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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 She needs helper and supervision.
 Dressing upper body
 Dressing lower body
 Toileting
 Sphincter Control
 Bladder management She needs total assistance
 Bowel management
 Transfer
 Bed, chair, wheel chair Helper + maximum assistance
 Toilet
 Locomotion
 Walk/Wheel chair Needs helper
 Stairs Modified independence (device)
 Communication
 Expression Auditory + visual (Both) – Moderate
Assistance
Vocal + Nonvocal (Both) – Minimal
assistance.
 Social cognition
 Social interaction It is not testable due to risk.
 Problem solving
Occupational Therapy 7

 Memory
Occupational Therapy 8
NURSING CARE PLAN
TITILE: Bathing/Hygiene Self-Care Deficit
Date Assessment Nursing Goal/Planning Nursing Intervention Rationale Evaluation
(Data Statement) Diagnosis
Subjective Data: Short-term Goals:  Provide time for a rest  The client’s increased The client has
Client verbalized that I am  The client will participate period during the client’s activity increases his or verbalized that I

Bathing/Hygiene self-care deficit.
disturbed due to self initiated in self-care activity daily schedule. her need for rest. now participate in
goal direct activities and poor within one week. self-care activities
personal hygiene. Inability to  Observe the client for signs  The client may be and also estab-
Long-term Goals:
follow though with completion of fatigue and monitor his or unaware of fatigue or lished adequate
 The client will adequate
of daily tasks, apathy and unable her sleep patterns. may ignore the need for balance of rest,
balanced of rest and
to use energy productivity. rest. sleep and activity.
sleep pattern.
Objective Data: Decrease stimuli before  Limiting stimuli will The client was
A 78 years old client was  The client will 
demonstrate to initiate bedtime (dim lights, turn off help encourage rest and taking her treat-
admitted in Medical Unit-III television). sleep. ment effectively,
after attack of CVA. She is daily tasks with maintaining
looking untidy, uncombed hair. assistance.
 Use comfort measures or  Comfort measures and adequate nutrition
Chills and rashes, facial sleeping medication if medications can enhance and also meeting
grimaces, restlessness and  The client will personal needs
established normal needed. the ability to sleep.
uncomfortable. with assistance.
nutritional eating pattern
till discharge.  Encourage the client to  Talking with the client
Vital signs: follow a routine of sleeping during night hours will
Blood Pressure: 150/100 mmHg at night rather than during interfere with sleep by
Pulse Rate: 100 beat/min the day, limit interaction stimulating the client and
Resp. Rate: 22 per min. with the client at night and giving attention for not
Investigation allow only a short nap sleeping. Sleeping exces-
Hb: 9 mg/dl during the day. sively during the day
Urine D/R: Normal may decrease the client’s
CT Scan was done appeared ability to sleep at night.
normal.
 Monitor the client’s calorie,  The client may be
protein and fluid intake. You unaware of physical
may need to record intake needs or may ignore
and output. feelings of thirst and
hunger.
Occupational Therapy 9
Occupational Therapy 10

Interventions Rationales

 The client may need a high-calorie diet and supplemental feeding.  The client’s increased activity increases nutrition requirements.

 Provide foods that the client can carry with him or her.  If the client is unable or unwilling to sit and eat, highly nutritious foods that
require little effort to eat may be effective.

 Monitor the client’s elimination patterns  The client may be unaware of or ignore the need to defecate. Constipation is
a frequent adverse effect of antipsychotic medications.

 If necessary, assist the client with personal hygiene, including mouth  The client may be unaware of or lack interest in hygiene. Personal hygiene
care, bathing, dressing, and laundering clothes. can foster feelings of well-being and self-esteem.

 Encourage the client to meet as many of his or her own needs as  The client must be encouraged to be as independent as possible to promote
possible. self-esteem.
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

• When you approach the client, be • The client’s fear may be triggered by
nonthreatening and professional. authority figures or other
characteristics.

• Remain nonjudgmental in you • It is important not to reinforce blame
interactions with the client that the client may have internalized
related to the experience.

• Initially, assign the same staff members • Limiting the number of staff
to the client if possible try to respect the members who interact with the
client’s fears and feeling. Gradually client at fist will facilitate familiarity
increase the number and variety of staff and trust. The client may have strong
members interacting with the client. 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.

• Educate yourself and other staff • Learning about the client’s
members about the client’s experience experience will help prepare you for
and about posttraumatic behavior. the client’s feelings and the details
of his or her experience.

• Examine and remain aware of your own • Traumatic evens engender strong
feelings regarding both the client’s feelings in others and may be quite
traumatic experience and his or her threatening. You may be reminded
feelings and behavior. Talk with other of a related experience or of your
staff members to ventilate and work own vulnerability, or issues related
through your feelings. 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.

• Be consistent with the client; convey • The client may test limits or the
acceptance of him or her as a person therapeutic relationship. Problems
while setting and maintaining limits with acceptance, trust, or authority
regarding behaviors. often occur with posttraumatic
behavior.

• Assess the client’s history of substance • Clients often use substances to help
use. repress emotions.
Interventions Rationales

• Be aware of the client’s use or abuse of • Substance use undermines therapy
substances. Set limits and consequences and may endanger the client’s
for this behavior; it may be helpful to health. Allowing input from the
allow the client or group to have input client or group may minimize power
into these decisions. struggles.

• Encourage the client to express his/her • Identification and expression of
feelings through talking, writing or in feelings are central to the grieving
which the client is comfortable. process.

• Teach the client and the family or • Knowledge about posttraumatic
significant others about posttraumatic behavior may help alleviate anxiety
behavior and treatment. or guilt and may increase hope for
recovery.

• Give the client positive feedback for • The client may feel that he/she is
expressing feelings and sharing burdening others with his/her
experiences. Remain nonjudgmental problems. It is important not to
toward the client. reinforce the client’s internalized
blame.

• If the client has a religious or spiritual • Guilt and forgiveness often are
orientation, referral to a member of the religious or spiritual issues for the
clergy or a chaplain may be appropriate. client.

• Encourage the client to make realistic • Integrating traumatic experiences
plans for the future, integrating his or and making future plans are
her traumatic experience. important resolution steps in the
grief process.

• Provide social skills and leisure time • Social isolation and lack of interest
counseling, or refer the client to a in recreational activities are common
recreational therapist as appropriate. problems following trauma.

• Talk with the client about employment, • Problems with employment
job-related stress, and so forth. Refer the frequently occur in clients with
client to vocational services as needed. posttraumatic behavior.

• Help the client arrange for follow-up • Recovering from trauma may be a
therapy as needed. long-term process. Follow-up
therapy can offer continuing support
in the client’s recovery.
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 Evaluation
Diagnosis
Subjective Data Immediate • Reassure the client that • The client is less likely to Immediate

Risk for violence: Self directed or directed at others related to responding 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. The client:
normal living activities, unaware of • Not harm others or explaining routines, • Is free from
environment, does not feel shame or guilt destroy property. procedures and so forth. injury.
on to be naked, speaks continuously • Establish contact
meaningless wording, does not maintain with reality. • Protect the client from • Client safety is a priority. • Does not harm
hygienic condition and when aggressive harming himself or Self destructive ideas may others or
• Demonstrate or
delusional thoughts or hallucinations.
throws any thing to any person or object others. come from hallucinations property.
verbalize decreased
present in front of him. or delusions.
psychotic symptoms
and feelings of • Has established
Objective Data
anxiety, agitation, • Remove the client from • The benefit of involving the contact with
A 34 years old male brought to the group, if his behavior client with the group is
and so forth. reality.
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
is unaware of environment, bizarre facial Stabilization • Participated in
The client will: to others. protection. therapeutic
expressions, disoriented feeling of
agitation, disorganized, illogical • Take medications as milieu.
• Help the client’s group • The client’s group benefits
thinking, having clothing but prescribed.
accept the client’s from awareness of others’ Stabilization
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 Takes medication as
others and property. manner.
client’s group as needed empathy. prescribed.
(e.g., “[client] is very sick
Vital Signs
right now; he needs our Expresses feelings in
Blood Pressure 100/70 mmHg
understanding and an acceptable manner.
Temperature 97 °F
support”).
Pulse 88 bpm
Respiratory Rate 20 per min 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 Characteristics Patient Snapshot
Disorder
Paranoid • Distrustful. A 45 years old female hospitalized aide

• Suspicious says that she was laid off because she
worked to hard and made her supervisor
• Attributes responsibility
look lazy. She says that when the same
for own problem to
things happened in a pervious job. She filed
others
a law suit against that hospital.
Personality Characteristics Patient Snapshot
Disorder
Schizoid 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.
Schizotypal 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 behavior without communicate with her. She never goes out
psychosis, most patient also on Thursday because this is dangerous day.
have major depressive She has few friends.
disorder.
Cluster B Disorders
Emotional, inconsistent or dramatic genetic or familial association with mood disorders
substance abuse and somato form disorder
Histrionic 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
relationships. throat felt like a hot poker. When he
swallowed and says that he feels so warm
that he must have a fever of at least 106.
Narcissistic 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
empathy for others. school. He says that he knows you will not
be offended because you understand that he
is better than your other patients.
Personality Characteristics Patient Snapshot
Disorder
Antisocial 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.
Borderline 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 impulsiveness. call her again. After your interview, she
Suicide attempts and tells you that all of the other doctors she has
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 (cutting or mechanism).
burning oneself). Often
comorbid with mood
disorders and eating
disorders.
Cluster C Disorders
Fearful, anxious, genetic or familial association with anxiety disorders
Avoidant Timid, sensitive to rejection A 35 years old woman, who works as a
and socially withdrawn laboratory assistant lives with her elderly
feelings of inferiority. 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.
Personality Characteristics Patient Snapshot
Disorder
Obsessive Perfectionistic, orderly, A 33 years old man reports that each night
compulsive stubborn, indecisive, feelings he creates a detailed schedule of his
of imperfection. 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
rules.
Dependent Allows other people to make A 32 years old woman says that her
decisions and assume husband is angry because she calls him at
responsibility for them the office many times each day to ask him
because of poor 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 sleep-

wake 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
Patient’s Name: Mr. Khalid
Age: 40 Years
Medical Diagnosis: Bipolar Disorder
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.
Assessment Nursing Planning Interventions Rationales Evaluation
Diagnosis
Subjective Data Immediate • Provide safe environment. • Physical safety of the client Immediate

Risk for other directed violence related to risk of behaviors in which an
According to the client’s mother, The client will: and other is a priority. The The client demons-

individual demonstrates that he can be physically, emotionally,
“Mr. Khalid does not interest in • Demonstrate decreased client may be used many trated decreased
normal living activities, unaware restlessness, hyperactivity, common items and restlessness, hyper-
of environment, does not maintain and agitation environmental situations in activity & agitation
hygienic condition, restlessness, • Demonstrate decreased a destructive manner. and also not harm
agitation, hyperactivity, hostile hostility. • Decrease environmental • The client’s ability to deal others or himself.
behavior, threatened or actual and/or sexually harmful to others.
• Not harm others and stimuli whenever possible. with stimuli is impaired.
aggression towards self or others himself. Respond to cues of Stabilization
and low self-esteem. agitation by removing The client be free
Stabilization stimuli and perhaps of restlessness,
Objective Data hyperactivity and
A 40 years old male brought to The client will: isolating the client; a
private room may be agitation.
Psychiatric Ward by his parents • Be free of restlessness,
with the complaint of psychiatric hyperactivity and agitation. beneficial
problem. Client is unaware of • Be free of threatened or • Provide a consistent, • Consistency and structure He also be free of
environment, bizarre facial actual aggression toward structured environment. Let can reassure the client. The threatened and
the client know what is client must know what is actual aggression
expressions, disoriented feeling of self or others.
agitation, disorganized, expected of him. Set goals expected before he can toward self or
with the client as soon as work toward meeting those others.
restlessness, hostile behavior
towards others and self. possible. expectations.
• 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.
Nursing Care Plan

Interventions Rationales
• Encourage the client to verbalize feelings such as anxiety and anger. Explore • Ventilation of feelings may help relieve anxiety, anger, and so forth.
ways to relieve tension with the client as soon as possible.

• Encourage supervised physical activity. • Physical activity can diminish tension and hyperactivity in a healthy, nondestructive
manners.

• Give the client positive feedback for controlling aggression, fulfilling • The client is limited in the ability to deal with complex stimuli. Stating a limit tells
responsibilities, and expressing feelings appropriately, especially angry feelings. the client what is expected. Arguing interjects doubt and undermines limits.

• Do not attempt to discuss feelings when the client is agitated. • Positive feedback provides reinforcement for desired behaviors and can enhance self-
esteem. It is essential that the client receive attention for positive behaviors, not only
for unacceptable behaviors.

• Encourage the client to seek a staff member when he is becoming upset or • Seeking staff assistance allows intervention before the client can no longer control
having strong feelings. his or her behavior and encourages the client to recognize feelings and seek help.

• Withdraw your attention (ignore the client) when the client is verbally abusive. • Withdrawing attention can be more effective than negative reinforcement in
Tell the client that you are doing this, but you will give attention for appropriate decreasing unacceptable behaviors. The client may be seeking attention with this
behavior. If the client and others, and then withdraw your attention from the behavior. It is important to reinforce positive behaviors rather than
client. unacceptable ones.

• Do not argue with the client. • Arguing with the client can reinforce adversarial attitudes and undermine limits.

• Calmly and respectfully assure the client that you will provide control if he • The client may fear loss of control and may be afraid of what he may do if he begins
cannot control himself, but do not threaten the client. to express anger. Showing that you are in control without competing with the client
can reassure the client without lowering his self-esteem.
Depression 52

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.
Depression 53

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.
Depression 54

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 Signs Comments

S Sleep Insomnia and early awakening.

I Interest Involvement in usual activities and motivation
are decreased.

G Guilt Many patient feel excessive self-blame.

E Energy Loss of vigor is common (hard to get though
routine task).

C Concentration Cognitive problems (e.g., difficulty in paying
attention and memory disturbance.

A Appetite Decreased desire for food and sex.

P Psychomotor activity Decreased physical activity, psychomotor
retardation, less common psychomotor
agitation occurs.

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.
Depression 58

 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:
Depression 59

• Safe and effective.

• Works quickly.
Depression 60

 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. Obsessive-

compulsive 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.
Depression 66
NURSING CARE PLAN
Patient’s Name: Miss. Shumaila
Age: 24 Years
Medical Diagnosis: Depression
Nursing Diagnosis: Impaired social interaction related to loss of intimate relationship
Assessment Nursing Expected Interventions Rationales Evaluation
Diagnosis Outcome
Subjective Data Short term goals Introduction to the client. To establish a therapeutic Short term Goal

Impaired social interaction related to loss of intimate relationship
According to the client’s parent, “she is The client will relationship. The Client verbalized
feeling difficulty in falling asleep, demonstrate Assess the level of severity It provides a baseline data for the satisfaction with
anorexia and loss weight ,does not increased and condition of the patient. management of situation. quantity and quality of
taking part in any activity and mostly involvement in Encourage patient to express Assist client to examine social social interaction.
lives alone, calm and quite, and social interaction how she feels by scheduling at experience and verbalize feelings Client communicated
complains headache, chest, back pain with in one week. least 10 minutes, twice a day and encourage therapeutic and participated with
and indigestion after engagement focus on client problem / topic. relationship. others and community
broken and failed in BA examination,”. The client will Continually assess the client’s Depressed clients have potential She reestablished or
participate in daily potential for suicide. for suicide that may be change by maintained relation-
Objective Data activities. pre effective interventions. ships and a social life
An adult girl of moderate build and Evaluate patient communi- Improve communication skills and and also established
with rough, unhygienic and Long term goals cation skills and help her to interactive process. support system.
inappropriate dressing and face. The client will be find alternative during
Looks pale, sad, with inappropriate able to initiate interaction with patient. Long term
interaction with Help the client to obtain a Help patient in achieving goal, and Client participated in
eye contact, facial grimaces present,
others to maintain realistic perception of self by improves self-concept. normal daily activities
and malnourished. relationship and focusing on and enhancing and normal routine life.
Delayed response with slow motor social life. strength during conferences
behavior, gait slow, restlessness, with patient. The client verbalized
confused and tremors present Allow client to choose social Promote self-confidence and social satisfaction with quality
communications with low volume, interactions for role play for interaction by allowing practice in of interactions.
and slurred speech, 10 minutes twice a day time. a safe environment.
Oriented and Poor in judgment and Involve patient in daily care to Improve self-concept, and increase The client identified
in decision making. help the patient in planning motivation. Decrease feelings of and demonstrated a
Suicidal ideas, feeling of and decision making about powerlessness. number of measures
helplessness, and hopelessness own care. that increase social
Initiate referrals to support Client’s contact with community interaction.
groups prior to discharge. group to interact to decrease social
isolation.
Depression 67

Assessment Nursing Expected Interventions Rationales Evaluation
Diagnosis Outcome
Vital Signs
Assign one staff permanent for the Limiting the number of new contacts
Blood Pressure 100/70 mmHg
care of the client. will facilitate familiarity and trust among
Temperature 97 °F client and staffs.
Pulse 88 bpm
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 Expressing of feelings may help to
feelings in comfortable way. 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.
Depression 68

Assessment Nursing Expected Interventions Rationales Evaluation
Diagnosis Outcome
Help the client to participate in Increase social skills by providing social
group interactions. contact.

Include client in group activities Reinforcement encourages positive
and assign activities that will be behavior and enhances self-esteem.
easily accomplished and provide
positive reinforcement.

Discuss with support system ways Support system understanding facilitates
in which they can facilitate client the maintenance of new behavior after
interaction. discharge.

Involve client and family in Family involvement enhances the
planning, implementing and effective ness of the interventions.
promoting in reduction or
elimination of impaired social
interaction.

Encourage the client to participate Increases social contacts and interact
in diversional activities, especially -ional skills.
those involving groups, daily.

Encourage the client to use It will increase self-esteem and self-
assistive or corrective devices. confidence.

Limit the amount of time client Provide opportunities for client to
can spend alone in the room. practice new role behavior in a safe and
supportive environment.

Document all the procedure in the For continuation of nursing care in the
client’s file. 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: Mrs. Sultana W/o Shahid Age: 30 Years Bed No. 11 Ward No.: 20 Date of Admission: 24-09-2007.
Medical Diagnosis: Depression
Nursing Diagnosis: Chronic Low Self-Esteem related to long-standing negative self-evaluation/feelings about self or self-capabilities.
Date Assessment Nursing Goal/Planning Nursing Intervention Rationale Evaluation
(Data Statement) Diagnosis
Subjective Data: Short-term Goals:  Encourage the client to  When the client can focus The client has

Chronic Low Self-Esteem related to long-standing negative self-evaluation/feeling
The client’s mother verbalize  The client will verbalize become involved with staff on other people or demonstrated
that she has less abilities and increased feelings of self- and other clients in the interactions cyclic, behavior
strength to develop and self worth. milieu through interactions negative thoughts are consistent with
evaluation thinking about  The client express and activities. interrupted. increased self-
criticism of other as evidence by feelings directly and  Give the client positive  Positive feedback esteem.
lack of job performance, openly. feedback for completing increases the likelihood
hopelessness, suicidal attempts,  The client evaluate own responsibilities and inter- that the client will continue The client has
self-depreciation, loss of self- strengths realistically. acting with others. the behavior. made plans for
confidence, ideas of guilt or  Involve the client in  The client needs to the future
worthlessness, disturbed sleep Long-term Goals: consistent with
pattern, decreased sexual about self or self-capabilities  The client will
activities that are pleasant or experience pleasurable
personal
recreational as a break from activities that are not
desires, loss of energy and demonstrate behavior self-examination. related to self and strengths and
fatigue, appetite and weight consistent with increased problems. expressed
changes, headache, persistent self-esteem.  If negativism dominates the  The client will feel you are satisfaction
backache, chest pain,  The client makes plans client’s conversation, it may acknowledging his or her with self and
palpitation, hyperventilation and for the future consistent help to structure the content feelings yet will begin personal
wiping episodes. with personal strengths. of interactions, for example, practicing the conscious qualities.
 The client expresses by making an agreement to interruption of negativistic
Objective Data:
satisfaction with self and listen to 10 minutes of thought and feeling
A 30 years old client looked pale
personal qualities. “negative” interaction, after patterns.
with depressed mood. She is
having low self-esteem. Her which the client will interact
communication is slow and on a positive topic.
irregular, loss of interest,  Provide simple activities  The client may be limited
insufficient thinking, worrying, that can be accomplished in his or her ability to deal
and restlessness. easily and quickly. Begin with complex tasks or
with a solitary project; stimuli. Any task that the
Vital signs: progress to group occupa- client is able to complete
Blood Pressure: 110/70 mmHg tional and recreational provides in opportunity for
Pulse Rate: 70 beat/min therapy sessions. Give the positive feedback to the
Resp. Rate: 20 per min. client positive feedback for client.
Temp. 98° F participat6ion
Nursing Care Plan

Interventions Rationales

 Give the client honest praise for accomplishing small responsibilities by  Clients with low self-esteem do not benefit from flattery or undue praise.
acknowledging how difficult it can be for the client to perform these Positive feedback provides reinforcement for the client’s growth and can
tasks. enhance self-esteem.

 Gradually increase the number and complexity of activities expected of  As the client’s abilities increase, he or she can accomplish more complex
the client; give positive feedback at each level of accomplishment. activities and receive more feedback.

 It may be necessary to stress to the client that he or she should begin  The client will have the opportunity to recognize his or her own
doing things to feel better, rather than waiting to feel better before doing achievements and will receive positive feedback. Without this stimulus, the
things. client may lack motivation to attempt activities.

 Explore with the client his or her personal strengths. Making a written  While you can help the client discover his or her strengths, it will not be
list is sometimes helpful. 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 Date of Admission: 24th September, 2007.
Psychiatric Diagnosis: Anger (The Client who will not eat)
Nursing Diagnosis: Imbalanced Nutrition Less than Body Requirement
Date Assessment Nursing Goal/Planning Nursing Intervention Rationale Evaluation
(Data Statement) Diagnosis
Subjective Data: Short-term Goals:  Reassure the client and their  For cooperation. The client has

(Intake of nutrient insufficient to meet metabolic needs).
According to attendant, the  The client will family. able to eat and

Imbalanced nutrition less than body requirement
client may not eat for physical or establish adequate  Strictly monitor intake and  Information on intake and shown interest
psychological reasons. She is nutrition, hydration output in an unobtrusive way. output is necessary the during eating.
refusing to eat and unaware of and elimination. Record the type and amount of client’s nutrition state.
the need or desire to eat, lack of food and the times of eating. She has better
appetite, lack of interest in Long-term Goals:  Weight the client regularly, at  Being matter of fact about than before.
eating, aversion to eat, weight  The client will the same time of day and in a weight measurement will
loss (around 10 Kg), difficulty in demonstrate weight matter of fact manner. help to separate issues of
eating, malnutrition, inadequate gain, if appropriate. weight and eating from
hydration, electrolyte imbalance,  The client will emotional issues.
starvation, difficulty in demonstrate in food  Provide nursing care and  The client physical health is
swallowing, lack of awareness and fluid intake. facilitate medical treatment for a priority many physical
of need for food and fluids, physical problem related to problems can contribute to
delusion, anger and hostility, client no eating. result from the client not
manic behavior, low self-esteem, eating.
gait and disturbance in  Provide fruit juice and food  Fruit, juice and foods high
elimination. high in fiber. in fiber content promote
adequate elimination.
Objective Data:
 Try to accommodate the client  Reinforcing previous
18 years old female client
normal or previous eating normal eating habit
Momal lying on bed well
habits as much as possible. increases the likelihood that
oriented with time, place and
 Make culturally or ethnically the client will eat.
person. She is looking:
appropriate food available. The  The client may be more apt
 Pale, irritable.
client significant others may be to eat food that are
 Aggressive behavior. able to provide guidance or culturally acceptable or
 Refused from eating. food acceptable to the client. provide by family members
 Dry mucus membrane or significant others.
 Dehydrated  Gradually decrease the  The transition from feeding
frequency of suggestions and the client to independent
allow the client to take eating is more likely to be
responsibility for eating, again, successful if it is gradual.
record change.
Nursing Care Plan

Date Assessment Nursing Goal/Planning Nursing Intervention Rationale Evaluation
(Data Statement) Diagnosis
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
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 Nursing Goal/Planning Nursing Intervention Rationale Evaluation
(Data Statement) Diagnosis
Subjective Data: Short-term Goals: • Introduce yourself and try to • To establish a trustworthy Short-term Goals:

Significant others anxiety due to divorce related to divorce
The client’s attendant, she was The client will feel spend more time with the relationship. The client verbalized
fine a month ago, suddenly she relaxed with appro- client. that she feel relax and
develop sign and symptoms of priate social behavior comfortable and can
lack of concentration, irritability, and cope to reduce • Assist the client to identify • To cope with anxiety and to call the nurse by
poor appetite, sleeplessness, anxiety level and fear. anxious feelings. reduce its level. name. Expressed
hopelessness, fear, restlessness, reduce anxiety level
increased motor movements, Long-term Goals: • Encourage patient to • Verbalizing feelings will and fear. Immobility
false beliefs and increased level The client will make verbalize feelings of anxiety. reduce level of anxiety. dependence.
of anxiety. full attention. Discuss
current events, and
• Discuss relationship between • To differentiate changes
Objective Data: oriented with the date Long-term Goals:
increased anxiety and between anxiety and
A 40 years lady having history and time. The client The client made
behavior pattern. Note time behavior pattern.
of anxiety due to divorce is relates an increase in decision about reality,
and occasion.
lying on the bed uncomfortably. psychological and and feelings. Also
She is looking restlessness, pale, physiological comfort. cope with the anxiety
insomnia, loss of appetite and • Teach relaxation techniques. • Enables client to reduce level and pain.
poor confidence. anxiety and fear levels Accurately described
whenever occur. relationship between
Vital Sign anxiety and behavior
Blood Pressure: 120/70 mmHg • Encourage the client to use • Family support can help to pattern.
Temperature: 99°F support system. reduce anxiety and fear.
Pulse: 100 bpm
Respiratory Rate: 24 per min. • Observe for side effects of • To reduce side effects of
analgesic. medication and further
follow up.

• Assess vital signs. • To collect basic data for
further follow up.
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 Traditional healers Healing practices.
European Nurse Exercise, Medications, modified diets,
American Physician amulets and religious healing rituals.

African Elderly woman healers, Herbs, poultices, religious healing
American Granny , voodoo healer through rituals, talismans worm
around the wrist or neck or carried in
Spiritualist, root doctor. a pouch to ward off disease

Hispanic Curandero, Espiritualist Hot and cold application, Herbal teas,
American Yerbero, Santiguadora. Prayers and religious medals,
Brujo, and Sobadora. massage, Azabache and three bath.

Asian American Herbalist Hot and cold, Herbs and soups,
Physician Cupping, pinching and rubbing,
Medication, Acupuncture, application
of tiger balm or energy balancing.

Native Shaman Plants and herbs, Blessed medicine,
American Medicine man /woman burned sweet grass, Estafiate (dried
leaves), the blessing ceremony ritual
and sand paintings.
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. • Establish a therapeutic relationship
with client and relatives
• Assess and determine the client • For baseline data for future planning
strength and weaknesses to develop to help the client in successful coping
the method and level of adaptation. ability enhancement.
• Assess causative and contributing • To provide baseline data for planning,
factors as disapproval, inadequate management and developing and
support system and culture. enhancing coping ability of the client.
• Check vital signs. • To see the effectiveness of medication
and severity of disease.
• Establish rapport by spending time, • Coping effectively requires successful
provision of support system, management of task.
conveying of honesty and empathy.
• Encourage the client to ventilate her • Ventilating feeling can help the client
feelings. Convey your acceptance of to identify, and work through the
the client’s feeling. feeling and to remain nonjudgmental.
• Sit with the client many times to • Communication of the concerns and
discuss the current concern, feelings, supportive environment can facilitate
know her perception about stressor development of the coping behavior.
and help to realize and face reality.
• Involve the client as much as • Assess the client and promote the
possible in her treatment. Provide sense of the control and responsibility
with achievable task, goal and
activities, and opportunity to make
decision.
• Convey your interest in the client • Your presence demonstrate interest
and approach her for interaction at and caring and convey the client your
least once per shift or allow visit to continued caring.
significant others.
• Provide the opportunity for the • Client need to develop skills and
client to express emotion and fears replace the behavior, create the
to release tension and help the client supportive environment and develop
identify the situation which would coping ability in the client to pace this
promote more comfortable feeling. critical situation.
• Teach relaxation techniques such as • Reduce the stress and provide
exercise, deep breathing, imaginary alternative coping strategies.
to decrease physical tension.
• Assist the client to develop • To overcome on the maladaptive
appropriate effective coping condition.
strategies
• Identify previous coping • Determine the successful strategies,
mechanisms, and assist patient to helps to have satisfaction in activities.
fined new one.
Depression120

Nursing Interventions Rationales
• Help the client find alternatives or • Helps client continue to have
modification in previous lifestyle satisfaction in activities and provides
behavior by using assistive devices, a sense of control in lifestyle.
participation in activities and
learning new behavior.
• Encourage independence in self care • Provides a sense of control and
activities by focusing on patient’s increase self-esteem and adjustment.
strengths rewarding small success.
• Assess the client with achievable • To assist the client, promote positive
task, goal, and opportunities to make self-esteem and sense of control.
decision.
• Teach the client social skills and • Client may lack skills and confidence
encourage for practice with staff in social interaction, and enhances
members and other clients. Give the coping ability.
client feedback regarding the social
interaction.
• Provides the client familiar needed • Promotes the client’s sense of control
objects for activities. in meeting safety and security need.
• Encourage the client to identify and • Increase the client support system
develop relationship with supportive may help decrease future suicidal
people outside the hospital behavior.
environment.
• Assist the client to identify and use • Procedure to reach the short-term and
available support system before the long-term goal.
discharge from hospital and help to
use the plan of care and in the
community
• Provide social reinforcement and • Reinforcement encourages positive
other behavioral rewards for behavior and enhances self-esteem
demonstration of adaptation and coping mechanism.
• Assist the client in identifying and • Support system can facilitate the
developing support system and plan client’s coping ability and strategies.
for their use.
• Be alert to the client’s behaviors, as • These behaviors may indicate the
less talkative, comments about client decision to commit suicide.
death, frustration, low tolerance,
dependence, and disinterest in
surrounding and concealing feelings.
• Do not joke about death, belittle the • Client ability to understand and use
client’s wishes, feelings, or make obstruction
insensitive remarks such as every
body want to live to change
behavior.
Depression121

Nursing Interventions Rationales
• Allow the client to develop solution • To develop new behavior to solve her
that the best fit her concern. The problem and improve the self-esteem.
nurse role is to provide assistance
and feedback encourages creative
approaches to problem solving.
• Encourage the client to pursue • Recreational activities can help
personal interest, hobbies and increase the client social interaction
recreational activities. and may provide social action.
• Provide client with an environment • Appropriate level of sensory input
that will optimize sensory input. decreases disorganization, confusion
This includes hearing aids, and maximizing the client coping
eyeglasses, pencil and paper, ability.
decreased noise and appropriate
lighting.
• Schedule a meeting with the • Promotes the development of a
identified support system to assist trusting relationship and provides the
them in understanding alternatives in support system with the information
the client’s health. that they utilize, be more effective.
• Provide client with group interaction • Assess the client to express personal
4-6 member for 15-30minutss. importance to other while enhancing
interpersonal relationship skills.
• Develop trusting and respectful • This will help in coping, problem
relationship among client, family solving and decrease the conflict
and community. among the community members.
• Teach coping strategies for • Coping strategies to maintain healthy
managing tension and strain in the emotional and psychological health
event of previous techniques losing may be necessary. This is especially
their effectiveness. true for individual from a culture that
discourages placing individual needs
or emotion ahead of those of the
family.
• Discuss examples with the family • Increases awareness of problems in
and community of ineffective coping the community and stimulates
in order to begin problem solving. interest.
• Educate the community about • Increases awareness in the targeted
cultural diversity, adaptation and community and enhances adaptation
coping mechanism through TV, of the other culture and importance of
radio, news papers, seminars, and effective coping mechanisms.
internet.
• Document the procedure in the • For continuation of the patient care in
patient file. the next shift.
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 non-
epinephrine, 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.
Interventions
 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.
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 Nursing Expected Interventions Rationales Evaluation
Diagnosis Outcome
Subjective Data Short term goals Introduction to the client. To establish a therapeutic Short term Goal

Impaired social interaction related to loss of intimate relationship
According to the client’s parent, “she is The client will relationship. The Client verbalized
feeling difficulty in falling asleep, demonstrate Assess the level of severity It provides a baseline data for the satisfaction with
anorexia and loss weight ,does not increased and condition of the patient. management of situation. quantity and quality of
taking part in any activity and mostly involvement in Encourage patient to express Assist client to examine social social interaction.
lives alone, calm and quite, and social interaction how she feels by scheduling at experience and verbalize feelings Client communicated
complains headache, chest, back pain with in one week. least 10 minutes, twice a day and encourage therapeutic and participated with
and indigestion after engagement focus on client problem / topic. relationship. others and community
broken and failed in BA examination,”. The client will Continually assess the client’s Depressed clients have potential She reestablished or
participate in daily potential for suicide. for suicide that may be change by maintained relation-
Objective Data activities. pre effective interventions. ships and a social life
An adult girl of moderate build and Evaluate patient communi- Improve communication skills and and also established
with rough, uncleaned and Long term goals cation skills and help her to interactive process. support system.
inappropriate dressing and face. The client will be find alternative during
Looks pale, sad, with inappropriate able to initiate interaction with patient. Long term
interaction with Help the client to obtain a Help patient in achieving goal, and Client participated in
eye contact, facial grimaces present,
others to maintain realistic perception of self by improves self-concept. normal daily activities
and malnourished. relationship and focusing on and enhancing and normal routine life.
Delayed response with slow motor social life. strength during conferences
behavior, gait slow, restlessness, with patient. The client verbalized
confused and tremors present Allow client to choose social Promote self-confidence and social satisfaction with quality
communications with low volume, interactions for role play for interaction by allowing practice in of interactions.
and slurred speech, 10 minutes twice a day time. a safe environment.
Oriented and Poor in judgment and Involve patient in daily care to Improve self-concept, and increase The client identified
in decision making. help the patient in planning motivation. Decrease feelings of and demonstrated a
Suicidal ideas, feeling of and decision making about powerlessness. number of measures
helplessness, and hopelessness own care. that increase social
Vital Signs Initiate referrals to support Client’s contact with community interaction.
Blood Pressure 100/70 mmHg groups prior to discharge. group to interact to decrease social
Temperature 97 °F isolation.
Pulse 88 bpm
Depression134

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

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 Expressing of feelings may help to
feelings in comfortable way. 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 Expected Interventions Rationales Evaluation
Diagnosis Outcome
Help the client to participate in Increase social skills by providing social
group interactions. contact.

Include client in group activities Reinforcement encourages positive
and assign activities that will be behavior and enhances self-esteem.
easily accomplished and provide
positive reinforcement.

Discuss with support system ways Support system understanding facilitates
in which they can facilitate client the maintenance of new behavior after
interaction. discharge.

Involve client and family in Family involvement enhances the
planning, implementing and effective ness of the interventions.
promoting in reduction or
elimination of impaired social
interaction.

Encourage the client to participate Increases social contacts and interact
in diversional activities, especially -ional skills.
those involving groups, daily.

Encourage the client to use It will increase self-esteem and self-
assistive or corrective devices. confidence.

Limit the amount of time client Provide opportunities for client to
can spend alone in the room. practice new role behavior in a safe and
supportive environment.

Document all the procedure in the For continuation of nursing care in the
client’s file. 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: Zaibunisa

 Age: 21 Years

 Sex Female

 Address: 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. • Provides baseline for evaluating
effectiveness of measures.

• Monitor vital signs • Provides baseline for evaluating
effectiveness of measures planned.

• Assess for signs and symptoms of
diarrhea: frequent, loose stools,
abdominal pain or cramping.
- Measure amount of liquid stools. • Quantifies loss of fluids.
- Identify exacerbating and alleviating • Provides basis for nursing measures.
factors

• Obtain stool cultures as prescribed by • Identifies pathogenic organism
physician, Administer antimicrobial
therapy as prescribed.
Therapeutic Communication146

Interventions Rationales

• Initiate measures to reduce hyperactivity • Bowel rest may decrease acute
of bowel. episodes.
- Maintain food and fluid restrictions - Reduces stimulation of bowel.
as prescribed by physician.

- Discourage smoking - Nicotine acts as bowel stimulant.

- Avoid bowel irritants such as foods - Prevents stimulation of bowel
high in fat, fried foods, raw and abdominal distention.
vegetables and fruits, nuts, onions,
popcorn, carbonated beverages,
spicy foods, and foods of extreme
temperatures.

- Offer small, frequent meals.

• Administer anticholinergic antispas- • Decreases intestinal spasms and
modics as prescribed. motility.

• Administer opiates or opiate-like • Decreases intestinal spasms and
medications as prescribed by physician. motility.

• Maintain fluid intake of at least 2500 ml • Prevents hypovolemia.
unless contraindicated.

• Explain the interventions required to • Most acute episode of diarrhea are
prevent future episodes managed with the symptomatic
therapy with fluid and electrolyte
replacement.

• Explain the effects of diarrhea on • To prevent diarrhea in future.
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: Low Self-Esteem
Date Assessment Nursing Goal/Planning Nursing Intervention Rationale Evaluation
(Data Statement) Diagnosis
Subjective Data: Short-term Goals:  Encourage the client to  When the client can focus The client has
Client verbalized that she has  The client will verbalize become involved with staff on other people or demonstrated

Chronic Low Self-Esteem.
less abilities and strength to increased feelings of and other clients in the interactions cyclic, behavior
develop and self evaluation self-worth. milieu through interactions negative thoughts are consistent with
thinking about criticism of other  The client express and activities. interrupted. increased self-
as evidence by lack of job feelings directly and  Give the client positive  Positive feedback esteem.
performance. openly. feedback for completing increases the likelihood
 The client evaluate own responsibilities and inter- that the client will continue The client has
Objective Data: strengths realistically. acting with others. the behavior. made plans for
A 30 years old client looked pale  Involve the client in  The client needs to the future
and depressed mood, feeling of Long-term Goals: activities that are pleasant or experience pleasurable consistent with
despair, worthlessness and  The client will recreational as a break from activities that are not personal
having low self-esteem, demonstrate behavior self-examination. related to self and strengths and
communication was slow and consistent with problems. expressed
irregular. increased self-esteem.  If negativism dominates the  The client will feel you are satisfaction
 The client makes plans client’s conversation, it may acknowledging his or her with self and
Vital signs: for the future consistent help to structure the content feelings yet will begin personal
Blood Pressure: 110/70 mmHg with personal strengths. of interactions, for example, practicing the conscious qualities.
Pulse Rate: 70 beat/min  The client expresses by making an agreement to interruption of negativistic
Resp. Rate: 20 per min. satisfaction with self listen to 10 minutes of thought and feeling
Temp. 98° F and personal qualities. “negative” interaction, after patterns.
which the client will interact
on a positive topic.
 Provide simple activities  The client may be limited
that can be accomplished in his or her ability to deal
easily and quickly. Begin with complex tasks or
with a solitary project; stimuli. Any task that the
progress to group occupa- client is able to complete
tional and recreational provides in opportunity for
therapy sessions. Give the positive feedback to the
client positive feedback for client.
participat6ion
Therapeutic Communication155
Therapeutic Communication156

Interventions Rationales

 Give the client honest praise for accomplishing small responsibilities by  Clients with low self-esteem do not benefit from flattery or undue praise.
acknowledging how difficult it can be for the client to perform these Positive feedback provides reinforcement for the client’s growth and can
tasks. enhance self-esteem.

 Gradually increase the number and complexity of activities expected of  As the client’s abilities increase, he or she can accomplish more complex
the client; give positive feedback at each level of accomplishment. activities and receive more feedback.

 It may be necessary to stress to the client that he or she should begin  The client will have the opportunity to recognize his or her own
doing things to feel better, rather than waiting to feel better before doing achievements and will receive positive feedback. Without this stimulus, the
things. client may lack motivation to attempt activities.

 Explore with the client his or her personal strengths. Making a written  While you can help the client discover his or her strengths, it will not be
list is sometimes helpful. 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 • Identification of the behavior and
relationship to activity, events, people, causative factors enhances
etc. intervention plan

• Assist the level of coping mechanisms • To improve effective coping patterns
and sense of ability to manage
anxiety

• Provide reassurance and comfort by staying • To reduce the effects of anxiety.
with the patient.

• Speak slowly and calmly and monitor • To provide calm environment and
anxiety and relationship to activity events. help the client to understand her
anxiety.

• Encourage significantly others to stay • Provide emotional support and
within patient limit and not to force encourage sharing may help a client
conversation. clarify her fear.

• Monitor vital sign at least every 4 • Assists in deter-mining the effect of
hourly while awake. anxiety

• Assist patient to develop coping skills. • Determine what has helped in past
Review past coping behaviors and and determines if the measures are
success or lack of success. still useful.

• Administer anti-anxiety medication as • Effectiveness of medication is
ordered by the doctor. Monitor and determined so that modification
document effects of medication 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 Balancing factor absent
Realistic perception of event Distorted perception of event
+ and
Adequate situational support No adequate situation support
+ and
Adequate coping mechanism No adequate coping mechanism
Result in Result in
Resolution of problem Problem unresolved
↓ ↓
Equilibrium regained Disequilibrium continues
↓ ↓
No Crises 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: Ineffective Coping.
Date Assessment Nursing Goal/Planning Nursing Intervention Rationale Evaluation
(Data Statement) Diagnosis
 Low frustration tolerance. Short-term Goals:  Encourage the client to • These clients frequently The client has
 Impulsive behavior.  The client will verbalize identify the action that deny responsibility for verbalized feeling

inadequate choices of practiced responses and/or inability to use available resources.
 Poor judgment. express feelings precipated hospitalization. consequences through especially anger.

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

Prenatal Chromosomal and hormonal factors influence the gender of
the fetus. The gender of the fetus is determined by the 7th
week.

Birth - 2 years 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.

2 – 5 Years 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.

5 – 12 Years Sex play between age mates occurs. Curiosity about
reproduction occurs. Friendships develop predominantly with
same sex age mates.

13 – 20 Years 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.

Young adulthood 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.

Middle Adulthood Self acceptance is achieved. Performance anxiety decreases
Frequency of intercourse decreases. Hormonal changes and
menopause occur. Secondary sex characteristics decrease.

Late Adulthood Sexual activity is focused on intimacy rather than intercourse.
Sexual accommodation is made for physical handicaps.
Frequency of intercourse decreases.

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 non-
genogram. 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 By establishing realistic boundaries
acting, that are friendly and interested but are helping the client to assume
with clear boundaries of sexual control over body and sexual
involvement. activities.

Ask the client to keep a record of feelings. The on-going recording and follow-up
discussion of client’s feeling expend
awareness and understanding of
behavior.

Discuss the meaning of sexual expression. Sexual expression is an intimate way
of relating to another in a committed
relationship.

Assess the client’s understanding of the It is important that ask to discuss the
information presented. information.

Discuss the spiritual significance of Sexuality is an expression of our
sexuality. spirituality. In that sexuality
transcends the individual and it’s
creative.

Discuss with client the spiritual resources May find spiritual support and
(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 Nursing Goal/Planning Nursing Intervention Rationale Evaluation
(Data Statement) Diagnosis
Subjective Data: Short-term Goals: • Inform and reassure client. • Establish relationship. Short-term Goals:

Altered perception related to disturbed thought process due to biochemical alterations
The client’s attendant, she was The client will feel The client verbalized
fine a month ago, suddenly she relaxed with appro- • The client must lying in • To handle client easily. that she feel relax and
develop sign and symptoms of priate social behavior. comfortably and relaxed comfortable and
lack of concentration, irritability, reduce disturb
poor appetite, sleeplessness, Long-term Goals: • Use communication helps • To encourage client. thoughts.
hopelessness, fear, restlessness, The client will make client to maintain own
increased motor movements, full attention. Discuss individuality. Long-term Goals:
false beliefs and increased level current events, well The client made
of anxiety. oriented to time and decision about reality,
• Provide company of family • To change the thinking.
place and express feeling and follow
or friends.
Objective Data: feelings constructively through with
A 50 years lady lying on the bed appropriate action to
with uncomfortably, untidy and • Diversional therapy • To decrease anxiety. change provocative
in unhygienic conditions. She is situations in personal
looking restlessness insomnia, • Avoid making promises that environment physio-
loss of appetite and poor cannot be fulfilled. logical reaction to
confidence. panic attack decease.
• Verify your interpretation, • To decrease fear. Expressed panic
Vital Sign what client is experiencing. attack about road
Blood Pressure: 120/80 mmHg traffic accident and
Temperature: 98°F • Provide balanced diet. • To improve the general blood injury and its
Pulse: 100 bpm health, alternative method of effect in future.
Respiratory Rate: 24 per min. coping Accurately described
relationship between
Investigation revealed: • Assist the client to set limits panic attack and
Hb: 11.12 on own behavior. occurrence of physio-
Blood Sugar: 120 mg/dl logical symptoms
Urine D/R: Normal • Encourage family to bring • To divert clients attention.
familiar objects from home.
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 204

References

 Corit, P.C. (1999). Family Therapy.

 Kissane, D.W. (2006). Family Therapy.

 Mackenzie, M. (2005). American Family Therapy Association Inc.

 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
Suicide 205

23rd July, 2005
Suicide 206

OBJECTIVES

At the end of this presentation, the participants will
be able to:

1. Define suicide.

2. Explain epidmiology and risk factors.

3. Enumerate causes.

4. Describe suicide as a symptom of psychiatric
illness.

5. Explain predisposing factors – theories of
suicide.

6. Describe diagnosis of suicide.

7. Illustrate application of the nursing process with
suicidal client.

8. Describe suicide precautions – sample
protocol.
Suicide 207

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.
Suicide 208

In direct self-destructive behavior, the person has an
awareness of the desired outcome. Examples of self-
destructive 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 self-
destructive 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.
Suicide 209

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.
Suicide 210

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.
Suicide 211

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.
Suicide 212

Causes

There are so many causes but some of them are mention
below:

1. Prior family history or tendencies.

2. Early trauma.

3. Rigid, disorganized or dysfunctional family system.

4. Disturbed parent child relationship.

5. Unresolved loss.

6. History of abuse.

7. Lost of both parents early in life.

8. Loss of job, money and social position.

9. Somatic symptoms (insomnia, headaches, stomach
aches).

10. Suffering from a major physical illness such as stroke,
cancer or diabetes.

11. History of diagnosed depression.
Suicide 213

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. Depression.

2. Delusions.

3. Guilt.

4. Paranoid thoughts.

5. Social withdrawal.

6. Hopelessness and feelings of worthlessness.

7. Somatic symptoms (insomnia, headaches, stomach
aches).

8. Irritability.

9. Feeling of exhausted.

10. Headaches.

11. Muscle aches.

12. Trouble sleeping.

13. Change in appetite.

14. Constipation.

15. Weight loss.

16. Everyone would be better off, if I died.

17. I wish I were dead.
Suicide 214

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) identify
hopelessness as a central underlying factor in the
predisposition to suicide.

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.
Suicide 215

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 Protective Factors
• Previous suicide attempt. • Effective and appropriate clinical care for mental,
• Mental disorders, particularly mood disorders physical and substance abuse disorders.
such as depression and bipolar disorder. • Easy access to a variety of clinical interventions
• Co-occurring mental and alcohol and substance and support for help seeking.
abuse disorders. • Restricted access to highly lethal methods of
• Family history of suicide. suicide.
• Family and community support.
• Hopelessness.
• Support from on-going medical and mental
• Impulsive and/or aggressive tendencies.
health care relationships.
• Barriers to accessing mental health treatment.
• Learned skills in problem solving, conflict
• Relational, social, work, or financial loss. resolution and nonviolent handling of disputes.
• Physical illness. • Cultural and religious beliefs that discourage
suicide and support self-preservation instincts.
Contd.
217 Suicide

Risk Factors Protective Factors
• Easy access to lethal methods, especially guns.
• Unwillingness to seek help because of stigma
attached to mental and substance abuse
disorders and/or suicidal thoughts.
• 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 suicide that have a
contagious influence.
• Isolation, or a feeling of being cut off from other
people.
218 Suicide

Assessing the Degree of Suicidal Risk

Intensity of Risk
Behavior
Low Moderate High
Anxiety Mild Moderate High or panic
Depression Mild Moderate Severe
Isolation; withdrawal Some feelings of isolation; Some feelings of helpless- Hopeless, helpless,
no withdrawal ness, hopelessness and withdrawal and self-
withdrawal deprecating.
Daily functioning Fairly good in most Moderately goo in some Not good in any
activities activities activity.
Resources Several Some Few or none
Coping strategies being Generally constructive Some that are constructive Predominantly
used destructive
Significant others Several who are available Few or only one available Only one or none
available
Contd.
219 Suicide

Intensity of Risk
Behavior
Low Moderate High
Psychiatric help in past None, or positive attitude Yes, and moderately Negative view of
toward satisfied with results help received
Lifestyle Stable Moderately stable Unstable
Alcohol or drug use Infrequently to excess Frequently to excess Continual abuse
Previous suicide attempts None, or of low lethality One or more of moderate Multiple attempts of
lethality high lethality
Disorientation; None Some Marked
disorganization
Hostility Little or more Some Marked
Suicidal plan Vague, fleeting thoughts Frequent thoughts, Frequent or
but no plan occasional ideas about a constant thought
plan with a specific plan
Suicide 220

Diagnosis
1. Self-destructive behavior related to wish to punish other
for their perceived lack of support and love.
2. Suicidal thoughts related to feelings of hopelessness and
despair.
3. Altered role of performance related to unemployment.
4. Ineffective individual coping related to disease process.
5. Altered nutrition less than body requirements related to
conflict over sexual maturation, evidenced by loss of
30% pre-illness weight.
6. Self-esteem disturbed related to perceived feelings of
loss of control.
Purposes of Suicide
Shneidman (1996) identified what he calls the “Ten
Commonalties of Suicide”.
1. The common purpose of suicide is to seek a solution.
2. The common goal of suicide is cessation of
consciousness.
3. The common stimulus of suicide is unbearable
psychological pain.
4. The common stressor in suicide is frustrated
psychological needs.
5. The common emotion in suicide hopelessness and
helplessness.
6. The common cognitive state in suicide is ambivalence.
7. The common perceptual state in suicide is constriction.
8. The common action in suicide is escape.
9. The common interpersonal act in suicide is
communication of intention.
10. The common pattern in suicide is consistency of lifelong
styles.
Suicide 221

Application of the Nursing Process with the Suicidal
Client
Assessment
The following should be considered when conducting suicidal
assessment demographics, presenting symptoms/ medical-
psychiatric 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 personnel and
business executives are at highest risk.
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.
Suicide 222

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?
Suicide 223

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.

1. To guide and supervise client activities.

2. Support formal and informal group activities to promote
sharing, cooperation, compromise and leadership.

3. Provide for basic needs of the client, including safety,
privacy, activities of daily living and shelter.

4. Stay with the client while all medications are taken.

5. The plan may be started without a physician’s order, but
a psychiatric consultation must be arranged as soon as
possible.

6. 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.

7. Use no restraints on general hospital floors.

8. Do not allow the client to leave the unit for tests or
procedures.

9. Allow visitors and telephone calls unless the client
wishes otherwise. The nurse maintains one-to-one
supervision during visits.
Suicide 224

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.

11. 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.

12. Check that visitors do not leave potentially harmful
objects in the client’s room.

13. Serve the client’s meals in an isolation meal tray that
contains no glass or metal silverware.

14. 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.

15. Do not discontinue these measures without an order
form a psychiatrist.
Suicide 225

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 Suicide

NURSING CARE PLAN
Patient Name: Mr. Kamran
Age 30 years
Sex Male
Medical Diagnosis Suicide
Nursing Diagnosis Hopelessness
Assessment Nursing Goal Intervention Evaluation
Diagnosis
Subjective Data Short Term Goal

Hopelessness related to absence of support system and
According to the client’s parents, he is a • The client will • Evaluation of suicidal is an

perception of worthlessness evidenced by verbal cues.
Identify stressors in client’s
unmarried man. He is alright before one week ongoing process accomplished
verbalize a measure life that precipitated current
and perform his duty well. Sudden he through continuous reassessment
of hope and crises.
changes his behavior and become of the client as well as
aggressive. At home everyone feel his
acceptance of life • Determine coping behaviors determination of goal
and situations over
behavior and worried about his condition. He previously used and client’s achievement. Once the
which he has no
is not taking proper food and drinks. He does perception of effectiveness immediate crises have been
control.
not take part in any activities. His condition then and now. resolved, extended
becomes more and more serious and he id • Encourage the client to psychotherapy may be indicated.
developing abnormal behavior. • The client will make
explore and verbalize feeling
positive statements Objective
Objective Data and perceptions.
about his life. The client develops and
Mr. Kamran, 30 years old man came in • Provide expressions of hope maintains a more positive self-
Psychiatric OPD with complain of abnormal Long Term Goal to client in positive low-key concept and learns more effective
behavior. He looks irritate, drozy, pale and manner.
weak. His walking is imbalance and he
• The client will find a ways to express feeling to others
job. • Help client identify areas of and look free of tension.
speaks loudly.
life situation that are under
Vital Signs own control. Subjective
• The client will The clients recognized that he
• Blood Pressure 100/70 mmHg
participate in group • Identify sources that client
achieved successful interpersonal
• Temperature 98 °F activities. may use after discharge relationships and feel accepted
• Pulse 70 bpm when crises occur or feelings by others and achieve sense of
• Respiratory rate 20 per min of hopelessness and belonging.
possible suicidal ideation
prevail.
References
1. Harber, Hoskins and Leach (1978). Comprehensive
Psychiatric Nursing. 3rd Edition. USA; p 920.
2. Carson Verna Benner (2000). Mental Health Nursing.
2nd Edition. USA; pp 886-900.
3. Wilson S Holly and Kneisl Carol Ren (1979). Psychiatric
Nursing. Wesley California; pp 554-644.
2. Mosby S. Medical Nursing and Allied Health Dictionary. 4th
Edition; p 552.
3. Shives Louise Rebraca and Isaacs Ann (2002). Suicide In:
Basic Concepts of Psychiatric-Mental Health Nursing. 5th
Edition. Lippincott William and Wilkins Philadelphia; pp 512-
527.
4. The Suicidal Client In: Therapeutic Approaches in Psychiatric
Nursing Care. Pp 256-265.
5. Taylor Monat Cecelia (1994). Essential of Psychiatric Nursing.
14 Edition. USA; pp 242-247.
6. Townsend Marry C (1941). Psychiatric Mental Nursing. pp
450-459.
7. Jacobs (2000). A 52 Year Old Suicidal Man. JAMA
283(20):2693. Assessed by http://www.google.com on July 15,
2005.
8. http://www.yahoo.com.esk. com.askjeeves. Assessed on July
15, 2005.
9. http://www.msn.search.com.lycos.search.lycos.com. Assessed
on July 15, 2005.
10. http://www.hotpot.search.hotpot.com. Assessed on July 15,
2005.
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 Your presence and telling the client
bring up the loss in a supportive manner, if you will return the demonstrate caring
the client refuse to discuss it, withdraw and and support. The client may need
state your intention to return. 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 Rationales

Encourage appropriate expression of all Feelings are not inherently bad or
types of feeling toward the lost person or good. Giving the client support for
object. Ensure the client that negative expressing feelings may help the
feeling like anger and resentment are client except uncomfortable feeling.
normal and healthy in grieving.

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, non-
activity, 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 Sharing grief with other can help the
support among client. Use longer groups for client identify and express feeling and
our general discussion of loss and grief. For feel normal. Dwelling on grief in
ever help the client understand that they are social interaction can result in other
limits to sharing grief in our social contexts. 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 Your presence and telling the client
bring up the loss in a supportive manner, if you will return the demonstrate caring
the client refuse to discuss it, withdraw and and support. The client may need
state your intention to return. 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 Rationales

Encourage appropriate expression of all Feelings are not inherently bad or
types of feeling toward the lost person or good. Giving the client support for
object. Ensure the client that negative expressing feelings may help the
feeling like anger and resentment are client except uncomfortable feeling.
normal and healthy in grieving.

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, non-
activity, 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 Sharing grief with other can help the
support among client. Use longer groups for client identify and express feeling and
our general discussion of loss and grief. For feel normal. Dwelling on grief in
ever help the client understand that they are social interaction can result in other
limits to sharing grief in our social contexts. 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: Anxiety Related to Disturb Thought Process
Date Assessment Nursing Goal/Planning Nursing Intervention Rationale Evaluation
(Data Statement) Diagnosis
 Erratic, impulsive behavior. Short-term Goals:  The client may need to be • The client’s physical The client has
 Poor judgment.  The client will be free secluded or restrained if he or safety, health and well- verbalized decrease

Disturb thought process related to impaired social interaction.
 Agitation from self-inflected she attempts self-mutilation or being are priorities. feeling of fear, guilt
 Feeling of distress harm. harm. and anxiety.
 Illogical thinking, irrational  The client will  Try to substitute a physically  Substitute behaviors
ideas. verbalize feelings of safe behavior for harmful may satisfy the client’s The client has
fear, guilt and anxiety, practices, even if the new need for compulsive expressed feeling
 Extreme intense feeling.
and express feelings behavior is compulsive or behaviors but protect nonverbally in safe
 Refusal to except actual
nonverbally in a safe ritualistic. For example, if the the client’s safety and manner.
information from other.
manner. client is cutting himself or provide a transition
 Socially inappropriate or
herself, direct him or her toward decreasing
odd behavior in certain
Long-term Goals: toward tearing paper. these behaviors.
situation.
 The client will manage  If the client’s behaviors are  Preventing feelings
his or her anxiety not harmful, try not to call may help diminish the
response attention to the compulsive client’s anxiety and
independently. acts initially. thus diminish
 The client will obsessive thoughts and
demonstrate decrease compulsive acts.
in obsessive thought to  Encourage the client to  Expressing feelings
a level at which the verbally identify his or her may help diminish the
client can function concerns, life stresses, fears, client’s anxiety and
independently. and so forth. thus diminish
 The client will obsessive thoughts &
maintain adequate compulsive acts.
psychological  Encourage the client to  The client may be
functioning follow express his or her feelings in uncomfortable with
through with continue way that are acceptable to the some ways of
therapy if needed. client. expressing emotions or
find them unacceptable
initially.
Date Assessment Nursing Goal/Planning Nursing Intervention
(Data Statement) Diagnosis
 Difficulty or slowness completing  If the client is ruminating •
daily living activities because of (e.g., on his or her
ritualistic behavior. 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 Nursing Goal/Planning Nursing Intervention
(Data Statement) Diagnosis
• 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.
NURSING CARE PLAN
Patient’s Name: Razia W/o Akram Ward No: 20 Bed No. 8 Date of Admission: 02-09-2007.
Age: 34 Years
Medical Diagnosis: Depression
Nursing Diagnosis: Ineffective individual coping related to depression in response to identifiable stressor (Death of Husband).
Date Assessment Nursing Planning Interventions Rationales Evaluation
Diagnosis
Subjective Data Short term goal • Assess the causative and • To identify the stressors of the Short term goal

Ineffective individual coping related to depression in response to
The client verbalize that she is The client will contributive factors towards situation. The client verbalized
suffering from tension due to verbalize the feeling loss related grief. the feeling related to
the death of her husband and related to her • Establish report by spend • To provide supportive her emotional state.
I cannot live without him, my emotional state. time with client. companionship to build good
life is nothing. Long term goal

identifiable stressor (Death of Husband).
rapport.
Long term goal • Offer support and • Let the client know that, we are The client made
Objective Data The client will: encourage expression of her understanding her feeling. decision and follow
A 34 years old client sitting on • Make decision feelings. through with appro-
bed, low mood, low self and follow up. priate actions to
• Listen carefully as client • To collect facts and observe
esteem, anxiety, lacks • Through with change provocative
spoke. facial expression.
interpersonal skills, loneliness, appropriate situations in personal
headache, restlessness, • Encourage the client to • To motivate the client towards environment.
actions to change develop interest in the routine life.
insomnia, loss of appetite, poor provocative
judgment, and suicidal ideas. activities.
situations in
• Mobilize into a gradual • To reduce the chances of social
personal
increase in activity in daily and drawl.
environment.
Vital Signs routine for a set time span.
Blood Pressure 110/70 mmHg • Facilitate emotional support • To develop the self esteem and
Temperature 99 °F from others. self concept.
Pulse 90 bpm • Promote hopefulness and • To maintain the reality contract,
Respiratory Rate 22 per min setting of realistic goals and reduce the potential
with client and family. 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. Identify the basis of personal identity.

3. 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. The human imagination.

2. Human spirits.

3. 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 Nursing Goal/Planning Nursing Intervention Rationale Evaluation
(Data Statement) Diagnosis
Subjective Data: Short-term Goals: • Inform and reassure client • To establish a trustworthy Short-term Goals:

Disturbed self esteem related to separation.
The client’s attendant, she was The client will feel relationship. The client verbalized
fine, but after separation, she comfortable and that she feel relax and
developed sign and symptoms of relaxed with improved • Client must be relaxed and • To handle the client easily. comfortable and can
depression, sleeplessness, self esteem level. comfortable. call the nurse by
weight loss, loss of appetite, name. Expressed
restlessness, poor body Long-term Goals: • Provide privacy and a safe • To keep the client tension improved self esteem
presentation, posture, eye The client will make environment. free. level.
contact movements, self abusive full attention toward
behavior and suicide attempts. herself and discuss
• Encourage the client to • To reduce depression and
current events. She Long-term Goals:
express feelings especially improve self esteem.
Objective Data: also well oriented with The client made
about way she thinks or views
A 25 years lady having history the date and time. decision about reality,
self.
of disturbed self esteem related The client relates an and feelings. Also
to separation is to lying on the increase in psycho- cope with the anxiety
bed uncomfortably. She is logical and physio- • Explore realistic alternatives. • To change the thinking. level and took part in
looking restlessness, pale, logical comfort. daily activities.
insomnia, loss of appetite, poor • Use diversional therapy. • This increase anxiety and
confidence and self abusive improve self esteem.
behavior (nail biting).
• Provide balanced diet. • To improve the general
Vital Sign health of the client.
Blood Pressure: 90/60 mmHg
Temperature: 98°F • Avoid criticism. • To encourage and give
Pulse: 70 bpm respect to the client.
Respiratory Rate: 20 per min.
Weight: 40 Kg • Administered medication as • For accurate treatment of the
Jaundice: Negative prescribed by the doctor. disease.
Odema: Negative
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.
ii) 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.
iii) 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.
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 by
disturbances of thought and a flattened or silly affect.
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.

8. Sensory/perceptual alteration, hallucination, auditory and
visual related to social withdrawal as evidenced by
listening to sounds.

9. Ineffective individual coping related to lack of trust in
others evidenced by refusal to take medicine.

10. Social isolation related to inability to accept
shortcomings in others, evidenced by excessive criticism
of friends.

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. Administer antipsychotic medication for example,
stalazine, canpozine, clopazine, risperdal.

2. Assure the patient that you understand that these
experiences must be frightening.

3. Show respect for patient as individual by speaking
directly to them.

4. When patient are hallucinating, attempt to distract them
and focus their attention on real object and situation.

5. Encourage realistic perceptions by using social
reinforces for example, attention, praise.

6. Provide structured environment.

7. To decrease stimuli that may precipitate hallucination.

8. Use concrete, simple, communication rather than
abstract laughty ones.

9. Encourage the expression of feeling for example, fear,
anxiety in a realistic manner.
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: Miss Jamila
Age 23 years
Sex Female
Medical Diagnosis Schizophrenia
Nursing Diagnosis Thought Disorder
Assessment Nursing Goal Intervention Evaluation
Diagnosis
Subjective Data Altered thought Short Term Goal • Be sincere and honest when Objective
According to the parents, Jamila left her process related The client will be free The patient seen a decreased
communicating with client
home at the age of 18 years and attend the to delusional from injury and anxiety level and reality base
avoid vague or evasive
college. She performed well during her first thinking, as deceased anxiety level. thinking, increase attention
remark.
semester. evidence by span and feeling of wellness.
When she come to home on Eid festival, she verbalization Long Term Goal • Do not make promises that
blaming her roommate that she wanted to kill that coworkers The client will identify you can’t keep. Subjective
her and after that she did not take interest in are plotting trusting characteristic in • Encourage the client to talk The patient recognizes the
the study and wanted to live alone in the against patient a relationship till to with you, but do not try for delusional thought and will
room. She did not want to talk with anyone extreme hospitalization. information. adopt social relation.
and did not take part in any activity of daily suspicion and
life. anxiety. • Interact with the patient on
the basis of real things.
Objective Data • Do not be judgmental or
A 23 years old female, college student was
brought to the Psychiatric unit by her parents joke about the client belief.
with a complain of psychiatric problem, false • Give positive feedback for
believe and looking non-reality base-thinking the client success.
disoriented and short attention span, impaired • Never convey to the client
judgment incoherence speech, inappropriate
that you accept the
affect, unhygienic condition and felling of
delusions as reality.
confusion.
Vital Signs
• Blood Pressure 120/180 mmHg
• Temperature 99 °F
• Pulse 80 bpm
• Respiratory rate 22 per min
NURSING CARE PLAN
Patient Name: Mr. Kamran
Age 30 years
Sex Male
Medical Diagnosis Suicide
Nursing Diagnosis Hopelessness
Assessment Nursing Goal Intervention Evaluation
Diagnosis
Subjective Data Hopelessness Short Term Goal Evaluation of suicidal is an
According to the client’s parents, he is a related to • The client will • Identify stressors in client’s ongoing process
unmarried man. He is alright before one week absence of accomplished through
verbalize a measure life that precipitated current
and perform his duty well. Sudden he support system continuous reassessment of
of hope and crises.
changes his behavior and become and perception the client as well as
aggressive. At home everyone feel his of
acceptance of life • Determine coping behaviors determination of goal
and situations over
behavior and worried about his condition. He worthlessness previously used and client’s achievement. Once the
which he has no
is not taking proper food and drinks. He does evidenced by perception of effectiveness immediate crises have been
control.
not take part in any activities. His condition verbalcues. then and now. resolved, extended
becomes more and more serious and he id • Encourage the client to psychotherapy may be
developing abnormal behavior. • The client will make indicated.
explore and verbalize feeling
positive statements
Objective Data and perceptions.
about his life. Objective
Mr. Kamran, 30 years old man came in • Provide expressions of hope The client develops and
Psychiatric OPD with complain of abnormal Long Term Goal to client in positive low-key maintains a more positive
behavior. He looks irritate, drozy, pale and manner.
weak. His walking is imbalance and he
• The client will find a self-concept and learns more
job. • Help client identify areas of effective ways to express
speaks loudly. feeling to others and look free
life situation that are under
Vital Signs own control. of tension.
• The client will
• Blood Pressure 100/70 mmHg
participate in group • Identify sources that client
Subjective
• Temperature 98 °F activities. may use after discharge The client recognized that he
• Pulse 70 bpm when crises occur or achieved successful
• Respiratory rate 20 per min feelings of hopelessness interpersonal relationships
and possible suicidal and feel accepted by others
ideation prevail. and achieve sense of
belonging.
References
References
1. Wilson S Holly. Psychiatric Nursing. Wesley California;
p 825.
3. Lancaster Jeanette (1988). Adult Psychiatric Nursing.
3rd Edition. New York; pp 369-372.
4. Harber, Hoskins and Leach (1978). Comprehensive
Psychiatric Nursing. 3rd Edition. USA; p 1126.
5. Taylor Monat Cecelia (1994). Essential of Psychiatric Nursing.
14 Edition. USA; pp 242-247.
6. Sundeen and Stuart (1991). Principles and Practice of
Psychiatric Nursing. 4th Edition. Philadelphia; p 494.
7. Carson Verna Benner. Mental Health Nursing.
nd
2 Edition. USA; pp 668-669.
8. White Lois (2001). Foundation of Nursing. 6th Edition. USA; p
1195.
9. http://www.schizophrenia.com/family52.overview.htm.
10. http://www.schizophrenia.com/ami/index.htl accessed on July
13, 2005.
11. Http://www.schizophrenia.com/ecgslo.php accessed on July
10, 2005.
12. Townsend Marry C (1941). Psychiatric Mental Nursing. pp
450-459.
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 Evaluation
Diagnosis
Subjective Data Short term goal • Be sincere and hones when • Delusional clients are extremely Short term

Disturbed thought process related to as evidenced by inability
As the client’s brother verbalized The client will communicating with the client. sensitive about others and can goal
that the client shows aggressive free from injury. Avoid vague or evasive recognize insincerity. Evasive The client
behavior even sometime lash out Demonstrate remarks. comments or hesitation reinforces becomes free

to evaluate reality secondary to schizophrenia
on family members. He also decreased anxiety mistrust or delusions. from injury and
shows suspiciousness toward his level. • Be consistent in setting • Clear, consistent limits provide a his anxiety
sisters that they are hostile to me. expectations, enforcing rules, secure structure for the client. level decreased
As he stated that the client did not Long term goal and so forth. as now he did
sleep even two or more days. He Interact on reality • Do not make promises that you • Broken promises reinforce the not show
told that the client hear voices of based topic. cannot keep. client’s mistrust of others. aggressive
unfamiliar person and client said Sustain attention behavior after
• Encourage the client to talk • Probing increases the client’s
that Bush has send army for me. and concentration two days.
with you, but do not pry for suspicion and interferes with the
to complete task
Objective Data information. therapeutic relationship.
or activities. Long term
A 30 years old client sitting on • Explain procedures, and try to • When the client has full know-
bed, but frequently changing his be sure the client understands ledge of procedures, he or she is goal
place. Sometimes on bed and then the procedures before carrying less likely to feel tricked by the Client able to
on chair. He was not fully them out. staff. realize things in
oriented with time, place but some better
• Give positive feedback for the • Positive feedback for genuine
oriented with persons. way.
client’s successes. success enhances the client’s
Non reality based thinking, labile His attention
sense of well being and helps
affect, short attention and span span increased
make nondelusional reality a
impaired judgments, dist- and now he
more positive situation for the
ractibility, impulsivity, restless, complete daily
client.
and anxious. activities with
• Recognize the client’s delusions • Recognizing the client’s concentration
Vital Signs as the client’s perception of the perceptions can help you after five days.
Blood Pressure 110/70 mmHg environment. understand the feelings he or she
Temperature 99 °F • Initially, do not argue with the is experiencing.
Pulse 90 bpm client or try to convince the • Logical argument does not dispel
Respiratory Rate 22 per min client that the delusions are delusional ideas and can interfere
false or unreal. with the development of trust.
Nursing Care Plan

Intervention Rationale
• Interact with the client on the basis of real things; do not dwell on the delusional • Interacting about reality is healthy for the client.
material.

• Engage the client in one-to-one activities at first, then activities in small groups, • A distrustful client can best deal with one person initially. Gradual introduction of
and gradually activities in larger groups. others as the client tolerates is less threatening.

• Recognize and support the client’s accomplishments. • Recognizing the client’s accomplishments can lessen anxiety and the need for
delusions as a source of self-esteem.

• Show empathy regarding the client’s feelings; reassure the client of your • The client’s delusions can be distressing. Empathy conveys your caring, interest,
presence and acceptance. and acceptance of the client.

• Do not be judgmental or belittle or joke about the client’s beliefs. • 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.

• Never convey to the client that you accept the delusions as reality. • Indicating belief in the delusion reinforces the delusion (and the client’s illness).

• Directly interject doubt regarding delusions as soon as the client seems ready to • As the client begins to trust you, he or she may become willing to doubt the
accept this. Do not argue, but present a factual account of the situation. delusion if you express your doubt.

• Ask the client if he or she can see that the delusions interfere with or cause • Discussion of the problems caused by the delusions is a focus on the present and is
problems in his or her life. reality based.
Cognitive-Behavioral Therapy 292

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.
Cognitive-Behavioral Therapy 293

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.
Cognitive-Behavioral Therapy 294

References

 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
Cognitive-Behavioral Therapy 295

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. Explain the indication.

4. Formulate the nursing diagnoses.

5. Identify the cognitive-behavioral interventions,
nursing and psychological intervention.
Cognitive-Behavioral Therapy 296

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 self-
concept 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.
Cognitive-Behavioral Therapy 297

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.
Cognitive-Behavioral Therapy 298

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 self-
responsibility 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.
Cognitive-Behavioral Therapy 299

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 Apply techniques of systematic
images to identify desensitization by inducing a
misconceptions and test predetermined sequence of
distorted views against reality. 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 300

Indications
Cognitive-behavioral therapy is a clinically and research
proven break through in mental health care, which is used in
the following conditions.
1. Depression and mood swings.
2. Shyness and social anxiety.
3. Panic attacks and phobias.
4. Obsessions and compulsions.
5. Chronic anxiety or worry.
6. Post traumatic stress symptoms.
7. Eating disorders and obesity.
8. Insomnia and other sleep problems.
9. Difficulty establishing staying in relationship.
10. Problem with marriage or other relationship.
11. Job career of school difficulty.
12. Feeling stressed out.
13. Insufficient self-esteem.
14. In educate coping skills self- or ill-chosen method of
coping.
15. Passivity – Procrastination and “passive aggression”.
16. Substance abuse co-dependency and “enabling”.
17. Trouble keeping feeling such as anger sadness, fear,
guilt, shame, eagerness, excitement, etc. within bounds.
18. Over-inhibition of feeling or expression.
Cognitive-Behavioral Therapy 301

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 302

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 303

Types of Distraction
1) Visual distraction.
i) Reading or watching television.
ii) Watching a baseball game.
iii) Guided imagery.
2) Auditory distraction.
i) Humor.
ii) Listening to music.
3) Tactile distraction.
i) Slow, rhythmic breathing.
ii) Massage.
iii) Holding or stroking a pet or toy.
4) Intellectual distraction
i) Crossword puzzles.
ii) Card games (e.g. bridge)
iii) 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.
304 Cognitive-Behavioral Therapy

Interventions within a Therapeutic Milieu

Structure Containment Support Involvement Validation
Regular meal times Physical aspects of Nourishment Mutual goal setting Reality orientation
Scheduled activities the facility include the Medication Self-care Feedback and acceptance
Predictability and interior design, safety Social support Client contracting Interaction and contact
routine features, atmosphere, Reassurance Community meetings with the world
Consistency space, privacy, lighting Visitors Family involvement Music, touch, warmth, and
Bowel/bladder location, temperature, Physical therapy Client self-evaluation creative expression
program noise, odors, colors, and occupational Suggestion box Sensory stimulation
Shift change infection control, therapy Client autonomy and Focus on positive aspects
Medication time restraints, confine- Spiritual expression decision making of behavior
Vita signs ment, isolation, Consistent positive Group work “Downplay” of negative
Regular MD visits “homey” atmosphere staff attitudes Newspaper and TV
Primary nursing of client rooms, Handrails One-on-one relationships
Care planning roommates, access to Mutual goal setting Excursions outside
Evaluation public transportation, Exercise
“knock before
entering” policy
Cognitive-Behavioral Therapy 305

Nursing Intervention

1. Use environmental manipulation to assist patient to
cooperate with plan for activities of daily living.

2. Allow use of toilet articles brought from home, play soft
music or relaxation tapes at rest or bedtime.

3. Give positive reinforcement with praise, smiles and
rewarding experiences for cooperation in activities.

4. Establish an effective communication pattern depending
on degree of deterioration.

5. Speak calmly, clearly and slowly one sentence at a time
and repeat as necessary, use short and simple
sentences.

6. If patient is confrontive yelling or belligerent do not argue
or raise your voice, speak gently and calmly and patient
will calm down.
Cognitive-Behavioral Therapy 306

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 307

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.
308 Cognitive-Behavioral Therapy

NURSING CARE PLAN
Name: Mr. Jim
Age 58 Years
Sex Male
Medical Diagnosis Depression
Nursing Diagnosis Sleep pattern disturbance with depression.

Assessment Nursing Expected Intervention Rationale Evaluation
Diagnosis Outcomes
Subjective Data Short term goals • Suggest sleep preparatory • Carbohydrates stimulate • Client kept a
According to the patient, after the death •
difficulty remaining asleep and statement by client that he is not
Disturbed sleep pattern related to depression as evidenced by
Will verbalized activities such as quiet music, secretion of insulin. Insulin sleep diary for
of his wife, he was having difficulty
adjusting to the death of his wife and decreased warm fluids, and decreased decreases all amino acids 7 days.
was not sleeping well. His affect was number
complaints
of active exercise at least one
hour prior to scheduled sleep
but tryptophan in larger
quantities in the brain
• Follow up visit
blunted as he stated that he thought he in one week.
would be the first to die. He did not want regarding loss time. Provide high carbohydrate increases production of
to take any medication for insomnia or of sleep. snacks. serotonin, a neuro- • He was able to
depression, but that he was willing to try transmitter then reduces sleep 5-6 hours
alternative measures to sleep better at • Will report an sleep. each night.
night. improvement in • Assist to bathroom or bedside • The urge to void interrupts • He was able to
sleeping well.

his sleep commode, or offer bedpan at the sleep cycle during the discuss his
Objective Data pattern. 09:00 PM. night. feelings with his
Mr. Jim, a 58 years old male come in
Psychiatric OPD with complain of Long term goals
• Maintain room temperature at • Environment temperature sister and
i.e., the most conducive to brother-in-law
disturbed sleep pattern related to 68 to 72°F.
depression.. He looks irritate and drozy. • Will demons- sleep. and had
decided to
His walking is imbalance. He looks pale trated at least 6
to 8 hours of
• Schedule all patient’s • Promotes uninterrupted attend grief
and week with slow speak. sleep. counseling at
uninterrupted therapeutics prior to 09:00 PM.
Vital Signs sleep night. • Once patient is sleeping place, • Promotes uninterrupted their church.
• Blood Pressure 120/80 mmHg put do not disturb sign on door. sleep.
• Temperature 98 °F • Increase exercise and activities • Promote regular diurnal
• Pulse 70 bpm during the day as appropriate rhythm.
• Respiratory rate 20 per min for patient’s condition.
Cognitive-Behavioral Therapy 309

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.
13. Harber, Hoskins and Leach (1978). Behavioral and
Cognitive Theory and Application In: Comprehensive
Psychiatric Nursing. 3rd Edition. USA; pp 467-484.
14. Walker JI. Essentials of Clinical Psychiatry. ISBN 0-397-
50642-2; pp 386-390.
15. Elsevier Nam Boodiri (2005). Cognitive Therapy In:
Concise Textbook of Psychiatric. 2nd Edition. Raj Kamal
Electric Press Delhi; p 347,
16. Townsend Marry C (1941). The nursing process across
the life span In: Psychiatric Mental Nursing. pp 893-896.
17. 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.
18. http://www.google.com. Scott J (2001). Cognitive therapy
for depression. B Med Bulletin; 57:101-113.
19. 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.
20. http://www.yahoo.com. Bush JW. The Basis of Cognitive
Behavior Therapy.
21. 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.

LIAQUAT UNIVERSITY OF MEDICAL
AND HEALTH SCIENCE
Cognitive-Behavioral Therapy 310

JAMSHORO SINDH

Cognitive-Behavioral Therapy

ACN III

Shahnawaz
BScN Year-II Student
College of Nursing, JPMC

Madam Yasmin

23rd July, 2005
Cognitive-Behavioral Therapy 311

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. Explain risk factors.

9. Describe nursing diagnoses.

10. Discuss cognitive-behavioral interventions,
nursing and psychological intervention.
Cognitive-Behavioral Therapy 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 self-
concept 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 self-
monitoring 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 re-
evaluate 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.
2. 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.
3. Evoking strong anxiety is used as another way to
decondition anxiety. In this, two techniques are used;
(a) flooding and (b) abreaction.
4. 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.
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. Extinction – is a decrease in the rate of neurotic behavior
when the behavior is not reinforced.
2. Spontaneous recovery – is the tendency for neurotic
behavior to recur periodically, even in the absence of
reinforcement.
3. Generalization – is the tendency to transfer the learning
in one situation to similar situations.
4. Discrimination – is the ability to notice the similarities and
differences in like situations.
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 social-
learning 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 Apply techniques of systematic
images to identify desensitization by inducing a
misconceptions and test predetermined sequence of
distorted views against reality. 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. Depression and mood swings.
19. Shyness and social anxiety.
20. Panic attacks and phobias.
21. Obsessions and compulsions.
22. Chronic anxiety or worry.
23. Post traumatic stress symptoms.
24. Eating disorders and obesity.
25. Insomnia and other sleep problems.
26. Difficulty establishing staying in relationship.
27. Problem with marriage or other relationship.
28. Job career of school difficulty.
29. Feeling stressed out.
30. Insufficient self-esteem.
31. In educate coping skills self- or ill-chosen method of
coping.
32. Passivity – Procrastination and “passive aggression”.
33. Substance abuse co-dependency and “enabling”.
34. Trouble keeping feeling such as anger sadness, fear,
guilt, shame, eagerness, excitement, etc. within bounds.
35. 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) Reading or watching television.
v) Watching a baseball game.
vi) Guided imagery.
2) Auditory distraction.
iii) Humor.
iv) Listening to music.
3) Tactile distraction.
iv) Slow, rhythmic breathing.
v) Massage.
vi) Holding or stroking a pet or toy.
4) Intellectual distraction
iv) Crossword puzzles.
v) Card games (e.g. bridge)
vi) 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 Containment Support Involvement Validation
Regular meal times Physical aspects of Nourishment Mutual goal setting Reality orientation
Scheduled activities the facility include the Medication Self-care Feedback and acceptance
Predictability and interior design, safety Social support Client contracting Interaction and contact
routine features, atmosphere, Reassurance Community meetings with the world
Consistency space, privacy, lighting Visitors Family involvement Music, touch, warmth, and
Bowel/bladder location, temperature, Physical therapy Client self-evaluation creative expression
program noise, odors, colors, and occupational Suggestion box Sensory stimulation
Shift change infection control, therapy Client autonomy and Focus on positive aspects
Medication time restraints, confine- Spiritual expression decision making of behavior
Vita signs ment, isolation, Consistent positive Group work “Downplay” of negative
Regular MD visits “homey” atmosphere staff attitudes Newspaper and TV
Primary nursing of client rooms, Handrails One-on-one relationships
Care planning roommates, access to Mutual goal setting Excursions outside
Evaluation public transportation, Exercise
“knock before
entering” policy
Cognitive-Behavioral Therapy 323

Nursing Intervention

1. Use environmental manipulation to assist patient to
cooperate with plan for activities of daily living.

7. Allow use of toilet articles brought from home, play soft
music or relaxation tapes at rest or bedtime.

8. Give positive reinforcement with praise, smiles and
rewarding experiences for cooperation in activities.

9. Establish an effective communication pattern depending
on degree of deterioration.

10. Speak calmly, clearly and slowly one sentence at a time
and repeat as necessary, use short and simple
sentences.

11. If patient is confrontive yelling or belligerent do not argue
or raise your voice, speak gently and calmly and patient
will calm down.
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.
Cognitive-Behavioral Therapy 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.
22. Harber, Hoskins and Leach (1978). Behavioral and
Cognitive Theory and Application In: Comprehensive
Psychiatric Nursing. 3rd Edition. USA; pp 467-484.
23. Walker JI. Essentials of Clinical Psychiatry. ISBN 0-397-
50642-2; pp 386-390.
24. Elsevier Nam Boodiri (2005). Cognitive Therapy In:
Concise Textbook of Psychiatric. 2nd Edition. Raj Kamal
Electric Press Delhi; p 347,
25. Townsend Marry C (1941). The nursing process across
the life span In: Psychiatric Mental Nursing. pp 893-896.
26. 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.
27. http://www.google.com. Scott J (2001). Cognitive therapy
for depression. B Med Bulletin; 57:101-113.
28. 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.
29. http://www.yahoo.com. Bush JW. The Basis of Cognitive
Behavior Therapy.
30. 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.
327 Cognitive-Behavioral Therapy

NURSING CARE PLAN
Name: Mr. Jim
Age 58 Years
Sex Male
Medical Diagnosis Depression
Nursing Diagnosis Sleep pattern disturbance with depression.

Assessment Nursing Goal Intervention Evaluation
Diagnosis
Subjective Data Short term goals • Suggest sleep preparatory • Carbohydrates stimulate • Client kept a
According to the patient, after the death •

difficulty remaining asleep and statement by client that he is not
Disturbed sleep pattern related to depression as evidenced by
Will verbalized activities such as quiet music, secretion of insulin. Insulin sleep diary
of his wife, he was having difficulty
adjusting to the death of his wife and decreased warm fluids, and decreased decreases all amino acids for 7 days.
was not sleeping well. His affect was number
complaints
of active exercise at least one
hour prior to scheduled sleep
but tryptophan in larger
quantities in the brain
• Follow up
blunted as he stated that he thought he visit in one
would be the first to die. He did not want regarding loss time. Provide high carbohydrate increases production of
of sleep. snacks. serotonin, a neuro- week.
to take any medication for insomnia or
depression, but that he was willing to try transmitter then reduces • He was able
alternative measures to sleep better at • Will report an sleep. to sleep 5-6
night. improvement in • Assist to bathroom or bedside • The urge to void interrupts hours each
sleeping well.

his sleep commode, or offer bedpan at the sleep cycle during the night.
Objective Data pattern. 09:00 PM. night. • He was able
Mr. Jim, a 58 years old male come in
Psychiatric OPD with complain of Long term goals
• Maintain room temperature at • Environment temperature to discuss his
i.e., the most conducive to feelings with
disturbed sleep pattern related to 68 to 72°F.
depression.. He looks irritate and drozy. • Will demons- sleep. his sister and
brother-in-law
His walking is imbalance. He looks pale trated at least 6
to 8 hours of
• Schedule all patient’s • Promotes uninterrupted and had
and week with slow speak. sleep. decided to
uninterrupted therapeutics prior to 09:00 PM.
Vital Signs sleep night. • Once patient is sleeping place, • Promotes uninterrupted attend grief
counseling at
• Blood Pressure 100/65 mmHg put do not disturb sign on door. sleep. their church.
• Temperature 98 °F • Increase exercise and activities • Promote regular diurnal
• Pulse 70 bpm during the day as appropriate rhythm.
• Respiratory rate 20 per min for patient’s condition.
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 self-
concept 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 self-
monitoring 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 re-
evaluate 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.
5. 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.
6. Evoking strong anxiety is used as another way to
decondition anxiety. In this, two techniques are used;
(a) flooding and (b) abreaction.
7. 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.
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. Extinction – is a decrease in the rate of neurotic behavior
when the behavior is not reinforced.
5. Spontaneous recovery – is the tendency for neurotic
behavior to recur periodically, even in the absence of
reinforcement.
6. Generalization – is the tendency to transfer the learning
in one situation to similar situations.
7. Discrimination – is the ability to notice the similarities and
differences in like situations.
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 social-
learning 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 Apply techniques of systematic
images to identify desensitization by inducing a
misconceptions and test predetermined sequence of
distorted views against reality. 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. Depression and mood swings.
36. Shyness and social anxiety.
37. Panic attacks and phobias.
38. Obsessions and compulsions.
39. Chronic anxiety or worry.
40. Post traumatic stress symptoms.
41. Eating disorders and obesity.
42. Insomnia and other sleep problems.
43. Difficulty establishing staying in relationship.
44. Problem with marriage or other relationship.
45. Job career of school difficulty.
46. Feeling stressed out.
47. Insufficient self-esteem.
48. In educate coping skills self- or ill-chosen method of
coping.
49. Passivity – Procrastination and “passive aggression”.
50. Substance abuse co-dependency and “enabling”.
51. Trouble keeping feeling such as anger sadness, fear,
guilt, shame, eagerness, excitement, etc. within bounds.
52. 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) Guided imagery.
2) Auditory distraction.
v) Humor.
vi) Listening to music.
3) Tactile distraction.
vii) Slow, rhythmic breathing.
viii) Massage.
ix) Holding or stroking a pet or toy.
4) 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 Containment Support Involvement Validation
Regular meal times Physical aspects of Nourishment Mutual goal setting Reality orientation
Scheduled activities the facility include the Medication Self-care Feedback and acceptance
Predictability and interior design, safety Social support Client contracting Interaction and contact
routine features, atmosphere, Reassurance Community meetings with the world
Consistency space, privacy, lighting Visitors Family involvement Music, touch, warmth, and
Bowel/bladder location, temperature, Physical therapy Client self-evaluation creative expression
program noise, odors, colors, and occupational Suggestion box Sensory stimulation
Shift change infection control, therapy Client autonomy and Focus on positive aspects
Medication time restraints, confine- Spiritual expression decision making of behavior
Vita signs ment, isolation, Consistent positive Group work “Downplay” of negative
Regular MD visits “homey” atmosphere staff attitudes Newspaper and TV
Primary nursing of client rooms, Handrails One-on-one relationships
Care planning roommates, access to Mutual goal setting Excursions outside
Evaluation public transportation, Exercise
“knock before
entering” policy
Cognitive-Behavioral Therapy 341

Nursing Intervention

1. Use environmental manipulation to assist patient to
cooperate with plan for activities of daily living.

12. Allow use of toilet articles brought from home, play soft
music or relaxation tapes at rest or bedtime.

13. Give positive reinforcement with praise, smiles and
rewarding experiences for cooperation in activities.

14. Establish an effective communication pattern depending
on degree of deterioration.

15. Speak calmly, clearly and slowly one sentence at a time
and repeat as necessary, use short and simple
sentences.

16. If patient is confrontive yelling or belligerent do not argue
or raise your voice, speak gently and calmly and patient
will calm down.
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.
Cognitive-Behavioral Therapy 343

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.
Cognitive-Behavioral Therapy 344

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.
31. Harber, Hoskins and Leach (1978). Behavioral and
Cognitive Theory and Application In: Comprehensive
Psychiatric Nursing. 3rd Edition. USA; pp 467-484.
32. Walker JI. Essentials of Clinical Psychiatry. ISBN 0-397-
50642-2; pp 386-390.
33. Elsevier Nam Boodiri (2005). Cognitive Therapy In:
Concise Textbook of Psychiatric. 2nd Edition. Raj Kamal
Electric Press Delhi; p 347,
34. Townsend Marry C (1941). The nursing process across
the life span In: Psychiatric Mental Nursing. pp 893-896.
35. 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.
36. http://www.google.com. Scott J (2001). Cognitive therapy
for depression. B Med Bulletin; 57:101-113.
37. 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.
38. http://www.yahoo.com. Bush JW. The Basis of Cognitive
Behavior Therapy.
39. 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.
345 Cognitive-Behavioral Therapy

NURSING CARE PLAN
Name: Mr. Jim
Age 58 Years
Sex Male
Medical Diagnosis Depression
Nursing Diagnosis Sleep pattern disturbance with depression.

Assessment Nursing Goal Intervention Evaluation
Diagnosis
Subjective Data Short term goals • Suggest sleep preparatory • Carbohydrates stimulate • Client kept a
According to the patient, after the death •

difficulty remaining asleep and statement by client that he is not
Disturbed sleep pattern related to depression as evidenced by
Will verbalized activities such as quiet music, secretion of insulin. Insulin sleep diary
of his wife, he was having difficulty
adjusting to the death of his wife and decreased warm fluids, and decreased decreases all amino acids for 7 days.
was not sleeping well. His affect was number
complaints
of active exercise at least one
hour prior to scheduled sleep
but tryptophan in larger
quantities in the brain
• Follow up
blunted as he stated that he thought he visit in one
would be the first to die. He did not want regarding loss time. Provide high carbohydrate increases production of
of sleep. snacks. serotonin, a neuro- week.
to take any medication for insomnia or
depression, but that he was willing to try transmitter then reduces • He was able
alternative measures to sleep better at • Will report an sleep. to sleep 5-6
night. improvement in • Assist to bathroom or bedside • The urge to void interrupts hours each
sleeping well.

his sleep commode, or offer bedpan at the sleep cycle during the night.
Objective Data pattern. 09:00 PM. night. • He was able
Mr. Jim, a 58 years old male come in
Psychiatric OPD with complain of Long term goals
• Maintain room temperature at • Environment temperature to discuss his
i.e., the most conducive to feelings with
disturbed sleep pattern related to 68 to 72°F.
depression.. He looks irritate and drozy. • Will demons- sleep. his sister and
brother-in-law
His walking is imbalance. He looks pale trated at least 6
to 8 hours of
• Schedule all patient’s • Promotes uninterrupted and had
and week with slow speak. sleep. decided to
uninterrupted therapeutics prior to 09:00 PM.
Vital Signs sleep night. • Once patient is sleeping place, • Promotes uninterrupted attend grief
counseling at
• Blood Pressure 100/65 mmHg put do not disturb sign on door. sleep. their church.
• Temperature 98 °F • Increase exercise and activities • Promote regular diurnal
• Pulse 70 bpm during the day as appropriate rhythm.
• Respiratory rate 20 per min for patient’s condition.
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: BScN-II
Topic: Demonstration of various teaching styles.
Venue: Classroom CoN,

JPMC, Karachi.

Time Objectives Content Method of Evaluation
Teaching
45 minutes

At the end of this
session, the learners
will be able to:
• Definition of • Lecture method. • Question
• Define Teacher teacher. and answer
• Discussion
• Discuss various • Various styles
styles of teaching. of teaching. • Role play
• Quiz.
• Describe the • The blend of • Whiteboard with
blend of various various styles marker.
styles of teaching. of teaching.
• Overhead
• Enlist some • Some projector with
important tips for important tips transparencies.
effective for effective
teaching. teaching.

Assignment: Pre-reading. Reference:
Felder, R.M., & Saloman, B. (2003). Learning

styles and strategies In: Varlla, 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 Date of Admission: 26th September, 2007.
Psychiatric Diagnosis: Panic Disorder
Nursing Diagnosis: Ineffective Individual Coping related to Blood Injury.
Date Assessment Nursing Goal/Planning Nursing Intervention Rationale Evaluation
(Data Statement) Diagnosis
Subjective Data: Short-term Goals: • Assess possible contributing • Build up trust. Short-term Goals:

Ineffective Individual Coping related to Blood Injury
The client verbalized that she The client will factors The client called the
has seen a road traffic accident verbalize the • Perception of threatening • Give help in assisting the nurse by her name
with major injuries and blood. feelings of being stimulus client. and remove
After that she developed heart comfortable and • Unfamiliar environment • Client feels comfortable and hesitation.
palpation, pounding of the relaxed. She also confidence The client felt
heart, increase blood pressure, develops ability to relaxed, satisfied and
• Intrusion on personal space • Decrease the fear.
tingling sensation, feeling of take decision with comfortable
chocking, chest pain, full concentration • Life- style change (promotion, • Decrease the anxiety level.
discomfort, feeling of and confidence. marriage/ divorce, retirement) Long-term Goals:
unreality, fear of dying, chill • Biologic and physiologic • Client enables to take proper The client made
and hot flushes, sleeplessness, Long-term Goals: change (dysfunction, disability, decisions. decision about reality,
lack of concentration, The client will make pain) feeling and follow
irritability and nightmares, full attention and • Self-esteem threat (abandon- • Develop the feeling of through with
sensation of short-ness of free from action to ment, rejection) comfortable. appropriate action to
breath, going crazy, change probative • Distorted perceptions of • Verbalizes feeling of panic change provocative
depression, feeling of dread, situations in dangerous stimulus attack. situations in personal
and fright. personal physio- • Age-related fears • Decrease the fear level. environ-ment
logical reaction to • Orient to environment using • Verbalizes the feeling of physiological reaction
Objective Data: panic attack simple explanation. chocking. to panic attack
A 25 years old client sitting on decrease • Speak slowly and calmly. • Identifies event that increase decease. Expressed
bed looking upset and irritable, panic attack about
the attack
restlessness, lack of road traffic accident
• Avoid surprises and painful • Identifies increase panic
concentration, insomnia, loss and blood injury and
of appetite and poor stimuli. attack as a precursor to its effect in future.
confidence. alteration in behavior. Accurately described
• Use soft lights and music. • Decrease in restlessness. relationship between
Vital Sign • Plan one-day-at-a-time familiar • Identifies effective coping panic attack and
Blood Pressure: 150/90 mmHg routine. mechanisms. occurrence of physio-
Temperature: 99°F • Encourage gradual mastery of • Uses relaxation techniques to logical symptoms
Pulse: 120 bpm a situation. decrease anxiety.
Respiratory Rate: 30 per min. • Remain with person until fear • Uses support of family.
subside Later, establish
frequent
• Distorted perceptions • Activities divert the attention
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 predisposing factors of panic
disorder.

17. Discuss epidemiology of panic disorder.

18. Explain nursing diagnosis and nursing
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.
Panic Disorder382

Diagnostic Crietera for Panic Disorder and Panic Attacks
1) The patient must have both:
a) Recurrent unexpected panic attacks.
b) 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) Palpitations, pounding heart, or accelerated heart rate.
b) Sweating.
c) Trembling or shaking.
d) Sensations of shortness of breath or smothering.
e) Feelings of choking.
f) Chest pain or discomfort.
g) Nausea or abdominal distress.
h) Feeling dizzy, unsteady, lightheaded, or faint.
i) Derealization or depresonalization.
j) Fear of losing control or going crazy.
k) Fear of dying.
l) Paresthesias.
m) 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.
Panic Disorder384

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) Abnormalities in the hypothalamic-pituitary-adrenal and
hypothalamic-pituitary-thyroid axes.

2) Acute myocardial infarction.

3) Pheochromocytomas.

4) Substance intoxication and withdrawal (cocaine, alcohol,
marijuana, opioids).

5) Hypoglycemia.

6) Caffeine intoxication.

7) Mitral valve prolapse.

8) Complex partial seizures.
Panic Disorder385

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.
Panic Disorder386

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 him-
or 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) 20 to 80 mg per day

 Paroxetine (Paxil) 10 to 50 mg per day

 Sertraline (Zoloft) 50 to 200 mg per day

 Fluvoxamine (Luvox) 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) 2 to 10 mg per day

 Lorazepam (Ativan) 2 to 6 mg per day

 Clonazepam (Klonopin) 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.
Panic Disorder389

Treating Patients with Panic Disorder

Patient meets DSM-IV
criteria for panic disorder

Yes Offer alcohol detoxification
Is current alcohol abuse and maintenance program
present? with follow up to reassess
panic disorder
No
Yes
Is rapid action needed for Consider short-term
the patient to function? therapy with a
benzodiazepine while long-
No

Offer treatment with
antidepressants or CBT (4
to 12 sessions)

Antidpressants: Continue
for 6 months and
Reassess at 2 and 10 consider
weeks to discuss medication with-
effectiveness and side drawal with
monthly follow
up for relapse.

Is the patient panic-free or Yes CBT: Follow
patient monthly
functioning well? for relapse after
sessions are
No discontinued.

Offer additional treatment Benzodiazepines: Taper
with another therapy, benzodiazepine.
If unsuccessful,
combination therapy, offer CBT during
increased medication tapering period.
dosage, or additional CBT
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.

2) 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.

3) Ineffective individual coping is related to anxiety as
evidenced by his/her excessive dependency on (which
thing has lost).

4) Ineffective family coping is compromised related to
anxiety as evidenced by inability to set realistic limits on
his/her demands for attention.
Panic Disorder391

Nursing Interventions for Panic Disorder

1. Remain with the client at all times when levels of anxiety
are high (severe or panic).

2. Move the client to a quiet area with minimal or
decreased stimuli (such as small room or seclusion
area).

3. Offer reassurance of safety and security to the client.

4. Use short, simple and clear statements.

5. Be aware for your own feelings and level of discomfort.

6. Administer tranquilizing medication, as ordered by
physician. Assess for effectiveness and for side effects.

7. When level of anxiety has been reduced, explore
possible reasons for occurrence.

8. Encourage the client’s participation in relaxation
exercises (such as deep breathing, progressive muscle
relaxation, medication and imagining being in a quiet
peaceful place).

9. Teach the client to use relaxation techniques
independently.

10. Help the client to see that mild anxiety can be a positive
catalyst for change and does not need to be avoided.
Panic Disorder392

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: Ms. M
Age 29 Years
Sex Female
Medical Diagnosis Panic Disorder

Assessment Nursing Expected Outcome Intervention Rationale Evaluation
Diagnosis
Subjective Data
She told that during the prior 3 weeks,
Short term goals
The client will respond
• Stay with the client and offer • The client may fear for her Short term
Ms. M has been

evidenced by all of the physical symptoms identified by the DSM-
Panic anxiety related to perceived threat to biological integrity as
she experienced 4 episodes of to relaxation techniques reassurance of safety and life. reduced her
palpitation and chest discomfort. with a decreased security. anxiety level
Following two of these episodes, she anxiety level by 2-3 • Maintain a calm, non- • Anxiety is contagious and severe to
wen to the emergency department for days. threatening matter-of-fact may be transferred from moderate.
treatment. She total that her symptoms approach. staff to client or vice versa.
were due to anxiety and panic. Long term goals Long term
The client will be able • Keep immediate surrounding • A stimulating environment Ms. M verbalized
Objective Data to recognize symptoms low in stimuli. may increase level of symptoms of
Ms. M, a 29 years old female has of onset of anxiety and anxiety. onset of anxiety
• •
IV-TR criteria.

experienced anxiety since early to intervene before Administer tranquilizing Antianxiety medication and able to
childhood and first underwent reaching panic level by medication as ordered by provides relief from the intervene before
psychotherapy when she was 12. Her 1 week to 3 weeks. physician. immobilizing effects of reaching panic
anxiety was treated with a variety of anxiety. level.
antidepressants, without improvement.
She is smoker and sometimes uses • When the level of anxiety • Recognition of precipi-
alcohol. There is no association of mood has been reduced, explore tating factors is the first
and anxiety disorder with her family. possible reasons for step in teaching client to
occurrence. interrupt escalation of
Vital Signs anxiety.
• Blood Pressure 100/80 mmHg • Teach relaxation techniques, • Relaxation techniques
• Temperature 98 °F which reduce the anxiety. result in a physiological
• Pulse 70 bpm response opposite that of
• Respiratory rate 22 per min the anxiety response.
Depression394

References
1. Wilson S Holly. Psychiatric Nursing. Wesley California;
p 718.
40. Lancaster Jeanette (1988). Adult Psychiatric Nursing.
3rd Edition. New York; p 228.
41. Harber, Hoskins and Leach (1978). Comprehensive
Psychiatric Nursing. 3rd Edition. USA; p 623.
42. Taylor Monat Cecelia (1994). Essential of Psychiatric
Nursing. 14 Edition. USA; p 456.
43. Sundeen and Stuart (1991). Principles and Practice of
Psychiatric Nursing. 4th Edition. Philadelphia;
pp 576-577.
44. Carson Verna Benner. Mental Health Nursing.
2nd Edition. USA; p 621.
45. White Lois (2001). Foundation of Nursing. 6th Edition.
USA; p 813.
46. Townsend Marry C (1941). Psychiatric Mental Nursing.
pp 516-517.
47. http://www.apa.org/pubinfo/panic.html.
48. http://www.aafp.org/afp/980515ap/saeed.html.
49. Http://www.google.com. Gorman JM (2001). A 28-Year-
Old Woman with Panic Disorder. JAMA; 286:450-457.

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. Depress mood.

2. Loss of pressure and interest in all or nearly all of one’s
usual activities and past time.

3. Insomnia or some time hypersomnia.

4. Anorexia and weight loss or sometime hyperphagia and
weight gain.

5. Mental showing and loss of concentration feeling of guilt.

6. Worthlessness and helplessness.

7. Thought of death and suicide.

8. Anhedonia.

9. Change in sleep pattern.

10. Lack of energy.
Depression399

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. Self-
destructive 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.
Depression402

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. Depression can induce with resepine.
2. 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.
Depression403

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 Potential Side Effects
Name

Fluoxetine Prozac Abnormal dreams, anxiety, diarrhea,
drowsiness, excessive sweating,
headache, insomnia, nervousness,
pruritus, seizures, tremors.

Fluvoxamine Luvox Constipation, diarrhea, dizziness, dry
month, drowsiness, dyspesia,
headache, insomnia, nausea,
nervousness, weakness.

Paroxetine Paxil Anxiety, constipation, diarrhea,
dizziness, drowsiness, dry mouth,
ejaculatory disturbance, headache,
insomnia, nausea, sweating,
weakness, tremors.
Depression404

Tricyclic Antidepressants

Generic Name Trade Potential Side Effects
Name
Amitriptyline Elavil Arrhythmia, blurred vision,
hydrochloride constipation, dry eyes, dry mouth,
hypotension, lethargy, sedation.
Clomipramine Anafranil Arrhythmia, blurred vision,
hydrochloride constipation, dry eyes, dry mount,
lethargy, male sexual dysfunction.
Imipramine Tofranil Arrhythmia, blurred vision,
hydrochloride 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).
Depression405

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: 100/70 mmHg.

 Temperature: 97°F

 Pulse: 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: Miss. Saira
Age 20 Years
Sex Female
Medical Diagnosis Depression

Assessment Nursing Expected Intervention Rationale Evaluation
Diagnosis Outcome
Depression410
Subjective Data Short term goals • Encourage patient to • Assist patient to examine social Short term
Saira was brought to Psychiatric unit by The client will • Patient will

Impaired social interaction related to loss of intimate relationship
her parent. According to her parent, she participate in daily express how she feels by experience and verbalize
was alright two months back. Her activities. scheduling at least 10 feelings and encourage verbalize satis-
engagement broken and she also failed minutes, twice a day focus therapeutic relationship. faction with
in her BA examination. After this Long term goals on this topic. quantity and
incident, she is feeling difficulty in falling The client will be • Evaluate patient communi- • Improve communication skills. quality of social
interaction.
asleep, anorexia and weight loss. She is able to initiate cation skills and help him
not taking part in any activity and mostly interaction with or her to find alternative • Will communi-
lives alone, calm and quite. She does others to maintain ones during interaction cate and parti-
not share with others. Sometimes she relationship and with patient. cipate with
complains headache, chest and back social life.
pain and indigestion. • Help patient obtain a • Help patient to see that no one is others
community
and
realistic perception of self perfect and improves self-
Objective Data by focusing on and concept. • Will reestablish
A 20 years, young girl sitting on bed enhancing strength during or maintain
quiet depressed mode, without facial conferences with patient. relation-ships
expression, loss of concentration, • Allow patient to choose • Promote self-confidence in and a social life
and also
feeling of guilt, unwashed and social interactions for role social situations by allowing
uncombed hair, wrinkled, uncoordinated establish
play for 10 minutes twice a practice in a safe environment. support system.
clothes. Her speech is slow and bodies day time.
movement looking lethargic. No hope is
seen in her eyes. • Involve patient in daily • Improve self-concept, and Long term
care to help the patient to increase motivation. Decrease Patient participates
Vital Signs make decision about own feeling of powerlessness. in normal daily
• Blood Pressure 100/70 mmHg care. activities and
normal routine life.
• Temperature 97 °F • If patient is in isolation, • Avoids feeling of total isolation
• Pulse 88 bpm spend at least two minutes for patient.
every hour with patient.
• Initiate referrals to support • Patient contact with community
groups prior to discharge. group to interact to decrease
social isolation.
References
1. White Lois (2001). Foundation of Nursing. 6th Edition. USA; pp
1181-1186.
2. Carson Verna Benner. Mental Health Nursing.
nd
2 Edition. USA; p 621.
3. Schultz JM and Videbeek SL. Psychiatric Nursing.
7th Edition; pp 178-179.
4. Jhon Wolk. Essential of Clinical Psychiatric. 3rd Edition.
5. Townsend Marry C (1941). Psychiatric Mental Nursing.
6. Harber, Hoskins and Leach (1978). Comprehensive
Psychiatric Nursing. 3rd Edition. USA; p 623.
7. http://www.apa.org/pubinfo/depression.html.
8. http://www.yahoo.com/yahooseach/depression.
9. Http://www.google.com/googlesearch/depression.
10. 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

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 newer-

married, 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: Ineffective Coping
Date Assessment Nursing Goal/Planning Nursing Intervention Rationale Evaluation
(Data Statement) Diagnosis
 Ambivalence regarding Short-term Goals:  Observe the client’s eating,  The client may be unaware The client has
decisions or choices.  The client will identify drinking and elimination of physical needs or may verbalized

Ineffective coping
 Disturbances in normal stress, anxieties, and patterns, and assist the client ignore feelings of hunger, decrease feeling of
functioning due to conflicts. as necessary. thirst, the urge to defecate, fear, guilt and
obsessive thoughts or  The client will verbalize and so forth. anxiety.
compulsive behaviors. realistic self-evaluation.
 Inability to tolerate  The client will establish  Assess and monitor the  Limiting noise and other The client has
deviations from a balance of rest, sleep client’s sleep patterns, and stimuli will encourage rest expressed feeling
standards and activity. prepare him or her for and sleep. Comfort nonverbally in
 Rumination. bedtime by decreasing measures and sleep safe manner.
 Low self-esteem Long-term Goals: stimuli, giving a backrub, and medications will enhance
 Feelings of  The client will identify other comfort measures or the client’s ability to relax
worthlessness alternative methods of medications. and sleep.
 Lack of insight dealing with stress and
anxiety.  You may need to allow extra  The client’s thoughts or
 Difficulty or slowness
 The client will complete time, or the client may need to ritualistic behaviors may
completing daily living
daily routine activities. be verbally directed to interfere with or lengthen
activities because of
 The client will verbalize accomplish activities of daily the time necessary to
ritualistic behavior
knowledge of illness, living (personal hygiene, perform tasks.
treatment plan, and safe preparation for sleep and so
use of medications. forth).
 The client will maintain
adequate physiologic  Encourage the client to try to  Gradually reducing the
functioning. gradually decease the frequency of compulsive
frequency of compulsive behaviors will help
behaviors. Work with the diminish the client’s
client to identify a baseline anxiety and encourage
frequency and keep a record success.
of the decrease.
Family Therapy423
Date Assessment Nursing Goal/Planning Nursing Intervention Rationale Evaluation
(Data Statement) Diagnosis
 As the client’s anxiety • The client may need to The client has
decreases and as a trust learn ways to manage established a balance of
relationship builds, talk anxiety so he or she can rest, sleep and activity.
with the client about his or deal with it directly. This
her thoughts and behavior will increase the client’s The client has identified
and the client’s feelings confidence in managing alternative methods of
about them. Help the anxiety and other feelings. dealing with anxiety.
client identify alternative
methods for dealing with
anxiety.

 Convey honest interest in • Your presence and interest
and concern for the client. 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.

 Provide opportunities for • The client may be limited
the client to participate in in the ability to deal with
activities that are easily complex activities or in
accomplished or enjoyed relating to others. Activities
by the client; support the that the client can
client for participation. accomplish and enjoy can
enhance self-esteem.

 Teach the client and • The client and family or
family or significant significant others may have
others about the client’s little or no knowledge
illness, treatment or about these.
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 self-

assessment 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

• Reassure the client that the environment • The client is less likely to feel
is safe by briefly and simply explaining threatened if the surroundings are
routines, procedures and so forth. known.

• Protect the client from harming himself • Client safety is a priority. Self-
or herself or others. destructive ideas may come from
hallucination or delusions.

• Remove the client from the group if his • The benefit of involving the client
or her behavior becomes too bizarre, with the group is outweighed by
disturbing or dangerous to others. the group’s need for safety and
protection.

• Help the client’s group accept the • The client’s group benefits from
client’s “strange” behavior. Give simple awareness of others’ need and can
explanations to the client’s group as help the client by demonstrating
needed. empathy.

• Consider the other clients’ needs. Plan • Remember that other clients have
for at least one staff member to be their own needs and problems. Be
available to other clients if several staff careful not to give attention only
members are needed to care for this to the “sickest” client.
client.

• Explain to other clients that they have • Other clients may interpret verbal
not done anything to warrant the client’s or physical threats as personal or
verbal or physical threats; rather, the may feel that they are doing
threats are the result of the client’s something to bring about the
illness. threats.

• Set limits on the client’s behavior when • Limits are established by others
he or she is unable to do so. Do not set when the client is unable to use
limits to punish the client. internal controls effectively.

• Decrease excessive stimuli in the • The client is unable to deal with
environment. The client may not excess stimuli. The environment
respond favorably to competitive should not be threatening to the
activities or large groups if he or she is client.
actively psychotic.

• Be aware of PRN medications and the • Medication can help the client
client’s varying need for them. gain control over his or her own
behavior.
…Therapy431

Interventions Rationales

• Reorient the client to person, place, and • Repeated presentation of reality is
time as indicated. concrete reinforcement for the
client.

• Spend time with the client when he or • Your physical presence is reality.
she is unable to respond coherently. Nonverbal caring can be conveyed
Convey your interest and caring. even when verbal caring is not
understood.

• Make only promises that you can • Breaking your promise can result
realistically keep in increasing the client’s mistrust.

• Limit the client’s environment to • Unknown boundaries or a
enhance his or her feelings of security. perceived lack of limits can foster
insecurity in the client.

• Help the client establish what is real and • The unreality of psychosis must
unreal. Validate the client’s real not be reinforced; reality must be
perceptions, and correct the client’s reinforced. Reinforced ideas and
misperceptions in a matter of fact behavior will recur more
manner. Do not argue with the client, frequently.
but do not give support for
misperceptions.

• Be simple, direct and concise when • The client is unable to process
speaking to the client. complex ideas effectively.

• Talk with the client about simple, • The client’s ability to deal with
concrete things; avoid ideological or abstractions is impaired.
theoretical discussions.

• Initially, assign the same staff members • Consistency can reassure the
to work with the client. client.

• Begin with one-to-one interactions, and • Initially, the client will better
then progress to small groups as tolerate and deal with limited
tolerated. contact.

• Establish and maintain a daily routine; • The client’s ability to adapt to
explain any variation in this routine to change is impaired.
the client.

• Set realistic goals. Set daily goals and • Unrealistic goals will frustrate the
expectations. client. Daily goals are short term
and easier for the client to
accomplish.
…Therapy432

Interventions Rationales

• Make the client aware of your • The client must know what is
expectations for him or her. expected before he or she can
work toward meeting those
expectations.

• At first, do not offer choices to the • The client’s ability to make
client. Instead, approach the client in a decisions is impaired. Asking the
directive manner. client to make decisions at this
time may be very frustrating.

• Gradually, provide opportunities for the • The client needs to gain
client to accept responsibility and make independence as soon as he or she
personal decisions. is able. Gradual addition of
responsibilities and decisions give
the client a greater opportunity for
success.

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 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).

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 Behavioral Therapy

Similarities
Formulate symptoms in behavioral terms, Same
and design specific set of operations to
alter maladaptive behavior.

Collaborate with and coach client Same
regarding reactive responses.

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 Age: 22 Years Sex: Female

Status: Single Occupation: Domestic work/Factory labor.

Diagnosis: 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.

 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
Difficulty to develop meet daily
relation on job and with need Apprehension
relatives, denial her and Worrying
weaknesses about mother
illness

Love and seeking help Kulsoom Depress, thought
behavior after death of father Diagnosis stopping and
and sickness of mother
Tremors in Conversion disorder sleeplessness
Difficulty in
hands with communication
nonstop hiccups Distort perception, with others
attributes with
decrease diet
intake
…Therapy449
NURSING CARE PLAN
TITILE: Ineffective Individual Coping
Date Assessment Nursing Goal/Planning Nursing Intervention Rationale Evaluation
(Data Statement) Diagnosis
Subjective Data: Short-term Goals:  Assess and determine the  For baseline data for The client has
Client verbalized that I am  The client will identify client strength and weak- future planning to help verbalized that I

Ineffective individual coping related to disease process as evidence by difficulty to
worrying about my mother. the stressor and learn nesses to develop the the client. have identify the
There is no one to care her. I the strategy to cope with method that successful and stressor and start
have difficult to cope with job them within 5 days. level of adaptation in future. to use strategy to
environment and I have left my  Client will identify  Encourage the client to  Ventilating feeling can cope with them.
job. I don’t know what I do. alternative ways of ventilate his/her feelings. help the client to identify, Now I am going
dealing with stress, Convey your acceptance of accept and work through on job and
Objective Data: emotional problem and the client’s feeling. the feeling and to remain maintaining
A 22 years old client was participate in the treat- nonjudgmental. routine relation-
admitted in Psychiatric unit with ment program within 5  Set with the client many  Communication of the ship with all
a complaint of conversion days. times to discuss the current concerns and supportive people.
disorder. She has nonstop
cope with life events.

concern, feelings, know her environment can facilitate
hiccup, tremors in hands, and Long-term Goals:
perception about stressor development of the
sleeplessness. Looking  The client will demons- and help to realize and face coping behavior. The client was
worrying, depress with non- trate the behavior and reality. taking her
reality thinking and avoid to thinking according to treatment
 Involve the client as much  Assess the client and
face life situation. She had less develop coping plan and
possible in her treatment. promote the sense of the effectively and
eye contact with low mood and use it effectively till
Provide with achievable control and responsibility. taking care of
unable to solve her own discharge her mother and
task, goal and activities, and
problems.  The client will verbalize opportunity to make was using
plan for using alternate decision. coping plan and
Vital signs: ways of dealing with
 Convey your interest in the  Your presence demons- strategy
Blood Pressure: 100/60 mmHg stress and emotional
client and approach her for trate interest and caring effectively. The
Pulse Rate: 100 beat/min problems when they
interaction at least once per and convey the client client was also
Resp. Rate: 22 per min. occur after discharge. getting help
shift or allow visit to your continued caring.
Investigation  The client will maintain from community
significant others.
Hb: 10 mg/dl satisfying relationship in frequently..
Na: 135 mEq/dl the community and on
K: 3 mg/dl job.
…Therapy450

Interventions Rationales
 Provide the opportunity for the client to express emotion and fears to  Client need to develop skills and replace the behavior and create the
release tension and help the client identify the situation which would supportive environment.
promote more comfortable feeling.
 Be alert to the client’s behaviors, especially decreased communication,  These behaviors may indicate the client decision to commit suicide.
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  Client ability to understand and use obstruction
insensitive remarks such as every body want to live to change behavior.
 Assess the client with achievable task, goal, and opportunities to make  To assess the client, promote positive self-esteem and sense of control.
decision.
 Allow the client to discover and develop solution that the best fit her  To develop new behavior to solve her problem and improve the self-esteem.
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,  Reduce the stress and provide alternative coping strategies.
imaginary to decrease physical tension.
 Teach the client the social skills and encourage her to practice with staff  Client may lack skills and confidence in social interaction, this contributes
members and other clients. Give the client feedback regarding the social to the clients anxiety or social isolation
interaction.
 Assist the client in modifying her negative thoughts and thinking with  To facilitate the care.
positive thoughts and reduce the factors which cause such behavior.
 Encourage the client to pursue personal interest, hobbies and  Recreational activities can help increase the client social inter and may
recreational activities. provide social action.
 Encourage the client to identify and develop relationship with  Increase the client support system may help decrease future suicidal
supportive people outside the hospital environment. behavior.
 Assist the client to identify and use available support system before the  Procedure to reach the short-term and long-term goal.
discharge from hospital and help to use the plan of care and in the
community
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 same-

sex 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. Trauma-

related 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
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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.
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6. Ensight

• Present
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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.
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 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
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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
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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.
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 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) Asking the women if abuse is occurring.

ii) Identifying behavior and seriousness of abuse.

iii) Expressing belief in the women’s stories and telling the men to stop abuse.

iv) Help to identify services available, organizations, shelters and resources.

 Help to inhibit the responses by:

i) Demonstrating anger or irritation and blaming.

ii) Advising the women to accept battering as better than nothing.

iii) Withholding help until leaves her abuser.

iv) 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:
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 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) Responsible for the overall plan of care.

ii) Assist the victim in access to community resources.

iii) Trained the social worker.

iv) Ensure the victim maintains compliance in order to psychiatric treatment.
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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.