 Mental Status Examination (MSE)  Appearance
• • • • • •

Poor grooming. Impaired hygienic condition. Facial expression suspicious and sad. Eye contact is not appropriate. General health not satisfactory. Malnourished.

Behavior
• • • •

Decrease concentration. Poor social interpersonal relationship. Rapid talking and walking. Frustration and irritability.

Psychomotor Behavior
• • •

Is not good. Activities mild retarded. Motor behavior is brisk and slow in activity.

Communication
• •

Speech rate and volume slow. Amount Talkative and self-talking. Logic – interrupted. Clarity – clear.

Thought process

Therapeutic Communication143

Feel delusion so that altered though process and loosing of association.

Mood and Affect

Patient looks sad and congruency.

Cognitive pattern
• •

Loose memory Remote

Sensory perceptions
• • •

She has little knowledge of self perception. Illusion is present. Thinking impaired.

Ensight
• •

Absent. Judgments not contact.

Nursing Diagnosis        Impaired skill integrity. Diarrhea. Abdominal cramps. Risk for infection. Altered nutrition – less than body requirements. Altered thought processes. Anticipatory grieving.

Other Related Nursing Diagnosis   Anxiety. Ineffective coping.

Therapeutic Communication144   Social isolation. Ineffective role performance.

Therapeutic Communication145 Short-term Goals The client will:
• • • •

Identify decreasing episodes of diarrhea and abdominal cramping. Verbalize adequate maintenance of fluid status. Demonstrate decreased anxiety, fear, guilt and so forth. Participate in treatment program.

Long-term Goals The client will:
• • • • •

Free from diarrhea till discharge. Exhibits return to normal bowel pattern. Identify strengths and weaknesses realistically. Demonstrate an increased ability to cope with weaknesses. Verbalize knowledge of illness, treatment plan, or safe use of medications, if any.

Nursing Interventions and Rationales Interventions

Rationales

Assess patient’s normal bowel habits. Monitor vital signs Assess for signs and symptoms of diarrhea: frequent, loose stools, abdominal pain or cramping. Measure amount of liquid stools.

Provides baseline for evaluating effectiveness of measures. Provides baseline for evaluating effectiveness of measures planned.

Quantifies loss of fluids. Provides basis for nursing measures. Identifies pathogenic organism

Identify exacerbating and alleviating • factors

Obtain stool cultures as prescribed by • physician, Administer antimicrobial therapy as prescribed.

Therapeutic Communication146

Interventions

Rationales Bowel rest may decrease acute episodes. Reduces stimulation of bowel. Nicotine acts as bowel stimulant. Prevents stimulation of bowel and abdominal distention.

Initiate measures to reduce hyperactivity • of bowel. Maintain food and fluid restrictions as prescribed by physician. Discourage smoking Avoid bowel irritants such as foods high in fat, fried foods, raw vegetables and fruits, nuts, onions, popcorn, carbonated beverages, spicy foods, and foods of extreme temperatures. Offer small, frequent meals. antispas- •

Administer anticholinergic modics as prescribed.

Decreases intestinal spasms and motility. Decreases intestinal spasms and motility. Prevents hypovolemia. Most acute episode of diarrhea are managed with the symptomatic therapy with fluid and electrolyte replacement. To prevent diarrhea in future.

Administer opiates or opiate-like • medications as prescribed by physician. Maintain fluid intake of at least 2500 ml • unless contraindicated. Explain the interventions required to • prevent future episodes

Explain the effects of diarrhea on • hydration.

Evaluation      The client has verbalized normal bowel habits. The client reported decreasing episodes of diarrhea and abdominal cramping. The client maintained adequate fluid intake. The client maintained body weight and reported no additional weight loss. The client identified and avoided foods that irritate the gastrointestinal tract.

Therapeutic Communication147 References  Agency for Health Care Policy and Research (1994). Evaluation and management of early HIV infection. Clin Pract Guideline No 7. USA.   Management of Patients with HIV Infection and AIDS. pp. 1340-1379. Carpenito, L.J. (1997). Nursing Diagnosis. Application to Clinical Practice. 7th Edition. Lippincott Philadelphia.  Carson, V.B. (2000). Mental Health Nursing. The Nursing Patient Journey. 2nd Edition.  Johnson. (1989). Mental Health Nursing. 2nd Edition. Lippincott Philadelphia.

Liaquat University of Medical and Health Sciences Jamshoro Sindh
College of Nursing, JPMC Therapeutic Communication ACN III Practical Scenario (Assignment # 1)

Therapeutic Communication148

Mukhtari Sardar
BScN Year II

Mrs. Munira A. Ali

Therapeutic Communication149 Therapeutic communication represents the points of interpersonal connection, through which clients are able to tell the story of their journey and the nurse is able to provide encouragement, support and resourceful information. As patients speak of their immediate experiences and the life events that led up to their current circumstances, they give voice to their fears, feelings, beliefs, hopes, desires and private realities. Definition Therapeutic communication is defined as a form of communication with a health related purpose that develops as a continuous interaction between nurse and patient. Purposes The primary purpose of therapeutic communication is to help client come to know themselves in ways that allow them to recognize possibilities in their lives and to alter ineffective life pattern. The nurse’s role in the communication process is to help patients transform vague, tangential, or distorted statements into clear, concrete, workable statements that have common meaning to both. The nurse uses these mutually developed statements as the basis for therapeutic intervention. The nurse enlists the patients as collaborators in the process of self-discovery and uses words, actions and knowledge to help patients develop a more positive view of themselves and more adaptive ways of interacting in the world. Responsibilities of the Nurse  Communication occurs within designated time frames and terminates when therapeutic goals are achieved.  Responsibility for the structure and conduct of the conversation is ultimately the nurse’s.   Communication is purposeful and directed towards mutually established goals. The focus of the conversation is always on the needs and concerns of the patient.

Therapeutic Communication150  The purpose is for the patient to achieve greater self-understanding from the relationship.  Self-disclosure of the nurse’s private life is limited and acceptable only under certain circumstances.   Conversation does not always reflect adherence to the rules of social etiquette. Formally terminates with the end of the session or relationship.

Preparing the Details for a Therapeutic Interaction The physical setting, timing, and therapeutic approach all can influence the sending and receiving of effective communication.  Physical Setting – use the room for each session away from the mainstream of activity.  Time – is an important variable to consider when planning for a therapeutic interaction.  Therapeutic Approach – successful communication is dependent on your ability to learn your client’s language. Strategies for Therapeutic Communication     Using active listening. Facilitating active communication Using minimal encouragers. Asking questions.
• • •

Open-Ended Questions. Closed-Ended Questions. Focused Questions.

Therapeutic Communication151 Factors that Enhance Therapeutic Relationships  Advocacy – is a broad concept that recognized as an essential role for the psychiatric nurse.  Caring – is an intangible interactive process with physical, psychosocial, and spiritual dimensions that finds expression through actions designed to promote the health and well-being of client.  Mutuality – involves inclusion and connection; it implies equal partnership in achieve a goal.  Unconditional Acceptance – It is easier to respect people, whose ideas and values parallel our own. Unconditional acceptance as the capacity of the nurse to affirm the client’s humanity and to validate his or her life experience without questioning its validity or judging it in any way.  Empathy – represents a mutual interpersonal process in which the nurse is able to capture the inner struggle of the client, bring together different aspects of the client’s situation in a meaningful way, and communicate that understanding in a way that is understood as truth by the patient.  Authenticity – means being real with the patient, not hiding behind the mask of professionalism.  Trust – is a mutual process and is the foundation of the nurse-patient relationship.

Therapeutic Communication152

Liaquat University of Medical and Health Sciences Jamshoro Sindh
College of Nursing, JPMC Therapeutic Communication ACN III Major NCP (Assignment # 2) Mukhtari Sardar
BScN Year II

Mrs. Munira A. Ali

Therapeutic Communication153 Scenario A 30 years old female verbalized that she has less abilities and strength in developing relationship with others. I feel people will defeat me and criticize me, therefore, I have lack of involvement in job performance and seek of evaluation from others. She has depressed mood, feeling of worthlessness and looking pale.

Therapeutic Communication154 NURSING CARE PLAN TITILE:
Date

Low Self-Esteem
Nursing Diagnosis Chronic Low Self-Esteem. Goal/Planning Short-term Goals:   The client will verbalize increased feelings of self-worth.  The client express feelings directly and  openly.  The client evaluate own strengths realistically.  Long-term Goals:  The client will demonstrate behavior consistent with increased self-esteem.   The client makes plans for the future consistent with personal strengths.  The client expresses satisfaction with self and personal qualities. Nursing Intervention Encourage the client to  become involved with staff and other clients in the milieu through interactions and activities. Give the client positive  feedback for completing responsibilities and interacting with others. Involve the client in  activities that are pleasant or recreational as a break from self-examination. If negativism dominates the  client’s conversation, it may help to structure the content of interactions, for example, by making an agreement to listen to 10 minutes of “negative” interaction, after which the client will interact on a positive topic. Provide simple activities  that can be accomplished easily and quickly. Begin with a solitary project; progress to group occupational and recreational therapy sessions. Give the client positive feedback for participat6ion Rationale When the client can focus on other people or interactions cyclic, negative thoughts are interrupted. Positive feedback increases the likelihood that the client will continue the behavior. The client needs to experience pleasurable activities that are not related to self and problems. The client will feel you are acknowledging his or her feelings yet will begin practicing the conscious interruption of negativistic thought and feeling patterns. The client may be limited in his or her ability to deal with complex tasks or stimuli. Any task that the client is able to complete provides in opportunity for positive feedback to the client. Evaluation The client has demonstrated behavior consistent with increased selfesteem. The client has made plans for the future consistent with personal strengths and expressed satisfaction with self and personal qualities.

Assessment (Data Statement) Subjective Data: Client verbalized that she has less abilities and strength to develop and self evaluation thinking about criticism of other as evidence by lack of job performance. Objective Data: A 30 years old client looked pale and depressed mood, feeling of despair, worthlessness and having low self-esteem, communication was slow and irregular. Vital signs: Blood Pressure: 110/70 mmHg Pulse Rate: 70 beat/min Resp. Rate: 20 per min. Temp. 98° F

Therapeutic Communication155

Therapeutic Communication156 Interventions  Give the client honest praise for accomplishing small responsibilities by  acknowledging how difficult it can be for the client to perform these tasks. Gradually increase the number and complexity of activities expected of  the client; give positive feedback at each level of accomplishment. It may be necessary to stress to the client that he or she should begin  doing things to feel better, rather than waiting to feel better before doing things. Explore with the client his or her personal strengths. Making a written  list is sometimes helpful. Rationales Clients with low self-esteem do not benefit from flattery or undue praise. Positive feedback provides reinforcement for the client’s growth and can enhance self-esteem. As the client’s abilities increase, he or she can accomplish more complex activities and receive more feedback. The client will have the opportunity to recognize his or her own achievements and will receive positive feedback. Without this stimulus, the client may lack motivation to attempt activities. While you can help the client discover his or her strengths, it will not be useful for you to list the client’s strengths. The client needs to identify them but may benefit from your supportive expectation that he or she will do so.

References  Harber, Hoskins and Leach (1978). Comprehensive Psychiatric Nursing. 3rd Edition. USA.  Shives, L.R. and Isaacs, A. (2002). Basic Concepts of Psychiatric-Mental Health Nursing. 5th Edition. Lippincott Philadelphia.  Schultz, J.M. and Videbeek, S.L. (2004). Lippincott’s Manual of Psychiatric Nursing Care Plans.7th Edition. Lippincott Philadelphia.  Tromblhy, C.A. and Radomski, M.V. (2001). Occupational therapy for physical dysfunction. 5th Edition. Lippincott Philadelphia.

Liaquat University of Medical and Health Sciences Jamshoro Sindh
College of Nursing, JPMC Aging People ACN III

Muhammad Yousaf BScN Year II Mrs. Ruth K. Alam

Old age is generally considered to begin between the ages of sixty and sixty-five years. The process of growth and development involves a series of changes that usually occur in an elderly and predicable sequence but at variable rates. The onset and the effect of those changes are influenced by numerous biological, physical, psychosocial and environment factors. In older adulthood, the process of aging becomes progressively more rapid. Therefore, elder people can be defined as, those people who are physically weak and unable to perform heavy work due to age factor. In our society, when any person’s age is more than 60-65 years, they were respected and given more importance. According to the famous poet William Shakespeare, “A human being posses different states in their life from birth to death, one of them is an old age when a man reached at this stage they have facing different problems in their life.” There are so many roles of the elder people in the society. The most important role of the elder once is decision making of the family in which they have a great importance in the family. They know very well about the ups and downs of the life because of having more experience of life in the society. In Pakistani culture, the elder people are respected, and regarded by their family. They are the caretakers of the family, well oriented about the situation, make plans and create better ways for their family and society. According to experience of life, the major task of old age is primary concerned with the maintenance of social contacts and relationship. Elder people centers in main cities or community and town serving as a key point from where the aged can make use of their talents and skills for new nation building activity and also keep themselves within the main stream of society. It is very important to promote a sharing of experience and information. We have observed on of the main social problem faced by the elder couple having no children. In this stage of life, they are facing lot of problems especially about their health care. They need more attention and if one of them is disabled they need nursing care for their

survival. They also face economical problems, as they are unable to earned enough money to meet their daily requirements. Their health is also not permitting them to perform all activities of daily life requirements. If they become poor they are treated in the hospital or may be a nurse attached to take care of them at home. Mental illness in old age is broadly classified as being either organic or functional. Organic mental disorder (dementia) affects around 10% of those aged over 65 years. A small number of older people are also affected by schizophrenia. Affective disorder includes depression, other persistent mood disorders mania and manic depressive illness. Common health problem of ole people include eye disease, hearing problem, painful joint and loss of memory. Illness can severely disturb an elder adult’s ability to function independently. The client is under increase physical and emotional stress, which increases the risk for complications because of the lack of physiologic resources. During this age disease like cardiac diseases, respiratory diseases, diabetic mellitus, renal function failure, etc., whose signs and symptoms include hypertension, hyperglycemia, sleep disturbance and general weakness. The oldest people may display some overall decrease in sleep efficiency but not enough for average are in fact in sleeping pills are not a good idea for the elder people. Reynolds (1991) suggests that the eldest may have better sleep hygiene than younger person. Brief naps during the day may be refreshing for them so long as their nighttime sleep is not affected. However, they can enjoy the world through all of their sense, sometimes with the aid of assistive/prosthetic devices. Every care plan for the oldest should include health maintenance monitoring of all sense including drug effects. Psychiatric Disorder     Depression Delirium and Dementia Disturbance intellectual function Disorientation

       

Poor memory Liable mood Anxiety Schizophrenia Meaningless character. Altered level of conscious Poor judgment Altered attention spasm.

Assessment Criteria  Physical dimension:

Family history No any previous family history of illness Client’s perception of the quality of his/her relationship and of himself or herself within these relationships. Present time he/she takes excessive drugs.

Individual health history No any physical illness. Sleep pattern is very disturbed; some time takes day nap and also lesser activity. Clients may be dissatisfied and experiencing discomfort. Spends most of time in his/her room. Not taking proper diet.

Emotion dimension Aggression.

Egocentricity. Racism. Sexism Complaining critical May discouraged other from befriending.

Intellectual dimension Partially think about disease and understand to take medication. Decreased self-esteem. Difficulty in decision making.

Social dimension Does not share any activity with anyone. Does not want to make relationships with others. Does not trust on any person.

Spiritual dimension Client spiritual beliefs and feelings. Support from spiritual beliefs. Client relationships to higher power. Spent more time in pray for satisfaction.

Mental Status Examination  Appearance
• • • •

Client is looking normal hygienic. Facial expression anxious and suspicious. Eye contact excessive and sometime absent. General health is normal.

Behavior

• • • • •

Unable to talk properly. Talkative. Not trust on others. Tremor present. Motor Behavior Gait is very slow Level of activity low.

Communication Pattern
• • •

Speak rapidly and loudly. Whispering and talkative Illogical speech.

Cognitive pattern
• •

Loose memory Remote

Thought process
• •

Delusion Positive obsession and idea of suicidal

Sensory perception

Tactile hallucination

Ensight

Partially absent.

Nursing Diagnosis   Sleep pattern disturb Altered thought process

 

Impaired social interaction Anxiety.

Short-term Goals The client will:      Participate in therapeutic relationship. Verbalize decrease feeling of anxiety. Increase contact with other. Demonstrate increased interpersonal contact. Identify strategy to prevent feeling of anxiety and stress.

Long-term Goals The client will:    Express satisfaction with leisure and social activities. Demonstrate increase communication, social and leisure activity skill. Maintain on-going interpersonal relationships that are satisfying.

Nursing Interventions and Rationales Interventions

Rationales

Assess the level of anxiety.

For baseline data and to know the cause.

Monitor anxiety behavior and • relationship to activity, events, people, etc.
Assist the level of coping mechanisms

Identification of the behavior and causative factors enhances intervention plan
To improve effective coping patterns and sense of ability to manage anxiety

Provide reassurance and comfort by staying with the patient. Speak slowly and calmly and monitor anxiety and relationship to activity events.

• •

To reduce the effects of anxiety.
To provide calm environment and help the client to understand her anxiety. Provide emotional support and encourage sharing may help a client clarify her fear. Assists in deter-mining the effect of anxiety

Encourage significantly others to stay • within patient limit and not to force conversation. Monitor vital sign at least every 4 • hourly while awake. Assist patient to develop coping skills. • Review past coping behaviors and success or lack of success. Administer anti-anxiety medication as • ordered by the doctor. Monitor and document effects of medication

Determine what has helped in past and determines if the measures are still useful. Effectiveness of medication is determined so that modification can be provided if needed. Medication helps to reduce anxiety to a manageable level.

Evaluation   Client verbalized the techniques to reduce anxiety. Client was using coping mechanism effectively and was ready to participate and face the daily needs.  Client has implemented a plan to reduce the risk for anxiety.

References

Alford DM (2004). Nursing Care of the Oldest Old. [Online] available. dalfordl@airmail.net.

Carson, V.B. (2000). Mental Health Nursing. The Nursing Patient Journey. 2nd Edition.

Harber, Hoskins and Leach (1978). Comprehensive Psychiatric Nursing. 3rd Edition. USA.


Marry, T.C. (1941). Psychiatric Mental Nursing. Rogers D (1979). Nursing Care of Elderly People. p 368. Schultz, J.M. and Videbeek, S.L. Psychiatric Nursing. 7th Edition.

Liaquat University of Medical and Health Sciences, Jamshoro Sindh College of Nursing, JPMC, Karachi BScN Year-II, Session 2006-2008 Crises Intervention Advanced Concept of Nursing III

Naseem Akhter Mrs. Mustaqima Begum Dated: ______________

Crisis is defined as an upset in the persons steady state provoked when an individual finds an obstacle to important life goal (Caplan). It is also defined as a response condition wherein psychological homeostasis has been disrupted, one’s usual coping mechanism have failed to reestablish homeostasis, and some evidence of functional impairment (Everly & Mitchell, 1961, 1964). Types of Crisis – Origin of crisis is as important as the types of crisis. Hoff (1989) pointed out that if we know how the crisis began, we have better opportunity to intervene effectively. There are three types of crisis origin. Developmental or Transitional Crisis – these are the transitions between the stages of life that we all go through. These major times of transition are often marked by “rites of passage” at clearly defined moments e.g., puberty, adulthood, getting married, retirement, becoming an elder or dying. Situational Crisis – sometimes called “accidental crisis” are more culture and situation specific e.g., loss of job, income, home, accident, loss through separation or divorce. Complex Crisis – these are not part of our everyday experience or shared accumulated knowledge, so we find them harder to cope with. It includes: (1) severe trauma – such as violent personal assault, natural or man made disaster often directly involving both individuals and their families, (ii) crisis associated with severe mental illness – the stress of crisis can precipitate episodes of mental illness in those who are already venerable e.g., (PTSD) developmental, situational and complex crises may overlap and one may lead to the other. Stages of Crisis – A crisis can be thought of as having three stages: (1) pre-crisis, (2) crisis, and (3) post-crisis. Pre-crisis Stage – is stage of maintaining or attempting to maintain equilibrium. If the individual’s problem solving method is successful, the person avoids a crisis and reverts to a

state of dynamic equilibrium. If the problem is too severe or if the balancing factors are inadequate, equilibrium is not maintained, the problem is not solved and a crisis results. Crisis Stage – is the reaction to the event. Reactions to such events or traumas are highly individuals. In this the balancing factors have failed and individual fall in a crisis state. Interpersonal conflicts are great, anxiety and tension increase. Individual makes erratic attempts to solve the problem. This state is so disruptive that an individual cannot maintain this state for long time. Crisis states are time limited and do not last longer than six weeks. Post-crisis Stage – because the crisis phase is time limited, every one who experience a crisis enter the post-crisis phase. During this phase the individual arrives at or develop a new equilibrium. This equilibrium may be close of to that of pre-crisis state or it may be more positive or more negative state. If the new equilibrium is more positive the person experience growth, a better social network, new found problems solving abilities or improved self image. If new equilibrium is more negative that individual may lose skills, adopt a regressive stance or develop socially unacceptable behaviors. Effects of balancing factor in stressful events are: Human organism ↓ Stressful event State of equilibrium Stressful event ↓ State of disequilibrium ↓ Need to restore equilibrium Balancing factor present Realistic perception of event + Adequate situational support + Adequate coping mechanism Result in Resolution of problem ↓ Equilibrium regained ↓ No Crises Balancing factor absent Distorted perception of event and No adequate situation support and No adequate coping mechanism Result in Problem unresolved ↓ Disequilibrium continues ↓ Crisis

Crisis Intervention is defined as the provision of emergency psychological care to victim as to assist those victims in returning to an adaptive level of functioning and to prevent or mitigate the potential negative impact of psychological trauma (Everly & Mitcheel, 1999). Eighty percent of people are able to work through these situations themselves with support from significant others. Twenty percent have difficulties that require intervention and assistance. While there is no single model of crisis intervention, there is a common agreement on general principles to be employed to alleviate the acute distress of victim. There are five basic principles of crisis intervention. These are: Intervene Immediately – by definition crisis is emotionally hazardous situation that place victims at high risk for maladaptive coping or even for being immobilized, the presence on site of emergency mental health personnel as quickly as possible is paramount. Stabilize – one important immediate goal is stabilization of the victim community actively mobilizing resources and support network. Such mobilization provides the needed tools for victims to begin to function independently. Facilitate Understanding – is another important step in restoring victims to pre-crisis level of functioning to facilitate their understanding of what has occurred by gathering the facts, listening to the victim’s recount events, encouraging the expression of difficult emotion and helping them understanding the impact of critical event. Focus on Problem Solving – actively assisting victims to use available resources to regain control is an important strategy. Assisting the victim in solving problem within the context of what the victim feels is possible enhances independent functions. Encourage Self-Reliance – emphasis on restoring self-reliance in victims as an additional means to restore independent functioning and to address the aftermath of traumatic events. Victims should be assisted in assessing the problem at hand in developing practical

strategies to address those problems and finding those strategies to restore a more normal equilibrium. Summary A crisis is a period of transition in the life of individual, family or group, presenting individuals with a turning point in their lives, which may be seen as challenge or a threat a make or break, new possibility or risk, a gain or a loss, or both simultaneously. Most crises are part of normal range of life experience that most people can expect and the most people recover without professional intervention. However, there are crises outside the bounds of person’s everyday experience or coping mechanism which may require expert help to achieve recovery. The need for crisis intervention services is clear. Yet the efforts to provide those services must well-timed and well-measured. Consideration of aforementioned principles may assist the crisis worker in the most effective application of crisis intervention strategies.

References  Flannery, R.B., & Everly, G.S., et al. (2000). Crisis intervention. Retrieved from www.goolge.com/pk. Retrieved on September, 10, 2007.  Kneisl, C.R., & Wilson, H.S. Psychiatric nursing. 4th Edition.

Liaquat University of Medical and Health Sciences Jamshoro Sindh
College of Nursing, JPMC Personality Disorder ACN III Major NCP (Assignment # 2) Naseem Akhter BScN Year II Mrs. Munira A. Ali

NURSING CARE PLAN TITILE:
Date           

Ineffective Coping.
Assessment (Data Statement) Low frustration tolerance. Impulsive behavior. Poor judgment. Conflict with authority Difficulty following rules and obey laws. Lack of feeling of remorse. Socially unacceptable behavior. Dishonesty. Ineffective interpersonal relationship. Manipulative behavior Failure to learn or change behavior based on past experience or punishment. Failure to accept or handle responsibility. Nursing Diagnosis Ineffective coping related to inability to form a valid appraisal of the stressors, inadequate choices of practiced responses and/or inability to use available resources. Goal/Planning Short-term Goals:   The client will verbalize express feelings especially anger.  The client demonstrates  adequate daily living skill. Long-term Goals:  The client will maintain  satisfactory work performance.  Meet own needs without interfering on the right of  other.  Nursing Intervention Encourage the client to • identify the action that precipated hospitalization. Give positive feedback for  honesty. The client may try to avoid responsibility by acting as though he or she is helpless. Identify unacceptable  behavior either general or specific. Develops specific cones-  quences for unacceptable behavior. Avoid any discussion about  why requirement exist. Inform the client of  unacceptable behavior and the resulting consequences in advance of their occurrence. Communicate & document  in the client care plan all behaviors & consequences in specific terms. Rationale These clients frequently deny responsibility for consequences through their own action. Honest identification of the consequences for the client behavior is necessary for future behavior change. You must supply clear concrete limit when the client is unable or unwilling to do. Unpleasant consequences may help decrease unacceptable behavior. The client my attempt to bend the rule just this one with numerous excuses and justification. The client must be aware of expectations and consequences. The client may attempt to gain favor with staff member or play one staff member against other. Evaluation The client has verbalized feeling especially anger. The client has demonstrates adequate daily living skills.

Date

Assessment (Data Statement)

Nursing Diagnosis

Goal/Planning 

Nursing Intervention Avoid try to coax or  convince the client to do the right thing. Avoid immediate positive feedback or reward for acceptable behavior. Encourage the client to identify sources of frustration and any unpleasant consequences that result. Explore alternative socially, legally acceptable method of dealing with frustration. Help the client try alternative as situation arise. Give positive feedback, when the client uses these alternatives.

Liaquat University of Medical and Health Sciences Jamshoro Sindh
College of Nursing, JPMC Personality Disorder

ACN III Practical Scenario (Assignment # 1) Naseem Akhter BScN Year II Mrs. Munira A. Ali

Personality disorder is evidenced by a client’s enduring pattern of thinking, behaving and behaving that deviates markedly from the expectations of his or her culture (APA 2000). The individual has difficulties with impulse control; interpersonal functioning; cognition or affect. These maladaptive coping patterns and skewed perceptions of self or others are long standing and are present in many life situations, even though they are ineffective or cause significant distress or impaired functioning. Clients with other psychiatric diagnoses may also have a personality disorder that makes their care more complex. Types       Paranoid personality disorder Schiziod and schizotypal personality disorder Antisocial personality disorder Borderline personality disorder Dependent personality disorder Passive aggressive personality disorder

Etiology        No clear etiology has been identified May be environmental and hereditary factors involved Genetic and experimental factors Behavioral problems History of abused or neglected as a child History of physical or sexual abuse Loss of parent

Symptoms  Anxiety

             

Depression Poor adjustment Chronic medical condition Mood disorder and mood swing Impaired thoughts Aggressive behavior Suicidal behavior Self mutilating behavior Extreme stress Unusual perceptual experience Beliefs in superstition Low self esteem Powerless Delusions

Nursing Diagnoses         Ineffective coping Disturbed thought process Impaired social interaction Ineffective therapeutic regimen management Impaired adjustment Social isolation Risk for self mutilation Powerlessness

General Intervention    Treatment focused on symptom management (e.g., aggression or depression). The client behavior is self centered and based on desire of movement. Personality disorders are at increase risk for suicide and self-injury. Ensuring the client safety is a key nursing goal.  Build trust relationship and minimize manipulative behavior. The client safety is always primary nursing goal.          Development of basic skill and confidence. Communicating clear consistence expectations can be helpful. Facilitate the client accepting responsibility. Encouraging direct expression of feeling. Promoting effective coping skill. Do not discuss yourself, other staff member or other client with the client. Do not attempt to be popular, liked, or the favorite staff member of this client. Give attention and support when the client behavior is appropriate. Give the client positive feedback when he or she is able to express anger verbally or in non-destructive manner.

Liaquat University of Medical and Health Sciences Jamshoro Sindh
College of Nursing, JPMC Personality Disorder ACN III Practical Scenario (Assignment # 1) Naseem Akhter BScN Year II Mrs. Munira A. Ali

Personality disorder is evidenced by a client’s enduring pattern of thinking, behaving and behaving that deviates markedly from the expectations of his or her culture (APA 2000). The individual has difficulties with impulse control; interpersonal functioning; cognition or affect. These maladaptive coping patterns and skewed perceptions of self or others are long standing and are present in many life situations, even though they are ineffective or cause significant distress or impaired functioning. Clients with other psychiatric diagnoses may also have a personality disorder that makes their care more complex. Types       Paranoid personality disorder Schiziod and schizotypal personality disorder Antisocial personality disorder Borderline personality disorder Dependent personality disorder Passive aggressive personality disorder

Etiology        No clear etiology has been identified May be environmental and hereditary factors involved Genetic and experimental factors Behavioral problems History of abused or neglected as a child History of physical or sexual abuse Loss of parent

Symptoms  Anxiety

             

Depression Poor adjustment Chronic medical condition Mood disorder and mood swing Impaired thoughts Aggressive behavior Suicidal behavior Self mutilating behavior Extreme stress Unusual perceptual experience Beliefs in superstition Low self esteem Powerless Delusions

Nursing Diagnoses         Ineffective coping Disturbed thought process Impaired social interaction Ineffective therapeutic regimen management Impaired adjustment Social isolation Risk for self mutilation Powerlessness

General Intervention    Treatment focused on symptom management (e.g., aggression or depression). The client behavior is self centered and based on desire of movement. Personality disorders are at increase risk for suicide and self-injury. Ensuring the client safety is a key nursing goal.  Build trust relationship and minimize manipulative behavior. The client safety is always primary nursing goal.          Development of basic skill and confidence. Communicating clear consistence expectations can be helpful. Facilitate the client accepting responsibility. Encouraging direct expression of feeling. Promoting effective coping skill. Do not discuss yourself, other staff member or other client with the client. Do not attempt to be popular, liked, or the favorite staff member of this client. Give attention and support when the client behavior is appropriate. Give the client positive feedback when he or she is able to express anger verbally or in non-destructive manner.

References  Carson, V.B. (2000). Mental Health Nursing. The Nursing Patient Journey. 2nd Edition.  Harber, Hoskins and Leach (1978). Comprehensive Psychiatric Nursing. 3rd Edition. USA.    Marry, T.C. (1941). Psychiatric Mental Nursing. Schultz, J.M. and Videbeek, S.L. Psychiatric Nursing. 7th Edition. http://www.google.com. Scott, J. (2001). Cognitive Therapy for Depression. B Med Bulletin; 57:101-113.

Liaquat University of Medical and Health Sciences Jamshoro Sindh
College of Nursing, JPMC Sexuality ACN III Naseem Akhter

BScN Year II Mrs. Ruth K. Alam

Human sexuality is an area in which treatment team member’s feelings are often evoked and must be consider because it is basic to everyone, sexuality may be a factor with any client in a number of ways. Adequate knowledge base sexuality is a life long process. In the past decades, sexuality has been refined in a holistic perspective and has become recognized as an important component of the total person interacting with the environment. Definition  Sexuality is defined as the characteristic quality of the male and female reproductive elements.  It also refers to the constitution of an individual in relation to sexual attitudes and behavior. Problems of Sexuality

A change in sexual habits and feelings, such as first sexual activities, marriage or loss of a sexual partner.

         

Injury, illness and disability (disturbed body image). Traumatic experience i.e., incest, rape. Post traumatic stress disorder (sexual, emotional, or physical abuse). Crime i.e., exhibitionism, rape, incest, etc. Feeling guilty about masturbation. Lack of social skill in the area of social and intimate relationship. Side effects from psychotropic medications. Menopausal symptoms. Chromosomal abnormalities Psychosis

Stages of Human Psychosexual Development Stages Prenatal Characteristics Chromosomal and hormonal factors influence the gender of the fetus. The gender of the fetus is determined by the 7th week. Gender is assigned at birth. Societal influence reinforces the child’s sexual identity. The infant is in the oral phase of development. Infants exhibit reflexive signs of sexual arousal. Physical affection toward the child is essential for normal psychosocial development. The child is in the anal phase of development. The concept of privacy is manifest. Self exploration of the genitals occurs. Awareness and mimicking behaviors begins. Association b/w genitals and pleasure begins. The child has an attraction to the opposite sex parent. Sex play between age mates occurs. Curiosity about reproduction occurs. Friendships develop predominantly with same sex age mates. Sexual self consciousness begins. There is an increase in sexual fantasy. Dating the opposite sex occurs. Physical changes occur. Menarche, breast enlargement, and widening of the hips in females. Broadening shoulders increase in muscle mass and development of body hair in males occur. Masturbation, petting, and intercourse occur. Individual is learning how to handle sexuality responsibly. Sexual experimentation and focus on sexual technique develop. Individual establishes long term relationships. Pregnancy and childbearing are possible. Self acceptance is achieved. Performance anxiety decreases Frequency of intercourse decreases. Hormonal changes and menopause occur. Secondary sex characteristics decrease. Sexual activity is focused on intimacy rather than intercourse. Sexual accommodation is made for physical handicaps. Frequency of intercourse decreases.

Birth - 2 years

2 – 5 Years

5 – 12 Years

13 – 20 Years

Young adulthood

Middle Adulthood

Late Adulthood

Factors The following factors include:  Predisposing factors

 

Precipitant factors Maintaining factors

Drugs known to have side effects that can disturb sexual function:          Antianxiety Antidepressants Anticholinergics Narcotics Alcohol Sedative hypnotics Antihypertensive Antipsychotics Hormones.

Nurse’s Role in Discussing Sexuality The nurse must become educated regarding sexuality and sexual health through the life span. It is important for the nurse to examine his/her own beliefs and feelings concerning sexuality, sexual function, and what is considered sexually normal and abnormal. Many nurses have difficulty providing care in the area of sexuality. The PLISSIT model is helpful for the nurse to providing care in the area of sexuality. Permission - Convey to person and significant others a willingness to discuss sexual thought and feelings Limited Information - Provide the person and significant other with information on the effects certain situations (e.g., pregnancy) conditions (e.g., cancer) and treatments (e.g., medications) can have on sexuality and sexual function.

Specific Suggestions - Provide specific instructions that can facilitate positive sexual functioning (e.g., changes in coital positions). Intensive Therapy - Refers people who need more help to appropriate health care professionals (e.g., sex therapist, surgeon). Assessment     Age, sex, marital status and relationship status Sexual orientation/preference Number of children and siblings Physical Dimension

Family health history Client’s perception of the quality of his/her relationship with significant or partner. How has your health problem affected your ability to function as a wife, mother, partner, etc? How has your health problem affected your ability to function sexually? No mental illness, use of drugs, any other physical problem.

Individual health history Any physical illness i.e., Diabetes, Myocardial infarction, any surgical procedure, psychological illness i.e., depression, anxiety

Activities of daily living Daily activities are disturbed. Diet and elimination may or may not be normal. Sleep pattern disturbed

Sexuality Sexually active or not.

Interest in sexuality. Questions about sexual functioning and sexual concerns. Body changes. Coping skills may be uncomfortable exploring sexual issues. Control of life and safe measures.

Emotional Dimension Anger, fear, shame, depression, anxiety, confusion, fear of pain, etc.

Intellectual Dimension Self destructive thoughts, impaired perceptions, difficult in concentration, disinterest or other cognitive symptoms

Social Dimension Socially interaction with the partner, interpersonal relationship with the partner, trust or mistrust on partner, self esteems in sexuality

Spiritual Dimension Religious beliefs in regard to sexual behavior and sexual knowledge, sexual concerns may conflict with the religious beliefs and cultural values.

Nursing Diagnoses   Sexuality dysfunction Ineffective sexuality pattern

Related Diagnoses     Postrauma syndrome Impaired social interaction Deficient knowledge Risk for self mutilation

Powerlessness.

Short-term Goals   The client will discuss her/his feelings about her/his family situation. The client will discuss the connection b/w her own lack of a stable, loving relationship with the partner.   The client will identify the behavior when she/he relating to the partner The patient will use spiritual resources to alleviate the spiritual distress

Long-term Goals  The client will recognize the link between the meaningful relationship with partner and her/his willingness to engage in sexual intercourse.  The client will identify practices and coping patterns that will help her/his to achieve meaningful relationships with partner and will acknowledge restoration of sexual desire.  The client will find spiritual comfort.

Nursing Interventions and Rationales Interventions Rationales

Help the client to complete a family A family genogram is the nongenogram. emotional method of diagramming and examining family patterns Teach client about family patter – how A family approach provides with a behavior and attitudes are transmitted from way of analyzing and problem solving one generation to other. about own situation. Help client to recognize the patterns of A family approach provides with a relationship in family. way of analyzing and problem solving about own situation. Encourage client to identify and discuss the By recognizing and discussing own feelings about the parents and the feelings and changing behavior. subsequent relationships. Encourage to identify alternative ways of Identifying alternative modes of interaction with partner in meaningful ways behaving before a situation presence but without premature intimacy. itself is an empowering strategy.

Interventions

Rationales

Encourage the client that it is possible to Encouragement provides hope for change unhealthy patterns of behavior. pursuing change. Encourage client to role-play various By asking the client to role-play to situation in which interact with partner. allowing to see own behavior in a different and more objective way. Ask the client to analyze the responses to To characterize own behavior and behavior that received from the partner. recognizing there is change to made. Explore alternative behaviors, ways of acting, that are friendly and interested but with clear boundaries of sexual involvement. Ask the client to keep a record of feelings. By establishing realistic boundaries are helping the client to assume control over body and sexual activities. The on-going recording and follow-up discussion of client’s feeling expend awareness and understanding of behavior. Sexual expression is an intimate way of relating to another in a committed relationship.

Discuss the meaning of sexual expression.

Assess the client’s understanding of the It is important that ask to discuss the information presented. information. Discuss the sexuality. spiritual significance of Sexuality is an expression of our spirituality. In that sexuality transcends the individual and it’s creative. and

Discuss with client the spiritual resources May find spiritual support (prayer, medication, a reading of scripture strength from these resources. or other inspirational materials) that might be helpful and supportive.

Ask the client to might support in efforts to Offering the self is caring therapeutic attain comfort and consolation. modality that shows support and help for the client who is spiritual distress. Give homework assignments in which the The client focused on the areas for client keeps a journal of interactions with change and active participation in the partner and try out new behavior. change.

Evaluation The client has met all of the short-term goals and able to examine the family situation, easily recognized that the pattern of relating to partner was linked to early family experiences and the behavior. The client has met all of the expected outcomes. The client involved social activities with groups of friends and to seek a committed relationship with a partner before engaging in sexual activity.

References  Barbara, W.F. and Richard, W.J. (1990). Bailliere’s Nurses’ Dictionary. Bailliere Tindall Limited London.  Brunner and Suddarth, D.S. (1988). Textbook of Medical-Surgical Nursing. (6th ed.). Philadelphia J.B. Lippincott Company.  Carson, V.B. (2000). Mental Health Nursing. The Nursing Patient Journey. 2nd Edition.

Liaquat University of Medical and Health Sciences, Jamshoro Sindh College of Nursing, JPMC, Karachi BScN Year-II Session 2006-2008 Nursing Care Plan & Reflection Log Advance Concept of Nursing-III Nahid Jamal Mrs. Mustaqima Begum

Nursing Care Plan Introduction Disturbed thought process describes an individual with altered perception and cognition that interferes with daily living. Causes are biochemical or psychological disturbance. For example, depression, personality disorders, etc. Focus of nursing is to reduce disturbed thinking and promote reality orientation. Nurse should be cautioned when using this diagnosis as a (waste basket) diagnosis. All patients with disturbed thinking or confusion, frequently confusion in older adults is erroneously attributed to aging. Metabolic disorder depression causes impaired thinking in older adults and remain additional information. Disturbed thought process individual experiences a disruption in such mental activities as conscious thought, reality orientation, problem solving, judgment, and comprehension related to coping personality and mental disorder.

NURSING CARE PLAN
Name: Perveen Age: 50 Years Sex: Female Psychiatric Diagnosis: Disturbed Though Process Nursing Diagnosis: Altered perception related to disturbed thought process due to biochemical alterations.
Date Assessment (Data Statement) Nursing Diagnosis Goal/Planning Nursing Intervention Rationale Evaluation

Altered perception related to disturbed thought process due to biochemical alterations

Subjective Data: The client’s attendant, she was fine a month ago, suddenly she develop sign and symptoms of lack of concentration, irritability, poor appetite, sleeplessness, hopelessness, fear, restlessness, increased motor movements, false beliefs and increased level of anxiety. Objective Data: A 50 years lady lying on the bed with uncomfortably, untidy and in unhygienic conditions. She is looking restlessness insomnia, loss of appetite and poor confidence. Vital Sign Blood Pressure: 120/80 mmHg Temperature: 98°F Pulse: 100 bpm Respiratory Rate: 24 per min. Investigation revealed: Hb: 11.12 Blood Sugar: 120 mg/dl Urine D/R: Normal

Short-term Goals: • The client will feel relaxed with appro- • priate social behavior. Long-term Goals: • The client will make full attention. Discuss current events, well oriented to time and • place and express feelings constructively • • • •

Inform and reassure client.

Establish relationship. To handle client easily. To encourage client.

The client must lying in • comfortably and relaxed Use communication helps • client to maintain own individuality. Provide company of family • or friends. Diversional therapy Avoid making promises that cannot be fulfilled. Verify your interpretation, • what client is experiencing. Provide balanced diet. • •

Short-term Goals: The client verbalized that she feel relax and comfortable and reduce disturb thoughts.

• •

Assist the client to set limits on own behavior. Encourage family to bring • familiar objects from home.

Long-term Goals: The client made decision about reality, To change the thinking. feeling and follow through with appropriate action to To decrease anxiety. change provocative situations in personal environment physiological reaction to panic attack decease. To decrease fear. Expressed panic attack about road traffic accident and To improve the general blood injury and its health, alternative method of effect in future. coping Accurately described relationship between panic attack and occurrence of physiological symptoms To divert clients attention.

Disturbed Thought Process
Reflection

Introduction To fulfill my requirement of BSc Nursing, I went to Psychiatric unit (Ward 20). With the permission of the Head Nurse, I selected a client who was 50 years old lady. She was laying on the bed with complaint of disturbed though process. To relate this disease altered perception causes are biochemical or psychological disturbances, for example, depression, personality disorder, etc. The focus as nursing is to reduce disturbed thinking and promote reality orientation. This psychotic disorder of impaired thinking is occurred more frequently in older adults. Analysis I analyzed the client’s condition and observe reduce the client’s problem as nurse gives and discuss alternative methods of coping like taking a walk instead of crying, cognitive therapy and behavior therapies given, encourage and support the client in decision making process, helps the client to recognize behaviors that stimulate rejection, provide client sensor input that is sufficient and meaningful. Conclusion Thought process describes as altered perception and cognition. Disturbances personality, depression and anxiety cause biochemical or psychological disturbances. Focus of nursing is to reduce the symptoms of disease and promote reality orientation. Impaired thinking in older adults’ problem solving, judgment and comprehension related to coping personality are common psychotic disorders.

Disturbed Thought Process Future Consideration In future, if I get a chance to work with clients suffering of disturbed thought process, I will spend more time with them and help them to overcome their problems. This will develop a trustworthy relationship and motivate them to cope with their present status of mental disorder and become one of the useful independent lives. Learning I learned from this clinical about many things. I start the client that come psychiatric ward with the complaint of disturbed thought process. The clients that are depressed, confused, dementia, psychological disturbed. I give comfortable bed and reduce anxiety. Give good environment because client already disturbed.

Family Therapy200 References  Schultz, J.M. and Videbeek, S.L. (2004). Lippincott’s Manual of Psychiatric Nursing Care Plans.7th Edition. Philadelphia: Lippincott.  Shives, L.R. and Isaacs, A. (2002). Basic Concepts of Psychiatric-Mental Health Nursing. 5th Edition. Philadelphia: Lippincott.

Liaquat University of Medical and Health Sciences, Jamshoro Sindh College of Nursing, JPMC, Karachi BScN Year-II Session 2006-2008 Family Therapy Advance Concept of Nursing-III Nahid Jamal Mrs. Mustaqima Begum

Family Therapy201 Introduction Family therapy is based on family system theory, which understands living organisms. Problems are treated by changing the way the system works. Family system theory is based on major concepts such as:   Identifying client. Homeostasis (balance) means family system seeks to maintain it customary organization and functioning.  Extended family field – nuclear family – grand parents and other members at the extended family intergenerational transmission of attitudes, problems, behaviors and other issues.  Differentiation – maintain ability of each family member. Family therapy is a type of psychotherapy. It helps families or individuals within a family to understand and improve the way family members interact with each other and resolve conflicts. Issues in which Family Therapy is Important     To assist in resolving pathological conflicts and anxiety. Family environment (marital problems). Family critical upsets e.g., divorce. Influence the orientation of the family identify and values towards health, eating disorders such as anorexia or bulimia.      Modify behavior (work stress). Family therapies are based on behavioral or psychodynamic principles. Emotional abuse or violence. Financial problems. Chronic health problems such as asthma or cancer.

Family Therapy202    Substance abuse. Parenting skills. Depression or bipolar disorder.

The Work of Family Therapy    In family therapy, families together in therapy session. Family members may also see a Family Therapist individually. Family therapy may include nonfamily members such as school teacher, other health care providers or representatives of social services agencies.  Family Therapist, you and your family will examine your family ability to solve problems and express thoughts and emotions. Explore family roles, rules and behavior patterns according to believe, solves problems.     Family therapy helps you identify your family’s strength. To provide confidence. To set individual and family goals and work on ways to achieve them. Family therapy is based on family system theory, which understands living organism.

Choose of Good Family Therapist      Family therapists are licensed mental health professionals. Master’s or Doctoral degree. Graduate training in marriage and family therapy. Training under supervision of other experts. American Association and Marriage and Family Therapy, which sets eligibility criteria. Conclusion

Family Therapy203 Family therapy refers to the use of meaningful family to assist people who have difficulty in achieving health members. Family therapy is a form of psychotherapy that involves all the members of a nuclear or extended family. Family therapy understands, improves and resolves conflicts.

Suicide References     Corit, P.C. (1999). Family Therapy. Kissane, D.W. (2006). Family Therapy. Mackenzie, M. (2005). American Family Therapy Association Inc.

204

Polatajko, H.J. (2007). Enabling Therapy and Justice through therapy. Ottawa: CAOT Publications ACE.

LIAQUAT UNIVERSITY OF MEDICAL AND HEALTH SCIENCE JAMSHORO SINDH

Suicide ACN III Parveen Akhter
BScN Year-II Student College of Nursing, JPMC

Madam Yasmin

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205

23rd July, 2005

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OBJECTIVES
At the end of this presentation, the participants will be able to: 1. 2. 3. 4. Define suicide. Explain epidmiology and risk factors. Enumerate causes. Describe suicide as a symptom of psychiatric illness. 5. Explain predisposing factors – theories of suicide. 6. 7. Describe diagnosis of suicide. Illustrate application of the nursing process with suicidal client. 8. Describe protocol. suicide precautions – sample

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SUICIDE
Introduction Suicide is not a disorder, but it is a behavior. According to Ghosh and Victor (1994), the life is a gift of God and that taking it is strictly forbidden. Historical Perspectives More than 90 percent of suicides are by individuals who are psychiatrically ill at the time of suicide (Conwell and Henderson 1996). In the Middle Ages, suicide was viewed as a selfish or criminal act. Most philosphers of the 17th and 18th centuries condemned suicide, but some writers recognized a connection between suicide and melancholy or other severe mental disturbances (Minois 1999). Most religions consider suicide as a sin against God. Judaism, Christianity, Islam, Hinduism, and Buddhism all condemn suicide. In 1995, Pope John II restated Church opposition to suicide, euthanasia, and abortion as crimes against life, not unlike homicide and genocide (Medscape Psychiatry 2001). Definition Suicide is defined as the intentional taking of one’s own life or Informal, the ruin or destruction of one’s own interest. It may also be defined as a person who commits or attempts self destruction. Indirect self destructive behavior refers to activities that are potentially detrimental to a person’s physical, psychological, social and spiritual well being (these behaviors may result in death but without the persons conscious intent or awareness. Examples of these behaviors include anorexia, bulimia with purging, use of alcohol or other drugs of abuse and engaging in unprotected sex with multiple partners.

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In direct self-destructive behavior, the person has an awareness of the desired outcome. Examples of selfdestructive behaviors include wrist lashing, self-mutilation, buying, a gun and monitors for the purpose of ending life and taking an overdose of prescribed medications. Para-suicidal behaviors are those actions that are intentionally self-injuries, such as cutting the wrists or taking a non lethal overdose of drugs (Kreitman 1977; Linehan 1993). The suicidal ideation refers to a person’s thoughts about suicide. The suicide attempt or suicide gesture is the use of direct selfdestructive behavior for the express purpose of killing oneself. The term “completed suicide” refers to willful self-inflicted, life threatening acts that result in death. The term “level of lethality of suicide threat” refers to the seriousness of a suicide threat – the degree to which it is likely to result in death.

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Epidemiological Factors Approximately 30,000 persons in the United States end their lives each year by suicide. These statistics have established suicide as the eight leading cause of death among adults and the third leading cause of death-behind accidents and homicide-among young Americans (ages 15 to 24 years) (Crisis Hotline 2001). Suicide has become a major health-care problem in the United States today. Risk Factors Marital Status – the suicide rate for single persons is twice that of married person. Divorced, separated, or widowed persons have rates four to five times greater than those of married persons (Nicholas and Golden 2001). Gender – women attempt suicide more, but men succeed more often. Successful suicides number about 70% for men and 30% for women. This has to do with the lethality of the means. Women tend to overdose; men use more lethal means such as firearms. This difference between men and women may also reflect a tendency for women to seek and accept help from friends or professionals, whereas men often view help-seeking as a sign of weakness (Murphy 1998). Age – suicide risk and age are positively correlated. The rates rise sharply during adolescence, peak between 30 and 40, and level off until age 65, when it rises again for the remaining years (Murphy 1998). The suicide rate among adolescents has tripled during the past 30 years (Nicholas and Golden 2001). Several factors put the adolescent at risk for suicide, including impulsive and high risk behaviors, untreated mood disorders e.g., major depression and bipolar disorder), access to lethal means (e.g., firearms), and substance abuse.

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The suicide rate for the elderly has risen 9 percent between 1980 and 1992. Although the elderly make up only 13 percent of the population, they account for 25 percent of all suicides. Eighty one percent of elderly suicides are male which is 13 times greater than for females (Hospice Association 2002). Religion - Protestants have significantly higher rates of suicide than Catholics and Jews (Kaplan and Sadock 1998). A strong feeling of cohesiveness and integration within a religious organization seems to be a more important factor than single religious affiliation. Socioeconomic Status – individuals in the very highest and lowest social classes have higher suicide rates than those in the middle classes (Kaplan and Sadock 1998). With regard to occupation, suicide rates are higher among physicians, musicians, dentists, law enforcement officers, lawyers and insurance agents. Ethnicity – With regard to ethnicity, most studies demonstrate that white are at highest risk for suicide, followed by Native Americans, African, Americans, Hispanic Americans and Asian Americans (Ghosh and Victor 1994). Spiritual Factors – According to the Vanzant (1992) spirit is the life essence, which is covered and protected by the skeletal frame we call the body. Spirit has only one purpose and mission, which was determined by God at the time of creation. Everything that has life can create life, nurtures life or serves a purpose in life is spirit. Frankl (1964) observed that when people find life meaningless and without purpose and God seems distant and uncaring, there is no reason to like. He also viewed hope has an expression of a healthy spirit and a prerequisite to survival and believed that hopelessness, an expression of a depleted spirit, could be fatal.

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Other Risk Factors – individuals with mood disorders (major depression and bipolar disorder) are far more likely to commit suicide than those in any other psychiatric or medical risk group. Suicide risk may increase early during treatment with antidepressants, as the return of energy brings about an increased ability to act out self-destructive wishes. Other psychiatric disorders that may account for suicidal behavior include psychoactive substance abuse disorders, and panic disorders (Murphy 1994). Several, insomnia are associated with increased suicide risk, even in the absence of depression. Use of alcohol, and particularly a combination of alcohol and barbiturates, increases the risk of suicide. Psychosis, especially with command hallucinations, poses a higher than normal risk. Affliction with a chronic painful or disabling illness also increases the risk of suicide. Higher risk is also associated with a family history of suicide, especially in a same-sex parent, and with previous attempts. Between 50 percent and 80 percent of those who ultimately commit suicide have a history of a previous attempt (Crisis Hotline 2001). Loss of a loved one through death or separation and lack of employment or increased financial burden increase risk.

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Causes There are so many causes but some of them are mention below: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Prior family history or tendencies. Early trauma. Rigid, disorganized or dysfunctional family system. Disturbed parent child relationship. Unresolved loss. History of abuse. Lost of both parents early in life. Loss of job, money and social position. Somatic symptoms (insomnia, headaches, stomach aches). Suffering from a major physical illness such as stroke, cancer or diabetes. History of diagnosed depression.

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Suicide as a Symptom of Psychiatric Illness Suicide is one of the outcomes of untreated depression from 15% to 20% of all patients diagnosed with major depression complete suicide. Additionally, patients with psychotic depression have a high risk for completing suicide. This is due to the combination of symptoms including: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. Depression. Delusions. Guilt. Paranoid thoughts. Social withdrawal. Hopelessness and feelings of worthlessness. Somatic symptoms (insomnia, headaches, stomach aches). Irritability. Feeling of exhausted. Headaches. Muscle aches. Trouble sleeping. Change in appetite. Constipation. Weight loss. Everyone would be better off, if I died. I wish I were dead.

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Presenting Symptoms/Medical-Psychiatric Diagnosis Psychiatric disorders in which suicide may be a risk include anxiety disorders, schizophrenia, and borderline and antisocial personality disorders (Medscape Psychiatry 2001). Other chronic and terminal physical illnesses have also precipitated suicidal acts Predisposing Factors – Theories of Suicide Anger Turned Inward – suicide was a response to the intense self-hatred that an individual possessed and occurred as a result of an earlier repressed desired to kill someone else (Freud 1957). He also interpreted suicide to be an aggressive act towards the self that often was really directed towards others. Hopelessness – Ghosh and Victor (1994) hopelessness as a central underlying factor predisposition to suicide. identify in the

Desperation and Guilt – desperation is another important factor in suicide. With desperation, an individual feels helpless to change, but he or she also feels that life is impossible without such change. Guilt and self-recrimination are other aspects of desperation (Hendin 1991). History of Aggression and Violence – some studies have indicated that violent behavior often goes hand-in-hand with suicidal behavior (Ghosh and Victor 1994). Shame and Humiliation – some individuals have views suicide as a “face-saving” mechanisms – a way to prevent public humiliation following a social defeat such as a sudden loss of status or income. Often these individuals are too embarrassed to seek treatment or other support systems.

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Developmental Stressors – have associated developmental level with certain life stressors and their correlation to suicide. The stressors of conflict, separation and rejection are associated with suicidal behavior in adolescence and early adulthood. The principal stressor associated with suicidal behavior in the 40- to 60-year-old group is economic problems. Medical illness plays an increasingly significant role after age 60 and becomes the leading predisposing factor to suicidal behavior in individuals over age 80. Sociological Theory – Durkheim (1951) proposed relationship between suicide and social conditions and described three social categories of suicide. Egotistical suicide is the response of the individual who feels separate and apart from the mainstream of society. Altruistic suicide is the opposite of egoistic suicide. The individual who is prone to altruistic suicide is excessively integrated into the group. Anomic suicide occurs in response to changes in an individual’s life (e.g., divorce, and loss of job) that disrupts feelings of relatedness to the group. Biological Theories Genetics – twin studies has shown a much higher concordance rate between monozygotic twins than between dizygotic twins. These results suggest a possible existence of genetic predisposition toward suicidal behavior (Ghosh and Victor 1994). Neurochemical Factors – a number of studies have been conducted to determine if there is a correlation between neurochemical functioning in the central nervous system and suicidal behavior. Some studies have revealed a deficiency of serotonin in depressed clients who attempted suicide (Kaplan and Sadock 1998).

216

Suicide

Suicide Risk Factors and Protective Factors Risk Factors
• Previous suicide attempt. • Mental disorders, particularly mood disorders

Protective Factors
• Effective and appropriate clinical care for mental,

physical and substance abuse disorders.
• Easy access to a variety of clinical interventions

such as depression and bipolar disorder.
• Co-occurring mental and alcohol and substance

and support for help seeking.
• Restricted access to highly lethal methods of

abuse disorders.
• Family history of suicide. • Hopelessness. • Impulsive and/or aggressive tendencies. • Barriers to accessing mental health treatment. • Relational, social, work, or financial loss. • Physical illness.

suicide.
• Family and community support. • Support from on-going medical and mental

health care relationships.
• Learned

skills in problem solving, conflict resolution and nonviolent handling of disputes. suicide and support self-preservation instincts.
Contd.

• Cultural and religious beliefs that discourage

217

Suicide

Risk Factors
• Easy access to lethal methods, especially guns. • Unwillingness to seek help because of stigma

Protective Factors

attached to mental and substance disorders and/or suicidal thoughts.

abuse

• Influence of significant people – family members,

celebrities, peers who have died by suicide – both through direct personal contact or inappropriate media representations.
• Cultural and religious beliefs – for instance, the

belief that suicide is a noble resolution of a personal dilemma.
• Local

epidemics of contagious influence. people.

suicide

that

have

a

• Isolation, or a feeling of being cut off from other

218

Suicide

Assessing the Degree of Suicidal Risk Behavior Low Anxiety Depression Isolation; withdrawal Mild Mild Intensity of Risk Moderate Moderate Moderate High High or panic Severe

Some feelings of isolation; Some feelings of helpless- Hopeless, helpless, no withdrawal ness, hopelessness and withdrawal and selfwithdrawal deprecating. Fairly good activities Several in most Moderately goo in some Not good in any activities activity. Some Some that are constructive Few or only one available Few or none Predominantly destructive Only one or none available
Contd.

Daily functioning Resources

Coping strategies being Generally constructive used Significant others Several who are available

219

Suicide

Behavior Low Psychiatric help in past Lifestyle Alcohol or drug use

Intensity of Risk Moderate High of

None, or positive attitude Yes, and moderately Negative view toward satisfied with results help received Stable Infrequently to excess Moderately stable Frequently to excess Unstable Continual abuse

Previous suicide attempts None, or of low lethality Disorientation; disorganization Hostility Suicidal plan None Little or more

One or more of moderate Multiple attempts of lethality high lethality Some Some Marked Marked

Vague, fleeting thoughts Frequent thoughts, Frequent or but no plan occasional ideas about a constant thought plan with a specific plan

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Diagnosis 1. 2. 3. 4. 5. Self-destructive behavior related to wish to punish other for their perceived lack of support and love. Suicidal thoughts related to feelings of hopelessness and despair. Altered role of performance related to unemployment. Ineffective individual coping related to disease process. Altered nutrition less than body requirements related to conflict over sexual maturation, evidenced by loss of 30% pre-illness weight. Self-esteem disturbed related to perceived feelings of loss of control. what he calls the “Ten

6.

Purposes of Suicide Shneidman (1996) identified Commonalties of Suicide”. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. The common consciousness. goal of

The common purpose of suicide is to seek a solution. suicide of in is cessation is is of

The common stimulus psychological pain. The common stressor psychological needs.

suicide suicide

unbearable frustrated

The common emotion in suicide hopelessness and helplessness. The common cognitive state in suicide is ambivalence. The common perceptual state in suicide is constriction. The common action in suicide is escape. The common interpersonal communication of intention. act in suicide is

The common pattern in suicide is consistency of lifelong styles.

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Application of the Nursing Process with the Suicidal Client Assessment The following should be considered when conducting suicidal assessment demographics, presenting symptoms/ medicalpsychiatric diagnosis, suicidal ideas or acts, interpersonal support system, analysis of the suicidal crises, psychiatric/ medical/family history, and coping strategies. Demographics – the following demographics are assessed. Age – suicide is highest in persons older than 50 years. Adolescents are also at high risk. Gender – males are at higher risk than females. Ethnicity – Caucasians are at higher risk than are Native Americans, who are at higher risk than African Americans. Martial Status – single, divorced, and widowed are at higher risk than married. Socioeconomic Status – individuals in the highest and lowest socioeconomic classes are at higher risk than those in the middle classes. Occupation – professional health-care business executives are at highest risk. personnel and

Method – use of firearms presents a significantly higher risk than overdose of substances. Religion – Protestants are at greater risk than Catholics or Jews. Family History – higher risk if individual has family history of suicide.

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Interpersonal Support System Does the individual have support persons on whom he or she can rely during a crisis situation? Lack of a meaningful network of satisfactory relationships may implicate an individual at high risk for suicide during and emotional crises. Analysis of the Suicidal Crisis The Precipitating Stressor – life stresses accompanied by an increase in emotional disturbance include the loss of a loved person either by death or by divorce, problems in major relationships, changes in roles, or serious physical illness. Relevant History – has the individual experienced numerous failures or rejections that would increase his or her vulnerability for a dysfunctional response to the current situation? Life-Stage Issues – the ability to tolerate losses and disappointments is often compromised if those losses and disappointments occur during various stages of life in which the individual struggles with developmental issues (e.g., adolescence, midlife). Psychiatric / Medical / Family History The individual should be assessed with regard to previous psychiatric treatment. Medical history should be obtained to determine presence of chronic, debilitating, or terminal illness. Family history should also be obtained to find out any depressive disorder in the family, and has a close relative committed suicide in the past? Coping Strategies How has the individual handled previous crisis situations? How does this situation differ from previous ones?

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Basic Suicide Precautions - Sample Protocol 1. Promote coping skills such as decision making, practical living skills and activities that prepare for return to the community. To guide and supervise client activities. Support formal and informal group activities to promote sharing, cooperation, compromise and leadership. Provide for basic needs of the client, including safety, privacy, activities of daily living and shelter. Stay with the client while all medications are taken. The plan may be started without a physician’s order, but a psychiatric consultation must be arranged as soon as possible. Provide one-to-one nursing supervision. The nurse must be in the room with the client at all times. When the client uses the bathroom, the bathroom door must remain open. Stay within arm’s reach of the client at all times. Staff should sit next to the client’s bed at night. Use no restraints on general hospital floors. Do not allow the client to leave the unit for tests or procedures. Allow visitors and telephone calls unless the client wishes otherwise. The nurse maintains one-to-one supervision during visits.

1. 2. 3. 4. 5.

6.

7. 8. 9.

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10.

Look through the client’s belongings in the client’s presence and remove any potentially harmful objects, e.g., pills, matches, belts, razors, tweezers, and mirrors or other glass objects. If suicide precautions are initiated after the client has been on the unit for any length of time, make a complete search of the room. Check that visitors do not leave potentially harmful objects in the client’s room. Serve the client’s meals in an isolation meal tray that contains no glass or metal silverware. Prior to instituting these measures, explain to the client what you will be doing and why physician must also explain this to the client. Document this explanation in the chart. Do not discontinue these measures without an order form a psychiatrist.

11.

12. 13. 14.

15.

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Scenario
Mr. Kamran, a 30 years old man, was alright two years back, then he had a road traffic accident while going to a picnic by coach and developed multiple injuries on the body especially his genital area. He was hospitalized for about one month, after which he was discharged from hospital, but after one week of discharge he again visited doctor in Outpatient Department, complaining of sexual weakness along with lack of interest in life and daily quarrels with feelings of hopelessness for future. He always feel alone and absence of support. He has unsuccessfully tried several times to end his life.

226 NURSING CARE PLAN Patient Name: Age Sex Medical Diagnosis Nursing Diagnosis Mr. Kamran 30 years Male Suicide Hopelessness
Nursing Diagnosis Hopelessness related to absence of support system and perception of worthlessness evidenced by verbal cues. Goal Short Term Goal • The client will verbalize a measure of hope and acceptance of life and situations over which he has no control. Intervention

Suicide

Assessment Subjective Data According to the client’s parents, he is a unmarried man. He is alright before one week and perform his duty well. Sudden he changes his behavior and become aggressive. At home everyone feel his behavior and worried about his condition. He is not taking proper food and drinks. He does not take part in any activities. His condition becomes more and more serious and he id developing abnormal behavior. Objective Data Mr. Kamran, 30 years old man came in Psychiatric OPD with complain of abnormal behavior. He looks irritate, drozy, pale and weak. His walking is imbalance and he speaks loudly. Vital Signs • Blood Pressure • Temperature • Pulse • Respiratory rate 100/70 mmHg 98 °F 70 bpm 20 per min

Evaluation Evaluation of suicidal is an ongoing process accomplished through continuous reassessment of the client as well as determination of goal achievement. Once the immediate crises have been resolved, extended psychotherapy may be indicated. Objective The client develops and maintains a more positive selfconcept and learns more effective ways to express feeling to others and look free of tension. Subjective The clients recognized that he achieved successful interpersonal relationships and feel accepted by others and achieve sense of belonging.

• •

The client will make positive statements about his life.

• • • •

Long Term Goal • The client will find a job.

The client will participate in group activities.

Identify stressors in client’s life that precipitated current crises. Determine coping behaviors previously used and client’s perception of effectiveness then and now. Encourage the client to explore and verbalize feeling and perceptions. Provide expressions of hope to client in positive low-key manner. Help client identify areas of life situation that are under own control. Identify sources that client may use after discharge when crises occur or feelings of hopelessness and possible suicidal ideation prevail.

References 1.
2.

Harber, Hoskins and Leach (1978). Psychiatric Nursing. 3rd Edition. USA; p 920.

Comprehensive

Carson Verna Benner (2000). Mental Health Nursing. 2nd Edition. USA; pp 886-900. Wilson S Holly and Kneisl Carol Ren (1979). Psychiatric Nursing. Wesley California; pp 554-644. Mosby S. Medical Nursing and Allied Health Dictionary. 4th Edition; p 552. Shives Louise Rebraca and Isaacs Ann (2002). Suicide In: Basic Concepts of Psychiatric-Mental Health Nursing. 5th Edition. Lippincott William and Wilkins Philadelphia; pp 512527. The Suicidal Client In: Therapeutic Approaches in Psychiatric Nursing Care. Pp 256-265. Taylor Monat Cecelia (1994). Essential of Psychiatric Nursing. 14 Edition. USA; pp 242-247. Townsend Marry C (1941). Psychiatric Mental Nursing. pp 450-459. Jacobs (2000). A 52 Year Old Suicidal Man. JAMA 283(20):2693. Assessed by http://www.google.com on July 15, 2005. http://www.yahoo.com.esk. com.askjeeves. Assessed on July 15, 2005. http://www.msn.search.com.lycos.search.lycos.com. Assessed on July 15, 2005. http://www.hotpot.search.hotpot.com. Assessed on July 15, 2005.

3.
2.

3.

4. 5. 6.
7.

8. 9. 10.

Liaquat University of Medical and Health Sciences Jamshoro Sindh
College of Nursing, JPMC Community Grief and Disaster Response ACN III Riffat Yasmin BScN Year II Mrs. Ruth K. Alam

Terrorism, large-scale violence, and disaster are severely disturbing problems that engender feelings of profound grief, anxiety, vulnerability and loss of control throughout the communities that they affect, whether local or worldwide incidence like the terrorist attack on the World Trade Center, awareness of these issues have increase profoundly. Biological and chemical weapon attack, and natural disaster or major accident also trigger this type of response, which has been called incidence, stress or disaster response, thought deliberate human attack general result in more severe stress. Definition Community grief refer to grief shared by member of community in response to a significance loss or change such as natural disaster, accident, or crime in which many people are killed or injured. Risk Factor       Health for example, injury, disability, or illnesses. Job or status. Loved one death or separation. Termination of a relationship. Traumatic loses inability to share grief with others. Lack of interpersonal support.

Assessment  Physical dimension
• • • • •

Denial of loss Difficulty in accepting significant loss Denial of feeling Difficulty in expressing feeling Fair of intensity of feeling

• • •

Rumination Feeling of despair, hopelessness, disillusionment. Feeling of helplessness and powerlessness.

Social dimension
• • • • • • •

Loss of interest in activity of daily living. Anhedonia (inability to experience pleasures). Ambivalent feeling towards the lost person or object. Gilt feeling Crying Anxiety Agitation

Emotional and Intellectual dimension
• • • • • • •

Fatigue Sleep disturbance. Self destructive behavior. Accident proneness. Anger, hostility, or aggressive behavior. Depressive behavior Withdrawn behavior

Spiritual dimension
• •

Beliefs toward highest power action that effected on him or herself. Faith on any folk remedies or any other alternatives.

Nursing Diagnosis  Dysfunctional grieving.

   

Risk for other directed violence. Risk for suicide. Ineffective health maintenance. Disturb sleep pattern.

Short-term Goals The client will be:
• • • •

Be free of self inflicted harm. Identify the loss. Verbalize or demonstrate decrease suicidal aggressive behavior. Express feeling verbally and nonverbally.

Long-term Goals The client will be:
• • •

Demonstrate reestablished relationship or social support in the community. Participate in continue therapy, if indicated. Progress through the grieving process.

Nursing Interventions and Rationales Interventions Rationales

Initially, assigned the same staff member to The client may be overwhelmed by the client then gradually vary the staff and fear facing the loss. The client people. ability to respond to other may be impaired. Limit the number of new contact provides consistency and facilitate familiarity. After establishing rapport with the client bring up the loss in a supportive manner, if the client refuse to discuss it, withdraw and state your intention to return. Your presence and telling the client you will return the demonstrate caring and support. The client may need emotional support to face and express painful feeling.

Encourage the client to recall experience Discussing the lost object or person and talk about the relationship with the lost help the client identifies and expresses

person. Discuss change in the client feeling what the lost means to him or her and towards self, others and the lost person. his or her feeling.

Interventions Encourage appropriate expression of all types of feeling toward the lost person or object. Ensure the client that negative feeling like anger and resentment are normal and healthy in grieving.

Rationales Feelings are not inherently bad or good. Giving the client support for expressing feelings may help the client except uncomfortable feeling.

Convey to the client although feeling may The client may fear the intensity of be uncomfortable, they are natural and his or her feeling. necessary and they will not harm him or her. Provide opportunities for the client to Physical activity provides a way to release tension, anger, show physical relieve tension in a health, nonactivity, and promote this as a healthy mean destructive manner. of dealing with stress. Encourage the client to talk with other about The client needs to develop the loss, his or her feeling, and change independence skill of communicating resulting from the loss. feeling and expressing grief to others. Facilitate sharing, ventilating, feeling, and support among client. Use longer groups for our general discussion of loss and grief. For ever help the client understand that they are limits to sharing grief in our social contexts. Sharing grief with other can help the client identify and express feeling and feel normal. Dwelling on grief in social interaction can result in other person discomfort with their own feeling and avoid the client.

Teach the client and significant other about The client and significant other may the grief process. have little or no knowledge of grief or the process involved in recovery. In each interaction with the client try to The client need to integrate the loss include some discussion of goal, the future, into his or her life. and discharge plan. Evaluation   The client has express feeling verbally and nonverbally be free of self inflected harm. The client has verbalized the knowledge of grief process and verbalize acceptance of laws.

References  Carson, V.B. (2000). Mental Health Nursing. The Nursing Patient Journey. 2nd Edition.  Harber, Hoskins and Leach (1978). Comprehensive Psychiatric Nursing. 3rd Edition. USA.    Schultz, J.M. and Videbeek, S.L. Psychiatric Nursing. 7th Edition. Marry, T.C. (1941). Psychiatric Mental Nursing. http://www.google.com. Scott, J. (2001). Cognitive Therapy for Depression. B Med Bulletin; 57:101-113.

Liaquat University of Medical and Health Sciences Jamshoro Sindh
College of Nursing, JPMC Community Grief and Disaster Response ACN III Riffat Yasmin

BScN Year II Mrs. Ruth K. Alam

Terrorism, large-scale violence, and disaster are severely disturbing problems that engender feelings of profound grief, anxiety, vulnerability and loss of control throughout the communities that they affect, whether local or worldwide incidence like the terrorist attack on the World Trade Center, awareness of these issues have increase profoundly. Biological and chemical weapon attack, and natural disaster or major accident also trigger this type of response, which has been called incidence, stress or disaster response, thought deliberate human attack general result in more severe stress. Definition Community grief refer to grief shared by member of community in response to a significance loss or change such as natural disaster, accident, or crime in which many people are killed or injured. Risk Factor       Health for example, injury, disability, or illnesses. Job or status. Loved one death or separation. Termination of a relationship. Traumatic loses inability to share grief with others. Lack of interpersonal support.

Assessment  Physical dimension
• • • • •

Denial of loss Difficulty in accepting significant loss Denial of feeling Difficulty in expressing feeling Fair of intensity of feeling

• • •

Rumination Feeling of despair, hopelessness, disillusionment. Feeling of helplessness and powerlessness.

Social dimension
• • • • • • •

Loss of interest in activity of daily living. Anhedonia (inability to experience pleasures). Ambivalent feeling towards the lost person or object. Gilt feeling Crying Anxiety Agitation

Emotional and Intellectual dimension
• • • • • • •

Fatigue Sleep disturbance. Self destructive behavior. Accident proneness. Anger, hostility, or aggressive behavior. Depressive behavior Withdrawn behavior

Spiritual dimension
• •

Beliefs toward highest power action that effected on him or herself. Faith on any folk remedies or any other alternatives.

Nursing Diagnosis  Dysfunctional grieving.

   

Risk for other directed violence. Risk for suicide. Ineffective health maintenance. Disturb sleep pattern.

Short-term Goals The client will be:
• • • •

Be free of self inflicted harm. Identify the loss. Verbalize or demonstrate decrease suicidal aggressive behavior. Express feeling verbally and nonverbally.

Long-term Goals The client will be:
• • •

Demonstrate reestablished relationship or social support in the community. Participate in continue therapy, if indicated. Progress through the grieving process.

Nursing Interventions and Rationales Interventions Rationales

Initially, assigned the same staff member to The client may be overwhelmed by the client then gradually vary the staff and fear facing the loss. The client people. ability to respond to other may be impaired. Limit the number of new contact provides consistency and facilitate familiarity. After establishing rapport with the client bring up the loss in a supportive manner, if the client refuse to discuss it, withdraw and state your intention to return. Your presence and telling the client you will return the demonstrate caring and support. The client may need emotional support to face and express painful feeling.

Encourage the client to recall experience Discussing the lost object or person and talk about the relationship with the lost help the client identifies and expresses

person. Discuss change in the client feeling what the lost means to him or her and towards self, others and the lost person. his or her feeling.

Interventions Encourage appropriate expression of all types of feeling toward the lost person or object. Ensure the client that negative feeling like anger and resentment are normal and healthy in grieving.

Rationales Feelings are not inherently bad or good. Giving the client support for expressing feelings may help the client except uncomfortable feeling.

Convey to the client although feeling may The client may fear the intensity of be uncomfortable, they are natural and his or her feeling. necessary and they will not harm him or her. Provide opportunities for the client to Physical activity provides a way to release tension, anger, show physical relieve tension in a health, nonactivity, and promote this as a healthy mean destructive manner. of dealing with stress. Encourage the client to talk with other about The client needs to develop the loss, his or her feeling, and change independence skill of communicating resulting from the loss. feeling and expressing grief to others. Facilitate sharing, ventilating, feeling, and support among client. Use longer groups for our general discussion of loss and grief. For ever help the client understand that they are limits to sharing grief in our social contexts. Sharing grief with other can help the client identify and express feeling and feel normal. Dwelling on grief in social interaction can result in other person discomfort with their own feeling and avoid the client.

Teach the client and significant other about The client and significant other may the grief process. have little or no knowledge of grief or the process involved in recovery. In each interaction with the client try to The client need to integrate the loss include some discussion of goal, the future, into his or her life. and discharge plan. Evaluation   The client has express feeling verbally and nonverbally be free of self inflected harm. The client has verbalized the knowledge of grief process and verbalize acceptance of laws.

References  Carson, V.B. (2000). Mental Health Nursing. The Nursing Patient Journey. 2nd Edition.  Harber, Hoskins and Leach (1978). Comprehensive Psychiatric Nursing. 3rd Edition. USA.    Schultz, J.M. and Videbeek, S.L. Psychiatric Nursing. 7th Edition. Marry, T.C. (1941). Psychiatric Mental Nursing. http://www.google.com. Scott, J. (2001). Cognitive Therapy for Depression. B Med Bulletin; 57:101-113.

Liaquat University of Medical and Health Sciences Jamshoro Sindh
College of Nursing, JPMC Delusional Disorder ACN III Practical Scenario (Assignment # 1)

Riffat Yasmin BScN Year II Mrs. Munira A. Ali

The primary feature of a delusional disorder is the persistence of a delusion or false belief that is limited to a specific area of thought and not related to any organic or major psychiatric disorder. The different types of delusion disorders include: Erotomaniac - This is an erotic delusion that is love by another person usually famous person the may come into contact with the law as he or she write letter make telephone call. Grandiose - The client usually convinced that a spouse or partner is unfaithful has created a fantastic invention has a religious calling or believes. Jealous - The client believes that a spouse is not a true. The client may fallow the partner read mail and so forth. Persecutory - This type of delusion is the most common. The client believe that he or she is being spied on followed harassed drugged and may seek to remedy. Somatic - The client believe that he or she emit a foul odor from somebody orifice has infestation of bugs or parasites. Etiology No clear etiology has been identified but severe stress, hearing impairment and low socioeconomic status may be risk factors Epidemiology Delusion disorder are most prevalent in people 40to 55 years old, thought the age of onset ranges from adolescence to old age. Nursing Diagnosis     Disturb thought processes Ineffective role performance Impaired social interaction Risk for other directed violence

General Intervention Because the delusion may persist despite effort to extinguish it, the goal is not to eliminate the delusion but to contain its effect on client’s life. It is important to provide the client with a safe person with whom he or she can discuss the delusional belief and validate perception or plan of action to prevent the client from acting base on that delusional belief.    Give the client now that all feeling ideas, beliefs, are permissible to share with you. Give the client feedback that other does not share his or her perception and belief. Assist the client to identify difficulties in daily life that are caused by or related to delusional ideas.  Explore with the client ways he or she can redirect some of energy or anxiety generated by the delusional ideas.  Encourage the client to use his or her contact person as often as needed. It may be helpful to use telephone contact rather than always scheduling an appointment.

References  Carson, V.B. (2000). Mental Health Nursing. The Nursing Patient Journey. 2nd Edition.  Harber, Hoskins and Leach (1978). Comprehensive Psychiatric Nursing. 3rd Edition. USA.    Marry, T.C. (1941). Psychiatric Mental Nursing. Schultz, J.M. and Videbeek, S.L. Psychiatric Nursing. 7th Edition. http://www.google.com. Scott, J. (2001). Cognitive Therapy for Depression. B Med Bulletin; 57:101-113.

Liaquat University of Medical and Health Sciences Jamshoro Sindh
College of Nursing, JPMC Delusional Disorder ACN III Major NCP (Assignment # 2)

Riffat Yasmin BScN Year II Mrs. Munira A. Ali

NURSING CARE PLAN TITILE:
Date        

Anxiety Related to Disturb Thought Process
Assessment (Data Statement) Erratic, impulsive behavior. Poor judgment. Agitation Feeling of distress Illogical thinking, irrational ideas. Extreme intense feeling. Refusal to except actual information from other. Socially inappropriate or odd behavior in certain situation. Nursing Diagnosis Disturb thought process related to impaired social interaction. Goal/Planning Short-term Goals:   The client will be free from self-inflected harm.  The client will  verbalize feelings of fear, guilt and anxiety, and express feelings nonverbally in a safe manner. Long-term Goals:  The client will manage  his or her anxiety response independently.  The client will demonstrate decrease in obsessive thought to  a level at which the client can function independently.  The client will maintain adequate psychological  functioning follow through with continue therapy if needed. Nursing Intervention The client may need to be • secluded or restrained if he or she attempts self-mutilation or harm. Try to substitute a physically  safe behavior for harmful practices, even if the new behavior is compulsive or ritualistic. For example, if the client is cutting himself or herself, direct him or her toward tearing paper. If the client’s behaviors are  not harmful, try not to call attention to the compulsive acts initially. Encourage the client to  verbally identify his or her concerns, life stresses, fears, and so forth. Encourage the client to  express his or her feelings in way that are acceptable to the client. Rationale Evaluation

The client’s physical The client has safety, health and well- verbalized decrease feeling of fear, guilt being are priorities. and anxiety. Substitute behaviors client has may satisfy the client’s The expressed feeling need for compulsive behaviors but protect nonverbally in safe the client’s safety and manner. provide a transition toward decreasing these behaviors. Preventing feelings may help diminish the client’s anxiety and thus diminish obsessive thoughts and compulsive acts. Expressing feelings may help diminish the client’s anxiety and thus diminish obsessive thoughts & compulsive acts. The client may be uncomfortable with some ways of expressing emotions or find them unacceptable initially.

Date 

Assessment (Data Statement) Difficulty or slowness completing daily living activities because of ritualistic behavior.

Nursing Diagnosis

Goal/Planning 

Nursing Intervention If the client is ruminating • (e.g., on his or her worthlessness), acknowledge the clients feelings, but then try to redirect the interaction. Discuss the client’s perceptions of his or her feelings and possible ways to deal with these feelings. If the client continues to ruminate, withdraw your attention and state when you will return or will be available for interaction again. Do not argue with the • client about the logic of delusional fears. Acknowledge the client’s feelings, interject reality briefly, and move on to discuss a concrete subject.

Date

Assessment (Data Statement)

Nursing Diagnosis

Goal/Planning •

Nursing Intervention

Observe the client’s eating, drinking, and elimination patterns, and assist the client as necessary. Assess and monitor the client’s sleep patterns, and prepare him or her for bedtime by decreasing stimuli, giving a backrub, and other comfort measures or medications. You may need to allow extra time, or the client may need to be verbally directed to accomplish activities of daily living (personal hygiene, preparation for sleep, and so forth). Provide opportunities for the client to participate in activities that are easily accomplished or enjoyed by the client; support the client for participation. Teach the client and family or significant others about the client’s illness, treatment or medications, if any.

Liaquat University of Medical and Health Sciences, Jamshoro Sindh College of Nursing, JPMC BScN Year-II, Session 2006-2008 Nursing Care Plan & Reflection Log Advance Concept of Nursing-III Sharifa Bibi Mrs. Mustaqima Begum January 24, 2008

Nursing Care Plan Introduction A 34 years old client named Razia residing in a rented house at Karachi. According to the client, she worked in a private firm as a receptionist. She has two children one daughter and one son. She is spending her time with her family happily and satisfactorily. But after the death of her husband in road traffic accident two months back. She went into minor shock and after recovery she was suffering from depression and therefore she was admitted in the hospital for treatment.

Patient’s Name: Age: Medical Diagnosis: Nursing Diagnosis:
Date

NURSING CARE PLAN Razia W/o Akram Ward No: 20 Bed No. 8 Date of Admission: 02-09-2007. 34 Years Depression Ineffective individual coping related to depression in response to identifiable stressor (Death of Husband).
Nursing Diagnosis Planning Interventions Rationales Evaluation

Assessment

Ineffective individual coping related to depression in response to identifiable stressor (Death of Husband).

Subjective Data The client verbalize that she is suffering from tension due to the death of her husband and I cannot live without him, my life is nothing. Objective Data A 34 years old client sitting on bed, low mood, low self esteem, anxiety, lacks interpersonal skills, loneliness, headache, restlessness, insomnia, loss of appetite, poor judgment, and suicidal ideas. Vital Signs Blood Pressure 110/70 mmHg Temperature 99 °F Pulse 90 bpm Respiratory Rate 22 per min

Short term goal • The client will verbalize the feeling related to her • emotional state. Long term goal The client will: • Make decision and follow up. • Through with appropriate actions to change provocative situations in personal environment. • • • • • •

Assess the causative and • contributive factors towards loss related grief. Establish report by spend • time with client. Offer support and encourage expression of her feelings. Listen carefully as client spoke. Encourage the client to develop interest in the activities. Mobilize into a gradual increase in activity in daily routine for a set time span. Facilitate emotional support from others. Promote hopefulness and setting of realistic goals with client and family. • • • • • •

To identify the stressors of the Short term goal The client verbalized situation. the feeling related to To provide supportive her emotional state. companionship to build good Long term goal rapport. Let the client know that, we are The client made decision and follow understanding her feeling. through with appropriate actions to To collect facts and observe change provocative facial expression. situations in personal To motivate the client towards environment. routine life. To reduce the chances of social and drawl. To develop the self esteem and self concept. To maintain the reality contract, and reduce the potential complication of depression.

Psychotic Disorder Reflection

Introduction During my clinical day, as I entered in Psychiatric Ward, I saw all the clients admitted in the ward and also observed a silent environment. It was round time. One of the nurses was busy with medication. She wants to complete administrating medication before round. During that time, suddenly one of the client hold the medicine tray and start shouting over the nurse “that you are my enemy, you stolen my things, I will se you.” The attendant of that client hold him and ward staff also rush over there to handle the situation. On doctor’s advice the Charge Nurse administered injection to the client. Within a few minutes, the client becomes relaxed and slept. I was surprised and anxious to saw this situation. The Charge Nurse told me that this client has history of psychotic attacks and he become normal after the attack. After getting necessary psychotic medications, he becomes normal and relaxed. After spending some time in the ward and observing clients suffering from various psychotic diseases, I went to that client and still found him sleeping. I interviewed his attendant. According to him, he was fine one year back, but after having fall from ladder, he complained headache. All necessary diagnosis was carried out including MRI, but reports were found clear. Now from the last few months we observed aggressive behavior, trying to threat others, self harming attitude, suicidal ideas, uncomfortable and sleeplessness. We brought him to the hospital for treatment. While taking interview, the client awake up. He is looking fresh and calm. I addressed him by asking small question for which he replied satisfactorily but with impaired speaking power. I spend some time with him and talked about his activities. This helps in developing of trustworthy environment and relationship.

Psychotic Disorder

After spending time with the client, I learned that, if we spend some time with psychotic clients and heard them what they feel, we can help, motivate and encourage them to become one of the good and useful citizens of the country. In future, if an opportunity comes in my life, I would like to devote my services for such clients and especially for those who were suffering from both physical and mental disorders. I also try to help and encourage my colleagues to make efforts to spend some time for rehabilitations of such clients.

References  Schultz, J.M. and Videbeek, S.L. (2004). Lippincott’s Manual of Psychiatric Nursing Care Plans.7th Edition. Philadelphia: Lippincott.  Shives, L.R. and Isaacs, A. (2002). Basic Concepts of Psychiatric-Mental Health Nursing. 5th Edition. Philadelphia: Lippincott.

Liaquat University of Medical and Health Sciences, Jamshoro Sindh College of Nursing, JPMC Self Awareness Advance Concept in Nursing-III Sharifa Bibi
BScN Year II

Mrs. Durr-e-Shahwar

Self awareness is a unique type of consciousness in that it is not always present, and is not sought after. Repetitive tasks, as well as some school of thought in art theory and existentialism seek to reduce self-awareness, at least temporarily. Meditation usually is used to increase and develop self-awareness. Self awareness remains a critical mystery in physiology, psychology, biology and artificial intelligence. According to Locke (1689), personal identity (the self) depends on consciousness not on substances, nor on the soul. Self awareness can be defined as the concept in which individual know about one self for self awareness. You can relate yourself with other for similarity. Self consciousness is a personal understanding of the core of one’s own identity in which one individual knows about behavior, thought, attitude and identity by the self consciousness. One becomes able to know more about oneself internally in the environment. Self consciousness play an important role in behavior because of self consciousness one known more and recognize oneself and also modify behavior positively and reflect back toward culture awareness and religious living standards. Human self-awareness leads us to recognize three core features of the human conditions: The human imagination has no physical boundaries, but our bodies do. In our minds, we can instantly travel to the ends of the universe, the center of the earth, even the center of the sun. As seen as we discover something with any instrument, we can make images of it in our minds. The boundless production of fiction literature is evidence of the creative powers of the human imagination. Human spirits can motivate the noblest and holiest thoughts, the most altruistic actions, and the most beneficial generosities. But they can also produce the most horrible cruelties and violence against countless people, including suicide of the perpetrators. Our will

effortlessly moves our thoughts one way and then another, untamed by moral law or conscience. Leaders can sway whole populations to do things – benevolent or malevolent – that individuals would never, on their own, have contemplated. How can these two extremes coexist in the same individual? We don’t observe such extremes in other animals. They are exclusive to the human condition. Human actions and our very lives are motivated by hope – that we can make a difference that we can learn and grow and build and make things better. Yet physically speaking we know that we are mortal, we are made of dust, and we will return to dust. Despite this realization, hope springs eternal. Without hope, as Albert Camus said, the only serious philosophical question is why we should not commit suicide. Hope gets us up in the morning, and drives us forward every day. Aspirations – for hope, meaning, significance, purpose, identity, peace, happiness, beauty, love – are all aspects of human spirituality. Unlike self-awareness, self-consciousness has connotations of being unpleasant, and is often linked to self-esteem. Self-consciousness is credited with the development of identity, because it is during periods of self-consciousness that people come closest to knowing themselves objectively. Self-consciousness plays a large role in behavior, as it is common to act differently when people lose themselves in a crowd. Self-consciousness affects people in varying degrees, as some people are in constant self-monitoring, while others are completely oblivious about themselves. As already stated above that, personal identity (the self) depends on consciousness, not on substance non on the soul. We are the same person to the extent that we are conscious of our past and future thoughts, an action in the same way as we are conscious of our present thoughts and action. Personal identity is only founded on the repeated act of consciousness. When one is feeling self-conscious, one can feel too aware of even the smallest of one’s own actions. Such awareness can impair one’s ability to perform complex actions.

For example, a piano player may “choke”, lose confidence, and even lose the ability to perform when they notice the audience. As self-consciousness fades one may regain the ability to focus. Goldberg et al. (2006) has demonstrated the functional separation of sensory processing and self awareness. Self awareness appears to be process in the superior frontal gyrus. In theatre, self-awareness refers to a fictional character, who is depicted as breaking character, perhaps by breaking the fourth wall. Theatre also concerns itself with awareness besides self-awareness. There is a possible fractal correlation between the experience of the theatre audience and individual self-awareness. In end it can be concluded that self-awareness is a unique type of consciousness in that it is not always present, and is not sought after. Self awareness remains a critical mystery in physiology, psychology, biology and artificial intelligence. The human imagination has no physical boundaries, but our bodies do. We detect something with any instrument; we can make images of it in our minds. Human spirits can motivate the noblest and holiest thoughts, the most altruistic actions, and the most beneficial generosities. But they can also produce the most horrible cruelties and violence against countless people, including suicide of the perpetrators. Human actions and our very lives are motivated by hope. We can make a difference that we can learn and grow and build and make things better. Personal identity (the self) depends on consciousness, not on substance non on the soul. We are the same person to the extent that we are conscious of our past and future thoughts, an action in the same way as we are conscious of our present thoughts and action. Personal identity is only founded on the repeated act of consciousness and self-awareness.

References   http://en.wikipedia.org/wiki/Self-awareness. Retrieved on August 16, 2007. www.google.com.pk/self awareness. Retrieved on August 16, 2007.

OBJECTIVES
At the end of this presentation, the students will be able to: 1. Define the terms:
 

Self awareness Self consciousness

2. 3.

Identify the basis of personal identity. Explain the physiological location for self

awareness.

SELF AWARENESS Definition
Self awareness can be defined as the concept in which individual know about one self for self awareness. You can relate yourself with other for similarity. Self awareness remains a critical mystery in physiology, psychology, biology and artificial intelligence.

SELF CONSCIOUSNESS Definition
Self consciousness is a personal understanding of the core of one’s own identity in which one individual knows about behavior, thought, attitude and identity by the self consciousness. One becomes able to know more about oneself internally in the environment. Self consciousness play an important role in behavior because of self consciousness one known more and recognize oneself and also modify behavior positively and reflect back toward culture awareness and religious living standards.

THE BASIS OF PERSONAL IDENTITY
According to Locke (1689), personal identity (the self) depends on consciousness not on substances, nor on the soul. We are the same person to the extent that we are conscious of our past and future thoughts, an action in the same way as we are conscious of our present thoughts and action. Personal identity is only founded on the repeated act of consciousness.

THE PHYSIOLOGICAL LOCATION FOR SELF AWARENESS
Goldberg et al. (2006) has demonstrated the functional separation of sensory processing and self awareness. Self awareness appears to be process in the superior frontal gyrus. Human self awareness leads us to recognize three core features of human condition: 1. 2. 3. The human imagination. Human spirits. Human actions and our very lives are motivated by hope.

CONCLUSION

The human imagination has no physical boundaries, but our bodies do, in our minds, we can instantly travel to the ends of the universe, the center of the earth and even the center of the sun. We detect something with any instrument; we can make images of it in our minds.

REFERENCES

http://en.wikipedia.org/wiki/Self-awareness. Retrieved on August 16, 2007.

Liaquat University of Medical and Health Sciences, Jamshoro Sindh College of Nursing, JPMC, Karachi BScN Year-II Session 2006-2008 Nursing Care Plan & Reflection Log Advance Concept of Nursing-III Shamim Lawrence Mrs. Mustaqima Begum

Nursing Care Plan Introduction A 25 years old lady was admitted in Psychiatric Ward. According to client’s attendant, she was fine, but after separation, signs and symptoms of depression, sleeplessness, weight loss, loss of appetite, restlessness, self abusive behavior (nail biting), lack of self esteem, loneliness, and suicidal attempts appeared. Self esteem is defined as, “the state in which an individual experiences or is at risk of experiencing negative self-evaluation about self or capabilities”. Self esteem is one of the four components of self concept. Disturbed self esteem is the general diagnostic category. Chronic low self esteem and situational low self esteem represent specific types of disturbed self esteem. Thus involving more specific interventions initially the nurse sufficient clinical data validate character overt or covert inability to set goals, lack of poor problem solving, signs of depression, lack of sleep and change in eating habits. Poor body presentation, posture, eye contact, movements, self abusive behavior and suicidal attempts are also recognized as sign and symptoms of low self esteem. Having the above mentioned signs and symptoms; the client’s relatives had brought her to Psychiatric Ward and admitted for treatment.

NURSING CARE PLAN
Name: Fouzia Age: 25 Years Sex: Female Psychiatric Diagnosis: Disturbed Self-esteem. Nursing Diagnosis: Disturbed self esteem related to separation.
Date Assessment (Data Statement) Nursing Diagnosis Goal/Planning Nursing Intervention Rationale Evaluation

Disturbed self esteem related to separation.

Subjective Data: The client’s attendant, she was fine, but after separation, she developed sign and symptoms of depression, sleeplessness, weight loss, loss of appetite, restlessness, poor body presentation, posture, eye contact movements, self abusive behavior and suicide attempts. Objective Data: A 25 years lady having history of disturbed self esteem related to separation is to lying on the bed uncomfortably. She is looking restlessness, pale, insomnia, loss of appetite, poor confidence and self abusive behavior (nail biting). Vital Sign Blood Pressure: 90/60 mmHg Temperature: 98°F Pulse: 70 bpm Respiratory Rate: 20 per min. Weight: 40 Kg Jaundice: Negative Odema: Negative

Short-term Goals: • The client will feel comfortable and relaxed with improved • self esteem level. Long-term Goals: • The client will make full attention toward herself and discuss • current events. She also well oriented with the date and time. The client relates an increase in psychological and physio- • logical comfort. • • • •

Inform and reassure client

Client must be relaxed and • comfortable. Provide privacy and a safe • environment. Encourage the client to • express feelings especially about way she thinks or views self. Explore realistic alternatives. Use diversional therapy. Provide balanced diet. • • • •

To establish a trustworthy Short-term Goals: The client verbalized relationship. that she feel relax and comfortable and can To handle the client easily. call the nurse by name. Expressed improved self esteem To keep the client tension level. free. To reduce depression and Long-term Goals: improve self esteem. The client made decision about reality, and feelings. Also cope with the anxiety To change the thinking. level and took part in daily activities. This increase anxiety and improve self esteem. To improve the general health of the client. To encourage and respect to the client. give

Avoid criticism.

Administered medication as • prescribed by the doctor.

For accurate treatment of the disease.

Disturbed Self Esteem
Reflection

Introduction On my clinical visit of Psychiatric unit (Ward 20), with the permission of the Head Nurse, I selected a client who was 25 years old lady. She was lying on the bed with complaint of depression, sleeplessness, loss of weight, loss of appetite, restlessness, poor body presentation, posture, eye contact movements, self abusive behavior (nail biting), lack of self esteem, loneliness, and suicidal attempts. Analysis I analyzed the client’s condition. She is looking sleeplessness, restless, uncomfortable pale, lack of self presentation, eye contact movements, and self abusive behavior (nail biting). On addressing her, she not responded, therefore, I took interview of her attendant. She told me that “the client was alright and enjoying her life with her In-laws. One day she receipt a notice of separation and after that sign and symptoms were appeared which are restless, sleeplessness, uncomfortable, poor body presentation, posture, eye contact movements, etc. She also showed loss of appetite, weakness, loss of weight and self abusive behavior along with suicidal attempts.” Conclusion Disturbed self esteem is the general diagnostic category of reduced self concept. Chronic low self esteem and situational low self esteem represent specific types of disturbed self esteem involving lack of poor problem solving, signs of depression, lack of sleep and change in eating habits, poor body presentation, posture, eye contact, movements, self abusive behavior and suicidal attempts by the client. To improved self esteem levels of such client, specific nursing interventions are required, which enable the client to cope with the situation and live useful independent life.

Disturbed Self Esteem Learning I had learned from this clinical practice about many things. I started my observations by taking history of the client which is one of the important parts of nursing diagnosis. During my observation, I provided her comfort and tried to spend more time with the client, encourage and motivate the client to express her feelings, which enables her to cope with the situation and improve the self esteem level. Future Consideration In future, I will like to work with clients suffering from disturbed/impaired self esteem levels. By spending more time with them, I will try to develop a trustworthy relationship and motivate them to cope with their present sufferings and encourage them to express their feelings, which in results enable me to provided necessary nursing care and intervention, to not only reduce mental disorder but also enable them to spend useful and independent lives.

References  Schultz, J.M. and Videbeek, S.L. (2004). Lippincott’s Manual of Psychiatric Nursing Care Plans.7th Edition. Philadelphia: Lippincott.  Shives, L.R. and Isaacs, A. (2002). Basic Concepts of Psychiatric-Mental Health Nursing. 5th Edition. Philadelphia: Lippincott.

Schizophrenia ACN III Sultan Mohammad Madam Yasmin

OBJECTIVES
At the end of this presentation, the participants will be able to: 9. Define Schizophrenia. 10. Describe phases and classification of schizophrenia. 11. Explain the positive and negative

symptoms of schizophrenia. 12. Describe predisposing factors, nursing diagnosis and medical management of schizophrenia. 13. Explain nursing intervention and

psychological therapies.

SCHIZOPHRENIA
“Schizophrenia is a severe mental disorder characterized by psychotic symptoms, thought disorder, hallucination, delusions, paranoia and impairment in job and social functioning”. Medical model diagnostic term for a disintegrative life pattern characterized by thinking disorder withdrawal from reality, regressive behavior, poor communication and impair intrapersonal relationship (Holly WS). The American Psychiatric Association (1980) defines Schizophrenic disorder as a large group of disorder usually of psychotic proportion, manifested by characteristic disturbances of language and communication thought, perception, affect and behavior (Jeanette L 1988).

Description of Schizophrenia
Schizophrenia is a particular form of psychosis, a term encompassing several severe mental disorders that result in the loss of contact with reality along with major personality derangement. The illness can be described as a collection of particular symptoms that usually in four basic categories; formal though disorder, perception disorder, feeling or emotional disturbance and behavior disorders. 1. Formal Thought Disorder – people with schizophrenia describe strange or unrealistic thoughts. Their speech is hard to follow due to disordered thinking. Phrases seem disconnected, and ideas move from topic to topic with no logical pattern, in what is being said. They possess extraordinary powers, super human strength, or superior insights, they may believe that their thoughts are being controlled by others or being broadcast over the public airways or that outside thoughts are being implanted in their heads. When such ideas are persistent, organized, they are called decisions.

2. Perception Disorder – in perception disorder regularly report unusual sensory experience, when the illness is in acute stage. These perceptions are in the form of auditory hallucination, command hallucination, visual hallucination.
i)

Auditory Hallucination – They are hearing someone talk to them, when in reality no one is there. The voice may be that of someone the individual recognizes or the voice may be unknown to the person. Command Hallucination – when the voice or voices tell the individual to harm themselves or some one else, in some manner. The voices may tell the individual to jump off of a bridge or building. Visual Hallucination – perceive some one or some things that is not actually these depending on the nature of hallucination, and whether the individual perceive it as threatening, the situation can be very frightening.

ii)

iii)

3. Feeling or Emotional Disturbance – events that would normally make a person happy or sad, such as wedding or funeral, often produce no emotional response in person with schizophrenia. Their facial expressions remain the same regardless of what happens around them. Such responses are called flatness of affect, which together with thought disorders are important sign of schizophrenia. It may be frequently result in social withdrawal. Schizophrenic patient avoids to contacts with friends and loses interest in daily life and events. 4. Behavior Disorder – peculiar repetitive moments also seen in schizophrenia, constantly shake their heads. They can stand in same position for several hours, unable to talk or eat. Schizophrenics may also become assaultive, making them dangerous to others, they may be overly intrusive.

Phases of Schizophrenia Phase I – The schizoid personality – different social relationship and have a very limited range of emotional experience and expression. Do not enjoy close relationships and prefer to be “loners”. Phase II – Prodromal Phase – social withdrawal impairment in role functioning. Due to disturbances in communication and lack of energy, the length of this phase is prolonged lasting for many years. Phase III – Schizophrenia – in this phase, psychotic symptom are prominent. Phase IV – Residual Phase – Schizophrenia is characterized by periods of remission and exacerbation. Classification of Schizophrenia 1. Catatonic Schizophrenia – it is characterized by various motor disturbances, including catatonic posture and waxy flexibility. 2. Paranoid Schizophrenia – a person suffers from delusions of persecution, grandeur or control. 3. Disorganized Schizophrenia – Characterized disturbances of thought and a flattened or silly affect. by

4. Undifferentiated Schizophrenia – it is characterized by fragments of the symptoms of different types of schizophrenia. 5. Residual Type – Absence of delusions, hallucination

Symptoms of Schizophrenia 1. Positive Symptoms – refer to thoughts, perceptions, and behaviors that are ordinarily absent in people in the general population, but are present in persons with schizo-affective disorders, depending on their severity, and may be absent for a long periods in some patients.

Hallucinations – are “false perception” that are, hearing, seeing, feeling or smelling things that are not actually there. The most common type of hallucination is auditory hallucinations. Delusions – are “false beliefs” that is the belief which the patient holds, but which others can clearly see is not true. Some patients have paranoid delusions, believes that others want to hurt them. The patients hold these beliefs strongly and cannot usually be talked out of them. Thinking Disturbances – the patient talk in a manner that is difficult to follow. For example, the patient may jump from one topic to the next, stop in the middle of the sentence, make up new words, or simply be difficult to understand. Disorganized Behavior – inappropriate sexual behavior, restless cogitative behavior, waxy flexibility.

2. Negative Symptoms Negative symptoms are the opposite of positive symptoms. They are the absence of thoughts, perceptions, or behaviors, that are, ordinarily present in people in the general population. These symptoms are often stable throughout much of the patient’s life.

Blunted Affect – the expressiveness of the patient’s face voice tone, and gestures is diminished or restricted, however this does not mean that the person is not reacting to his or her environment or having feelings. Apathy – the patient dose not feel motivated to persue goals and activities. The patient may feel lethargic or sleepy. Patient with apathy has little sense of purpose in their lives and have few interests. Anhedonia – the patient feel no pleasure from activities that he or she used to enjoy or that occur enjoy. The person may not enjoy watching sunset, going to the movies or a close relationship with another person. Poverty of Speech or Content of Speech – the patient says very little or when he or she talk, it does not amount to much. Sometime conversing with the patient can be unrewarding. Inattention – the patient has difficulty attending and is easily distracted. This can interfere with activities such as work, interacting with others and personal care skills.

Predisposing Factors 1. Genetic • • Twin studies. Adoption studies.

2. Biochemical • The Dopamine Hypothesis.

3. Physiological Influences • • • • Viral infection. Anatomical abnormalities. Histological changes. Physical condition.

4. Psychological • • Dysfunctional family system. Poor parent-child relationship.

5. Environmental Influences • • • Sociocultural factors – lower socioeconomic class. Stressful life event. Was born in the winter.

Nursing Diagnosis 1. Altered thought process related to delusional thinking, as evidenced by verbalizations that coworkers are plotting against patient, extreme suspicion and anxiety. Sensory/perceptual alteration, hallucination, auditory and visual related to social withdrawal as evidenced by listening to sounds. Ineffective individual coping related to lack of trust in others evidenced by refusal to take medicine. Social isolation related to inability to accept shortcomings in others, evidenced by excessive criticism of friends.

8.

9. 10.

Medical Management Patients with schizophrenia often do not respond to treatment or only partially improve and remain functionally impaired. Neuroleptic drug therapy greatly shortens episodes of psychosis. Antipsychotic drugs also referred to neuroleptics, are essential to the management of schizophrenia. Tablet Haloperidol 10 – 20 mg daily. Tablet Clozapine is also effective against psychotic symptoms without causing extrapyramidal manifestations side effect, bone marrow suppression. Resperidone (Risperdal) is more effective in the treatment of schizophrenia than Haloposidal in positive and negative symptoms of schizophrenia; a dosage 3 mg twice a day.

Nursing Intervention 1. 2. 3. 4. 5. 6. 7. 8. 9. Administer antipsychotic medication for stalazine, canpozine, clopazine, risperdal. example,

Assure the patient that you understand that these experiences must be frightening. Show respect for patient as individual by speaking directly to them. When patient are hallucinating, attempt to distract them and focus their attention on real object and situation. Encourage realistic perceptions by reinforces for example, attention, praise. Provide structured environment. To decrease stimuli that may precipitate hallucination. Use concrete, simple, communication rather than abstract laughty ones. Encourage the expression of feeling for example, fear, anxiety in a realistic manner. using social

Psychological Therapies

Behavioral Therapy is based on the belief that may of our actions are the result of things that we have learned. It is a very directive therapy, which sets objectives (in collaboration with patient) for the patient to attain. Patients are given homework assignments. It is particularly good for treating phobias, obsessional and compulsive behavior and can also be helpful for anxiety management and exposure therapy.

Anxiety Management includes education about the nature of anxiety e.g., fight or flight response, stress management and problem solving. Cognitive Therapy is based on thinking, which includes exposure, assertiveness and social skill raining. Compliance Therapy for severe mental illness, which is reluctant to take medication; it is the form of counseling. Counseling in primary care 6 – 12 sessions. Family interventions for people with schizophrenia. Interpersonal therapy. Problem solving. Psychodynamic therapy.

• • • •

Scenario
Critical Thinking Skills Jamila, a 23 years old woman, has just been admitted to the psychiatric unit by her parents. They explain over a few month, she become more withdrawn. She says in her room alone, but she has been heard talking and laughing to herself. Jamila left her home at the age of 18 years, to attend college. She performed well during the first semester when she returned to home on Eid festival, she blames her roommate steals her possession, and started writing to her parents that her roommate wanted to kill her and turning everyone against her. She got feared for her life and started missing classes and stayed on bed most of the time. Her parents took her home and she was hospitalized and diagnosed with paranoid schizophrenia and started antipsychotic medication. Jamila tells the admitting nurse that she quite taking her medication 4 weeks ago because the pharmacist who fills the prescription is plotting to have her killed. She believes, he is trying to poison her. She says that she got this information from a TV message. As Jamila speaks, the nurse notices that sometime she stops in mid-sentence and listens.

NURSING CARE PLAN Patient Name: Age Sex Medical Diagnosis Nursing Diagnosis Miss Jamila 23 years Female Schizophrenia Thought Disorder
Nursing Diagnosis Goal Intervention Evaluation

Assessment

Subjective Data According to the parents, Jamila left her home at the age of 18 years and attend the college. She performed well during her first semester. When she come to home on Eid festival, she blaming her roommate that she wanted to kill her and after that she did not take interest in the study and wanted to live alone in the room. She did not want to talk with anyone and did not take part in any activity of daily life. Objective Data A 23 years old female, college student was brought to the Psychiatric unit by her parents with a complain of psychiatric problem, false believe and looking non-reality base-thinking disoriented and short attention span, impaired judgment incoherence speech, inappropriate affect, unhygienic condition and felling of confusion. Vital Signs • Blood Pressure • Temperature • Pulse • Respiratory rate 120/180 mmHg 99 °F 80 bpm 22 per min

Altered thought process related to delusional thinking, as evidence by verbalization that coworkers are plotting against patient extreme suspicion and anxiety.

Short Term Goal The client will be free from injury and deceased anxiety level. Long Term Goal The client will identify trusting characteristic in a relationship till to hospitalization.

• • • • • •

Be sincere and honest when communicating with client avoid vague or evasive remark. Do not make promises that you can’t keep. Encourage the client to talk with you, but do not try for information. Interact with the patient on the basis of real things. Do not be judgmental or joke about the client belief. Give positive feedback for the client success. Never convey to the client that you accept the delusions as reality.

Objective The patient seen a decreased anxiety level and reality base thinking, increase attention span and feeling of wellness. Subjective The patient recognizes the delusional thought and will adopt social relation.

NURSING CARE PLAN Patient Name: Age Sex Medical Diagnosis Nursing Diagnosis Mr. Kamran 30 years Male Suicide Hopelessness
Nursing Goal Diagnosis Hopelessness Short Term Goal related to • The client will absence of verbalize a measure support system of hope and and perception acceptance of life of and situations over worthlessness which he has no evidenced by control. verbalcues. Intervention Evaluation Evaluation of suicidal is an ongoing process accomplished through continuous reassessment of the client as well as determination of goal achievement. Once the immediate crises have been resolved, extended psychotherapy may be indicated. Objective The client develops and maintains a more positive self-concept and learns more effective ways to express feeling to others and look free of tension. Subjective The client recognized that he achieved successful interpersonal relationships and feel accepted by others and achieve sense of belonging.

Assessment Subjective Data According to the client’s parents, he is a unmarried man. He is alright before one week and perform his duty well. Sudden he changes his behavior and become aggressive. At home everyone feel his behavior and worried about his condition. He is not taking proper food and drinks. He does not take part in any activities. His condition becomes more and more serious and he id developing abnormal behavior. Objective Data Mr. Kamran, 30 years old man came in Psychiatric OPD with complain of abnormal behavior. He looks irritate, drozy, pale and weak. His walking is imbalance and he speaks loudly. Vital Signs • Blood Pressure • Temperature • Pulse • Respiratory rate 100/70 mmHg 98 °F 70 bpm 20 per min

• •

The client will make positive statements about his life.

• • • •

Long Term Goal • The client will find a job.

The client will participate in group activities.

Identify stressors in client’s life that precipitated current crises. Determine coping behaviors previously used and client’s perception of effectiveness then and now. Encourage the client to explore and verbalize feeling and perceptions. Provide expressions of hope to client in positive low-key manner. Help client identify areas of life situation that are under own control. Identify sources that client may use after discharge when crises occur or feelings of hopelessness and possible suicidal ideation prevail.

References References 1.
3.

Wilson S Holly. Psychiatric Nursing. Wesley California; p 825. Lancaster Jeanette (1988). Adult 3rd Edition. New York; pp 369-372. Psychiatric Nursing.

4.

Harber, Hoskins and Leach (1978). Comprehensive Psychiatric Nursing. 3rd Edition. USA; p 1126. Taylor Monat Cecelia (1994). Essential of Psychiatric Nursing. 14 Edition. USA; pp 242-247. Sundeen and Stuart (1991). Principles and Practice of Psychiatric Nursing. 4th Edition. Philadelphia; p 494. Carson Verna Benner. nd 2 Edition. USA; pp 668-669. Mental Health Nursing.

5.
6.

7.

8.

White Lois (2001). Foundation of Nursing. 6th Edition. USA; p 1195. http://www.schizophrenia.com/family52.overview.htm. http://www.schizophrenia.com/ami/index.htl accessed on July 13, 2005. Http://www.schizophrenia.com/ecgslo.php accessed on July 10, 2005. Townsend Marry C (1941). Psychiatric Mental Nursing. pp 450-459.

9. 10.

11.

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Liaquat University of Medical and Health Sciences, Jamshoro Sindh College of Nursing, JPMC, Karachi BScN Year-II, Session 2006-2008 Nursing Care Plan & Reflection Log Advance Concept of Nursing-III Shagufta Majeed Mrs. Mustaqima Begum

Nursing Care Plan Introduction Faizan, a 33 years old client admitted in Psychiatric unit sitting on bed but frequently changing place from bed to chair and chair to bed. His appearance is disheveled and his hygiene is poor. I try to interview the client, but his answers were irrelevant. So I interviewed his brother and discovered that Faizan has been sleeping poorly, unable to concentrate on daily activities, show aggressive behavior, suspiciousness, hallucination and delusion. Faizan’s brother also described that he show this behavior off and on from last five years and diagnosed with schizophrenia from last four years, but now this has been working as clerk from last ten years but now he did not show interest in job and did not go to office from last one month. Faizan’s brother told that Faizan is married and have two daughters and one son. They lived in a house on rent in a joint family system. So I diagnosed that Faizan’s thought process is altered.

NURSING CARE PLAN Patient’s Name: Faizan Age: 30 Years Medical Diagnosis: Schizophrenia Nursing Diagnosis: Disturbed thought process related to as evidenced by inability to evaluate reality secondary to schizophrenia. Date Assessment Nursing Planning Interventions Rationales Diagnosis Subjective Data Short term goal • Be sincere and hones when • Delusional clients are extremely As the client’s brother verbalized The client will communicating with the client. sensitive about others and can that the client shows aggressive free from injury. Avoid vague or evasive recognize insincerity. Evasive behavior even sometime lash out Demonstrate remarks. comments or hesitation reinforces on family members. He also decreased anxiety mistrust or delusions. shows suspiciousness toward his level. • Be consistent in setting • Clear, consistent limits provide a sisters that they are hostile to me. expectations, enforcing rules, secure structure for the client. As he stated that the client did not Long term goal and so forth. sleep even two or more days. He Interact on reality • Do not make promises that you • Broken promises reinforce the told that the client hear voices of based topic. cannot keep. client’s mistrust of others. unfamiliar person and client said Sustain attention • Encourage the client to talk • Probing increases the client’s that Bush has send army for me. and concentration with you, but do not pry for suspicion and interferes with the to complete task information. therapeutic relationship. Objective Data or activities. • Explain procedures, and try to • When the client has full knowA 30 years old client sitting on bed, but frequently changing his be sure the client understands ledge of procedures, he or she is place. Sometimes on bed and then the procedures before carrying less likely to feel tricked by the on chair. He was not fully them out. staff. oriented with time, place but • Give positive feedback for the • Positive feedback for genuine oriented with persons. client’s successes. success enhances the client’s Non reality based thinking, labile sense of well being and helps affect, short attention and span make nondelusional reality a impaired judgments, distmore positive situation for the ractibility, impulsivity, restless, client. and anxious. • Recognize the client’s delusions • Recognizing the client’s as the client’s perception of the perceptions can help you Vital Signs environment. understand the feelings he or she Blood Pressure 110/70 mmHg is experiencing. • Initially, do not argue with the Temperature 99 °F • Logical argument does not dispel client or try to convince the Pulse 90 bpm client that the delusions are delusional ideas and can interfere Respiratory Rate 22 per min false or unreal. with the development of trust. Disturbed thought process related to as evidenced by inability to evaluate reality secondary to schizophrenia

Evaluation Short term goal The client becomes free from injury and his anxiety level decreased as now he did not show aggressive behavior after two days.

Long term goal
Client able to realize things in some better way. His attention span increased and now he complete daily activities with concentration after five days.

Nursing Care Plan
Intervention Interact with the client on the basis of real things; do not dwell on the delusional material. Engage the client in one-to-one activities at first, then activities in small groups, and gradually activities in larger groups. Recognize and support the client’s accomplishments. Rationale Interacting about reality is healthy for the client.

• • • • • • • •

• • •

A distrustful client can best deal with one person initially. Gradual introduction of others as the client tolerates is less threatening. Recognizing the client’s accomplishments can lessen anxiety and the need for delusions as a source of self-esteem. The client’s delusions can be distressing. Empathy conveys your caring, interest, and acceptance of the client. The client’s delusions and feelings are not funny to him or her. The client may not understand or may feel rejected by attempts at humor. Indicating belief in the delusion reinforces the delusion (and the client’s illness). As the client begins to trust you, he or she may become willing to doubt the delusion if you express your doubt. Discussion of the problems caused by the delusions is a focus on the present and is reality based.

Show empathy regarding the client’s feelings; reassure the client of your • presence and acceptance. Do not be judgmental or belittle or joke about the client’s beliefs. Never convey to the client that you accept the delusions as reality. Directly interject doubt regarding delusions as soon as the client seems ready to accept this. Do not argue, but present a factual account of the situation. • • •

Ask the client if he or she can see that the delusions interfere with or cause • problems in his or her life.

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Schizophrenia Reflection

Introduction It was my second clinical day in Psychiatric Unit. After getting introduction with all health team members, I took permission from the Head Nurse to go the clients’ bedside and select a client with the diagnosis of Schizophrenia. Schizophrenia is a mental disorder and it meant for splint mind. Due to this mental disorder, individual become unable to differentiae between real and unreal, to think logically and to deal with others persons effectively. The age of my client was 33 years. He was sitting on the bed uncomfortably and his dress was dirty. He was not looking neat and clean. According to his attendant, client is educated and a Government employee. But unfortunately due to that mental disorder, he is unable to care himself and also not cooperative with his attendant in the process of bathing and grooming. Analysis According to Orem’s theory (1971) a definition of nursing emphasis on the clients self care needs. Nursing has a special concern; man’s needs for self-care action and the provision and management of it on a continuous basis in order to sustain life and health, recover from disease or injury and cope with their effects. Self-care is a requirement of every person, men, women and child. When self-care is not maintained, illness, diseases or death will occur. Nurses sometimes manage and maintain required self-care continually for persons who are totally incapacitated. In other instances, nurses help persons to maintain required self-care by performing some but not all care measures by supervising others who assist clients and by instructing and guiding individuals as they gradually more toward self-care.

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Schizophrenia

According to the Orem, nursing care is necessary when the client is unable to meet or fulfill biological, psychological developmental or social needs. The nurse determines whey a client is unable to meet these needs and what must be done to enable the client to meet them. Learning I learned from this experience that self-care is one of the basic human needs necessary for survival and health. The extent to which basic needs are met is a major factor in determining person’s health status. The goal of nursing is increase, the client ability to independently meet these needs. Maintenance of personal hygiene is necessary for an individual’s comfort, safety and well being. Future Consideration Some people are capable of meeting their own hygienic needs, ill or physically challenged people may require assistance. So in future, if I get a chance then I will assist my clients in maintaining their self-care needs and I will educate my students and colleagues about the importance of self-care need and guide them how they can assess client’s self-care need and fulfill them.

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Erb, K., & Wilkinson, B. (1998). Fundamentals of Nursing: Concepts, Process and Practice, (5th ed.). New Jersey: Prentice Hall Health.

Schultz, J.M. and Videbeek, S.L. (2004). Lippincott’s Manual of Psychiatric Nursing Care Plans, (7th ed.). Philadelphia: Lippincott.

LIAQUAT UNIVERSITY OF MEDICAL AND HEALTH SCIENCE JAMSHORO SINDH

Cognitive-Behavioral Therapy
ACN III Shahnawaz
BScN Year-II Student College of Nursing, JPMC

Madam Yasmin 23rd July, 2005

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OBJECTIVES
At the end of this presentation, the participants will be able to: 1. Define and Describe Cognitive Theory,

Behavior and Cognitive Behavioral Therapy. 2. Differentiate between Cognitive and Behavioral Therapies. 3. 4. 5. Explain the indication. Formulate the nursing diagnoses. Identify the cognitive-behavioral interventions, nursing and psychological intervention.

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COGNITIVE-BEHAVIORAL THERAPY
Introduction Cognitive-behavioral therapy combines two very effective kinds of psychotherapy, cognitive therapy and behavior. It approaches to treatment useful for the patients experiencing ineffective individual coping, fear, and powerlessness and selfconcept disturbance. Cognitive-behavioral therapy is based on the notion that the way we think about something influences the way we behave and feel. Negative patterns of thinking tend to be automatic and pervasive, coloring individuals’ perceptions of the world around them and affecting their mood and self-esteem. Cognitive-behavioral therapy used often and successfully with depressed patients suggests that the depressed unrealistic negative thought processes are central to becoming and staying depressed (Belsky 1984). Definitions To understand the term cognitive-behavioral therapy it is necessary to go through the definitions of term’s cognitive theory and behavior. Cognitive Theory Cognitive theorists seek to help clients understand how negative and conflicting thought patterns influence their appraisals of certain situations, with the result that their emotional reactions to these situations – such as anger, depression, and fear – are exaggerated or inappropriate.

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Nurses in the teaching-learning, reasoning, understanding and remembering can use principles of cognitive learning. Thought and memory enter into every cognitive action. Cognitive therapy offers a way of effecting behavioral and emotional change through analysis and revision of the client’s thinking and perception. Behavior Wolpe’s Definition of Behavior According to Wolpe, behavior is a conditioned response, that is, a response, which has been rewarded. Many behaviors become habits, which are established, long-standing patterns of response to stimuli. Maladaptive behaviors are thought to have begun in response to uncomfortable levels of anxiety and to have been rewarded by decreased anxiety. Miller and Dollard’s Definition of Behavior According to Miller and Dollard, behavior reflects a way of coping with conflict and its associated anxiety. There are two kinds of conflicts. An avoidance-avoidance conflict occurs when one must choose between two undesirable alternatives. An approach-avoidance conflict occurs when one has ambivalent feelings about an object: one wishes, simultaneously, toe approach and avoid it.

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Cognitive-Behavioral Therapy

Cognitive-behavior therapy uses confrontation as a means of helping clients restructure irrational beliefs and behavior. The therapist confronts the client with a specific irrational thought process and helps to rearrange maladaptive thinking, perceptions or attitudes. Cognitive behavior therapy is considered a choice of treatment for depression and adjustment difficulties. Cognitive-behavioral therapy is based on the notion that the way we think about something influences the way we behave and feel. Negative patterns of thinking tend to be automatic and pervasive, coloring individual’s perceptions of the world around them and affecting their mood and self-esteem. Cognitive behavioral therapy, used often and successfully with depressed older people, suggests that the depressed elder’s unrealistic negative thought processes are central to becoming and staying depressed (Belsky 1984). Cognitive-behavioral therapy focuses on symptoms and thought processes (rather than a hypothetical unconscious cause) and fosters a sense of selfresponsibility and self-control, the patients are often receptive and willing to try it. Cognitive and behavioral approaches can be integrated, using the social-learning concept as a framework.

 

A comparison of Cognitive Therapy and Behavioral Therapy can be observed through the following given table.

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A Comparison of Cognitive Therapy and Behavioral Therapy Cognitive Therapy Behavioral Therapy Similarities
Formulate symptoms in Same behavioral terms, and design specific set of operations to alter maladaptive behavior. Collaborate with and coach client regarding reactive responses. Same Seek to alleviate overt symptoms or behavioral problems directly. Same Stress here and now, not the past.

Differences
Use induced and spontaneous images to identify misconceptions and test distorted views against reality. Apply techniques of systematic desensitization by inducing a predetermined sequence of images alternating with periods of relaxation. Modify attitudes, beliefs, or Modify behavior directly modes of thinking that influence (through reciprocal inhibition, behavior. systematic desensitization and so on). Modify ideational content (e.g., Modify behavior directly. irrational premises and inferences) to aid change in behavior. Work with internally experienced Work with observable behavior. cognitive structures (schemas) that influence client’s perceptions, interpretations, and images.

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Indications Cognitive-behavioral therapy is a clinically and research proven break through in mental health care, which is used in the following conditions. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. Depression and mood swings. Shyness and social anxiety. Panic attacks and phobias. Obsessions and compulsions. Chronic anxiety or worry. Post traumatic stress symptoms. Eating disorders and obesity. Insomnia and other sleep problems. Difficulty establishing staying in relationship. Problem with marriage or other relationship. Job career of school difficulty. Feeling stressed out. Insufficient self-esteem. In educate coping skills self- or ill-chosen method of coping. Passivity – Procrastination and “passive aggression”. Substance abuse co-dependency and “enabling”. Trouble keeping feeling such as anger sadness, fear, guilt, shame, eagerness, excitement, etc. within bounds. Over-inhibition of feeling or expression.

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Nursing Diagnoses There are six basic commonalties that link delirium, dementia, and amnestic disorders: impaired cognition, alteration in thought processes, impaired communication, behavioral disturbances, self-care deficits and impaired socialization. A comorbid medical condition may exist. These commonalties are considered during the formulation of the nursing diagnoses. Comprehensive Assessment of Impaired Cognition and Behavioral Manifestations History – include data regarding birth, developmental stages, medical history, medication, time of onset of clinical symptoms, rate of progression, and any family history of dementia. Physical Examination – mental status evaluation: obtain information regarding any past psychiatric treatments. General physical and neurologic examination. Studies – Complete blood count, sedimentation rate, chemistry panel (electrolytes, calcium, albumin, BUN, creatinine, transminase, blood sugar), thyroid function tests, VDRL or RPR, urinalysis, serum B12 and folate levels, human immunodeficiency virus (HIV), if permission is granted. Imaging – Chest x-ray, head computed tomography scan (CT scan), Electrocardiogram (ECG). Additional Studies – Electroencephalogram (EEG), Neuropsychiatric testing, Head magnetic resonance imaging (MRI) if vascular dementia suspected, Lumbar puncture (LP), Drug and alcohol toxicology, Heavy metal screen.

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Cognitive Behavioral Interventions It is preferable to try cognitive-behavioral therapy alone before prescribing medications, this is for several reasons. It would seem that cognitive behavior therapy, when applied to the patients, is a heuristic process. In practice, the preparation and ongoing evaluation of the treatment’s success, and its impact upon the client’s broader mental state, guarantee a collaborative approach sensitive to changes. The use of specific, individualized assessment tools such as the Beliefs About Voices Questionnaire, go further in providing the individuality that successful symptom management requires. The client who combats the fear to concentrate on conversations or television will require a strategy that assists cognitive functioning, not a strategy to assist affect regulation. Medications – Used judiciously, medication can be an effective adjunct to psychotherapy for mental disorders in patients. The high incidence of adverse drug reactions was observed in elderly patients, therefore careful monitoring and conservative dosages are required. Moreover, medical and nursing personnel caring for these patients taking psychoactive medication require special training and ongoing staff development. The goals of cognitive behavioral intervention are the following:
• • •

Alter pain perception. Alter pain behavior. Provide clients with greater sense of control over pain.

Many cognitive behavioral pain relies strategies are also used to relieve stress. Interventions such as progressive relaxation, guided imagery, therapeutic touch and biofeedback.

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Types of Distraction 1) Visual distraction. i) ii) iii) 2) Reading or watching television. Watching a baseball game. Guided imagery.

Auditory distraction. i) ii) Humor. Listening to music.

3)

Tactile distraction. i) ii) iii) Slow, rhythmic breathing. Massage. Holding or stroking a pet or toy.

4)

Intellectual distraction i) ii) iii) Crossword puzzles. Card games (e.g. bridge) Hobbies (e.g., stamp collecting, writing story).

Milieu Therapy – a broad, all-encompassing intervention, may be adapted to meet the needs of most of the nursing diagnostic categories. In particular, milieu therapy is appropriate for clients experiencing diversional activity deficit, self-care deficit, sleep pattern disturbance, self-concept disturbance, high risk for violence, altered thought processes, powerlessness, and impaired physical mobility. Precaution Benzodiazepine drugs such as alprazdom (Xanall) plus certain other types of tranquilizers can be habit forming, if taken over a long time or in high doses.

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Interventions within a Therapeutic Milieu Structure
Regular meal times Scheduled activities Predictability and routine Consistency Bowel/bladder program Shift change Medication time Vita signs Regular MD visits Primary nursing Care planning Evaluation

Containment
Physical aspects of the facility include the interior design, safety features, atmosphere, space, privacy, lighting location, temperature, noise, odors, colors, infection control, restraints, confinement, isolation, “homey” atmosphere of client rooms, roommates, access to public transportation, “knock before entering” policy

Support
Nourishment Medication Social support Reassurance Visitors Physical therapy and occupational therapy Spiritual expression Consistent positive staff attitudes Handrails Mutual goal setting Exercise

Involvement
Mutual goal setting Self-care Client contracting Community meetings Family involvement Client self-evaluation Suggestion box Client autonomy and decision making Group work

Validation
Reality orientation Feedback and acceptance Interaction and contact with the world Music, touch, warmth, and creative expression Sensory stimulation Focus on positive aspects of behavior “Downplay” of negative Newspaper and TV One-on-one relationships Excursions outside

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Nursing Intervention 1. 2. 3. 4. 5. Use environmental manipulation to assist patient to cooperate with plan for activities of daily living. Allow use of toilet articles brought from home, play soft music or relaxation tapes at rest or bedtime. Give positive reinforcement with praise, smiles and rewarding experiences for cooperation in activities. Establish an effective communication pattern depending on degree of deterioration. Speak calmly, clearly and slowly one sentence at a time and repeat as necessary, use short and simple sentences. If patient is confrontive yelling or belligerent do not argue or raise your voice, speak gently and calmly and patient will calm down.

6.

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Psychological Intervention Psychological interventions in psychosis have been found to produce positive responses in about 50% cases however, isolating the determinant factors that predict improved psychotic symptomatology have not been clearly demonstrated. Psychotic symptomatology refers to a broad range of features commonly associated with various psychiatric disorders. Generally, symptom management is achieved by enabling the client to link feelings and patterns of thinking and connect them to subjective distress and life disruption. This is usually done by examining the evidence in support of and against the distressing belief, using reasons and logic to find an acceptable explanation and challenging habitual patterns of thinking. The necessary collaboration and assessment is therapeutic in itself and the added focus and direction provided by specific interventions serves to guide and develop practice. Psychological preparation of children for surgery using behavioral strategies (e.g., relaxation and training in coping skills) has been beneficial in reducing postoperative anxiety and distress and generally improving psychological adjustment.

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Scenario
Mr. Jim, a 58 years old man, was seen by the nurse practitioner, two weeks after the death of his wife. They had been married 30 years and never had any children. Jim’s sister and brother-in-law suggested that he tell his primary clinician that he was having difficulty adjusting to the death of his wife. During the visit, Jim confided in the nurse that he had not been sleeping well. His affect was blunted as he stated that he thought he would be the first to die. He informed the nurse that he did not want to take any medication for insomnia or depression but that he was willing to try alternative measures to sleep better at night.

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Name: Age Sex Medical Diagnosis Nursing Diagnosis

NURSING CARE PLAN Mr. Jim 58 Years Male Depression Sleep pattern disturbance with depression.
Nursing Diagnosis Disturbed sleep pattern related to depression as evidenced by difficulty remaining asleep and statement by client that he is not sleeping well. Expected Outcomes Short term goals Intervention Rationale Evaluation

Assessment Subjective Data According to the patient, after the death of his wife, he was having difficulty adjusting to the death of his wife and was not sleeping well. His affect was blunted as he stated that he thought he would be the first to die. He did not want to take any medication for insomnia or depression, but that he was willing to try alternative measures to sleep better at night. Objective Data Mr. Jim, a 58 years old male come in Psychiatric OPD with complain of disturbed sleep pattern related to depression.. He looks irritate and drozy. His walking is imbalance. He looks pale and week with slow speak. Vital Signs • Blood Pressure • Temperature • Pulse • Respiratory rate 120/80 mmHg 98 °F 70 bpm 20 per min

Will verbalized decreased number of complaints regarding loss of sleep. Will report an improvement in his sleep pattern.

Suggest sleep preparatory activities such as quiet music, warm fluids, and decreased active exercise at least one hour prior to scheduled sleep time. Provide high carbohydrate snacks.

Carbohydrates stimulate secretion of insulin. Insulin decreases all amino acids but tryptophan in larger quantities in the brain increases production of serotonin, a neurotransmitter then reduces sleep. The urge to void interrupts the sleep cycle during the night. Environment temperature i.e., the most conducive to sleep. Promotes sleep. Promotes sleep. Promote rhythm. uninterrupted uninterrupted regular diurnal

• • • •

Client kept a sleep diary for 7 days. Follow up visit in one week. He was able to sleep 5-6 hours each night. He was able to discuss his feelings with his sister and brother-in-law and had decided to attend grief counseling at their church.

• • • • •

Assist to bathroom or bedside commode, or offer bedpan at 09:00 PM. Maintain room temperature at 68 to 72°F. Schedule all patient’s therapeutics prior to 09:00 PM. Once patient is sleeping place, put do not disturb sign on door. Increase exercise and activities during the day as appropriate for patient’s condition.

• • • • •

Long term goals

Will demonstrated at least 6 to 8 hours of uninterrupted sleep night.

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References 1. Shives Louise Rebraca and Isaacs Ann (2002). Cognitive Behavioral Therapy In: Basic Concepts of Psychiatric-Mental Health Nursing. 5th Edition. Lippincott Williams and Wilkins Philadelphia; p 418. Harber, Hoskins and Leach (1978). Behavioral and Cognitive Theory and Application In: Comprehensive Psychiatric Nursing. 3rd Edition. USA; pp 467-484. Walker JI. Essentials of Clinical Psychiatry. ISBN 0-39750642-2; pp 386-390. Elsevier Nam Boodiri (2005). Cognitive Therapy In: Concise Textbook of Psychiatric. 2nd Edition. Raj Kamal Electric Press Delhi; p 347, Townsend Marry C (1941). The nursing process across the life span In: Psychiatric Mental Nursing. pp 893-896. Cox HC, Hinz MD, Lubno MA, Newfield SA, Ridenour NA, Salater MM, Sridaromount KL (1996). Clinical Applications of Nursing Diagnosis – Adult, Child, Women’s, Psychiatric, Gerontic, and Home Health Considerations. McGraw Hill New York; pp 397-398. http://www.google.com. Scott J (2001). Cognitive therapy for depression. B Med Bulletin; 57:101-113. http://www.google.com. Bryant RA, Sackville T, Dang TS, Moulds M, Guthrie R (1999). Treating Acute Stress Disorder: An Evaluation of Cognitive Behavior Therapy and Supportive Counseling Techniques. http://www.yahoo.com. Bush JW. The Basis of Cognitive Behavior Therapy. http://www.yahoo.com. Holland M, Baguley I, Davies T (1999). Psychological Methods of Treating Hallucinations and Delusions: 1. B J Nursing; 8(15):998-1001.

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14.
15.

16. 17.

18. 19.

20. 21.

LIAQUAT UNIVERSITY OF MEDICAL AND HEALTH SCIENCE

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JAMSHORO SINDH

Cognitive-Behavioral Therapy
ACN III Shahnawaz
BScN Year-II Student College of Nursing, JPMC

Madam Yasmin 23rd July, 2005

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OBJECTIVES
At the end of this presentation, the participants will be able to: 6. Define and Describe Cognitive Theory,

Behavior and Cognitive Behavioral Therapy. 7. Differentiate between Cognitive and Behavioral Therapies. 8. 9.
10.

Explain risk factors. Describe nursing diagnoses. Discuss cognitive-behavioral interventions,

nursing and psychological intervention.

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312

COGNITIVE-BEHAVIORAL THERAPY
Introduction Cognitive-behavioral therapy combines two very effective kinds of psychotherapy, cognitive therapy and behavior. It approaches to treatment useful for the patients experiencing ineffective individual coping, fear, and powerlessness and selfconcept disturbance. Vague, abstract, and “mysterious” approaches to therapy are not tolerated well by patients. They seek a therapeutic relationship that provides some reciprocity. Nurses caring for them must invest themselves through active involvement and judicious self-disclosure to foster trust and a warm, caring relationship. Cognitive-behavioral therapy is based on the notion that the way we think about something influences the way we behave and feel. Negative patterns of thinking tend to be automatic and pervasive, coloring individuals’ perceptions of the world around them and affecting their mood and self-esteem. Cognitive-behavioral therapy used often and successfully with depressed patients suggests that the depressed unrealistic negative thought processes are central to becoming and staying depressed (Belsky 1984). A combination of cognitive and behavioral approaches has been found to work best with the elderly. These approaches are “practical” and very specific, providing concrete goals (e.g., behavior change or correction of negative thought patterns) and ongoing evaluation of progress through selfmonitoring of goals accomplishment.

Cognitive-Behavioral Therapy

313

Definitions To understand the term cognitive-behavioral therapy it is necessary to go through the definitions of term’s cognitive theory and behavior. Cognitive Theory Cognitive theorists seek to help clients understand how negative and conflicting thought patterns influence their appraisals of certain situations, with the result that their emotional reactions to these situations – such as anger, depression, and fear – are exaggerated or inappropriate. The interactive relationship between people and their environments makes it important to emphasize the clients’ active participation in the process of change: defining problems, selecting behavioral objectives, and evaluating outcomes. Nurses in the teaching-learning, reasoning, understanding and remembering can use principles of cognitive learning. Thought and memory enter into every cognitive action. Cognitive therapy offers a way of effecting behavioral and emotional change through analysis and revision of the client’s thinking and perception. Cognitive therapy is a collaborative ‘hypothesis-testing’ approach that uses guided discovery to identify and reevaluate distorted cognitions and dysfunctional beliefs. However, the common misconception that cognitive therapy uses a fixed set of behavioral (e.g., activity scheduling) and cognitive (e.g., challenging automatic thoughts) techniques is unfortunate. The therapy is not simply technique drive. The interventions are selected on the basis of a cognitive conceptualization the uniquely identifies the likely core negative beliefs of that individual and explains the onset and maintenance of their depression. If the patient shows a low level of functioning, behavioral techniques may be used to improve activity levels and improve moods, but the goal is still to identify and modify negative cognitions and maladaptive underlying beliefs.

Cognitive-Behavioral Therapy

314

Behavior Wolpe’s Definition of Behavior According to Wolpe, behavior is a conditioned response, that is, a response, which has been rewarded. Many behaviors become habits, which are established, long-standing patterns of response to stimuli. Maladaptive behaviors are thought to have begun in response to uncomfortable levels of anxiety and to have been rewarded by decreased anxiety. Wolpe’s Approach to Behavioral Therapy The behavioral therapist, in contrast to practitioners using other therapeutic approaches, takes total responsibility for the cure of the client. The client exhibits maladaptive behavior, and the therapist has the tools to correct it. The goals of treatment are to decondition anxiety and to alter maladaptive behavior. Deconditioning of anxiety is central to behavioral therapy four methods are used. 1. Assertive behavior is the expression of emotion appropriate to the current situation rather than an expression of anxiety. Systematic desensitization is a step-by-step use a counteracting emotion to overcome an undesirable emotional habit and can occurs in four steps (a) training in deep muscle relaxation, (b) use of a scale of subjective anxiety, (c) construction of anxiety hierarchies, and (d) use of relaxation techniques in conjunction with desensitization. Evoking strong anxiety is used as another way to decondition anxiety. In this, two techniques are used; (a) flooding and (b) abreaction. Operant conditioning is a method that deals with conditioned motor and cognitive behaviors rather than autonomic behavior. The point of operant conditioning is to elicit adaptive motor and cognitive behaviors.

2.

3.

4.

Cognitive-Behavioral Therapy

315

Miller and Dollard’s Definition of Behavior According to Miller and Dollard, behavior reflects a way of coping with conflict and its associated anxiety. There are two kinds of conflicts. An avoidance-avoidance conflict occurs when one must choose between two undesirable alternatives. An approach-avoidance conflict occurs when one has ambivalent feelings about an object: one wishes, simultaneously, toe approach and avoid it. Miller and Dollard’s Approach to Behavioral Therapy There are four fundamentals of learning: A drive – is motivation; it can be primary (biological) or secondary (learned). A cue – is a stimulus, a push to respond. A response – is a thought, feeling, or action caused by the cue. A reinforcement – is a reward for a response. Miller and Dollard consider a decrease in fear and anxiety to be the major reinforcement in neurotic behavior. Four principles of learning are based on these fundamentals: 1.
2.

Extinction – is a decrease in the rate of neurotic behavior when the behavior is not reinforced. Spontaneous recovery – is the tendency for neurotic behavior to recur periodically, even in the absence of reinforcement. Generalization – is the tendency to transfer the learning in one situation to similar situations. Discrimination – is the ability to notice the similarities and differences in like situations.

3.

4.

Cognitive-Behavioral Therapy

316

Cognitive-Behavioral Therapy Cognitive-behavior therapy uses confrontation as a means of helping clients restructure irrational beliefs and behavior. In other words, the therapist confronts the client with a specific irrational thought process and helps to rearrange maladaptive thinking, perceptions or attitudes. Thus, by changing thoughts, a person can change feelings and behavior. Cognitive behavior therapy is considered a choice of treatment for depression and adjustment difficulties. Rational emotive therapy is a type of cognitive therapy that is effective with groups whose members have similar problems. Cognitive-behavioral therapy is based on the notion that the way we think about something influences the way we behave and feel. Negative patterns of thinking tend to be automatic and pervasive, coloring individual’s perceptions of the world around them and affecting their mood and self-esteem. Cognitive behavioral therapy, used often and successfully with depressed older people, suggests that the depressed elder’s unrealistic negative thought processes are central to becoming and staying depressed (Belsky 1984). Because cognitive-behavioral therapy focuses on symptoms and thought processes (rather than a hypothetical unconscious cause) and fosters a sense of self-responsibility and self-control, the patient are often receptive and willing to try it. Furthermore, in cognitive-behavioral therapy, the patients are not required to reveal their private thoughts to the clinician. Cognitive and behavioral therapies differ in some important aspects, but they also have aspects in common. Cognitive and behavioral approaches can be integrated, using the sociallearning concept as a framework. As you study the rest of this section, which deals with the teaching-learning process, you will see areas in which an integration of the two approaches is possible. A comparison of Cognitive Therapy and Behavioral Therapy can be observed through the following given table.

Cognitive-Behavioral Therapy

317

A Comparison of Cognitive Therapy and Behavioral Therapy Cognitive Therapy Behavioral Therapy Similarities
Formulate symptoms in Same behavioral terms, and design specific set of operations to alter maladaptive behavior. Collaborate with and coach client regarding reactive responses. Same Seek to alleviate overt symptoms or behavioral problems directly. Same Stress here and now, not the past.

Differences
Use induced and spontaneous images to identify misconceptions and test distorted views against reality. Apply techniques of systematic desensitization by inducing a predetermined sequence of images alternating with periods of relaxation. Modify attitudes, beliefs, or Modify behavior directly modes of thinking that influence (through reciprocal inhibition, behavior. systematic desensitization and so on). Modify ideational content (e.g., Modify behavior directly. irrational premises and inferences) to aid change in behavior. Work with internally experienced Work with observable behavior. cognitive structures (schemas) that influence client’s perceptions, interpretations, and images.

Cognitive-Behavioral Therapy

318

Risk Factors Cognitive-behavioral therapy is a clinically and research proven break through in mental health care, which is used in the following conditions. 1. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. Depression and mood swings. Shyness and social anxiety. Panic attacks and phobias. Obsessions and compulsions. Chronic anxiety or worry. Post traumatic stress symptoms. Eating disorders and obesity. Insomnia and other sleep problems. Difficulty establishing staying in relationship. Problem with marriage or other relationship. Job career of school difficulty. Feeling stressed out. Insufficient self-esteem. In educate coping skills self- or ill-chosen method of coping. Passivity – Procrastination and “passive aggression”. Substance abuse co-dependency and “enabling”. Trouble keeping feeling such as anger sadness, fear, guilt, shame, eagerness, excitement, etc. within bounds. Over-inhibition of feeling or expression.

Cognitive-Behavioral Therapy

319

Nursing Diagnoses There are six basic commonalties that link delirium, dementia, and amnestic disorders: impaired cognition, alteration in thought processes, impaired communication, behavioral disturbances, self-care deficits and impaired socialization. A comorbid medical condition may exist. These commonalties are considered during the formulation of the nursing diagnoses. Comprehensive Assessment of Impaired Cognition and Behavioral Manifestations History – include data regarding birth, developmental stages, medical history, medication, time of onset of clinical symptoms, rate of progression, and any family history of dementia. Physical Examination – mental status evaluation: obtain information regarding any past psychiatric treatments. General physical and neurologic examination. Studies – Complete blood count, sedimentation rate, chemistry panel (electrolytes, calcium, albumin, BUN, creatinine, transminase, blood sugar), thyroid function tests, VDRL or RPR, urinalysis, serum B12 and folate levels, human immunodeficiency virus (HIV), if permission is granted. Imaging – Chest x-ray, head computed tomography scan (CT scan), Electrocardiogram (ECG). Additional Studies – Electroencephalogram (EEG), Neuropsychiatric testing, Head magnetic resonance imaging (MRI) if vascular dementia suspected, Lumbar puncture (LP), Drug and alcohol toxicology, Heavy metal screen.

Cognitive-Behavioral Therapy

320

Cognitive Behavioral Interventions It is preferable to try cognitive-behavioral therapy alone before prescribing medications, this is for several reasons. It would seem that cognitive behavior therapy, when applied to the patients, is a heuristic process. In practice, the preparation and ongoing evaluation of the treatment’s success, and its impact upon the client’s broader mental state, guarantee a collaborative approach sensitive to changes. The use of specific, individualized assessment tools such as the Beliefs About Voices Questionnaire, go further in providing the individuality that successful symptom management requires. The client who combats the fear to concentrate on conversations or television will require a strategy that assists cognitive functioning, not a strategy to assist affect regulation. Medications – Used judiciously, medication can be an effective adjunct to psychotherapy for mental disorders in patients. The high incidence of adverse drug reactions was observed in elderly patients, therefore careful monitoring and conservative dosages are required. Moreover, medical and nursing personnel caring for these patients taking psychoactive medication require special training and ongoing staff development. The goals of cognitive behavioral intervention are the following:
• • •

Alter pain perception. Alter pain behavior. Provide clients with greater sense of control over pain.

Many cognitive behavioral pain relies strategies are also used to relieve stress. Interventions such as progressive relaxation, guided imagery, therapeutic touch and biofeedback.

Cognitive-Behavioral Therapy

321

Types of Distraction 1) Visual distraction. iv) v) vi) 2) Reading or watching television. Watching a baseball game. Guided imagery.

Auditory distraction. iii) iv) Humor. Listening to music.

3)

Tactile distraction. iv) v) vi) Slow, rhythmic breathing. Massage. Holding or stroking a pet or toy.

4)

Intellectual distraction iv) v) vi) Crossword puzzles. Card games (e.g. bridge) Hobbies (e.g., stamp collecting, writing story).

Milieu Therapy – a broad, all-encompassing intervention, may be adapted to meet the needs of most of the nursing diagnostic categories. In particular, milieu therapy is appropriate for clients experiencing diversional activity deficit, self-care deficit, sleep pattern disturbance, self-concept disturbance, high risk for violence, altered thought processes, powerlessness, and impaired physical mobility. Precaution Benzodiazepine drugs such as alprazdom (Xanall) plus certain other types of tranquilizers can be habit forming, if taken over a long time or in high doses.

322

Cognitive-Behavioral Therapy

Interventions within a Therapeutic Milieu Structure
Regular meal times Scheduled activities Predictability and routine Consistency Bowel/bladder program Shift change Medication time Vita signs Regular MD visits Primary nursing Care planning Evaluation

Containment
Physical aspects of the facility include the interior design, safety features, atmosphere, space, privacy, lighting location, temperature, noise, odors, colors, infection control, restraints, confinement, isolation, “homey” atmosphere of client rooms, roommates, access to public transportation, “knock before entering” policy

Support
Nourishment Medication Social support Reassurance Visitors Physical therapy and occupational therapy Spiritual expression Consistent positive staff attitudes Handrails Mutual goal setting Exercise

Involvement
Mutual goal setting Self-care Client contracting Community meetings Family involvement Client self-evaluation Suggestion box Client autonomy and decision making Group work

Validation
Reality orientation Feedback and acceptance Interaction and contact with the world Music, touch, warmth, and creative expression Sensory stimulation Focus on positive aspects of behavior “Downplay” of negative Newspaper and TV One-on-one relationships Excursions outside

Cognitive-Behavioral Therapy

323

Nursing Intervention 1. 7. 8. 9. 10. Use environmental manipulation to assist patient to cooperate with plan for activities of daily living. Allow use of toilet articles brought from home, play soft music or relaxation tapes at rest or bedtime. Give positive reinforcement with praise, smiles and rewarding experiences for cooperation in activities. Establish an effective communication pattern depending on degree of deterioration. Speak calmly, clearly and slowly one sentence at a time and repeat as necessary, use short and simple sentences. If patient is confrontive yelling or belligerent do not argue or raise your voice, speak gently and calmly and patient will calm down.

11.

Cognitive-Behavioral Therapy

324

Psychological Intervention Psychological interventions in psychosis have been found to produce positive responses in about 50% cases however, isolating the determinant factors that predict improved psychotic symptomatology have not been clearly demonstrated. Psychotic symptomatology refers to a broad range of features commonly associated with various psychiatric disorders. Generally, symptom management is achieved by enabling the client to link feelings and patterns of thinking and connect them to subjective distress and life disruption. This is usually done by examining the evidence in support of and against the distressing belief, using reasons and logic to find an acceptable explanation and challenging habitual patterns of thinking. The necessary collaboration and assessment is therapeutic in itself and the added focus and direction provided by specific interventions serves to guide and develop practice. Psychological preparation of children for surgery using behavioral strategies (e.g., relaxation and training in coping skills) has been beneficial in reducing postoperative anxiety and distress and generally improving psychological adjustment.

Cognitive-Behavioral Therapy

325

Scenario
Mr. Jim, a 58 years old man, was seen by the nurse practitioner, two weeks after the death of his wife. They had been married 30 years and never had any children. Jim’s sister and brother-in-law suggested that he tell his primary clinician that he was having difficulty adjusting to the death of his wife. During the visit, Jim confided in the nurse that he had not been sleeping well. His affect was blunted as he stated that he thought he would be the first to die. He informed the nurse that he did not want to take any medication for insomnia or depression but that he was willing to try alternative measures to sleep better at night.

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326

References 1. Shives Louise Rebraca and Isaacs Ann (2002). Cognitive Behavioral Therapy In: Basic Concepts of Psychiatric-Mental Health Nursing. 5th Edition. Lippincott Williams and Wilkins Philadelphia; p 418. Harber, Hoskins and Leach (1978). Behavioral and Cognitive Theory and Application In: Comprehensive Psychiatric Nursing. 3rd Edition. USA; pp 467-484. Walker JI. Essentials of Clinical Psychiatry. ISBN 0-39750642-2; pp 386-390. Elsevier Nam Boodiri (2005). Cognitive Therapy In: Concise Textbook of Psychiatric. 2nd Edition. Raj Kamal Electric Press Delhi; p 347, Townsend Marry C (1941). The nursing process across the life span In: Psychiatric Mental Nursing. pp 893-896. Cox HC, Hinz MD, Lubno MA, Newfield SA, Ridenour NA, Salater MM, Sridaromount KL (1996). Clinical Applications of Nursing Diagnosis – Adult, Child, Women’s, Psychiatric, Gerontic, and Home Health Considerations. McGraw Hill New York; pp 397-398. http://www.google.com. Scott J (2001). Cognitive therapy for depression. B Med Bulletin; 57:101-113. http://www.google.com. Bryant RA, Sackville T, Dang TS, Moulds M, Guthrie R (1999). Treating Acute Stress Disorder: An Evaluation of Cognitive Behavior Therapy and Supportive Counseling Techniques. http://www.yahoo.com. Bush JW. The Basis of Cognitive Behavior Therapy. http://www.yahoo.com. Holland M, Baguley I, Davies T (1999). Psychological Methods of Treating Hallucinations and Delusions: 1. B J Nursing; 8(15):998-1001.

22.

23.
24.

25. 26.

27. 28.

29. 30.

327 NURSING CARE PLAN Name: Age Sex Medical Diagnosis Nursing Diagnosis Mr. Jim 58 Years Male Depression Sleep pattern disturbance with depression.
Nursing Diagnosis Disturbed sleep pattern related to depression as evidenced by difficulty remaining asleep and statement by client that he is not sleeping well. Goal Short term goals Intervention

Cognitive-Behavioral Therapy

Assessment Subjective Data According to the patient, after the death of his wife, he was having difficulty adjusting to the death of his wife and was not sleeping well. His affect was blunted as he stated that he thought he would be the first to die. He did not want to take any medication for insomnia or depression, but that he was willing to try alternative measures to sleep better at night. Objective Data Mr. Jim, a 58 years old male come in Psychiatric OPD with complain of disturbed sleep pattern related to depression.. He looks irritate and drozy. His walking is imbalance. He looks pale and week with slow speak. Vital Signs • Blood Pressure • Temperature • Pulse • Respiratory rate 100/65 mmHg 98 °F 70 bpm 20 per min

Evaluation

Will verbalized decreased number of complaints regarding loss of sleep. Will report an improvement in his sleep pattern.

Suggest sleep preparatory activities such as quiet music, warm fluids, and decreased active exercise at least one hour prior to scheduled sleep time. Provide high carbohydrate snacks.

Carbohydrates stimulate secretion of insulin. Insulin decreases all amino acids but tryptophan in larger quantities in the brain increases production of serotonin, a neurotransmitter then reduces sleep. The urge to void interrupts the sleep cycle during the night. Environment temperature i.e., the most conducive to sleep. Promotes sleep. Promotes sleep. Promote rhythm. uninterrupted uninterrupted regular diurnal

• • • •

Client kept a sleep diary for 7 days. Follow visit in week. up one

• • • • •

Assist to bathroom or bedside commode, or offer bedpan at 09:00 PM. Maintain room temperature at 68 to 72°F. Schedule all patient’s therapeutics prior to 09:00 PM. Once patient is sleeping place, put do not disturb sign on door. Increase exercise and activities during the day as appropriate for patient’s condition.

• • • • •

He was able to sleep 5-6 hours each night. He was able to discuss his feelings with his sister and brother-in-law and had decided to attend grief counseling at their church.

Long term goals

Will demonstrated at least 6 to 8 hours of uninterrupted sleep night.

Cognitive-Behavioral Therapy

328

LIAQUAT UNIVERSITY OF MEDICAL AND HEALTH SCIENCE JAMSHORO SINDH

Cognitive-Behavioral Therapy
ACN III Shahnawaz
BScN Year-II Student College of Nursing, JPMC

Madam Yasmin 23rd July, 2005

Cognitive-Behavioral Therapy

329

OBJECTIVES
At the end of this presentation, the participants will be able to: 11. Define and Describe Cognitive Theory,

Behavior and Cognitive Behavioral Therapy. 12. Differentiate between Cognitive and Behavioral Therapies. 13. Explain risk factors. 14. Describe nursing diagnoses.
15.

Discuss

cognitive-behavioral

interventions,

nursing and psychological intervention.

Cognitive-Behavioral Therapy

330

COGNITIVE-BEHAVIORAL THERAPY
Introduction Cognitive-behavioral therapy combines two very effective kinds of psychotherapy, cognitive therapy and behavior. It approaches to treatment useful for the patients experiencing ineffective individual coping, fear, and powerlessness and selfconcept disturbance. Vague, abstract, and “mysterious” approaches to therapy are not tolerated well by patients. They seek a therapeutic relationship that provides some reciprocity. Nurses caring for them must invest themselves through active involvement and judicious self-disclosure to foster trust and a warm, caring relationship. Cognitive-behavioral therapy is based on the notion that the way we think about something influences the way we behave and feel. Negative patterns of thinking tend to be automatic and pervasive, coloring individuals’ perceptions of the world around them and affecting their mood and self-esteem. Cognitive-behavioral therapy used often and successfully with depressed patients suggests that the depressed unrealistic negative thought processes are central to becoming and staying depressed (Belsky 1984). A combination of cognitive and behavioral approaches has been found to work best with the elderly. These approaches are “practical” and very specific, providing concrete goals (e.g., behavior change or correction of negative thought patterns) and ongoing evaluation of progress through selfmonitoring of goals accomplishment.

Cognitive-Behavioral Therapy

331

Definitions To understand the term cognitive-behavioral therapy it is necessary to go through the definitions of term’s cognitive theory and behavior. Cognitive Theory Cognitive theorists seek to help clients understand how negative and conflicting thought patterns influence their appraisals of certain situations, with the result that their emotional reactions to these situations – such as anger, depression, and fear – are exaggerated or inappropriate. The interactive relationship between people and their environments makes it important to emphasize the clients’ active participation in the process of change: defining problems, selecting behavioral objectives, and evaluating outcomes. Nurses in the teaching-learning, reasoning, understanding and remembering can use principles of cognitive learning. Thought and memory enter into every cognitive action. Cognitive therapy offers a way of effecting behavioral and emotional change through analysis and revision of the client’s thinking and perception. Cognitive therapy is a collaborative ‘hypothesis-testing’ approach that uses guided discovery to identify and reevaluate distorted cognitions and dysfunctional beliefs. However, the common misconception that cognitive therapy uses a fixed set of behavioral (e.g., activity scheduling) and cognitive (e.g., challenging automatic thoughts) techniques is unfortunate. The therapy is not simply technique drive. The interventions are selected on the basis of a cognitive conceptualization the uniquely identifies the likely core negative beliefs of that individual and explains the onset and maintenance of their depression. If the patient shows a low level of functioning, behavioral techniques may be used to improve activity levels and improve moods, but the goal is still to identify and modify negative cognitions and maladaptive underlying beliefs.

Cognitive-Behavioral Therapy

332

Behavior Wolpe’s Definition of Behavior According to Wolpe, behavior is a conditioned response, that is, a response, which has been rewarded. Many behaviors become habits, which are established, long-standing patterns of response to stimuli. Maladaptive behaviors are thought to have begun in response to uncomfortable levels of anxiety and to have been rewarded by decreased anxiety. Wolpe’s Approach to Behavioral Therapy The behavioral therapist, in contrast to practitioners using other therapeutic approaches, takes total responsibility for the cure of the client. The client exhibits maladaptive behavior, and the therapist has the tools to correct it. The goals of treatment are to decondition anxiety and to alter maladaptive behavior. Deconditioning of anxiety is central to behavioral therapy four methods are used. 1. Assertive behavior is the expression of emotion appropriate to the current situation rather than an expression of anxiety. Systematic desensitization is a step-by-step use a counteracting emotion to overcome an undesirable emotional habit and can occurs in four steps (a) training in deep muscle relaxation, (b) use of a scale of subjective anxiety, (c) construction of anxiety hierarchies, and (d) use of relaxation techniques in conjunction with desensitization. Evoking strong anxiety is used as another way to decondition anxiety. In this, two techniques are used; (a) flooding and (b) abreaction. Operant conditioning is a method that deals with conditioned motor and cognitive behaviors rather than autonomic behavior. The point of operant conditioning is to elicit adaptive motor and cognitive behaviors.

5.

6.

7.

Cognitive-Behavioral Therapy

333

Miller and Dollard’s Definition of Behavior According to Miller and Dollard, behavior reflects a way of coping with conflict and its associated anxiety. There are two kinds of conflicts. An avoidance-avoidance conflict occurs when one must choose between two undesirable alternatives. An approach-avoidance conflict occurs when one has ambivalent feelings about an object: one wishes, simultaneously, toe approach and avoid it. Miller and Dollard’s Approach to Behavioral Therapy There are four fundamentals of learning: A drive – is motivation; it can be primary (biological) or secondary (learned). A cue – is a stimulus, a push to respond. A response – is a thought, feeling, or action caused by the cue. A reinforcement – is a reward for a response. Miller and Dollard consider a decrease in fear and anxiety to be the major reinforcement in neurotic behavior. Four principles of learning are based on these fundamentals: 1.
5.

Extinction – is a decrease in the rate of neurotic behavior when the behavior is not reinforced. Spontaneous recovery – is the tendency for neurotic behavior to recur periodically, even in the absence of reinforcement. Generalization – is the tendency to transfer the learning in one situation to similar situations. Discrimination – is the ability to notice the similarities and differences in like situations.

6.

7.

Cognitive-Behavioral Therapy

334

Cognitive-Behavioral Therapy Cognitive-behavior therapy uses confrontation as a means of helping clients restructure irrational beliefs and behavior. In other words, the therapist confronts the client with a specific irrational thought process and helps to rearrange maladaptive thinking, perceptions or attitudes. Thus, by changing thoughts, a person can change feelings and behavior. Cognitive behavior therapy is considered a choice of treatment for depression and adjustment difficulties. Rational emotive therapy is a type of cognitive therapy that is effective with groups whose members have similar problems. Cognitive-behavioral therapy is based on the notion that the way we think about something influences the way we behave and feel. Negative patterns of thinking tend to be automatic and pervasive, coloring individual’s perceptions of the world around them and affecting their mood and self-esteem. Cognitive behavioral therapy, used often and successfully with depressed older people, suggests that the depressed elder’s unrealistic negative thought processes are central to becoming and staying depressed (Belsky 1984). Because cognitive-behavioral therapy focuses on symptoms and thought processes (rather than a hypothetical unconscious cause) and fosters a sense of self-responsibility and self-control, the patient are often receptive and willing to try it. Furthermore, in cognitive-behavioral therapy, the patients are not required to reveal their private thoughts to the clinician. Cognitive and behavioral therapies differ in some important aspects, but they also have aspects in common. Cognitive and behavioral approaches can be integrated, using the sociallearning concept as a framework. As you study the rest of this section, which deals with the teaching-learning process, you will see areas in which an integration of the two approaches is possible. A comparison of Cognitive Therapy and Behavioral Therapy can be observed through the following given table.

Cognitive-Behavioral Therapy

335

A Comparison of Cognitive Therapy and Behavioral Therapy Cognitive Therapy Behavioral Therapy Similarities
Formulate symptoms in Same behavioral terms, and design specific set of operations to alter maladaptive behavior. Collaborate with and coach client regarding reactive responses. Same Seek to alleviate overt symptoms or behavioral problems directly. Same Stress here and now, not the past.

Differences
Use induced and spontaneous images to identify misconceptions and test distorted views against reality. Apply techniques of systematic desensitization by inducing a predetermined sequence of images alternating with periods of relaxation. Modify attitudes, beliefs, or Modify behavior directly modes of thinking that influence (through reciprocal inhibition, behavior. systematic desensitization and so on). Modify ideational content (e.g., Modify behavior directly. irrational premises and inferences) to aid change in behavior. Work with internally experienced Work with observable behavior. cognitive structures (schemas) that influence client’s perceptions, interpretations, and images.

Cognitive-Behavioral Therapy

336

Risk Factors Cognitive-behavioral therapy is a clinically and research proven break through in mental health care, which is used in the following conditions. 1. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. Depression and mood swings. Shyness and social anxiety. Panic attacks and phobias. Obsessions and compulsions. Chronic anxiety or worry. Post traumatic stress symptoms. Eating disorders and obesity. Insomnia and other sleep problems. Difficulty establishing staying in relationship. Problem with marriage or other relationship. Job career of school difficulty. Feeling stressed out. Insufficient self-esteem. In educate coping skills self- or ill-chosen method of coping. Passivity – Procrastination and “passive aggression”. Substance abuse co-dependency and “enabling”. Trouble keeping feeling such as anger sadness, fear, guilt, shame, eagerness, excitement, etc. within bounds. Over-inhibition of feeling or expression.

Cognitive-Behavioral Therapy

337

Nursing Diagnoses There are six basic commonalties that link delirium, dementia, and amnestic disorders: impaired cognition, alteration in thought processes, impaired communication, behavioral disturbances, self-care deficits and impaired socialization. A comorbid medical condition may exist. These commonalties are considered during the formulation of the nursing diagnoses. Comprehensive Assessment of Impaired Cognition and Behavioral Manifestations History – include data regarding birth, developmental stages, medical history, medication, time of onset of clinical symptoms, rate of progression, and any family history of dementia. Physical Examination – mental status evaluation: obtain information regarding any past psychiatric treatments. General physical and neurologic examination. Studies – Complete blood count, sedimentation rate, chemistry panel (electrolytes, calcium, albumin, BUN, creatinine, transminase, blood sugar), thyroid function tests, VDRL or RPR, urinalysis, serum B12 and folate levels, human immunodeficiency virus (HIV), if permission is granted. Imaging – Chest x-ray, head computed tomography scan (CT scan), Electrocardiogram (ECG). Additional Studies – Electroencephalogram (EEG), Neuropsychiatric testing, Head magnetic resonance imaging (MRI) if vascular dementia suspected, Lumbar puncture (LP), Drug and alcohol toxicology, Heavy metal screen.

Cognitive-Behavioral Therapy

338

Cognitive Behavioral Interventions It is preferable to try cognitive-behavioral therapy alone before prescribing medications, this is for several reasons. It would seem that cognitive behavior therapy, when applied to the patients, is a heuristic process. In practice, the preparation and ongoing evaluation of the treatment’s success, and its impact upon the client’s broader mental state, guarantee a collaborative approach sensitive to changes. The use of specific, individualized assessment tools such as the Beliefs About Voices Questionnaire, go further in providing the individuality that successful symptom management requires. The client who combats the fear to concentrate on conversations or television will require a strategy that assists cognitive functioning, not a strategy to assist affect regulation. Medications – Used judiciously, medication can be an effective adjunct to psychotherapy for mental disorders in patients. The high incidence of adverse drug reactions was observed in elderly patients, therefore careful monitoring and conservative dosages are required. Moreover, medical and nursing personnel caring for these patients taking psychoactive medication require special training and ongoing staff development. The goals of cognitive behavioral intervention are the following:
• • •

Alter pain perception. Alter pain behavior. Provide clients with greater sense of control over pain.

Many cognitive behavioral pain relies strategies are also used to relieve stress. Interventions such as progressive relaxation, guided imagery, therapeutic touch and biofeedback.

Cognitive-Behavioral Therapy

339

Types of Distraction 1) Visual distraction. vii) Reading or watching television.

viii) Watching a baseball game. ix) 2) Guided imagery.

Auditory distraction. v) vi) Humor. Listening to music.

3)

Tactile distraction. vii) Slow, rhythmic breathing.

viii) Massage. ix) 4) Holding or stroking a pet or toy.

Intellectual distraction vii) Crossword puzzles.

viii) Card games (e.g. bridge) ix) Hobbies (e.g., stamp collecting, writing story).

Milieu Therapy – a broad, all-encompassing intervention, may be adapted to meet the needs of most of the nursing diagnostic categories. In particular, milieu therapy is appropriate for clients experiencing diversional activity deficit, self-care deficit, sleep pattern disturbance, self-concept disturbance, high risk for violence, altered thought processes, powerlessness, and impaired physical mobility. Precaution Benzodiazepine drugs such as alprazdom (Xanall) plus certain other types of tranquilizers can be habit forming, if taken over a long time or in high doses.

340

Cognitive-Behavioral Therapy

Interventions within a Therapeutic Milieu Structure
Regular meal times Scheduled activities Predictability and routine Consistency Bowel/bladder program Shift change Medication time Vita signs Regular MD visits Primary nursing Care planning Evaluation

Containment
Physical aspects of the facility include the interior design, safety features, atmosphere, space, privacy, lighting location, temperature, noise, odors, colors, infection control, restraints, confinement, isolation, “homey” atmosphere of client rooms, roommates, access to public transportation, “knock before entering” policy

Support
Nourishment Medication Social support Reassurance Visitors Physical therapy and occupational therapy Spiritual expression Consistent positive staff attitudes Handrails Mutual goal setting Exercise

Involvement
Mutual goal setting Self-care Client contracting Community meetings Family involvement Client self-evaluation Suggestion box Client autonomy and decision making Group work

Validation
Reality orientation Feedback and acceptance Interaction and contact with the world Music, touch, warmth, and creative expression Sensory stimulation Focus on positive aspects of behavior “Downplay” of negative Newspaper and TV One-on-one relationships Excursions outside

Cognitive-Behavioral Therapy

341

Nursing Intervention 1. 12. 13. 14. 15. Use environmental manipulation to assist patient to cooperate with plan for activities of daily living. Allow use of toilet articles brought from home, play soft music or relaxation tapes at rest or bedtime. Give positive reinforcement with praise, smiles and rewarding experiences for cooperation in activities. Establish an effective communication pattern depending on degree of deterioration. Speak calmly, clearly and slowly one sentence at a time and repeat as necessary, use short and simple sentences. If patient is confrontive yelling or belligerent do not argue or raise your voice, speak gently and calmly and patient will calm down.

16.

Cognitive-Behavioral Therapy

342

Psychological Intervention Psychological interventions in psychosis have been found to produce positive responses in about 50% cases however, isolating the determinant factors that predict improved psychotic symptomatology have not been clearly demonstrated. Psychotic symptomatology refers to a broad range of features commonly associated with various psychiatric disorders. Generally, symptom management is achieved by enabling the client to link feelings and patterns of thinking and connect them to subjective distress and life disruption. This is usually done by examining the evidence in support of and against the distressing belief, using reasons and logic to find an acceptable explanation and challenging habitual patterns of thinking. The necessary collaboration and assessment is therapeutic in itself and the added focus and direction provided by specific interventions serves to guide and develop practice. Psychological preparation of children for surgery using behavioral strategies (e.g., relaxation and training in coping skills) has been beneficial in reducing postoperative anxiety and distress and generally improving psychological adjustment.

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Scenario
Mr. Jim, a 58 years old man, was seen by the nurse practitioner, two weeks after the death of his wife. They had been married 30 years and never had any children. Jim’s sister and brother-in-law suggested that he tell his primary clinician that he was having difficulty adjusting to the death of his wife. During the visit, Jim confided in the nurse that he had not been sleeping well. His affect was blunted as he stated that he thought he would be the first to die. He informed the nurse that he did not want to take any medication for insomnia or depression but that he was willing to try alternative measures to sleep better at night.

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References 1. Shives Louise Rebraca and Isaacs Ann (2002). Cognitive Behavioral Therapy In: Basic Concepts of Psychiatric-Mental Health Nursing. 5th Edition. Lippincott Williams and Wilkins Philadelphia; p 418. Harber, Hoskins and Leach (1978). Behavioral and Cognitive Theory and Application In: Comprehensive Psychiatric Nursing. 3rd Edition. USA; pp 467-484. Walker JI. Essentials of Clinical Psychiatry. ISBN 0-39750642-2; pp 386-390. Elsevier Nam Boodiri (2005). Cognitive Therapy In: Concise Textbook of Psychiatric. 2nd Edition. Raj Kamal Electric Press Delhi; p 347, Townsend Marry C (1941). The nursing process across the life span In: Psychiatric Mental Nursing. pp 893-896. Cox HC, Hinz MD, Lubno MA, Newfield SA, Ridenour NA, Salater MM, Sridaromount KL (1996). Clinical Applications of Nursing Diagnosis – Adult, Child, Women’s, Psychiatric, Gerontic, and Home Health Considerations. McGraw Hill New York; pp 397-398. http://www.google.com. Scott J (2001). Cognitive therapy for depression. B Med Bulletin; 57:101-113. http://www.google.com. Bryant RA, Sackville T, Dang TS, Moulds M, Guthrie R (1999). Treating Acute Stress Disorder: An Evaluation of Cognitive Behavior Therapy and Supportive Counseling Techniques. http://www.yahoo.com. Bush JW. The Basis of Cognitive Behavior Therapy. http://www.yahoo.com. Holland M, Baguley I, Davies T (1999). Psychological Methods of Treating Hallucinations and Delusions: 1. B J Nursing; 8(15):998-1001.

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345 NURSING CARE PLAN Name: Age Sex Medical Diagnosis Nursing Diagnosis Mr. Jim 58 Years Male Depression Sleep pattern disturbance with depression.
Nursing Diagnosis Disturbed sleep pattern related to depression as evidenced by difficulty remaining asleep and statement by client that he is not sleeping well. Goal Short term goals Intervention

Cognitive-Behavioral Therapy

Assessment Subjective Data According to the patient, after the death of his wife, he was having difficulty adjusting to the death of his wife and was not sleeping well. His affect was blunted as he stated that he thought he would be the first to die. He did not want to take any medication for insomnia or depression, but that he was willing to try alternative measures to sleep better at night. Objective Data Mr. Jim, a 58 years old male come in Psychiatric OPD with complain of disturbed sleep pattern related to depression.. He looks irritate and drozy. His walking is imbalance. He looks pale and week with slow speak. Vital Signs • Blood Pressure • Temperature • Pulse • Respiratory rate 100/65 mmHg 98 °F 70 bpm 20 per min

Evaluation

Will verbalized decreased number of complaints regarding loss of sleep. Will report an improvement in his sleep pattern.

Suggest sleep preparatory activities such as quiet music, warm fluids, and decreased active exercise at least one hour prior to scheduled sleep time. Provide high carbohydrate snacks.

Carbohydrates stimulate secretion of insulin. Insulin decreases all amino acids but tryptophan in larger quantities in the brain increases production of serotonin, a neurotransmitter then reduces sleep. The urge to void interrupts the sleep cycle during the night. Environment temperature i.e., the most conducive to sleep. Promotes sleep. Promotes sleep. Promote rhythm. uninterrupted uninterrupted regular diurnal

• • • •

Client kept a sleep diary for 7 days. Follow visit in week. up one

• • • • •

Assist to bathroom or bedside commode, or offer bedpan at 09:00 PM. Maintain room temperature at 68 to 72°F. Schedule all patient’s therapeutics prior to 09:00 PM. Once patient is sleeping place, put do not disturb sign on door. Increase exercise and activities during the day as appropriate for patient’s condition.

• • • • •

He was able to sleep 5-6 hours each night. He was able to discuss his feelings with his sister and brother-in-law and had decided to attend grief counseling at their church.

Long term goals

Will demonstrated at least 6 to 8 hours of uninterrupted sleep night.

Panic Disorder346

Liaquat University of Medical and Health Sciences, Jamshoro Sindh College of Nursing, JPMC, Karachi BScN Year II, Session 2006-2008 Mental Status Examination Advanced Concept of Nursing Shagufta Rani Mrs. Mustaqima Begum Dated: ______________

Panic Disorder347 Definition The mental status examination is the most important diagnostic tool a psychiatrist has to obtain information to make an accurate diagnosis. Background The mental status examination comes from the psychiatric tradition. It is considered to be analogous to the physical examine in general medicine (Siassi, 1984). Although usually described as a type of interview. The mental status examination is really a protocol for organizing one’s observations of the client. The examination actually takes place throughout the interview. Legally, a mental status examination, if conducted against the patient’s will be considered assault with battery. It is important to secure the patient’s permission or to document that a mental status is being done without the patient’s approval if in an emergency. The mental status examination being the moment the patient enters in the office. When patient enter the office, pay grooming, hygiene, gait and also note things such as whether the patient is dressed appropriately according to the season. For example, note whether the patient has come to the clinic in the summer, with three layers of clothing and a jacket. These types of observations are important and may offer insight into the patient’s illness. The next step for the interviewer is to establish adequate rapport with the patient by introducing himself or herself. Speak directly tot the patient. During this introduction and pay attention to whether the patient is maintaining eye contact. If patient appears uneasy as they enter the office attempt to ease the situation by offering small talk or even a glass of water. Beginning with open-ended questions is desirable in order to put the patient further at ease and to observe the patient’s stream of thoughts (content) and thought process. Begin the examination with questions, such as “What brings you here today?” or “Tell me about yourself.” These types of questions elicit responses that provide the basis of the interview.

Panic Disorder348 Keep in mind throughout the interview to look for nonverbal cues from patient. For example, not if he or she is avoiding eye contact, acting nervous, playing with their hair, or tapping their foot repeatedly. In addition to the patient’s responses to questions, as the interview progresses, more specific or close-ended questions can be asked in order to obtain specific information needed to complete the interview. For example, if the patient is reporting feelings of depression, but only states “I am just depressed.” determining both the duration and frequency of these depressive episodes is important. Ask leading questions such as “How long have you had these feelings?” or “When did these feelings begin?” “How many days in the past week have you felt this way?” These types of question help patients understand what information is needed from me. For safety reasons, both the patient and interviewer should have access to the door in case of an emergency during the interview process. The interviewer develops his or her own comfortable pace and should not feel rushed to complete the interview in any time. The process of conducting an accurate history and mental status examination takes practice and patience, but it is very important in order to evaluate and treat patients effectively. Mental Status Examination The following areas are typically covered in the mental status examination section of a report. General Appearance and Behavior – when patient enter in the office; pay close attention to his or her personal grooming, hygiene, gesture, gait, posture and level of activity of the patient. Note the patient’s sex, age, race, ethnic background and nutritional status by observing the patient’s current body weight and appearance. Also note the patient’s facial expressions and behavior. Record whether the patient is hostile, defensive, friendly and cooperative.

Panic Disorder349 Speech – document information on all aspects of the patient, speech including quality, quantity, rate and volume of speech. You observe, is the client’s speech coherent. Is it slow or fast? Are there long silence? Does the client’s speech appear pressure? Does the client use usual words? Also note tone of the patient during speech. Mood – the mood of the patient is defined as “sustained emotion that the patient is experiencing.” Ask questions such as “How do you feel most days?” Describe the patient’s mode such as depressed, anxious, good, tired, euphoric, irritable, etc. Affect – a patient’s affect is define in terms of expansive (contagious), euthymic (normal), constricted (limited variation), blunted (minimal variation) and flat (no variation). A patient whose mode could be defined as expensive may be so cheerful and full of laughter that is difficult to refrain from smiling while conducting the interview. A patient’s affect is determined by the observations made by the interviewer during the interview. Thought Process – record the patient’s thought process information. The process of thoughts can be described as looseness of association (irrelevance), flight of ideas (change topics), racing (rapid thoughts), tangential (departure from topic with no return), neologism (creating new words), circumstantial (being vague), word salad (nonsensical responses e.g., Jabber Wocky), derailment (extreme irrelevance), clanging (rhyming words), punning (talking in riddles), thought blocking (speech is halted). Take all of these things into account when documenting the patient’s thought process. Thought Content – to determine whether or not a patient is experiencing hallucinations, ask some of the following questions. Do you hear voices when no one else is around? Can you see things that no one else can see? Do you have other unexplained sensations such as smells, sounds, or feeling? Importantly, always ask about command type hallucinations and inquire what the patient will do in response to these commanding hallucinations. For example, when the voices tell you do something, do you obey their instructions or ignore them? Types of

Panic Disorder350 hallucinations include auditory (hearing things), visual (seeing things), gustatory (tasting things), tactile (feeling sensation), and olfactory (smelling things). To determine if a patient is having delusion, ask some of these questions. “Do you have any thoughts that other people think are strange?” “Do you have any special powers or abilities?” “Does the television or radio give you special messages?” Types of delusion include grandiose (delusion of grandeur), religious (delusion of special status with God), persecution (belief that someone wants to cause them harm), erotomanic (belief that someone famous is in love with them), jealousy (belief that everyone wants what they have), thought insertion (belief that someone is putting ideas or thoughts into their mind) and ideas of reference (belief that everything refers to them). Obsession and Compulsions – ask the following questions to determine if a patient has any obsessions or compulsions. “Are you afraid of dirt?” “Do you wash your hands often or count things over and over?” “Do you perform specific acts to reduce certain thoughts?”. Phobias – determine of patient having any fears that cause them to avoid certain situations. Some possible questions to ask include: “Do you have any fears, including fear of animals, needles, heights, snakes, public speaking or crowds? Suicidal Ideation – inquiring about suicidal ideation at each visit always is very important. In addition, the interviewer should inquire about past acts of self-harm or violence. Ask the questions when determining suicidal ideation. “Do you have any thoughts of wanting to harm or kill yourself?” Homicidal Ideation – inquiring about homicidal ideation is also important during interview. Ask these types of questions to help determine homicidal ideation. “Do you have nay thoughts of waning to hurt anyone?” “Do you have nay feelings or thoughts that you wish someone were dead?” If the reply tone of these questions is positive, ask the patient if he or she has any specific plans to injure someone and how she or he plans to control these feelings if they occur again.

Panic Disorder351 Cognitive Functioning – can he client think abstractly? A commonly used strategy for assessing abstract thinking is to ask the client to interpret a proverb. For example, Don’t count your chickens before they are hatched. An answer that suggests the ability to think abstractly might be something like “it means don’t jump the gun. It is not a good idea to assume that everything is going to work out in your favor.” The client who responds, “well, chickens come from eggs and you shouldn’t count eggs because you might break them” may tend to think more concretely. Consciousness – levels of consciousness are determined by the interviewer and are rated as: coma – characterized by unresponsiveness, stuporous – characterized by response to pain, lethargic – characterized by drowsiness, and alert – characterized by full awareness. Orientation – to elicit responses concerning orientation. Ask the questions to the patient. What is you full name? (patient), Do you know where you are? (place) What is the month, the date, the year and the time? (time) Do you know why you are here? (situation). Concentration and Attention – ask the patient to subtract 7 from 100, then to repeat the task from that response. This is known as “serial 7s”. Reading and Writing – ask the patient to write a simple sentence (noun/verb), then ask patient to read a sentence (e.g., close your eyes). This part of the mental status examination evaluates the patient’s ability to sequence. Memory – to evaluate a patient’s memory, ask various types of questions. For example, What was the name of you grade teacher? (for remote memory), What did you eat for dinner last night (for recent memory). Repeat these three words, pen, chair, flag (immediate memory). Tell the patient to remember these words then after 5 minutes, have the patient to repeat the words. Abstract Thought – assess the patient’s ability to determine similarities. Ask the patient, “How two items are alike?” For example, an apple and an orange (good response is “fruit” and poor response is “round”). Assess the patient’s ability to understand proverbs. For

Panic Disorder352 example “Don’t cry over spilled milk” (good response is don’t get upset over the little things; poor response is spilling milk is bad). General Knowledge – test the patient’s knowledge by asking some questions like: “How many towns in the Karachi?” “Who is the president of the Pakistan?” the interviewer always should take into consideration the patient’s educational background. Intelligence – based on the information provided by the patient throughout the interview. The level of intellectual functioning based upon patient’s educational history, vocabulary, general information and ability of reasoning. Insight and Judgment – assess the patient’s understanding of the illness. Judgment – estimate the patient’s judgment based on the history on an imaginary scenario. To elicit responses that evaluate a patient’s judgment adequately, ask patient, “What would you do if you smelled smoke in a crowded theatre?” (good response is to call 9 or get help; poor response is do nothing or light a cigarette). Impulsivity – estimate the degree of the patient’s impulse control. Ask the patient about doing things without thinking or planning. Ask about hobbies such as painting and coin collecting, etc. Overview of Taking History The history and mental status examination are crucial first step in the assessment and are the only diagnostic tools. Psychiatrists have to select treatment for each patient. Every component of the patient history is crucial to the treatment and care of the patient. The patient history should begin with: Identifying Data – ask patients their name or what name he or she prefers to be called. Also ask the patient’s marital status, occupation, religious belief, living circumstances, sex and race. Chief Complaint – this is the patient’s problem or reason for the visit. Most often, this is recorded as the patient’s own words, in quotation marks.

Panic Disorder353 History of Present Illness – the important part of taking a history of present illness is listening. This is the patient’s story of the presenting problem. This is usually involves a triggering event or something that caused the patient to choose this point in life to seek help. Past Medical History – list medical problems and all medical illness. Even the most minute detail of patient’s medical history from as far back as childhood, could play a significant role in the presenting problem. Be certain to inquire about specific events that may have occurred in childhood, such as falls, head trauma, seizures, and injuries with loss of consciousness. All of these could be relevant to their current problem. Past Surgical History – list all surgical procedures the patient has undergone, including dates. Past Psychiatric History – list all of the patient’s treatment and therapy based. For example individual, couples, family, group, etc. Inquire about past psychotherapies medication and response, competence and dosages. Family History – list any psychiatric or medical illness, and methods of treatment such as hospitalization of family members and responses. Social History – obtain a complete social history of the patient. Ask patients about their marital status, employment status and obtain information related to it. Record an accurate educational history, sex and age of the patient. List the patient’s toxic habits. For example use of tobacco or alcohol. Ask patient’s housing status and supporting to him. Record legal problems, this should include jail time, probation and arrest. Patient’s history also includes hobbies, social activities and friends circle. Inquire about the patient’s and his or her parents religious beliefs like “did the patient grow up in a strict religious environment? Prenatal and Development History – record any relevant prenatal and development history. Ask about patient’s birth history. Inquire the patient how old they were when they spoke their first word or took their first step.

Panic Disorder354 Conclusion They mental status examination and history are the most important diagnostic tools. A psychiatrist has to obtain information to make an accurate diagnosis although these important tools have been standardized in their own right. When the patient enters in the office, pay close attention to their personal grooming, hygiene, dressing, gait, gesture and posture. The interview establishes adequate rapport with the patient. It is important to secure the patient’s permission or to document that a mental status examination is being done without the patient’s approval in an emergency situation. The process of conducting, taking accurate history and mental status examination takes practice and patience. The interviewer should not feel rushed to complete the interview in anytime. Beginning with open-ended questions and as the interview progresses, close ended questions can be asked in order to obtain specific information. Every component of the patient history is crucial to the treatment and care of the patient. The patient history should begin with identifying patient data, chief compliant, history of present illness, past medical and surgical histories, past psychiatric history, family history, social history and prenatal and development history. Once the history and mental status examination completed, document this event accurately and efficiency is important.

Panic Disorder355 References   Carson, V.B. Mental Health Nursing: The Nurse patient journey. 2nd Edition. Hecker, J.E., & Thope, G.L. (2005). Introduction to clinical, psychology sciences, practice and ethics. 1st edition. India: Publisher Person Education Pvt. Ltd.  Schmetzer, A.D. Article. Retrieved on September 25, 2007 from

www.google.com.pk/.

Liaquat University of Medical and Health Sciences, Jamshoro Sindh College of Nursing, JPMC BScN Year-II Session 2006-2008 Panic Disorder Advance Concept of Nursing-III Sajida Siddique Mrs. Durr-e-Shahwar

Panic Disorder356 A Case Study It is the first time Celia had a panic attack. She was working at McDonald’s. It was two days before her 20th birthday. As she handling a customer a big Mac, she had worst experience of her life. The earth began to seem to open up beneath her. Her heart began to pound. She felt she was smothering. She broke into a flop sweat and she was sure she was going to die. After about 20 minutes of terror, the panic disorder subsided. Trembling, she got in her car and raced home, and barely left the house for next three months. Since that time, Celia has had about three attacks a month. She does not know when they are coming. During attach, she feels dread scaring, chest pain, smothering and choking, dizziness and shakiness. She sometimes thinks this is all not real and she is going crazy. She also thinks she is going to die (Seligman, 1993). What is Panic Disorder? Afridi (2003) reported that “panic disorder and social phobia re the varieties of anxiety disorder. To make the correct distinction in them is important. Many people with any type of anxiety disorder are typically misdiagnosed as begin ‘depressed’. This occur because any one with an anxiety disorder, including panic and social anxiety is naturally depressed over their. The panic is disorder is the anxiety that caused by ‘depression’.” Definition Panic means sudden uncontrolled fear especially in commercial dealing. When panic attack becomes common occurrence, and not provoked by any particular situation and person begins to worry about having attack and change behavior as a result of worry, the diagnose is panic disorder. People who have panic disorder will often fear that they have life threatening illness. People with panic disorder may continue to believe that they are about to die of heart attack or some other crisis. They may seek medical care frequently from physician to physician to find out what is wrong with them. The other common belief about people of

Panic Disorder357 panic disorder is that they are going crazy and losing control. Many people with panic disorder feel ashamed of their disorder and try to hide it from other if left untreated. They may become demoralize and depressed. Theories of Panic Disorder Biological theories of panic disorder have been concerned with poor regulation of neurotransmitters in particular part of the brain and with the role of genetics theories of panic disorder. Neurotransmitter theories – most of the modern theories of the biology of panic disorder have been the result of the medication effect of the neurotransmitter (and the other reason norepinephrine). Other researches suggested that when people are given drugs that alter the activity of the norepinephrine can produce panic attack. Some women with panic attack increase in during their premenstrual period and the postmentural period due to the ovarian hormones or progesterone. Kindling Model – of panic disorder that draws a link between the anticipatory anxiety. Suffocation False Alarm Theory – another theory of why people with panic disorder have panic attacks, when they hyperventilate, inhalation carbon dioxide. Suffocation false alarm theory, each of these procedures elevates levels of carbon dioxide in the blood and brain. People who develop panic disorder may be hypersensitive to carbon dioxide, the brain register ‘suffocation’ and this triggers the autonomic nervous system into a full fight or flight response. Genetic Theories – finally panic disorder appears to run in families. One family history study of panic disorder found that rarely one-fourth of the first degree relative of patient with panic disorder also had a history of panic disorder.

Panic Disorder358 Symptoms of Panic Attack               Heart palpitation. Pounding heart beat. Tingling sensation. Chill or hot flashes. Sweating. Trembling or shaking. Sensation of shortness of breath. Feeling of choking. Chest pain and discomfort. Nausea and upset stomach. Feeling of unreality. Fear of losing control. Going crazy. Fear of dying. Most people who developed panic disorder were between late adolescence and their mid 30s. The panic disorder can be deliberating in its own right. People panic disorder often also suffers from chronic generalized anxiety, depression and alcohol abuse. About one-third to one an a half of people diagnosed with panic disorder and develops agoraphobia. Agoraphobia is the fear of places where help might not be available in case of an emergency. The people with agoraphobia fear crowded places such as market, the shopping mall, enclose space which as buses, subways. They also fear of open fields particularly they are alone. Types of Phobia

Panic Disorder359 Agoraphobia – fear of places where help might not be available in case of emergency. Specific Phobia – fear of specific object, place or situation. Natural Environmental Type – events or situation in the natural environment. Person has external fear of storms, height, or water. Situational Type – public transportation, bridges, elevators, flying, driving, etc. Blood, Injection, Injury Type – the person become panic when see any blood injury or injection. Social Phobia – fear of being judged or embarrassed by other. Person avoids all social situations. Placed Avoided by People with Agoraphobia Most of the people suffering from agoraphobia avoids to public places like shopping mall, theaters, buses, supermarket, trains, stores, subways, planes, tunnels, elevators, restaurants, and railway station, etc. Sample Structured Interview  Have you ever had a panic attack when you suddenly frightened, anxious or extremely uncomfortable?  Have you ever had four attacks like that in a four weeks period? If no, did you worry a lot about having another one? How long did you worry?    When was the last bad one expected? What was the first thing you noticed during the attacks? Were you short of breath? Have trouble catching your breath? Did you feel dizzy like you might faint? Did you then race or pound?  Did you tremble? Did you sweat? Did you feel if you were choking? Did you have nausea?  Did things around you seem unreal and did you feel detached from part of your body?

Panic Disorder360 Investigation    Neuropsychological test. Intelligence test. Magnetic resonance imaging (MRI) is the newest of the brain imaging techniques and holds several advantages over both computed tomography (CT) and PET.  Two other tests that are sometimes used to record the brain activity are: EEG a graph of the electrical activity in the brain, and PET scan of the human brain. PET scan provide picture of the activity in the brain.  Event Related Potential (ERP) is a component of EEG, when person has a thought or senses something in the environment. In short, CT, PET, MRI, EEG and ERP are use to investigate the structural and functional differences between the brain of the people with psychological disorder. Treatment of Panic Disorder By using Drugs and Medicines: Tricyclic Antidepressants – increase level of norepinephrine and a number of other neurotransmitters. Side effects include dry mouth, blurred vision, difficulty in urinating, constipation, increase heart rate, sweating, sleep disturbance, hypotension, dizziness, fatigue, weakness, weight gain and sexual dysfunction. Serotonin Reuptake Inhibitors – increase levels of serotonin. Side effects include gastrointestinal upset, irritability initial feelings of agitation, insomnia, drowsiness, tremor and sexual dysfunction. Benzodiazepines – suppress the central nervous system and influence functioning in the neurotransmitter systems. Side effects include addictive interfere with cognitive and motor functions; withdrawn symptoms are irritability, tremors, insomnia, anxiety, tingling sensation, etc.

Panic Disorder361 By Relaxation Exercises: Relaxation exercises can be used to combat the everyday anxiety and the tension associated with anger that arises in most people’s lives. Six-second Quieting Response – is a simple breathing technique that one can use very quickly and in almost any situation to relax when you feel anxious or angry. Draw a long, deep breath, hold it for 2 or 3 seconds, exhale slowly and completely and as you exhale, let your jaw and shoulders drop. Feel relaxation flow into your arms and hands. Quick Head, Neck, and Shoulder Relaxers – These exercises involve tensing or stretching certain muscles. If you have had a significant injury, such as whiplash or an injured back, you should not try these exercises without first consulting your physician or physical therapist. Some of the muscles that most commonly tense up when we are anxious or angry are the neck and shoulder muscles. A quick way to release some of this tension is to first tighten the neck and shoulder muscles as much as possible, then hold this for 5 to 10 seconds. Then completely release the muscles. Repeat this number of times, focusing on the contrast between the tension and the relaxation. Some neck and shoulder tension can also be released by gently rotating you shoulders first forward and then backward. You can also gently rotate your head from side to side and from front to back in a circular motion. Then repeat the movements in the opposite direction. Continue this exercise a number of times until you feel more relaxed. Perform this exercise very slowly and gently or you may strain neck muscles. Nursing Intervention Cognitive Behavioral Therapy – is highly effective in eliminating panic disorder. There are numbers of component of the cognitive behavior therapy.

Panic Disorder362 References   Afridi (2005). Panic Disorder: A report. Pakistan. Practice guideline for treatment of patient with panic disorder. American Psychiatric Association. 1998.  Hocksema, S.N. Abnormal Psychology. 2nd Edition. An International Edition.

Panic Disorder363 Objectives At the end of this session, the learners will be able to:     Define teacher. Discuss the various styles of teaching. Describe the blend of various styles of teaching. Enlist some important tips for effective teaching.

Lesson Plan Subject: Level of students: Topic: BScN-II Demonstration of various teaching styles. Venue: Classroom CoN, JPMC, Karachi. Time Objectives Content Method of Teaching Evaluation

45 minutes

At the end of this session, the learners will be able to: • • • Define Teacher • Definition teacher. of • • Lecture method. Discussion Role play Whiteboard with marker. Overhead projector with transparencies. • Quiz. • Question and answer

Discuss various • styles of teaching. Describe the • blend of various styles of teaching. Enlist some • important tips for effective teaching.

Various styles of teaching. • The blend of • various styles of teaching. • Some important tips for effective teaching. & strategies

Assignment: Pre-reading. Felder, styles

R.M., and

Saloman, In:

B. Varlla,

Reference: (2003). Learning M.C. Guide to

learning style. Pennsylvania State University.

Liaquat University of Medical and Health Sciences, Jamshoro Sindh College of Nursing, JPMC, Karachi BScN Year-II Session 2006-2008 Nursing Care Plan & Reflection Log Advance Concept of Nursing-III Sajida Siddique Mrs. Mustaqima Begum

Introduction Celia had a panic attack. She was working at McDonald’s. She had worst experience of her life. The earth began to seem to open up beneath her. Her heart began to pound. She felt she was smothering. She broke into a flop sweat and she was sure she was going to die. After about 20 minutes of terror, the panic disorder subsided. Trembling, she got in her car and raced home, and barely left the house for next three months. During attach, she feels dread scaring, chest pain, smothering and choking, dizziness and shakiness. She sometimes thinks this is all not real and she is going crazy. She also thinks she is going to die (Seligman, 1993).

Focus Assessment Subjective Data/Objective Data                      Heart palpitation. Pounding heart beat. Increased blood pressure Tingling sensation. Feeling of choking. Chest pain and discomfort. Feeling of unreality. Fear of dying. Chill or hot flashes. Flush/pallor, sweating, paresthesia. Insomnia, Lack of concentration, Irritability Nightmares. Pupil dilation Trembling or shaking and weakness. Sensation of shortness of breath. Nausea and upset stomach. Going crazy. Depression and alcohol abuse. Feeling of dread, fright, apprehension and/or behaviors of avoidance, narrowing of focus or danger, deficits in attention, performance and control.

Verbal reports of panic, obsessions, crying, dysfunctional immobility, aggression, compulsive mannerisms, escape, hypervigilance, and increased questioning/ verbalization.

    

Muscle tightness, fatigue and urinary frequency/urgency. Anorexia Nausea/vomiting Diarrhea/urge to defecate Dry mouth/throat.

Diagnosis Consideration        Neuropsychological test. Intelligence test. Magnetic resonance imaging (MRI). Computed tomography (CT) and PET. EEG PET. Event Related Potential (ERP) is a component of EEG. In short, CT, PET, MRI, EEG and ERP are use to investigate the structural and functional differences between the brain of the people with psychological disorder. Nursing Diagnosis Fear related to thought disorder. Planning  By using Drugs and Medicines:

Tricyclic Antidepressants. Serotonin Reuptake Inhibitors.

Benzodiazepines    By Relaxation Exercises: Six-second Quieting Response Quick Head, Neck, and Shoulder Relaxers.

Expected Outcomes        Communicates within normal limits of volume. Communicates appropriately. Verbalizes feelings of anger, fear, frustration. Verbalizes how anger affects her verbal communication. Maintains as much control as possible. Verbalizes goals and expectation. Verbalizes feelings of loss of control and helplessness.

Nursing Interventions The nursing interventions for the diagnosis fear are:  Assess possible contributing factors

Perception of threatening stimulus Unfamiliar environment Intrusion on personal space Life- style change (promotion, marriage/ divorce, retirement) Biologic and physiologic change (dysfunction, disability, pain) Self-esteem threat (abandonment, rejection)    Distorted perceptions of dangerous stimulus Age-related fears Unfamiliar environment

Orient to environment using simple explanation. Speak slowly and calmly. Avoid surprises and painful stimuli. Use soft lights and music. Remove threatening stimulus. Plain one-day-at-a-time familiar routine. Encourage gradual mastery of a situation. Provide transitional object with symbolic safeness.  Intrusion on personal space

Allow personal space Move person away from stimulus Remain with person until fear subside Later, establish frequent Use touch as tolerated  Threat to self-esteem

Encourage person to face the fear      Distorted perceptions Explore superficial interactions Fear of imaginary animals, intruders. Fear of pain. Fear of death.

Rationales

Psychological defense mechanisms are distinctly individual and can be adaptive or maladaptive.

Fear differs from anxiety in that fear is a feeling aroused by an identified threat (specific object) anxiety is a feeling aroused by a threat that cannot be easily identified.

   

Both fear and anxiety lead to disequilibrium. Activity uses energy and dissipates the physical reaction to fear. Anger may be an adaptive response to certain fears. Safety feelings increase when a person identifies with another person who has successfully dealt with a similar fearful situation.

A sense of adequacy in confronting danger reduces fear. Fear disguises itself. The expressed fear may be substitutes for other fear are not socially acceptable. Awareness of factors that cause nitrifications of fear enhances controls and prevents heightened feelings. Fear is reduced when the safe reality of a situation is confronted.

Fear can become anxiety fear becomes internalized and serves to disorganize instead of becoming adaptive.

Individuals interpret the degree of danger from a threatening stimulus. The physiologic and psychological systems react with equal intensity to the perceived threat increase BP, decrease heart rate, and respiratory rate.)

 

Fear is adaptive and is a healthy response to danger. Fear is different from phobia.

Evaluation   Voice raised only occasionally at 24 hours. Requests, observations, questions expressed verbally in an appropriate manner.

Verbalized frustration, fear, anger and loss of control; expressed fear and concern over loss of independence.

Apologized for shouting and belittling behavior; verbalized ways in which she used anger to avoid dealing with loss of control and loss of independence.

 

Described feeling dependent on nursing staff for satisfaction of basic needs. Established own schedule for ADL and dressing changes; consulted with physical therapist and chose time for therapy.

Identified realistic expectations for therapy, discharge, and rehabilitation; established goal for living situation. Identified changes that had occurred since hospital admission; expressed her perception of the effect of these changes on life-style; identified need to regain control and to learn to care for self.

Identified social supports, age, physical condition, life-style, and stamina; expressed desire to talk with discharge planner to facilitate interim plan for extended care facility.

After establishing schedule for ADL, began active participation in own care; self sufficient in ADL by 72 hours.

References   Afridi (2005). Panic Disorder: A report. Pakistan. Practice guideline for treatment of patient with panic disorder. American Psychiatric Association. 1998.  Hocksema, S.N. Abnormal Psychology. 2nd Edition. An International Edition.

Liaquat University of Medical and Health Sciences, Jamshoro Sindh College of Nursing, JPMC, Karachi BScN Year-II Session 2006-2008 Nursing Care Plan & Reflection Log Advance Concept of Nursing-III Sajida Siddique Mrs. Mustaqima Begum

Nursing Care Plan Introduction A 25 years old client named Khatoon w/o Rehman residing in own house in a combined family at Karachi. According to the client, she was alright one week back. After seeing a road traffic accident and major blood injury, she developed the behavioral change with the signs and symptoms of lack of appetite, irritability, lack of sleep, fear and poor concentration, restlessness, up-set, poor confidence, fear and unreliability feelings, pounding of the heart, fear of dying, trembling or sucking and weakness, sensation of shortness of breath. She was brought by her family member to the hospital and admitted in Psychiatric unit for treatment.

NURSING CARE PLAN
Name: Mrs. Khatoon W/o Rehman Age: 25 Years Sex: Female Psychiatric Diagnosis: Panic Disorder Nursing Diagnosis: Ineffective Individual Coping related to Blood Injury. Date of Admission: 26th September, 2007.

Date

Assessment (Data Statement)

Nursing Diagnosis

Goal/Planning

Nursing Intervention

Rationale

Evaluation

Ineffective Individual Coping related to Blood Injury

Subjective Data: The client verbalized that she has seen a road traffic accident with major injuries and blood. After that she developed heart palpation, pounding of the heart, increase blood pressure, tingling sensation, feeling of chocking, chest pain, discomfort, feeling of unreality, fear of dying, chill and hot flushes, sleeplessness, lack of concentration, irritability and nightmares, sensation of short-ness of breath, going crazy, depression, feeling of dread, and fright. Objective Data: A 25 years old client sitting on bed looking upset and irritable, restlessness, lack of concentration, insomnia, loss of appetite and poor confidence. Vital Sign Blood Pressure: 150/90 mmHg Temperature: 99°F Pulse: 120 bpm Respiratory Rate: 30 per min.

Short-term Goals: The client will verbalize the feelings of being comfortable and relaxed. She also develops ability to take decision with full concentration and confidence. Long-term Goals: The client will make full attention and free from action to change probative situations in personal physiological reaction to panic attack decrease

• • • • • • • • • • • • • • • • •

Assess possible contributing • factors Perception of threatening • stimulus Unfamiliar environment • Intrusion on personal space Life- style change (promotion, marriage/ divorce, retirement) Biologic and physiologic change (dysfunction, disability, pain) Self-esteem threat (abandonment, rejection) Distorted perceptions of dangerous stimulus Age-related fears Orient to environment using simple explanation. Speak slowly and calmly. • • • • • • • •

Short-term Goals: The client called the Give help in assisting the nurse by her name and remove client. Client feels comfortable and hesitation. The client felt confidence relaxed, satisfied and Decrease the fear. comfortable Decrease the anxiety level. Build up trust. Long-term Goals: Client enables to take proper The client made decisions. decision about reality, feeling and follow Develop the feeling of through with comfortable. appropriate action to Verbalizes feeling of panic change provocative situations in personal attack. environ-ment Decrease the fear level. Verbalizes the feeling of physiological reaction to panic attack chocking. decease. Expressed Identifies event that increase panic attack about the attack road traffic accident Identifies increase panic and blood injury and attack as a precursor to its effect in future. alteration in behavior. Accurately described Decrease in restlessness. relationship between Identifies effective coping panic attack and mechanisms. occurrence of physioUses relaxation techniques to logical symptoms decrease anxiety. Uses support of family. Activities divert the attention

Avoid surprises and painful • stimuli. Use soft lights and music. Plan one-day-at-a-time familiar routine. Encourage gradual mastery of a situation. Remain with person until fear subside Later, establish frequent Distorted perceptions • • • • •

Panic Disorder377 Panic Disorder
Reflection

Introduction I was deputed at Psychiatric Ward to fulfill my clinical requirement of BSc Nursing. Therefore, I reached at 08:00 AM at Psychiatric Ward. I learned that mental status examination is one of the most important diagnostic tools in the psychiatric to obtain information and to make an accurate diagnosis. I also learned that mental status examination is considered to be analogous to the physical examination in the general medicine. After lecture, with the permission of Head Nurse, I went in the female ward and selected a client admitted at Psychiatric ward. She was suffering from panic disorder related to mental illness. I examined the client by use of mental status examination and history taking technique. I felt that these methods were very useful to obtain complete information. Today I was very excited because when I performed mental status examination of the client, our teacher appreciated and encouraged for my best efforts. It is a great opportunity for me; therefore I tried my best to gain more knowledge especially in terms of managing the clients having psychiatric disorders. In future, if I get a chance to work with such clients, I will spend more time with them so that trustworthy relationship develops. I encourage and motivate them to cope with their present status of mental disorder and become one of the useful independent lives.

Panic Disorder378 References   Afridi (2005). Panic Disorder: A report. Pakistan. Practice guideline for treatment of patient with panic disorder. American Psychiatric Association. 1998.  Schultz, J.M. and Videbeek, S.L. (2004). Lippincott’s Manual of Psychiatric Nursing Care Plans.7th Edition. Philadelphia: Lippincott.  Shives, L.R. and Isaacs, A. (2002). Basic Concepts of Psychiatric-Mental Health Nursing. 5th Edition. Philadelphia: Lippincott.

LIAQUAT UNIVERSITY OF MEDICAL AND HEALTH SCIENCE JAMSHORO SINDH

Panic Disorder ACN III Sultan Salahuddin
BScN Year-II Student College of Nursing, JPMC

Panic Disorder379

Madam Yasmin
23rd July, 2005

Panic Disorder380

OBJECTIVES
At the end of this presentation, the participants will be able to: 14. Define panic disorder. 15. Explain panic attach and its signs and symptoms. 16. Describe disorder. 17. Discuss epidemiology of panic disorder. 18. Explain nursing diagnosis and nursing predisposing factors of panic

intervention for panic disorder.

Panic Disorder381

PANIC DISORDER
Introduction Panic disorder is an anxiety disorder, characterized by unexpected panic attack. Panic involves the disorganization of the personality. It is a frightening and paralyzing experience for the individual in which a person is unable to communicate or functioning effectively. The prolonged period of panic would result in exhaustion and death. Definition The current definition of panic disorder is derived from the Diagnostic and Statistical Manual of Mental Disorders. For the diagnosis, the patient should experience recurrent panic attacks and are distinguished from “provoked” or “situationally bound” attacks, which also occur in panic disorder and are linked to specific environmental cues. The panic attack itself is characterized by a sudden crescendo of a autonomic arousal and fear, lasting approximately 10 to 30 minutes. At least 4 of a possible 13 symptoms should be present for a “full-blown” attack, although “limited symptoms” attacks also occur and are clinically important.

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Diagnostic Crietera for Panic Disorder and Panic Attacks 1) The patient must have both: a) b) Recurrent unexpected panic attacks. At least one of the attacks followed by at least one month of ≥1 of the following:
• Persistent concern about having additional attacks. • Worry about the implications of the attack or its

consequences.
• A significant change in behavior related to the attack.

2) A panic attack is defined as a discrete period of intense fear or discomfort with ≥4 of the following symptoms that develop abruptly and peak in intensity within 10 minutes: a) b) c) d) e) f) g) h) i) j) k) l) m) Palpitations, pounding heart, or accelerated heart rate. Sweating. Trembling or shaking. Sensations of shortness of breath or smothering. Feelings of choking. Chest pain or discomfort. Nausea or abdominal distress. Feeling dizzy, unsteady, lightheaded, or faint. Derealization or depresonalization. Fear of losing control or going crazy. Fear of dying. Paresthesias. Chills or hot flushes.

Panic Disorder383

Predisposing Factors of Panic Disorder Psychodynamic Theory – it focuses on the inability of the ego to intervene when conflict occurs between the id and the superego, producing anxiety. When developmental defects in ego functions compromise the capacity to modulate anxiety, the individual resorts to unconscious mechanisms to resolve the conflict. Overuse or ineffective use of ego defense mechanisms results in maladaptive responses to anxiety. 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. When there is a disturbance in this central mechanism of cognition, there is a consequent disturbance in feeling and behavior. The individual feels vulnerable in a given situation, and the distorted thinking results in an irrational appraisal, fostering a negative outcome. Biological Aspects – research investigations into the psychobiological correlation of panic disorders have implicated a number of possibilities. Genetics – panic disorder has a strong genetic element. The concordance rate for identical twins is 30 percent, and the risk for the disorder in a close relative is 10 to 20 percent. Neuroanatomical – modern theory on the physiology of emotional states places the key in the lower brain centers, including the limbic system, the diencephalon and the reticular formation. Structural brain imaging studies in patients with panic disorder have implicated pathological involvement in the temporal lobes, particularly the hippocampus.

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Biochemical – abnormal elevations of blood lactate have been noted in clients with panic disorder. Likewise, infusion of sodium lactate into clients with anxiety neuroses produced symptoms of panic disorder. Although several laboratories have replicated these findings of increased lactate sensitivity in panic-prone individuals, no specific mechanism that triggers the panic symptoms can be explained. Neurochemical – stronger evidence exists for the involvement of the neurotransmitter norepinephrine in the etiology of panic disorder. Norepinephrine is known to mediate arousal, and it causes hyperarousal and anxiety. Medical Conditions – the following medical conditions have been associated to a greater degree with individuals who suffer panic disorders than in the general population: 1) 2) 3) 4) 5) 6) 7) 8) Abnormalities in the hypothalamic-pituitary-adrenal and hypothalamic-pituitary-thyroid axes. Acute myocardial infarction. Pheochromocytomas. Substance intoxication and withdrawal (cocaine, alcohol, marijuana, opioids). Hypoglycemia. Caffeine intoxication. Mitral valve prolapse. Complex partial seizures.

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Epidemiology of Panic Disorder

1.7% of the United States population (2.4 million Americans) experiences panic disorder. Women are twice as likely as men to develop panic disorder. Panic disorder typically strikes in young adulthood. Roughly half of all people who have panic disorder develop the condition before the age of 24 years. Heredity, other biologic, cognitive and psychodynamic factors are involved in the panic disorder. Appropriate treatment by an experienced professional can reduce or prevent panic attacks in 70% to 90% of people with panic disorder. Research shows that about 30% of people with panic disorder use alcohol and 17% use drugs such as cocaine and marijuana. The epidemiological research also shows that approximately 20% of people with panic disorder attempt suicide.

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Treatment and Medication of Panic Disorder

Most specialists agree that a combination of cognitive and behavioral therapies is the best treatment for panic disorder. Medication might also be appropriate in some cases. Combination therapy ( a combination of both medication and cognitive-behavioral therapy) more useful and effective in panic disorder. Remember that part of the treatment for panic disorder is to treat the anxiety surrounding the fear of experiencing another panic attack. This fear is called “anticipatory anxiety”. The person may also have phobias, or irrational fear, about places or situations where the panic attacks have occurred and try to create a zone of safety for himor her-self by avoiding those places or situations.

 

Panic Disorder387

Drugs Used for Treating Panic Disorder 1) Tricyclic antidepressants (TCAs)
   

Imipramine (Tofranil)

50 to 300 mg per day

Clomipramine (Anafranil) 25 to 250 mg per day Nortriptyline (Pamelor) 25 to 100 mg per day

Desipramine (Norpramin) 25 to 300 mg per day

2)

Selective serotonin reuptake inhibitors (SSRIs)
   

Fluoxetine (Prozac) Paroxetine (Paxil) Sertraline (Zoloft) Fluvoxamine (Luvox)

20 to 80 mg per day 10 to 50 mg per day 50 to 200 mg per day 500 to 300 mg per day

3)

Monoamine oxidase inhibitors (MAOIs)
 

Phenelzine (Nardil)

45 to 90 mg per day

Tranylcypromine (Parnate) 30 to 60 mg per day

4)

Benzodiazepines
  

Alprazolam (Xanax) Lorazepam (Ativan) Clonazepam (Klonopin)

2 to 10 mg per day 2 to 6 mg per day 1 to 3 mg per day

Panic Disorder388

Duration of Treatment Much of the success of treatment depends on patient’s willingness to carefully follow the outlined treatment plan. This is often multifaceted, and it won’t work overnight, but if you stick with it, we should start to have noticeable improvement within about 10 to 20 weekly sessions. If client continue to follow the program, within one year we will notice a tremendous improvement.

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Treating Patients with Panic Disorder
Patient meets DSM-IV criteria for panic disorder

Is current alcohol abuse present?

Yes

Offer alcohol detoxification and maintenance program with follow up to reassess panic disorder Consider short-term therapy with a benzodiazepine while long-

No
Is rapid action needed for the patient to function?

Yes

No
Offer treatment with antidepressants or CBT (4 to 12 sessions)

Antidpressants:

Reassess at 2 and 10 weeks to discuss effectiveness and side

Continue for 6 months and consider medication withdrawal with monthly follow up for relapse. Follow patient monthly for relapse after sessions are discontinued. Taper benzodiazepine. If unsuccessful, offer CBT during tapering period.

Is the patient panic-free or functioning well?

Yes

CBT:

No
Offer additional treatment with another therapy, combination therapy, increased medication dosage, or additional CBT
Benzodiazepines:

Panic Disorder390

Nursing Diagnosis/Outcome Identification Nursing diagnosis are formulated from the data gathered during the assessment phase and with background knowledge regarding predisposing factors to the disorder. Some common nursing diagnoses for clients with panic disorder include: 1) Panic anxiety related to real or perceived threat to biological integrity or self-concept evidenced by any or all of the physical symptoms identified by the DSM-IV-TR as being descriptive of panic or generalized anxiety disorder. Powerlessness related to impaired cognition evidenced by verbal expressions of no control over life situation and non-participation in decision making related to own care or life situation. Ineffective individual coping is related to anxiety as evidenced by his/her excessive dependency on (which thing has lost). Ineffective family coping is compromised related to anxiety as evidenced by inability to set realistic limits on his/her demands for attention.

2)

3)

4)

Panic Disorder391

Nursing Interventions for Panic Disorder 1. 2. Remain with the client at all times when levels of anxiety are high (severe or panic). Move the client to a quiet area with minimal or decreased stimuli (such as small room or seclusion area). Offer reassurance of safety and security to the client. Use short, simple and clear statements. Be aware for your own feelings and level of discomfort. Administer tranquilizing medication, as ordered by physician. Assess for effectiveness and for side effects. When level of anxiety has been reduced, explore possible reasons for occurrence. Encourage the client’s participation in relaxation exercises (such as deep breathing, progressive muscle relaxation, medication and imagining being in a quiet peaceful place). Teach the client independently. to use relaxation techniques

3. 4. 5. 6. 7. 8.

9. 10.

Help the client to see that mild anxiety can be a positive catalyst for change and does not need to be avoided.

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Scenario
Ms. M is a 29 years old lady brought to the hospital Emergency Department by her mother with symptoms of shortness of breath, fear of dying, palpitations and chest discomfort. She is full time student and works a job. She told that during the prior three weeks, she experienced four episodes of these symptoms. Her mother said that “Ms. M has experienced anxiety since early childhood and first underwent psychotherapy when she was 9 only. The symptoms included anxiety and worry. Ms. M has no other past medical and surgical history. CBC and Thyroid function test, are in normal limits. She told that I always had trouble dealing with people in social situations. I was really shy. I don’t think anyone diagnosed me with anxiety until I was in my 20s. Eventually, I found a therapist who said, “absolutely you have anxiety that’s causing depression” and started treating me with tab. Clonazepam, which really helped.

Panic Disorder393 NURSING CARE PLAN Name: Age Sex Medical Diagnosis Ms. M 29 Years Female Panic Disorder
Nursing Diagnosis Panic anxiety related to perceived threat to biological integrity as evidenced by all of the physical symptoms identified by the DSMIV-TR criteria. Expected Outcome Short term goals The client will respond to relaxation techniques with a decreased anxiety level by 2-3 days. Long term goals The client will be able to recognize symptoms of onset of anxiety and to intervene before reaching panic level by 1 week to 3 weeks. Intervention Rationale Evaluation Short term Ms. M has been reduced her anxiety level severe to moderate. Long term Ms. M verbalized symptoms of onset of anxiety and able to intervene before reaching panic level.

Assessment Subjective Data She told that during the prior 3 weeks, she experienced 4 episodes of palpitation and chest discomfort. Following two of these episodes, she wen to the emergency department for treatment. She total that her symptoms were due to anxiety and panic. Objective Data Ms. M, a 29 years old female has experienced anxiety since early childhood and first underwent psychotherapy when she was 12. Her anxiety was treated with a variety of antidepressants, without improvement. She is smoker and sometimes uses alcohol. There is no association of mood and anxiety disorder with her family. Vital Signs • Blood Pressure • Temperature • Pulse • Respiratory rate 100/80 mmHg 98 °F 70 bpm 22 per min

• • • • •

Stay with the client and offer reassurance of safety and security. Maintain a threatening approach. calm, nonmatter-of-fact

• • • • •

The client may fear for her life. Anxiety is contagious and may be transferred from staff to client or vice versa. A stimulating environment may increase level of anxiety. Antianxiety medication provides relief from the immobilizing effects of anxiety. Recognition of precipitating factors is the first step in teaching client to interrupt escalation of anxiety. Relaxation techniques result in a physiological response opposite that of the anxiety response.

Keep immediate surrounding low in stimuli. Administer tranquilizing medication as ordered by physician. When the level of anxiety has been reduced, explore possible reasons for occurrence. Teach relaxation techniques, which reduce the anxiety.

Depression394

References 1.
40.

Wilson S Holly. Psychiatric Nursing. Wesley California; p 718. Lancaster Jeanette (1988). Adult Psychiatric Nursing. 3rd Edition. New York; p 228. Harber, Hoskins and Leach (1978). Comprehensive Psychiatric Nursing. 3rd Edition. USA; p 623. Taylor Monat Cecelia (1994). Essential of Psychiatric Nursing. 14 Edition. USA; p 456. Sundeen and Stuart (1991). Principles and Practice of Psychiatric Nursing. 4th Edition. Philadelphia; pp 576-577. Carson Verna Benner. 2nd Edition. USA; p 621. Mental Health Nursing.

41.

42.
43.

44.

45.

White Lois (2001). Foundation of Nursing. 6th Edition. USA; p 813. Townsend Marry C (1941). Psychiatric Mental Nursing. pp 516-517. http://www.apa.org/pubinfo/panic.html. http://www.aafp.org/afp/980515ap/saeed.html. Http://www.google.com. Gorman JM (2001). A 28-YearOld Woman with Panic Disorder. JAMA; 286:450-457.

46.
47. 48. 49.

LIAQUAT MEDICAL AND HELATH SCIENCES JAMSHORO SINDH

Depression395

Depression ACN III Safrunisa
BScN Year II Student College of Nursing, JPMC

Madam Yasmin
23rd July, 2005

Depression396

0

OBJECTIVES
At the end of this presentation, the participants will be able to: 19. Define Depression. 20. Enumerate causes and characteristics of depression. 21. Describe levels of depression. 22. Discuss pathogenesis of depression. 23. Explain treatment of depression.

Depression397

DEPRESSION
Definition Authors defined depression, time to time. Some of these definitions are as under:
 

Depression is a decrease of vital functional activity. It is a mood disturbance characterized by feelings of sadness despair and discouragement resulting from and normally proportionates to some personal loss of tragedy (Lois White). An abnormal, emotional state characterized by exaggerated feelings of sadness melancholy dejection worthlessness, emptiness and hopelessness that are inappropriate and out of proportion to reality (Schultz and Videbeck).

Causes of Depression In people with terminal illness include:
         

Uncontrolled pain. Constipation. Anorexia and fatigue. Abnormal metabolic condition. Hypercalcemia, anemia, hypothyroidism. Sepsis contributing tumor of central nervous system or radiation therapy. Medication such as corticosteroid and chemotherapeutic agent. Financial condition. Loss of someone or something. Limited social support and diminished function habitually using and limited emotional range.

Depression398

Characteristics of Depression 1. 2. Depress mood. Loss of pressure and interest in all or nearly all of one’s usual activities and past time. Insomnia or some time hypersomnia. Anorexia and weight loss or sometime hyperphagia and weight gain. Mental showing and loss of concentration feeling of guilt. Worthlessness and helplessness. Thought of death and suicide. Anhedonia. Change in sleep pattern. Lack of energy.

3. 4.

5. 6. 7. 8. 9. 10.

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Levels of Depression Depression can be classified into effective, psychological, cognitive and behavioral manifestation. There are three levels of depression. Mild Depression – is characterized by its transitory nature. It is often participate by events in a person’s life but may occur for no clearly definable reasons. Events that may trigger mild depression include disappointments at school or work such as, failure in a test and failure to receive a promotion. The loss of someone or something highly valued or meaningful such as friend loves family member home or job ordinarily bring on deep sadness of limited duration. The manifestation of a mid transitory depression or almost exclusively emotional in nature mildly depressed people describe themselves as feeling some. Psychological change such as alteration sleeps pattern because it is emotional change, the person may increase use of drugs, alcohol to try to diminish their low mood. Moderate Depression – People experiencing a moderate level of depression are more likely to experience their condition as which persists over time and often leads them to seek help moderate effective cognitive behavioral and physiological changes occur. Effective Change – moderately depressed people describe their mood as one of despondency, dejection and gloom feeling of low self-esteem contribute to feelings of powerlessness, helplessness and effectiveness. Anxiety and anger may or may not felt. It may show diurnal variation that is a pattern of changes whereby certain time of the day such as morning and evening are consistently better and worse. Moderately depressed people or unable experience pleasure from activities. They ordinarily enjoy their Jove de vivre seems to have vanished.

Depression400

Cognitive Changes – these people thoughts are showed and their interests are narrow concentration become difficult and indecisiveness and self-doubt are common. Their thoughts tend to be ruminative, they go over the same content and issue with no movement forward or recognition of alternatives. Their thoughts have an absesional quality. A pessimistic out look that included self-blame combines to create a hopeless attitude about the possibility of change or the motivation to change suicidal thoughts may introduce as an aspect of hopelessness. Behavioral Change – depressed people tend to withdraw socially. Initially the withdrawal may appear to be simply a reluctance to socialize or interact with others. It may extend to other spheres of life such as school work and community involvement tears and irritability may be evident seemingly with no provocation change in personal hygiene may be noted. A formerly meticulous stylish dressed person may begin to appear at work with unwashed, uncombed hair and wrinkled, uncoordinated clothes. They may also be a slowing of movement and speech or agitated increasing but aim less activity such as pacing some. Such people will escalate their normal use of alcohol or drugs in an attempt to anesthetize their depression, anxiety or anger. Physiological Changes – it is very common for people with moderate levels of depression to experience somatic complaints such as headaches, chest or back pain, indigestion nausea and vomiting, constipation. Frequently they will seek medical care for these symptoms without associating them with other affective cognitive or behavioral change though the problem is not in true nature. They may frequently weight loss or increase the weight. Menstrual changes such as amenorrhea are common, as is decrease sexual desire. Responsiveness feeling, fatigue and weakness, sleep is desire but not satisfying some time difficulty. A falling (initial insomnia and middle insomnia) when person awake during sleep the return to sleep terminal insomnia early morning awaking.

Depression401

Severe Depression People who experience severe depression have intense pervasive and persistent manifestations of depression. Severe depression may or may not include a psychotic dimension. Effective Change – despair and hopelessness, the predominant feeling there seem no light at the end of dark tunnel, feeling of worthlessness and guilt are evident sense of isolation, loneness and over whelming feeling of bottomless, emptiness, envelops the severely depressed person. Cognitive Change – confusion inability to concentrate and indecisiveness are evident. These people have no interest in mobilizing themselves and no motivation to do so. Selfdestructive thoughts occur as a solution to the hopelessness of their situation and wish to die. These people feelings like delusion of cancer and delusions of poverty. Behavioral Change – These people develops psychomotor retardation. Their motor activity comes to a near-halt. Slow walking, the skiing hair, clothing posture is poor. After sits slumped or curledup amount of speech, they do not attend to their hygiene need. Physiological Change – Elimination is sluggish constipation may urinary retention or amenorrhea, lack of sexual interest, hypersomnia can occur. Person often feels worse in the morning and better as the day progresses.

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Pathogenesis Major depression in undoubtedly complex and not yet know because depressive episodes can be triggered by stressful life events in some people but not in other. It would appear that for some people a predisposition to depression exists social developmental and biological factors including genetic heritage. The Greeks were the first to introduce the term melancholia. They believed that depression was caused by excessive amount of black bile. Two neurotransmitters are correlated with depression; serotonin and norepinephrine. First serotonin which originates in the dorsal and median raph nuclei of the brain stem is widely distributed in the forebrain. This function of this system is thermo regulation feeding and regulation of mood and emotion it is also involved in the control of sleep wakefulness and sexual behavior (when serotonin is involved one is either awake, sleeping or having sex). It is also hypothesized effective disorders. The norepinephrine or noradrenergic pathway arises from the locus. Coeruleus and cells are scattered throughout the ventral and lateral segmental region of the medulla and the fibers are distributed throughout the neocortex and involve the hypothalamus. Norepinephrine as serotonin is involved in sleep and wakefulness as well as the hypothalamic function of thermo regulation thirst and hunger. This is why when people are depressed, they complain of decreased or increased appetite and weight loss or gain. 1. 2. Depression can induce with resepine. The drugs used to treat depression intensity monoamine. Mediated neurotransmission although these observation do indeed support the monamine hypothesis. It is likely that this somewhat simplistic theory will be need refinement as our understanding of brain depends.

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Treatment Depression can be treated with three modalities; drugs, electroconvalsive therapy (ECT) and psychotherapy. Each modality has a legitimate role. Drugs – are the primary therapy for major depression currently available antidepressants are: Selective Serotonin Reuptake Inhibitors (SSRIs)
Generic Name Trade Name Prozac Potential Side Effects

Fluoxetine

Abnormal dreams, anxiety, diarrhea, drowsiness, excessive sweating, headache, insomnia, nervousness, pruritus, seizures, tremors. Constipation, diarrhea, dizziness, dry month, drowsiness, dyspesia, headache, insomnia, nausea, nervousness, weakness. Anxiety, constipation, diarrhea, dizziness, drowsiness, dry mouth, ejaculatory disturbance, headache, insomnia, nausea, sweating, weakness, tremors.

Fluvoxamine

Luvox

Paroxetine

Paxil

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Tricyclic Antidepressants
Generic Name Amitriptyline hydrochloride Clomipramine hydrochloride Imipramine hydrochloride Trade Name Elavil Potential Side Effects Arrhythmia, blurred vision, constipation, dry eyes, dry mouth, hypotension, lethargy, sedation.

Anafranil Arrhythmia, blurred vision, constipation, dry eyes, dry mount, lethargy, male sexual dysfunction. Tofranil Arrhythmia, blurred vision, constipation, drowsiness, dry eyes, dry mouth, fatigue, hypotension, urinary retention.

Electroconvalsive Therapy (ECT) – was discovered in mid 1920. At that time it was only the treatment available and was frequently used and misused in 1960. It was used for general anesthesia and muscle relaxant. Most common ECT treatment was given three times in a week. The physician recommends ECT for a particular patient under what circumstances would you can concern about that recommendation. ECT is a procedure, wherein the client is treated with pulses of electrical energy sufficient to cause a brief convulsion or seizure (Bolwig 1993). Electroconvulsive therapy is carried out under anesthesia. Muscle-depolarizing agents are also given so that no actual convulsive movements occur; the primary effect of ECT is on the brain itself. Studies show that clients do not find the actual ECT treatment frightening, painful, or unpleasant. Although deaths have occurred from ECT, particularly in elderly clients or those with heart disease, the risk is quite low. Side effects depend on the specific technique used but are mostly limited to memory deficits (Frisch and Frisch 1998).

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Psychotherapy – is often called the talking cure because of its dependence on verbal interaction taking about difficult emotional. Situations with a competent and understanding therapist has helped many patients and families develop a better understanding of their psychotherapy was originally developed by friends and his colleagues in the 19th century as long term intervention to correct early psychological trauma and facilitate personality change. However, trends in psychiatry have forced psychotherapy into a time limits structure. The goals of brief psychotherapy are to help patients, overcome or modify feeling with their meeting personal goal. Brief psychotherapy models narrow the goal of personality change to focus on specific behavior and conflicts or issues that can be treated successfully in a short period.

Depression406

Scenario
Miss Saira, a 20 years old girl admitted in Psychiatric unit with history of insomnia, anorexia and weight loss. She was social and enjoy parties and having a number of friends. Her past history revealed that she was all right before three months ago, when an incident changes her life i.e., her engagement was broken. Furthermore, she failed in her final examination. After this incident, she become isolated and loss interest in life. She is single child of her parents. Her mother is working in a office and father is a businessman. Both are very busy, therefore, she becomes an isolated child.

Depression407

Assessment Saira, 20 years young girl brought to Psychiatric Ward by her parent. According to her parent, she was alright two months back. She was very active and taking part in all activities. She was a student of BA Part-II. She was also engaged two years back but suddenly her engagement was broken due to some family inter fair and she also fails in her BA final examination. After these incidences, she is feeling difficulty in falling asleep along with anorexia and weight loss. She is not taking part in any activity and mostly lives alone, calm and quite. She does not share with others and sometimes she complains headache, chest and back pain and indigestion. She sits with depressed mood without any facial expression, loss of concentration, feeling of guild unwashed and uncombed hair wrinkled uncoordinated cloth her speed is very slow head is down no eye contact, slow body movement, looking lethargic. No hope is seen in her eye. Her vital signs are:
  

Blood pressure: Temperature: Pulse:

100/70 mmHg. 97°F 88 beat per minute.

Nursing Diagnosis
  

Impaired social interaction related to loss of intimate relationship. Hopelessness related to lifestyle of helplessness related to sedation. Altered thought process related to loss of belief in transcendent values.

Depression408

Intervention Encourage patient to express how she feels by scheduling at least 10 minutes, twice a day focus on this topic.

Evaluate patient communication skills and help him or her to find alternative ones during interaction with patient. Help patient obtain a realistic perception of self by focusing on and enhancing strength during conferences with patient. Allow patient to choose social interactions for role-play for 10 minutes twice a day. Involve patient in daily care to help the patient to make decision about own care. If patient is in isolation, spend at least two minutes every hour with patient. Initiate referrals to support groups prior to discharge.

Depression409 NURSING CARE PLAN
Name: Age Sex Medical Diagnosis Miss. Saira 20 Years Female Depression Nursing Diagnosis Expected Outcome Intervention Rationale Evaluation

Assessment

Depression410
Impaired social interaction related to loss of intimate relationship Subjective Data Saira was brought to Psychiatric unit by her parent. According to her parent, she was alright two months back. Her engagement broken and she also failed in her BA examination. After this incident, she is feeling difficulty in falling asleep, anorexia and weight loss. She is not taking part in any activity and mostly lives alone, calm and quite. She does not share with others. Sometimes she complains headache, chest and back pain and indigestion. Objective Data A 20 years, young girl sitting on bed quiet depressed mode, without facial expression, loss of concentration, feeling of guilt, unwashed and uncombed hair, wrinkled, uncoordinated clothes. Her speech is slow and bodies movement looking lethargic. No hope is seen in her eyes. Vital Signs • Blood Pressure • Temperature • Pulse 100/70 mmHg 97 °F 88 bpm Short term goals The client will participate in daily activities. Long term goals The client will be able to initiate interaction with others to maintain relationship and social life.

Encourage patient to express how she feels by scheduling at least 10 minutes, twice a day focus on this topic. Evaluate patient communication skills and help him or her to find alternative ones during interaction with patient. Help patient obtain a realistic perception of self by focusing on and enhancing strength during conferences with patient. Allow patient to choose social interactions for role play for 10 minutes twice a day time. Involve patient in daily care to help the patient to make decision about own care. If patient is in isolation, spend at least two minutes every hour with patient. Initiate referrals to support groups prior to discharge.

Assist patient to examine social experience and verbalize feelings and encourage therapeutic relationship. Improve communication skills.

Short term

• •
Help patient to see that no one is perfect and improves selfconcept.

Patient will verbalize satisfaction with quantity and quality of social interaction. Will communicate and participate with others and community Will reestablish or maintain relation-ships and a social life and also establish support system.

• • • •

• • • •

Promote self-confidence in social situations by allowing practice in a safe environment. Improve self-concept, and increase motivation. Decrease feeling of powerlessness. Avoids feeling of total isolation for patient. Patient contact with community group to interact to decrease social isolation.

Long term Patient participates in normal daily activities and normal routine life.

References 1. 2.
3.

White Lois (2001). Foundation of Nursing. 6th Edition. USA; pp 1181-1186. Carson Verna Benner. nd 2 Edition. USA; p 621. Schultz JM and Videbeek 7th Edition; pp 178-179. Mental SL. Health Psychiatric Nursing. Nursing.

4.

Jhon Wolk. Essential of Clinical Psychiatric. 3rd Edition. Townsend Marry C (1941). Psychiatric Mental Nursing. Harber, Hoskins and Leach (1978). Psychiatric Nursing. 3rd Edition. USA; p 623. http://www.apa.org/pubinfo/depression.html. http://www.yahoo.com/yahooseach/depression. Http://www.google.com/googlesearch/depression. http://www.google.com. Scott J (2001). Cognitive therapy for depression. B Med Bulletin; 57:101-113. Comprehensive

5.
6.

7. 8. 9. 10.

Liaquat University of Medical and Health Sciences Jamshoro Sindh

College of Nursing, JPMC Family Therapy ACN III Practical Scenario (Assignment # 1) Violet Barkat
BScN Year II

Mrs. Munira A. Ali

The family is the basic unit of society composed of two or more individuals who come together to share common beliefs and values. The bounding factor of the family is that of commitment. The individual within the family may be related by marriage, blood or adoption. The form or structure of an individual family may very greatly. In addition to the traditional nuclear family, family may be composed of people not related by blood or marriage living together as a family group. Family therapy is a second specialty treatment modality, practiced by a nurse with a master’s degree and specialized training in family therapy. This family therapist treats the family as a unit or assists in individual in coping more effectively with family issues. Families are important to nurses because families are the context in which individuals live, and they are units to be analyzed. Family therapy is particularly useful in the situations when an individual is struggling with family as well as personal issues, when a family needs professional assistance in understanding the client’s perspective or coping with difficult feelings and when family unit is the focus of treatment, for example, in a divorce situation. Family Forms and Types  Nuclear – A father, mother and at least one child living together but apart from both sets of their parents.  Extended – three or more generation including married brothers and sisters and their families.  Three Generation – Any combination of first, second and third generation members living within household.   Dyad – Any two members, typically husband and wife living alone without children. Single Parent – Divorced, never married, separated or widowed man or woman with at least one child. Most single parent families are headed by woman.

Step-Parent – One or both spouses divorced or widowed and remarried into a family with at least one child.

Blended or Reconstituted – A combination of two families with children from one or both families and sometimes children of the newly married couple.

Single Adult Living Alone – An increasingly common occurrence for the newermarried, divorced or widowed.

 

Cohabiting – An unmarried couple living together. No Kin – A group of at least two people who have no legalized or blood ties but who share a relationship and exchange support.

  

Compound – One man or woman with several spouses. Gay – A homosexual couple living together with or without children. Commune – More than one monogamous couple sharing financial and social resources.

Group Marriage – All individuals married to each other and considered parents of all the children.

Family Therapy Family therapy as a treatment modality began in the 1950s and blossomed over the next two decades into a primary treatment modality. Early family theorists used biologically based treatment of clients and their families. The compared the family system to the human body, system failure in one part of the body affects other body systems. General principles of natural systems theory include the following.  Every subsystem is a part of a larger system. Individuals are part of a larger family system and families are part of a larger community system influenced by its culture, politics, and environmental changes.

The system is more than the sum of its parts. The whole can be understood only by looking at the pattern of relationships within the system rather than looking at individual parts in isolation.

Living systems demonstrate equifinality – the ability to achieve the same final goal in a variety of ways.

Systems strive for homeostasis – the tendency of systems to be self-regulating. Through a variety of mechanisms, systems maintain coherence within the system when challenges arise from the environment.

Systems have feedback loops defined as “the process by which a system gets the information necessary to self-correct in its effort to maintain a steady state or move toward a pre-programmed goal.

Bowen’s Family Systems Model Bowen viewed the basic forces shaping family functional behavior as:          Multigenerational transmission process. Differentiation of self. Triangles. Nuclear family emotional system. Family projection process. Emotional cut-off. Sibling position. Societal regression Spirituality.

Treatment

Bowen family therapists view themselves as coaches to the family. The role of the therapist is to help the family decrease its anxiety, gain a broader perspective on problems, and become aware of the ways emotional reactivity influences individual and family functioning. Coaching people to define self, that is, to develop a more solid self in the face of forces to fuse with others, is one of the main strategies. Starting with a genogram:  A Bowen family therapist gathers information that helps the family members look at relationships between family process and events, track multigenerational patterns and connect with important relationships.  Education, questioning, analogies, and observations are techniques the coach uses to attempt to maintain a neutral position, massage anxiety, and define self to the family. In this school of thought, the therapist considers it essential that each client continue to work on her or his own level of differentiation while concurrently participating in family therapy. Bowen advocated looking at what goes on between people rather than what goes on within them as the focus of treatment.  The client or family seeking family therapy is views as a partner in the process of looking at the family unit and in assuming full responsibility for his or her feelings.  Bowen therapist educates individual family members about triangles and coaches them to talk directly with each other rather than triangling in another family member to defuse their anxiety.  By coaching people to become aware of their own emotional process within the family. Minuchin’s Structural Theory Salvador Minuchin’s (1974) structural theory of family looks at three essential elements of family organization: structure, subsystems and boundaries. According to

Minuchin, structure refers to how the family is organized and the interdependent functioning of its subsystems as the major determinants of individual behaviors. Subsystem defined subgroups of people within the family who connect with each other to perform different family functions. Family systems have boundaries or imaginary walls, both around them and between their subsystems. These boundaries are invisible emotional limits that regulate the amount and intensity of interpersonal contact. Boundaries that are permeable and clear, allowing information to flow in and out, lead to open healthier systems. Boundaries that are impermeable shut the system off from information, resources, and sources of support. With a structural approach, the therapist’s role is an active one. The therapist actively challenges the maladaptive reactive transactional patterns to help the family system explore and develop a different level of homeostasis, one in which boundaries are reasonable, consistent, and open to emotional input from others without being compromised. According to Goldenberg and Goldenberg (1996), the goals of treatment are:   To help families develop clearly defined generational boundaries. To establish a common front on important family issues, such as discipline, and realistic behavioral standards for family members.  To help open communication pathways and to redefine pathological coalitions that exclude interdependency among all family members. A structural therapist would help Ben to take a more active role with Margie and would coach Marian to allow more emotional space for this to occur. The therapist might suggest homework assignments for Ben to take time with Margie alone. Another strategy would be to work out, with both parents, a united front in parenting Margie and time together, apart from Margie, to rebuild their spousal subsystem. Psychoeducation, a Prevention Tool

Psychoeducation is a family therapy tool that is becoming increasingly popular as a strategy to reduce risk factors associated with the development of behavioral symptoms. Examples of situations in which this would be appropriate include are:  Information and training about a specific area of family life, such as communication skills training or parent effectiveness training.  Information and support to families dealing with specific stress or crises, such as a family support group for Alzheimer’s disease.  Prevention and enrichment, such as premarital counseling, for families not in crisis.

Process The first interview can take place in a hospital, a psychiatric assessment center, a clinic, a mental health center or the home. The first interview sets the stage for the family to begin to see a family problem rather than an individual concern. The initial interview has many purposes. Information about family dynamics and family history must be obtained. Practical concerns such as phone numbers, health insurance information, and other health care sources are addressed. The family may come to the session wanting to talk about the problem and expecting that one session will even determine a solution. Most often, the therapist must help family members broaden perception to include the whole family. At times, family members are anxious or angry, and this first session is used to help them become calmer. The therapist’s challenge is to remain neutral and yet connect with each family member. As each member for a perception of the problem and indicate that all family members are important. What Client’s Need to Know?    How do I decide if our problems could be helped with family therapy? How do I know the theoretical orientation of the therapist, and does it matter? Is therapy covered under my insurance and how much will it cost?

 

What can I expect to happen during the first session? How long will therapy take?

Three parts to genogram construction must be considered:    Mapping family structure. Recording family information. Delineating family relationships.

Family Therapy Interventions  Teach the family members to decrease anxiety by focusing on thinking rather than feeling.  Broaden the family members’ perspectives by mapping the multigenerational family system, gathering facts, and reframing individual interpretations.   Manage your own self by monitoring your anxiety. Identify the primary triangles and teach the family members to manage themselves within them.    Track the family emotional process. Teach the family to explore connecting to others and healing cut-offs. Coach the family toward identifying possible solutions that come from family members.  Help family members monitor and become more aware of individual reactions to emotional triggers.    Increase awareness by teaching the family concepts of family functioning. Coach family members toward defining self. Maintain neutrality.

Liaquat University of Medical and Health Sciences Jamshoro Sindh
College of Nursing, JPMC Family Therapy ACN III Major NCP (Assignment # 2) Violet Barkat
BScN Year II

Mrs. Munira A. Ali

NURSING CARE PLAN TITILE:
Date  

Ineffective Coping
Assessment (Data Statement) Ambivalence regarding decisions or choices. Disturbances in normal functioning due to obsessive thoughts or compulsive behaviors. Inability to tolerate deviations from standards Rumination. Low self-esteem Feelings of worthlessness Lack of insight Difficulty or slowness completing daily living activities because of ritualistic behavior Nursing Diagnosis Ineffective coping Goal/Planning Short-term Goals:   The client will identify stress, anxieties, and conflicts.  The client will verbalize realistic self-evaluation.  The client will establish  a balance of rest, sleep and activity. Long-term Goals:  The client will identify alternative methods of dealing with stress and  anxiety.  The client will complete daily routine activities.  The client will verbalize knowledge of illness, treatment plan, and safe use of medications.  The client will maintain adequate physiologic  functioning. Nursing Intervention Observe the client’s eating,  drinking and elimination patterns, and assist the client as necessary. Assess and monitor the  client’s sleep patterns, and prepare him or her for bedtime by decreasing stimuli, giving a backrub, and other comfort measures or medications. You may need to allow extra  time, or the client may need to be verbally directed to accomplish activities of daily living (personal hygiene, preparation for sleep and so forth). Encourage the client to try to  gradually decease the frequency of compulsive behaviors. Work with the client to identify a baseline frequency and keep a record of the decrease. Rationale The client may be unaware of physical needs or may ignore feelings of hunger, thirst, the urge to defecate, and so forth. Limiting noise and other stimuli will encourage rest and sleep. Comfort measures and sleep medications will enhance the client’s ability to relax and sleep. The client’s thoughts or ritualistic behaviors may interfere with or lengthen the time necessary to perform tasks. Evaluation The client has verbalized decrease feeling of fear, guilt and anxiety. The client has expressed feeling nonverbally in safe manner.

    

Gradually reducing the frequency of compulsive behaviors will help diminish the client’s anxiety and encourage success.

Family Therapy423
Date Assessment (Data Statement) Nursing Diagnosis Goal/Planning  Nursing Intervention As the client’s anxiety • decreases and as a trust relationship builds, talk with the client about his or her thoughts and behavior and the client’s feelings about them. Help the client identify alternative methods for dealing with anxiety. Convey honest interest in • and concern for the client. Rationale The client may need to learn ways to manage anxiety so he or she can deal with it directly. This will increase the client’s confidence in managing anxiety and other feelings. Evaluation The client has established a balance of rest, sleep and activity. The client has identified alternative methods of dealing with anxiety.

Your presence and interest in the client convey your acceptance of the client. Clients do not benefit from flattery or undue praise, but genuine praise that the client has earned can foster self-esteem. The client may be limited in the ability to deal with complex activities or in relating to others. Activities that the client can accomplish and enjoy can enhance self-esteem. The client and family or significant others may have little or no knowledge about these.

Provide opportunities for • the client to participate in activities that are easily accomplished or enjoyed by the client; support the client for participation. Teach the client and • family or significant others about the client’s illness, treatment or medications.

…Therapy424 References  Carson, V.B. (2000). Mental Health Nursing. The Nursing Patient Journey. 2nd Edition.  Harber, Hoskins and Leach (1978). Comprehensive Psychiatric Nursing. 3rd Edition. USA.  Schultz, J.M. and Videbeek, S.L. (2004). Lippincott’s Manual of Psychiatric Nursing Care Plans.7th Edition. Lippincott Philadelphia.  Shives, L.R. and Isaacs, A. (2002). Basic Concepts of Psychiatric-Mental Health Nursing. 5th Edition. Lippincott Philadelphia.

Liaquat University of Medical and Health Sciences Jamshoro Sindh
College of Nursing, JPMC Substance Abuse ACN III Violet Barkat

…Therapy425 BScN Year II

Mrs. Ruth K. Alam

…Therapy426 Substance use has taken for many centuries. It is not a new problem for society. A substance is a drug, legal or illegal, that may cause physical or mental impairment with the great increase in world’s population. There are more people involved in substance abuse. Today’s speed of travel and communication had facilitated the broad distribution of substance. Substance disorders may be classified as intoxication, abuse or dependence (addiction). Definition Abuse is the misuse, excessive or improper use of a substance. Dependence (addiction) is reliance on a substance to such a degree that abstinence causes functional impairment. The person has no control over use of the substance and feels pleasure only when using the substance. Factors Related to Substance Abuse or Drug Abuse There are many factors that interact to influence a person’s substance abuse. Many people who have stopped substance abuse relapse (return to a previous behavior or condition) because of there same factors. These factors may be categorized as individual, family, lifestyle, environmental factors and developmental factors. Individual Factors – Genetic factors are being research as a possible reason for a person’s susceptibility to substance abuse. Research has produced some evidence to suggest the presence of an abnormal chromosome in addicted individuals. This does not guarantee addiction but may predispose the person to addiction. The variations in the intensity of the flow of neurotransmitters may cause to addiction. Psychologists have looked for factors that predict adolescent abuse of drug and alcohol. Researchers have discovered that certain personality factors in childhood are associated with late heavy drug use.

…Therapy427 Family Factors – Drug abuse, especially in the adolescent seems to be related to family relationship. Close family relationship with the parents involved in their children’s activities, appear to discourage substance abuse. Families with positive relationships between parents and children generally have less use of drugs. The parents seemed uninterested in their children and often had little contact with them, all the time neglecting, rejecting, not give praise and deal of blaming and criticism, the children especially adolescent, so that they gradually start using drugs. Lifestyle – All dimensions of a person’s life that influence how that person lives are termed as lifestyle. First is the physical dimension, which includes food, clothing, shelter and health care. The second is the social dimension, which includes friends, organizations and activities with others. Third is the intellectual/emotional dimension, which includes education, parental support of education, self-esteem and how the individual is treated by others. The fourth dimension is spiritual and includes a belief in a “higher being” caring and compassion for others, and being in touch with the inner self. Substance abuse or dependence may be the coping mechanism used by an individual who has problems in any dimension of lifestyle. Environmental Factors – There are many environmental factors that may encourage or predispose an individual to substance abuse. The social environment in which persons find themselves, the groups, clubs, gangs and other organizations influence the acceptance or rejection of substance abuser. The stress in a person’s life including accidents, disability, illnesses, stressful family relations, frequent job changes, divorce, death or precarious financial conditions may be too much for that person to handle. The maladaptive coping of substance abuse offers temporary relief because the symptoms of the stressors are reduced substance abuse is reinforced. Social traditions, especially in the use of alcohol may open the doors for abuse in certain individuals.

…Therapy428 Developmental Factors – Many individual have not had good role models in their life. They have not learned to identify with others and do not understand that their behavior effect others. Not learning skills and attitudes of problems solving leaves the individual unable to apply personal resources to situations and escape seems the only answer. Substance provides the escape. Learning the interpersonal skills of self-discipline, self-control and selfassessment help the individual to cope with tension and stress. These skills also work to prevent dishonesty with self. A lack of interpersonal skills results in dishonesty with others, resistance to feedback and inability to share feelings and give or accept. Help individuals who do not view themselves as empowered may choose drug use as a means of gratification. Types of Substance Abuse
       

Heroin addict. Alcohol. Cigarettes. Chares. Benzodiazepines drug (Antianxiety and Sleep pills). Antiinsect chemicals. Ghotteka. Many other excessive things used.

Assessment       Bizarre behavior. Regressive behavior. Loss of ego boundaries (inability to differentiate self from the external environment) Disorientation. Disorganized, illogical thinking. Flat or inappropriate affect.

…Therapy429   Feelings of anxiety, fear, or agitation. Aggressive behavior toward others or property.

Nursing Diagnosis Disturbed personality related to substance abuse. Short-term Goals The client will:     Be free from the habit of substance abuse. Not harm others or destroy property. Establish contact with reality. Verbalize decreased psychotic symptoms and feelings of anxiety, agitation and so forth.    Participate in the therapeutic milieu. Increase contact with other. Demonstrate increased interpersonal contract.

Long-term Goals The client will:      Take medications as prescribed. Express feelings in an acceptable manner. Cope effectively with the illness. Continue compliance with prescribed regimen. Maintain on-going interpersonal relationships that are satisfying.

…Therapy430 Nursing Interventions and Rationales Interventions

Rationales The client is less likely to feel threatened if the surroundings are known. Client safety is a priority. Selfdestructive ideas may come from hallucination or delusions. The benefit of involving the client with the group is outweighed by the group’s need for safety and protection. The client’s group benefits from awareness of others’ need and can help the client by demonstrating empathy. Remember that other clients have their own needs and problems. Be careful not to give attention only to the “sickest” client. Other clients may interpret verbal or physical threats as personal or may feel that they are doing something to bring about the threats. Limits are established by others when the client is unable to use internal controls effectively. The client is unable to deal with excess stimuli. The environment should not be threatening to the client. Medication can help the client gain control over his or her own behavior.

Reassure the client that the environment • is safe by briefly and simply explaining routines, procedures and so forth. Protect the client from harming himself • or herself or others. Remove the client from the group if his • or her behavior becomes too bizarre, disturbing or dangerous to others. Help the client’s group accept the • client’s “strange” behavior. Give simple explanations to the client’s group as needed. Consider the other clients’ needs. Plan • for at least one staff member to be available to other clients if several staff members are needed to care for this client. Explain to other clients that they have • not done anything to warrant the client’s verbal or physical threats; rather, the threats are the result of the client’s illness. Set limits on the client’s behavior when • he or she is unable to do so. Do not set limits to punish the client. Decrease excessive stimuli in the • environment. The client may not respond favorably to competitive activities or large groups if he or she is actively psychotic. Be aware of PRN medications and the • client’s varying need for them.

…Therapy431

Interventions

Rationales Repeated presentation of reality is concrete reinforcement for the client. Your physical presence is reality. Nonverbal caring can be conveyed even when verbal caring is not understood. Breaking your promise can result in increasing the client’s mistrust. Unknown boundaries or a perceived lack of limits can foster insecurity in the client. The unreality of psychosis must not be reinforced; reality must be reinforced. Reinforced ideas and behavior will recur more frequently.

Reorient the client to person, place, and • time as indicated. Spend time with the client when he or • she is unable to respond coherently. Convey your interest and caring. Make only promises that you can • realistically keep Limit the client’s environment to • enhance his or her feelings of security. Help the client establish what is real and • unreal. Validate the client’s real perceptions, and correct the client’s misperceptions in a matter of fact manner. Do not argue with the client, but do not give support for misperceptions. Be simple, direct and concise when • speaking to the client. Talk with the client about simple, • concrete things; avoid ideological or theoretical discussions. Initially, assign the same staff members • to work with the client. Begin with one-to-one interactions, and • then progress to small groups as tolerated. Establish and maintain a daily routine; • explain any variation in this routine to the client. Set realistic goals. Set daily goals and • expectations.

The client is unable to process complex ideas effectively. The client’s ability to deal with abstractions is impaired. Consistency client. can reassure the

Initially, the client will better tolerate and deal with limited contact. The client’s ability to adapt to change is impaired. Unrealistic goals will frustrate the client. Daily goals are short term and easier for the client to accomplish.

…Therapy432

Interventions

Rationales of your • The client must know what is expected before he or she can work toward meeting those expectations. The client’s ability to make decisions is impaired. Asking the client to make decisions at this time may be very frustrating. The client needs to gain independence as soon as he or she is able. Gradual addition of responsibilities and decisions give the client a greater opportunity for success.

Make the client aware expectations for him or her.

At first, do not offer choices to the • client. Instead, approach the client in a directive manner. Gradually, provide opportunities for the • client to accept responsibility and make personal decisions.

Evaluation  Client has verbalized feelings in an acceptable manner and coping effectively with the illness.   Client established contact with reality. Client has demonstrated the optimal level of functioning.

…Therapy433 References  Carson, V.B. (2000). Mental Health Nursing. The Nursing Patient Journey. 2nd Edition.  Harber, Hoskins and Leach (1978). Comprehensive Psychiatric Nursing. 3rd Edition. USA.  Shives, L.R. and Isaacs, A. (2002). Basic Concepts of Psychiatric-Mental Health Nursing. 5th Edition. Lippincott Philadelphia.  Schultz, J.M. and Videbeek, S.L. (2004). Lippincott’s Manual of Psychiatric Nursing Care Plans.7th Edition. Lippincott Philadelphia.

Liaquat University of Medical and Health Sciences Jamshoro Sindh College of Nursing, JPMC Cognitive Behavioral Therapy ACN III Practical Scenario (Assignment # 1) Zafar Iqbal BScN Year II

…Therapy434

Mrs. Munira A. Ali

…Therapy435 Cognitive-behavioral therapy combines two very effective kinds of psychotherapy, cognitive therapy and behavior. It approaches to treatment useful for the patients experiencing ineffective individual coping, fear, and powerlessness and self-concept disturbance. It based on the notion that the way we think about something influences the way we behave and feel. Negative patterns of thinking tend to be automatic and pervasive, coloring individuals’ perceptions of the world around them and affecting their mood and selfesteem. Cognitive-behavioral therapy used often and successfully with depressed patients suggests that the depressed unrealistic negative thought processes are central to becoming and staying depressed (Belsky 1984). To understand the term cognitive-behavioral therapy it is necessary to go through the definitions of terms cognitive theory and behavior. Cognitive Theory Cognitive theory seeks to help clients understand how negative and conflicting thought patterns influence their appraisals of certain situations, with the result that their emotional reactions to these situations – such as anger, depression, and fear – are exaggerated or inappropriate. Nurses in the teaching-learning, reasoning, understanding and remembering can use principles of cognitive learning. Thought and memory enter into every cognitive action. Cognitive therapy offers a way of effecting behavioral and emotional change through analysis and revision of the client’s thinking and perception. Behavior According to Wolpe, behavior is a conditioned response, that is, a response, which has been rewarded. Many behaviors become habits, which are established, long-standing patterns of response to stimuli. Maladaptive behaviors are thought to have begun in response to uncomfortable levels of anxiety and to have been rewarded by decreased anxiety.

…Therapy436 According to Miller and Dollard, behavior reflects a way of coping with conflict and its associated anxiety. There are two kinds of conflicts. An avoidance-avoidance conflict occurs when one must choose between two undesirable alternatives. An approach-avoidance conflict occurs when one has ambivalent feelings about an object: one wishes, simultaneously, toe approach and avoid it. Therapy Any treatment designed to remove health problems or disability or to cure an illness. Types       Cognitive therapy. Behavioral psychotherapy. Pharmacotherapy. Pscychotherapy, large and small group therapy. Family therapy. Milieu therapy.

Cognitive Therapy Cognitive therapy teaches the client about their thinking patterns that they can change their reaction to the situation that causes anxiety. These thinking negative thoughts distortion are treated change with positive thinking through cognitive therapy. It based on the ways people perceive the event rather than the event itself and the person’s emotional response. In this way they develop the belief about themselves that later become activated, which stimulate automatic cognitive interpretation to maintain the validity of these core belief. People develop intermediate belief that supports the core belief. These therapy depend on the principle of learning and recognized learning as internal process cannot be observed directly because the change occur in the person’s ability to respond in particular situation. Change in the behavior is reflection of the internal change. An individual, who learn new behavior is

…Therapy437 contingent on four variables; attention, retention motor reproduction and incentive. To learn the behavior through modeling, the individual: (1) directed attention toward target behavior, (2) intellectual ability to retain an image of model behavior and (3) physical capacity to reproduce the behavior. Beck (1976) postulated that negative thoughts and cognitive distortions contribute and perpetuate the patient’s emotional difficulties and moods that in turn prevent the goal achievement. Cognitive distortion and negative thoughts are includes:   Arbitrary inference – draw the conclusion about event without any evidence. Selective abstraction – draw the conclusion on the basis of one fact rather than the considering all the facts.    Over generalization – conclusion on the basis of single event or fact. Magnification and Minimization. In exact Labeling – draw conclusion on the emotional basis rather than the fact. The goal of cognitive therapy is to train the client to recognize these automatic negative thoughts, distortion and attributes. This therapy assesses these distortions and educate about dealing them that contribute the problem. Behavior Therapy Behavior therapy is a mood of treatment that focus on modifying observable and at least principle, quantifiable behavior by means of systematic manipulation of environment and variable thoughts to be functionally related to the behavior. Behaviorists believe that problem behavior ore learned and therefore can be eliminated or replaced by desirable behavior through new learning experience. Behavior therapy is the therapeutic modality, which address the observable behavior. Teaching approach based on the stimulus response pattern of the conditioning and reinforcement. Behavior therapy depends on the observational learning model, which take

…Therapy438 place when one sees others reward or punishment for their actions. The behavior methodologies are based on three theoretical approaches to learning, which focus on the ways learning occur. All these approaches facilitate the client journey toward learning. Learning includes: (1) learning through simple association (to observation or event occur frequently each become associated with others, which improve learning), (2) classical behavior conditioning (cues used to stimulate desire behavioral change), (3) operant conditioning refers to any voluntary behavior which affected by reinforcement, punishment and extinction. Too much reinforcement stops the desire behavior. Steps in application of behavior principle are: (1) assessment about behavioral problem (which include the client self report, application of appropriate test and direct observation of client’s behavior), (2) defining the problem (think of behavior, which switch the behavior or emotional influence it), and (3) target the behavior (consider those activities, which interfere the behavior, which effect the client’s functioning). It is effective in the stress of hospitalization unexpected medical procedure, unfamiliar hospital routines, restricted freedom can precipitate variety of behavioral responses in the clients that can impair the nurse-client relationship. Behavior such as non-compliance, manipulation, aggression and violence are generally treated with behavior therapy. Principle of behavior therapy includes: (1) faulty learning can result in psychiatric disorders, (2) behavior is modified through the application of principles of learning, (3) maladaptive behavior is considered to be deficient or excessive, (4) one’s social environment is source of stimuli that support symptoms. Therefore, it also can support changes in behavior through appropriate treatment measures. Behavior therapy techniques include: (1) behavior medication (stimulus elicits response), and (2) systematic desensitization (like live with dog).

…Therapy439 In the psycho-behavior therapy approaches are used to change the observable behavior, such as: (1) aversion therapy uses unpleasant or noxious stimuli to change inappropriate behavior, (2) cognitive behavior therapy uses confrontation as a means of helping clients restructure irrational beliefs and behavior, (3) assertiveness training, clients are taught how to appropriately relate to others using frank, honest, and direct expressions, whether these are positive or native in nature, (4) implosive therapy or flooding is the opposite of systematic desensitization. Persons are exposed to intense forms of anxiety producers, either in imagination or in real life, and (5) limit setting provide a framework for the client to function in, and enable the client to learn make requests. Eventually the client learns to control his/her own behavior. Cognitive Behavior Therapy Cognitive-behavior therapy uses confrontation as a means of helping clients restructure irrational beliefs and behavior. The therapist confronts the client with a specific irrational thought process and helps to rearrange maladaptive thinking, perceptions or attitudes. It is considered as a choice of treatment for depression and adjustment difficulties and based on the notion that the way we think about something influences the way we behave and feel. Negative patterns of thinking tend to be automatic and pervasive, coloring individual’s perceptions of the world around them and affecting their mood and self-esteem. Cognitive behavioral therapy, used often and successfully with depressed older people, suggests that the depressed elder’s unrealistic negative thought processes are central to becoming and staying depressed (Belsky 1984). Its approaches can be integrated, using the social-learning concept as a framework. It focuses on symptoms and thought processes (rather than a hypothetical unconscious cause) and fosters a sense of self-responsibility and self-control, the patients are often receptive and willing to try it.

…Therapy440 A comparison of Cognitive Therapy and Behavioral Therapy can be observed through the following given table. Cognitive Therapy Similarities Formulate symptoms in behavioral terms, Same and design specific set of operations to alter maladaptive behavior. Collaborate with and coach regarding reactive responses. client Same Behavioral Therapy

Seek to alleviate overt symptoms or Same behavioral problems directly. Stress here and now, not the past. Differences Use induced and spontaneous images to Apply techniques of systematic identify misconceptions and test distorted desensitization by inducing a views against reality. predetermined sequence of images alternating with periods of relaxation. Modify attitudes, beliefs, or modes of Modify behavior directly (through thinking that influence behavior. reciprocal inhibition, systematic desensitization and so on). Modify ideational content (e.g., irrational Modify behavior directly. premises and inferences) to aid change in behavior. Work with internally experienced Work with observable behavior. cognitive structures (schemas) that influence client’s perceptions, interpretations, and images. Problems Addressed through Cognitive Behavior Therapy Cognitive-behavioral therapy is a clinically and research proven break through in mental health care, which is used in the following conditions.    Depression and mood swings. Shyness and social anxiety. Panic attacks and phobias.

…Therapy441               Obsessions and compulsions. Chronic anxiety or worry. Post traumatic stress symptoms. Eating disorders and obesity. Insomnia and other sleep problems. Difficulty establishing staying in relationship. Problem with marriage or other relationship. Job career of school difficulty. Feeling stressed out. Insufficient self-esteem. In educate coping skills self- or ill-chosen method of coping. Passivity – Procrastination and “passive aggression”. Substance abuse co-dependency and “enabling”. Trouble keeping feeling such as anger sadness, fear, guilt, shame, eagerness, excitement, etc. within bounds.  Over-inhibition of feeling or expression.

Factors Affecting during Cognitive Behavior Therapy       Listening and talking. Release of emotions. Giving information. Providing rationale. Prestige suggestions. Therapeutic relationship.

…Therapy442 Purpose of Therapies     Attempt to change the behavior in direct way. To analyze conditions creating fears. To decrease tension, disturbance, fear, superstitious and social and sexual problems. The exchange the thinking process towards complex to simple by conversation, but not to emphases in past events. Only focus on the present situation and plan for future.   Ability to deal with problems. Relief from emotional disturbance and change antisocial behavior.

Cognitive Interventions     To increase the client’s sense of control over his/her goals and behavior. To increase the client’s self-esteem. To assist the client in modifying his/her negative expectations. Task of the nurse to move the client beyond his/her limiting preoccupation to other aspects of his/her world, which is related to it.  Nursing actions may then focus on modifying the client’s thinking. Depressed clients are noticeably dominated by negative thought.  In many cognitive behavioral pain relies strategies are also used to relieve stress, such as progressive relaxation, guided imagery, therapeutic touch and biofeedback. Behavioral Interventions      Nursing interventions focus on activating the client in a realistic, goal directed way. The implication is that the client can change, which instills hope. Complete successfully tasks tend to enhance the client’s self-esteem. They help restructure a system. They test the flexibility of a person or system and reveal areas of resistance to change.

…Therapy443 Psychological Interventions Psychological interventions in psychosis have been found to produce positive responses in about 50% cases however, isolating the determinant factors that predict improved psychotic symptomatology have not been clearly demonstrated. Psychotic symptomatology refers to a broad range of features commonly associated with various psychiatric disorders. Generally, symptom management is achieved by enabling the client to link feelings and patterns of thinking and connect them to subjective distress and life disruption. This is usually done by examining the evidence in support of and against the distressing belief, using reasons and logic to find an acceptable explanation and challenging habitual patterns of thinking. The necessary collaboration and assessment is therapeutic in itself and the added focus and direction provided by specific interventions serves to guide and develop practice. Psychological preparation of children for surgery using behavioral strategies (e.g., relaxation and training in coping skills) has been beneficial in reducing postoperative anxiety and distress and generally improving psychological adjustment.

Liaquat University of Medical and Health Sciences Jamshoro Sindh

…Therapy444

College of Nursing, JPMC Cognitive Behavioral Therapy ACN III Major NCP (Assignment # 2) Zafar Iqbal BScN Year II Mrs. Munira A. Ali

…Therapy445 Patient Name: Kulsoom D/o Mazarle Status: Single Occupation: Diagnosis: Age: 22 Years Sex: Female

Domestic work/Factory labor.

Conversion Disorder (Psychogenic hiccup) /Somatoform disorder.

Presenting Complaint:      Nonstop hiccup Tremors in hands. Sleeplessness Decrease intake behavior. Difficulty in develop and establish relationship on job and with relatives. The client was admitted through Accident & Emergency Department on 16-10-2006 with above mentioned complaint. She has suffered from this condition 5 times in last one year. This is the 6th attack. Patient has got education up to Matric and presently is jobless. She has got more severe symptoms after her mother got accident. General Physical Examination No any abnormal physical findings. Mental Status Examination Young woman, tall build, well dressed, looking fearful, tense and feeling of uncertainty, shaking of hands and mouth movement. Mood is depressed. No hallucation and delusion present. The client is oriented with time, place and person and her speech normal. Psychiatric Assessment  Physical dimension  Family history No history of any disease in family. However, mother has got accident and has fracture of femur and now she on bed at home. Father has died since two years. She has no brother. No one is present to take care of her mother.

…Therapy446  No history of drug use in the family. No any mental illness in family.

Individual history No any physical illness present.

Activity of Daily Living She is jobless. She spends most of time in home in stitching clothes and home work/domestic work. She is not taking proper diet now. She is weak and tall. She cannot sleep properly. She takes less part in leisure activities. She did not take any drug, alcohol or tobacco.

Sexuality Unmarried, cycle present.

Emotional dimension      Fearful Helpless Worrying about mother. Feeling of insecurity Jobless.

Intellectual dimension   Repeatedly concerning about mother illness. Loss of problem solving skill and left job.

Spiritual dimension  Hopeless

…Therapy447     Go to get help from religious leader. Use home remedies. Not God blaming about illness.

Social dimension      Inability to develop relationship at job and with relatives. She did know her capabilities. She takes less part in occasions. She cannot cope with job environment, so she left job. She is independent but family depends on her.

Mental Status Examination  Appearance Young 22 years, tall built lady wearing neat and appropriate clothes, maintaining her hygiene and looking worry and fearful. Decrease eye contact.  Behavior     Social – calm and less talkative. No answer hostile behavior. Motor Behavior – decrease activity and wall Level of activity – retarded and restless

Abnormal Movement   Tremors in hands Nonstop hiccups.

Communication   Decrease communication with others. Poverty of speech and slurred with hiccups.

Cognitive

…Therapy448    Oriented to time, place and person. Poor in judgment and in decision making.

Thought Process Thought process was intact. No delusion and illusion present but no thought stopping.

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Mood - Severe depress mood, ‘I want to weep but no tear is coming.’ Objective – looking depress and worry. Sensory Perception Five senses are intact. No hallucination and illusion present.

Ensight - is present. Inability to meet daily need

Difficulty to develop relation on job and with relatives, denial her weaknesses

Apprehension and Worrying about mother illness Depress, thought stopping and sleeplessness Difficulty in communication with others

Love and seeking help behavior after death of father and sickness of mother Tremors in hands with nonstop hiccups

Kulsoom Diagnosis Conversion disorder Distort perception, attributes with decrease diet intake

…Therapy449 NURSING CARE PLAN TITILE:
Date

Ineffective Individual Coping
Nursing Diagnosis Ineffective individual coping related to disease process as evidence by difficulty to cope with life events. Goal/Planning Short-term Goals:   The client will identify the stressor and learn the strategy to cope with them within 5 days.  Client will identify  alternative ways of dealing with stress, emotional problem and participate in the treatment program within 5  days. Long-term Goals:  The client will demonstrate the behavior and thinking according to  develop coping plan and use it effectively till discharge  The client will verbalize plan for using alternate ways of dealing with  stress and emotional problems when they occur after discharge.  The client will maintain satisfying relationship in the community and on job. Nursing Intervention Assess and determine the  client strength and weaknesses to develop the method that successful and level of adaptation in future. Encourage the client to  ventilate his/her feelings. Convey your acceptance of the client’s feeling. Set with the client many  times to discuss the current concern, feelings, know her perception about stressor and help to realize and face reality. Involve the client as much  possible in her treatment. Provide with achievable task, goal and activities, and opportunity to make decision. Convey your interest in the  client and approach her for interaction at least once per shift or allow visit to significant others. Rationale Evaluation

Assessment (Data Statement) Subjective Data: Client verbalized that I am worrying about my mother. There is no one to care her. I have difficult to cope with job environment and I have left my job. I don’t know what I do. Objective Data: A 22 years old client was admitted in Psychiatric unit with a complaint of conversion disorder. She has nonstop hiccup, tremors in hands, and sleeplessness. Looking worrying, depress with nonreality thinking and avoid to face life situation. She had less eye contact with low mood and unable to solve her own problems. Vital signs: Blood Pressure: 100/60 mmHg Pulse Rate: 100 beat/min Resp. Rate: 22 per min. Investigation Hb: 10 mg/dl Na: 135 mEq/dl K: 3 mg/dl

For baseline data for The client has future planning to help verbalized that I have identify the the client. stressor and start to use strategy to Ventilating feeling can cope with them. help the client to identify, Now I am going job and accept and work through on the feeling and to remain maintaining routine relationnonjudgmental. Communication of the ship with all concerns and supportive people. environment can facilitate development of the The client was coping behavior. taking her treatment Assess the client and promote the sense of the effectively and control and responsibility. taking care of her mother and was using coping plan and Your presence demons- strategy trate interest and caring effectively. The and convey the client client was also getting help your continued caring. from community frequently..

…Therapy450 Interventions Provide the opportunity for the client to express emotion and fears to release tension and help the client identify the situation which would promote more comfortable feeling. Be alert to the client’s behaviors, especially decreased communication, conversations about death, low frustration tolerance, dependence, disinterest in surrounding and concealing feelings. Do not joke about death, belittle the client’s wishes or feelings, or make insensitive remarks such as every body want to live to change behavior. Assess the client with achievable task, goal, and opportunities to make decision. Allow the client to discover and develop solution that the best fit her concern. The nurse role is to provide assistance and feedback encourage to creative approaches to problem behavior. Teach relaxation techniques such as exercise, yoga, deep breathing, imaginary to decrease physical tension. Teach the client the social skills and encourage her to practice with staff members and other clients. Give the client feedback regarding the social interaction. Assist the client in modifying her negative thoughts and thinking with positive thoughts and reduce the factors which cause such behavior. Encourage the client to pursue personal interest, hobbies and recreational activities. Encourage the client to identify and develop relationship with supportive people outside the hospital environment. Assist the client to identify and use available support system before the discharge from hospital and help to use the plan of care and in the community Rationales Client need to develop skills and replace the behavior and create the supportive environment. These behaviors may indicate the client decision to commit suicide. Client ability to understand and use obstruction To assess the client, promote positive self-esteem and sense of control. To develop new behavior to solve her problem and improve the self-esteem. Reduce the stress and provide alternative coping strategies. Client may lack skills and confidence in social interaction, this contributes to the clients anxiety or social isolation To facilitate the care. Recreational activities can help increase the client social inter and may provide social action. Increase the client support system may help decrease future suicidal behavior. Procedure to reach the short-term and long-term goal.

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Community Violence451 References  Boodiri, E.N. (2005). Cognitive Therapy In: Concise Textbook of Psychiatric. 2nd Edition. Raj Kamal Electric Press Delhi.  Cox, H.C., Hinz, M.D., Lubno, M.A., Newfield, S.A., Ridenour, N.A., Salater, M.M., Sridaromount, K.L. (1996). Clinical Applications of Nursing Diagnosis – Adult, Child, Women’s, Psychiatric, Gerontic, and Home Health Considerations. McGraw Hill New York.  Harber, Hoskins and Leach (1978). Behavioral and Cognitive Theory and Application In: Comprehensive Psychiatric Nursing. 3rd Edition. USA.  Rebraca, S.L. and Ann, I. (2002). Cognitive Behavioral Therapy In: Basic Concepts of Psychiatric-Mental Health Nursing. 5th Edition. Lippincott Williams and Wilkins Philadelphia.  http://www.google.com. Bryant, R.A., Sackville, T., Dang, T.S., Moulds, M., Guthrie, R. (1999). Treating Acute Stress Disorder: An Evaluation of Cognitive Behavior Therapy and Supportive Counseling Techniques.  http:/www.google.com. Scott, J. (2001). Cognitive therapy for depression. B Med Bulletin; 57:101-113.

Community Violence452

Liaquat University of Medical and Health Sciences Jamshoro Sindh
College of Nursing, JPMC Community Violence ACN III Zafar Iqbal
BScN Year II

Mrs. Ruth K. Alam

Community Violence453 Abuse of the children, elder and women as from youth become a great health problem and great deal of the public concern effecting individuals, all ethnic and socioeconomic background. Violence includes child abuse, work place violence, sexual harassment, abuse and rape, elder abuse, youth violence, transcultural consideration and dating violence. Community violence is a complex term that has been used to refer to wide range of events including riots, sniper attacks, gang wars, drive-by shootings, workplace assaults, terrorist attacks, torture, bombings, ware, ethnic cleansing, and widespread sexual, physical and emotional abuse. Another includes domestic violence, refers to abuse between two adults in a romantic relationship, child sexual and physical abuse refers to violence between a child and an adult. Definition Violence is defined as an act (from a pinch or a slap to murder) carried out with the intention of causing physical pain or injury to another person. According to WHO and Krug et al (2002), community violence is defined as “the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation.” Types Violence is not limited to the random and senseless murders that occur on the streets, it affects families – women, children and elders, friends and neighbors. Violence can be categorized into three, based on the relationship between the perpetrator(s) and the victim(s), settings where it occurs, i.e. within the family or the community. These are: Self-directed violence includes suicidal behavior and self-harm; Interpersonal violence includes violence inflicted against one individual by another, or by a small group of individuals, like family and intimate partner violence between family members, and intimate partners, including child

Community Violence454 abuse and elder abuse. This often takes place in the home and community violence involving violence between people who are not related, and who may or may not know each other (acquaintances and strangers). It generally takes place outside the home in public places; Collective violence includes violence inflicted by large groups such as states, organized political groups, militia groups or terrorist organizations. The community violence based on various places:  Work place violence – in some organizations, management used various methods to psychological threat on their workers/employees to achieve specific goals in a limited time period. On the other hand some colleagues also use psychological, physical and emotional methods of threat and even homicide to achieve their personal goals, interests, and benefits.  School violence – the students are at higher risk for a school-associated violent death includes those from racial and ethnic minorities (Kachur et al; 1996).  Dating violence – adolescents can experience violence within the context of a dating relationship. Person in a relationship uses abusive behaviors to demonstrate power or control over the other persons. It includes physical violence, sexual assault, and verbal or emotional abuse. Domestic Violence It can be defined as a pattern of abusive behavior in any relationship that is used by one partner to gain or maintain power and control over another intimate partner. It also refers to abuse between two adults in a romantic relationship. Domestic violence can happen to anyone regardless of race, age, sexual orientation, religion, or gender. It affects people of all socioeconomic backgrounds and education levels and occurs in both opposite-sex and samesex relationships and can happen to intimate partners who are married, living together or

Community Violence455 dating. Children population can be affected more than adults one. Domestic violence mostly present in the following forms:  Physical Abuse – includes hitting, slapping, shoving, grabbing, pinching, biting, etc. Physical abuse also includes denying a partner medical care or forcing alcohol or drug use.  Sexual Abuse – includes coercing or attempting to coerce any sexual contact or behavior without consent, which may be in form of marital rape, attacks on sexual parts of the body, forcing sex after physical violence or treating one in a sexually demeaning manner.  Emotional Abuse – includes undermining an individual’s sense of self-worth and/or self-esteem. It consists of criticism, diminishing one’s abilities, name-calling, or damaging one’s relationship with his or her children.  Economic Abuse – making or attempting to make an individual financially dependent by maintaining total control over financial resources, withholding one’s access to money, or forbidding one’s attendance at school or employment.  Psychological Abuse – includes causing fear by intimidation; threatening physical harm to self, partner, children, or partner’s family or friends; destruction of pets and property; and forcing isolation from family, friends or school and/or work.

Community Violence456 Domestic violence mostly occurs as a matter of power and control

Child Abuse The physical or mental injury, sexual abuse, negligent treatment, or maltreatment of a child under the age of 18 by a person who is responsible for the child’s welfare under circumstances, which indicate that the child’s health or welfare is harmed or threatened thereby. Types Maltreatment of children usually falls into the following general areas.   Physical abuse. Neglect – is an act of omission and refer to parent’s or other person failure to (1) meets a dependent basic need such as proper food, clothing, shelter, medical care, schooling or attention, (2) provide safe living condition, (3) provide physical or

Community Violence457 emotional care, and (4) provide supervision. It can occur in three levels i.e., in the home, institution and the society. Elder Abuse Elder abuse is a vide spread problem. Most frequent abusers of the elderly are adult children. The typical victim is female with average age limit of 76, depends upon the abuser for basic needs, and mentally or physically impaired. It may occur in variety of setting such as homes and general hospital. Youth Violence Youth violence perpetrates acts of violence against others or themselves or destructive family relationship pattern. Youth violence and homicide remained largely unaddressed by our health care system. It involved age 15 to 20 years. They involve gang related violence. Workplace Violence It is defined as repeated unwanted communication or approaches that induced fear in the victim (Wiseman, 1999). The work setting has not been immune from rash of aggressive outburst. The major crimes of the work place are homicide, assault, rape, robbery are frequent visitors to our work sites including health care setting. Other regularly violence faced includes police officer, security guard, taxi drivers, prisoner guarders, and high school teacher. Workplace violence can be classified as:   Type I: Incidence of the violence act performed by someone with no relationship. Type II: Incidence of the violence acts or threats by someone who received services from the workplace.  Type II: Incidence of violence acts from formal employee, supervisor, manager or relative.

Community Violence458 It also include sexual harassment, abuse and rape at workplace and can be defined as any well come sexual advance or conduct on the job that creates an intimidating or offensive work environment. Rape is considered a universal crime against woman. Predatory Violence Predatory violence, in which an individual tries to take something of value using physical threats or direct violence and interpersonal conflicts, in which two acquaintances are involved in a violent altercation with the intent to harm each other. It may be expressive or instrumental. However, both types include brutal acts such as shootings, rapes, stabbings, and beatings. Factors Causing Community Violence The various beliefs for causing community violence includes few costs of family violence, absence of effective social control, family and social structure that support violence and structural inequality of the family. The risk factors promoting community violence includes low socioeconomic status, gang affiliation, media (action movies, etc.), trends of violation of law, war, political issues and disputes, people with aggressive behavior and psychiatric illness, older age, females, children, alcohol and drug, abuse as mutual combat, religion and spirituality, etc.  For child, it includes rental stress, marital problems, financial difficulties, parent child conflict, neurological impairment, various psychiatric disorders, in which individuals are unable to control impulsive behavior, poor communication skills. Learn abusive behavior.  For elder, physical and mental disability, financial independency, personality conflict, societal attitude towards aging, and caregiver frustration.  At the workplace, such as angry dissatisfied consumers, clients with certain, domestic batterers, women with premenstrual tension, fearing of loss of job, and career

Community Violence459 criminals. Certain cultural practices place women at risk for abuse. Drug abuse and alcohol. Effects of Violence Violence effects can be experienced in the community in the following ways:  Children display disorganized or agitated behavior and have nightmares that may include monsters. They become withdrawn, fearful, and aggressive. They may regress to earlier behaviors such as sucking their thumbs and bed-wetting, and they may develop separation anxiety and also engage in play that compulsively reenacts the violence.  Adolescents experience nightmares and intrusive thoughts about the trauma. Traumarelated reactions can include impaired self-esteem and body image, learning difficulties, acting out or risk taking behaviors such as running away, drug or alcohol use, suicide attempts and inappropriate sexual activities.  Women are vulnerable to domestic violence as they are bound by traditional and cultural ideology from leaving an abusive spouse or from seeing themselves as a victim, which can be resulted in behavioral and psychological changes, bruises, suicidal thoughts, feeling of worthlessness, and feeling the need to account for every hour of the day to her mate. The cycle of abuse experience usually occurs in three predictable stages; 1) increasing tension; 2) explosion of anger and 3) loving reconciliation (the honeymoon phase).

Community Violence460 The Cycle of Violence

Assessment Assessment of the victim of abuse or violence requires that the nurse display sensitivity, empathy and confidentiality and privacy also necessary. Initial assessment have included psychological history taking, assessment of psychiatric symptoms, neurocognitive functioning and anti-social traits, report of the violence occurrence, substance abuse and quality of life of the community. Various scales and instruments used for assessment are as under:   Violence assessments based on the individual’s self-report of violence or its absence. Positive and Negative Symptom Scales to assess positive and negative psychiatric symptoms.  Quantified Neurological Scale.

Community Violence461  General demographic historical information for each subject including history of past psychiatric hospitalizations.  Lehman’s quality of Life Scale – a structured interview to evaluate important situation including examining general life satisfaction, daily activities and functioning, family, social relations, finances, work and school, legal and safety issues and health. To victim of violence can be assessed in terms of:  Physical Dimension • In my community’s street gathering places, housing, family and home environment was favorable for gang and drug mafia and for street crime. In my selected family the husband was offender as a drug abuser with aggressive behavior, wife and children were victims. • Family health history No evidence of any physical problem found in the family. Elder brother used drug since last three years. Husband has aggressive behavior and drug abuse and gang relation. • Individual victim and child history Neighbors witnessed for physical abuse, evidenced by the presence of cuts, bruises, punched, sexually victimized and deprived from leisure activities.  Emotional and Intellectual Dimension Use abuser threat and verbal expression, physical aggression, name calling and using bad language for relatives, threatened to not tell about the abuse, inability to express feeling, frustration, threatened to be killed, and divorce. Female looked helpless and fearful.  Spiritual Dimension

Community Violence462 Abuser mostly not involve in religious activities, but female believe and prayer to God. She also has belief on magic for healings and folk medicine in the home.  Social Dimension Abuser not allowed to the victim and children to meet their parents and relatives. Abuser also not participates or takes responsibilities in the family related activities. Sometime he brings strangers to the home and relation to bad people.  Mental Status Examination of Offender, Victim and Children • Appearance Wearing old stitched clothes, with sad, avoid to maintain eye contact and tell something. Children health conditions were not good. • Behavior Offender looking aggressive, agitate, restless and female was hostile. He frightened and threatened them many times. During verbal communication offender becomes reactive and ready for physical abuse to wife. • Communication Female was speaking in slow and low voice with poverty of speech but offender was interrupted her. • Thought Process Offender thought that his wife discussed him everywhere and even left home to meet relatives without obtaining permission from him. Female express her emotions and verbalized to suicidal thought or left home. • Mood She was looking worried and depressed. • Sensory Perception Offender believed that she gave valuable things to her relatives.

Community Violence463 6. Ensight • Present

Community Violence464 Problems Related to Violence Violence includes adjustment disorder with anxiety, adjustment disorder with depressed mood, major depressive disorder, dysthymic disorder, generalized anxiety disorder, alcohol dependence and abuse, other substance related disorders. The related nursing diagnose are anxiety, ineffective individual coping, altered family process, fear, spiritual distress, and hopelessness. Priority of Nursing Diagnosis Nursing diagnosis includes powerlessness, anxiety, an ineffective individual coping, fear, risk for violence and hopelessness. Medical Diagnose Adjustment disorder with anxiety  Powerlessness related to inability to control violent home situation as evidenced by physical injury and feelings of dissatisfaction over present life situation. Goal Planning  Short-term goals - Client will identify safe and supportive environment. - Client will identify two strategies to breakout cycle of abuse.  Long-term goals - Client will deal with any life threatening and physical injuries. - Client will experience comfort and power from other resources. - Client will identified component of safety plan checklist. - Individual will develop system to avoid abusive behavior and threatening. Nursing Interventions and Rationales  Reassure the client for her safety and provide calm and safe environment throughout hospitalization. Safety is the primary goal for both the client and children when abuse occurs.

Community Violence465  Determine and make arrangement for safety of woman and children. Can they stay with a relative, or does the child and woman protective service need to be contacted? Safety is the primary goal for both the client and children when abuse occurs.  Explore the effects of abuse on children and adequacy of their health care. It is important to be an advocate not only for the abuse mother but also for the children.  Conduct assessment in private, being especially attentive of a nonjudgmental and gentle approach. This type of approach maintains the client’s self-esteem.  Encourage the client to see comfort from religious resources. Spiritual distress is real for the abuse. It becomes difficult for them to pray or feel that God is loving, powerful force in their lives.  Provide privacy and support for any other additional measures such as medication and visual imagery and support services (address context of shelter relative or significant other). Spiritual distress is real for the abuse. It becomes difficult for them to pray or feel that God is loving, powerful force in their lives.  Plan care on daily basis and involve the client. It includes his/her like/dislike, routine according to client own pace and schedule. Allow the client to have control over environment and attributes. Evaluation  Client verbalized that she has regained control on her life and to live in environment free of violence.  Client has increase self-concept, reduce feeling of guilt and fear and establish effective family coping skills

Community Violence466 Domestic Violence Prevention Effected individuals and families is the key preventing the problems by helping the community leader to develop expertise to prevent community violence. They can help religious, educational and health care leaders and organizations set up relief centers and shelters and psychological services near the site of the violence. On international basis, various Community Violence Prevention Projects were started, which aims to strengthen and support the work of groups dedicated to addressing community violence by facilitating the exchange of knowledge and experiences among those working on issues of gun violence, sexual assault, domestic and family violence, and youth violence. The project strives to build a network of service and advocacy organizations that can help each other more effectively confront these problems. The project focuses on promoting preventive activities that go beyond responding to incidences of violence to tackle the causes of community violence. Domestic Violence Prevention Model

Community Violence467 Nurse Role in Violence Prevention Nursing responses to abuse are best analyzed by looking at three levels of preventions that are primary, secondary and tertiary. In the primary prevention, the nursing role is that of a community educator on the problems of battering and risk factors that place a woman at risk for battering and available community resources and services for women who are at risk for or are experiencing battering. Education is essential in preventing abuse. Nurses must work to heighten the public’s awareness of the extent and seriousness of battering. Nurses have been particularly effective in the areas of community education, lobbying and national policy. The secondary prevention includes all the screening activities within the community focusing on formal abuse assessment of women who seek care in emergency department, informal referrals among concerned friends and family members and referrals for abuse by health providers in other settings, such as mental health clinics, women’ health clinics and drug treatment centers. The tertiary prevention includes guiding the women toward examining her feelings, helping them to look at their situation realistically, supporting during the decision-making and through any crises and providing them with the opportunities to express their anger and to work through their depression. Nurses play important roles in shelters both in salaried and volunteer positions. The nurse’s role includes:    Assessing health status of the residents. Intervening to meet the health needs of residents Developing and coordinating programs designed to address the developmental and health needs of children.   Servicing as a resource to shelter staff regarding access to other community services. Offering support and guidance to the residents.

Community Violence468     Serving as a health teacher on important topics. Serving on the advisory board of the shelter. Teaching in violence experience. Act as a facilitator for the following responses: i) ii) iii) iv)  Asking the women if abuse is occurring. Identifying behavior and seriousness of abuse. Expressing belief in the women’s stories and telling the men to stop abuse. Help to identify services available, organizations, shelters and resources.

Help to inhibit the responses by: i) ii) iii) iv) Demonstrating anger or irritation and blaming. Advising the women to accept battering as better than nothing. Withholding help until leaves her abuser. Not responding to abuser and advising to leaving him.

Abused children usually required long-term therapeutic support in the following areas:  Providing corrective emotional experiences that allow the development of trust and empathy.  Teaching cognitive strategies such as thought-stopping, clarification, reframing beliefs, and linking stress directly to the trauma of abuse.   Desensitizing the fearful child to involvement with others. Role playing focused to teach the child to discriminate threatening exploitive behavior from safe behavior in others.   Training in empathy skills. Teaching relaxation and using psychopharmacological aids in achieving relaxation. Nursing interventions specific to violence includes:

Community Violence469  To develop a relationship with a victim who exhibits violent or threatening behaviors by examine your own feelings first, approach with empathy, demonstrate respect for victim, respect victim private space and listen respectfully.  To assess the victim health status by asking the questions very gently, regarding suicidal, homicidal or other destructive thoughts, anger rejection and frustration, duration and pattern of the aggressive behavior, drug abuse and access for bruises, lacerations, healed wound, hygiene, and identify social support system.  To teach the patient and/or the patient’s caregiver/significant others by avoiding threatening behaviors, recognizing violence earlier, removing self and others around the patient as a safety measure, explain importance, purposes and side effects of medication, relationship between medication and behavior control steps when get angry, stress management exercises and techniques, maintaining safety and spiritual help.  To demonstrate skills for the patient and/or caregiver by use stress management techniques, compliance with the medication regimen and plan of care, thought stopping techniques and other cognitive strategies and coping skills and safety measures.  Being a part of this plan of care, the other health professional might need to carry out following tasks: i) ii) iii) iv) Responsible for the overall plan of care. Assist the victim in access to community resources. Trained the social worker. Ensure the victim maintains compliance in order to psychiatric treatment.

Occupational Therapy470 References  Carson Zee B. (2000). Mental Health Nursing. The Nursing Patient Journey. 2nd Edition.  National Domestic Violence Hotline, National Center for Victims of Crime and WomensLaw.org.   Population Reference Bureau. Domestic Violence In: 1998 Women of Our World. Shives, L.R. and Isaacs, A. (2002). Basic Concepts of Psychiatric-Mental Health Nursing. (5th ed.). Philadelphia Lipponcott.  Steadman, H., Mulvey, E., Monahan, J., et al. (1998). Violence by People Discharged from acute Psychiatric inpatient facilities and by others in the same neighborhoods. Arch Gen Psy; 55:393-401.

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