RESEARCH

Research is a quest for an answer to a question. Knowing the answer to a question requires a scientific method and not merely asking from various persons or merely observing several situations that may out-rightly provide haphazard answers to posed questions. Systematic process of collecting and analyzing information in order to increase our understanding of the phenomenon about which we are concerned or interested. Is a careful, systematic study and investigation in some fields of knowledge undertaken to discover or establish facts or principles. The scientific method of doing a research may be briefly stated in these steps:

Step 1. Identify the problem A research originates from a problem, an unanswered question or an unsolved problem. An inquisitive person sparks the conduct of knowing why things go wrong or unusual that in some ways those may affect human life. Step 2. Limit the problem The problem may be very broad. Try to focus, know the scope, established boundaries, set the breadth or make a demarcation line so that you will know what are included and what are excluded. This will ultimately make your study manageable or specific. Step 3. Formulate Hypothesis Hypothesis is a brilliant conjecture or a tentative solution to a problem. It is testable statement of a resolution to a verifiable question. Some studies use the term assumption to mean the expected outcome of an investigation or inquiry. Step 4. Collect Data Implausible statements shall be supported by factual, unbias, truthful, and convincing evidences gathered through the execution of a carefully devised plan. The preponderance of needed information will make a genuine research. Step 5. Interpret Data and Make a Conclusion Extract meanings from tabulated, collated, sifted or organized data. Data will be meaningless if you will not deduce meanings or generalizations from them. Statistical tools may aid you in measuring the significance of one factor to another. The researcher may evaluate, accept, reject, decide or conclude based on the data gathered. Pure versus Applied Research Pure or basic research is a study oriented towards the development of a theory. It aims to provide knowledge or understanding. Applied research is an investigation that enriches a solution to a practical problem. It seeks to improve human condition by providing knowledge that can be used for practical application.

Qualitative versus Quantitative Research Qualitative Research is undertaken to answer questions about the plethora of phenomena primarily aimed at giving attributes and understanding of nature based on the observers view point. It also inquires on context and meaning, embarks on content analysis observation. Quantitative Research is conducted to find answers to questions about relationships among measurable variables with purpose of explaining, controlling, and predicting phenomena. It is knowing the outcome stated in numerical data.

COMPARATIVE CHARACTERISTICS OF QUANTITATIVE AND QUALITATIVE RESEARCHES

FEATURE Purpose QUANTITATIVE To explain and predict To confirm and validate To test theory QUALITATIVE To describe and explain To explore and interpret To build theory

Process

Focused Known variables Established guidelines Static design Context-free Detached view

Holistic Unknown variables Flexible guidelines Emergent design Context-bound Personal view

Data Collection

Representative Large sample Standardized instruments

Informative, small sample Observations, interviews

Data Analysis

Deductive analysis

Inductive analysis

Report of findings

Numbers Statistics, aggregated data Formal voice, scientific style.

Words Narratives Individual quotes Personal voice Library style.

PSYCHIATRIC NSG.

Alcoholic Beverage
An alcoholic drink contains ethanol, commonly termed as alcohol. Alcohol is a psychoactive drug that is central nervous system depressant and rapidly absorbed in the bloodstream. It can be addictive and the state of alcohol addiction is known as alcoholism.

Physiologic Effects of Alcohol Use

When a person drinks alcohol, he or she may experience relaxation and loss of inhibitions initially. However, when large amount of alcohol is ingested intoxication may occur. The person who is intoxicated may experience the following manifestations.

Slurred speech Unsteady gait Lack of coordination Decreased attention span Reduced concentration

Impaired memory Impaired judgment

An overdose of alcohol in a short period of time can result to the following manifestations:

Vomiting Loss of consciousness Respiratory depression

Physiologic Effects of Long-term Alcohol Use

Cardiac myopathy Wernickes encepalopathy Korsakoffs psychosis Pacreatitis Esophagitis Hepatitis Cirrhosis Leucopenia Thrombocytopenia Ascites

Treatment of Alcohol Overdose

1. Gastric lavage or dialysis. The procedure is performed to remove the drug from the systemic circulation. 2. Support of respiratory and cardiovascular functioning.

Alcohol Withdrawal
When an alcoholic withdraws from alcohol use, withdrawal symptoms usually starts at about 4 to 12 hours after a marked reduction or cessation of alcohol intake. The withdrawal may take 1 to 2 weeks. It can be life-threatening thus, prompt treatment and management is required or necessary. Symptoms of alcohol withdrawal are:

Coarse hand tremors Sweating Elevated pulse Increase blood pressure Insomnia Anxiety

Nausea and vomiting

Delirium Tremens (DTs)

In cases where the withdrawal signs and symptoms are not treated or becomes severe, the condition may progress to a condition called delirium tremens. Delirium tremens is an acute episode of delirium that is mainly caused after a long period of drinking and being stop abruptly and the person experiences withdrawal. It may also be triggered by head injury, infection, or illness in people with a history of heavy use of alcohol Signs and Symptoms of delirium tremens:

Transient hallucinations Seizures Delirium

Management for Alcohol Withdrawal

1. Detoxification under medical supervision 2. For mild alcohol withdrawal symptoms and the client can abstain from alcohol, home treatment is possible. 3. For severe cases where the client cannot abstain from alcohol during detoxification, a short admission (about 3-5 days) is done. 4. Safe withdrawal is accomplished through the administration of benzodiazepines such as Chlordiaxepoxide (Librium), Lorazepam (Ativan) or Diazepam (Valium) to suppress the withdrawal symptoms.

Alcohol Detoxification
Alcohol detoxification is the removal of alcohol from the body of an individual who is alcohol dependent or alcoholic. It is the abrupt cessation of alcohol intake coupled with the substitution of alcohol with drugs used to prevent alcohol withdrawal. Alcohol detoxification is not possible without support from friends and family. Most of all it needs a commitment on the part of the individual who will undergo detoxification to abstain from alcohol use. Alcohol Detoxification Process The process of alcohol detoxification requires that alcohol be eliminated from the human body and that any withdrawal or other symptoms that are bound to occur are treated medically or psychologically or both. As mentioned earlier, the detoxification process is largely determined by the alcoholic himself. The detoxification process is determined by the persons condition and by his approach.

In some cases, patients who undergo the alcohol detoxification process may suffer from hallucinations, delirium tremens and convulsions, which require immediate attention and treatment. To minimize these symptoms, medical drugs are given. However, the administration of these medications has to be monitored and accurately controlled. Usually such medications have are given at high dosages initially, but is gradually tampered down over a week. Withdrawal symptoms can be quite distressing and can even become fatal if the addiction to alcohol is very severe. Safe withdrawal is accomplished with the administration of benzodiazepines to suppress the withdrawal symptoms. Drugs under this category are:

Chlordiaxepoxide (Librium) is the benzodiazepine of choice in uncomplicated alcohol withdrawal due to its long half-life. Diazepam (Valium) is available as an injection for patients who cannot safely take medications by mouth. Lorazepam (Ativan) is available as an injection for patients who cannot safely take medications by mouth. This is also indicated in patients with impaired liver function because they are metabolized outside of the liver.

The most common drugs used for alcohol detoxification are benzodiazepines, with Chlordiazepoxide being the most preferred benzodiazepine used. Diazepam is also widely used, but fatal effects may occur if it is mixed with huge doses of alcohol. Hence, supervision is necessary for use of diazepam as a detoxifier. Where is alcohol detoxification done? In most cases, alcohol detoxification can be done at home. This is applicable when the alcohol consumption is just moderate. However, in cases where hallucinations, severe withdrawal symptoms and multi-substance misuse are noted, an inpatient detoxification is required.

Anorexia Nervosa is a disorder with an insidious onset that often affects adolescent girls. Sufferers are typically high achievers, with good grades and described by parents as perfect children. Disorder occurs commonly in upper middle class families. Usually the youngest child is affected. Unlike bulimics, anorexics uses denial and do not accept that they have a problem, thus, they are more difficult to treat. 10-20 % of anorexics die and half of these deaths are due to suicide. They are often not recognized because they eat normally in social situations but after eating they retreat to the nearest bathroom and purge themselves. In order to prevent themselves from eating and to help maintain their very restrictive dietary program, they avoid socializations such as parties, even family meals, thus becoming increasingly socially isolated. They often start as chubby children or overweight adolescents. The disorder begins with somebody took notice of their being overweight. Because the self

esteem of this person is based on the acceptance of others, they go on dieting to lose weight and feel accepted again. The personality is perfectionist, introverted, with low self-esteem and often has problems with peer relationships. They are good children who are conscientious, hard working, and ideal students. Typically they are people pleasers who seek approval and avoid conflict. The person may have low tolerance to change and do not adjust well to new situations. Often they are overly engaged with or dependent on parents or family. Dieting may represent avoidance or, or ineffective attempts to cope with, the demands of a new life stage such as adolescence. They may fear growing up and assuming adult responsibilities including an adult lifestyle. The symptoms of anorexia are thought to be a kind of symbolic language that expresses: Im not ready to grow up yet, or Im starving for attention. Another factor is that this individual may have felt worthless and helpless. They try to combat these feelings by taking over those parts of their life that they can control, that is, their weight and the food that they eat.

Types: 1. Restricting weight loss by dieting, fasting and excessive exercise. 2. Binge eating or purging uses self induced vomiting, abuses laxatives, diuretics or enema. 3. Assessment

Behaviors directed toward weight loss like dieting, exercise and purging. Withdrawn and socially isolated, refuses to eat with family on the table. Distorted body image, they see themselves as fat despite being emaciated. Intense fear of becoming fat. Due to misconception that food can make them obese and look ugly, their life is dominated by behavior directed at avoiding food intake and weight loss. They then become preoccupied with food and engage in bizarre behaviors such as peculiar way on handling food, hoarding food, collecting recipes, rearranging food on plate repeatedly, dawdling, reading multiple materials about food to the point of thinking that they have superior knowledge Depressed, sleep disturbances, suicidal tendencies and crying spells. Compulsive rituals. In women, amenorrhea for at least four months and lack of interest in sexual activity due to lack of nourishment, menstruation can occur only if a woman is able to maintain at least 17% of body fat. In men, level of sex hormones drop. Males develop eating disorders too. About 10% of patient with eating disorders are male. Physical symptoms include bradycardia, hypothermia, dehydration, dependent edema, hypotension due to decreased metabolic rate as a compensatory mechanism of the body to low food intake. Induce vomiting, uses enema, diet pills, excessive exercise, diuretics and laxatives.

As disease progresses, becomes deceitful, stubborn, hostile, and manipulative.Nursing Interventions

1. Cognitive and Behavioral therapy to positive and negative reinforcement: focus is on clients responsibility to gain weight. o Privileges are gained with weight gain. o Privileges are lost with weight loss. 2. Increase self-esteem by acceptance and non-judgmental approach so the patient will realize that they do not need to artificial perfection they believe thinness provides. Assist to find other positive qualities about self. 3. Teach about the disorder. The more information they receive that validates their problem, the less likely they will deny it. 4. Monitor weight three times a week but weigh with the patient facing away from the weighing scale to help them reduce their focus on weight. Make sure the patient is not hiding heavy objects under her clothing. 5. As soon as the ideal weight is gained, allow patient to regulate his or her own progression and program. 6. High protein and high carbohydrate diet, serve foods the patient prefer in small frequent feedings. NGT if the patient refuses to eat. 7. Setting limits to avoid manipulative behavior: o Restrict use of bathroom for 2 hour after eating. o Accompany to the bathroom to ensure that they will not self induce vomiting. o Stay with client during meals. o Do not accept excuses to leave eating area. 8. Help the patient identify and express feelings. Avoid being judgmental. People with eating disorders are thought to be afraid of expressing strong emotions; they express their feelings unconsciously by vomiting, starvation, and purging. 9. Help the patient to identify and express other bodily concerns such as hairstyle, clothing. Typically anorectic patients have little bodily awareness other than a distorted perception of their size. 10. Identify the patients non-weight related interests. This could help reduce anxiety, become creative outlet for energy, raise self-esteem and divert attention from eating and weight. 11. Avoid being confrontational and engaging in long discussions or explanations about food or body. 12. Ignore manipulative behaviors. 13. Refer to self-help groups.

Is a subjective, individual experience characterized by a feeling of apprehension, uneasiness, uncertainty, or dread. It occurs as a result of threats that may be actual or imagined, misperceived or misinterpreted, or from a threat to identity or self-esteem. It often precedes new experiences.

Types of Anxiety:

1. Normal o A healthy type of anxiety that mobilizes a person to action. 2. Acute o Precipitated by imminent loss or change that threatens the sense of security. 3. Chronic o Anxiety that the individual has lived with for a long time.

Levels of Anxiety:
1.Mild/ Alertness Level (+1)

This is the type of anxiety associated with the normal tension of everyday life. The individual is alert Perceptual field is increased Produce growth and creativity, as it increases learning The person uses adaptive coping mechanisms to solve problems and alleviate anxiety.

Nursing Interventions: 1. Recognize the anxiety by statements such as I notice you being restless today. 2. Explore causes of anxiety and ways to solve problems that cause anxiety by statements such as Lets discuss ways to 2. Moderate/ Apprehension Level (+2)

The response of the body to immediate danger and focus is directed to immediate concerns. Narrows the perceptual field to pay attention to particular details.

Selective inattentiveness occurs The increased tension makes this the optimal time for learning

The person uses palliative coping mechanisms.

Nursing Interventions: 1. 2. 3. 4. 5. 6. 7. 8. 9. Provide outlets for anxiety such as crying or talking. Tell client Its all right to cry. Encourage in motor activity to reduce tension. Make client be aware of his behavior and feelings by statements such as I know you feel scare Encourage client to move from affecting (feeling) to cognitive mode (thinking). Refocus attention Encourage the client to talk about felings and concerns. Help the client identify thoughts and feelings that occurred prior to the onset of anxiety. Provide anti-anxiety oral medications.

3. Severe/ Free-floating Level (+3)

Creates a feeling that something bad is about to happen, or feeling of an impending doom. Fight and flight response sets in Narrow perceptual field occurs and focus is on specific details or scaterred details so that learning and problem-solving is not possible. All behaviors are directed at alternative the anxiety The individual needs direction to focus Dilated pupils, fixed vision

The person uses maladaptive coping mechanisms.

Nursing Interventions: 1. 2. 3. 4. Do not focus on coping mechanisms Stay calm and stay with the client Give short and explicit direction Modify the environment by setting limits or seclusion, limit interaction with others, and reduce environmental stimuli to calm client. 5. Provide IM antianxiety medications. 4. Panic Level (+4)

Feelings of helplessness and terror The personality and behavior is disorganized The individual lessens perception of the environment to protect the ego from awareness and anxiety causing distorted perceptions and loss of rational thoughts. Is unable to communicate or function effectively Inability to concentrate If prolonged, panic can lead to exhaustion and death The person uses dysfunctional coping mechanisms.

Nursing Interventions: 1. Guide patient step by step to action 2. Restrain if necessary.

Behavior modification is a method of strengthening desired behavior or response through a positive or negative reinforcement of adaptive behavior or the reduction of a maladaptive behavior through extinction, punishment or therapy. For example you are an employee. You worked extra hours just to finish your tasks, arrives at work on time and sometimes you skip lunch just to complete the assigned job. A hard worker thats what you are! Now after a month of hard work your paycheck is delayed. Weeks and months passed and still the salary is not released. Would you perform the same effort towards your job now that you are still unpaid? You might still go to work with a change behavior or stop working. For working people, receiving a regular and on-time paycheck is a positive reinforcer that motivates the employees to do their job well. If this motivating factor is lacking, expect a less efficient job performance from the employees. Behaviorists believed that a behavior can be change through a system of rewards and punishments.

Positive and Negative Reinforcement

A positive reinforcement is provided by giving a person attention and positive feedback. For example, a child has successfully made it through the night without wetting the bed. The mother acknowledges the childs behavior in front of the family during breakfast period. A negative reinforcement on the other hand is done by removing a stimulus after a behavior occurred to prevent it from occurring again. For example, a student becomes anxious when he is seated at the back during classes. He or she may ask the professor to be seated in front to prevent such anxiety.

Indication

Obsessive-compulsive behavior (OCD) Attention deficit hyperactivity disorder (ADHD) Phobias Enuresis (bed-wetting) Generalized anxiety disorder Separation anxiety disorder

Behavior Modification Techniques

ABC approach A Antecedents Antecedents are the events that occur before a particular behavior is demonstrated. What comes directly before the behavior? B Behaviors The behavior developed as a result of the presence of antecedent. What does the behavior look like? C Consequences These are the events that occur after the behavior. What comes directly after the behavior? After the ABCs are assessed, the data gathered is analyzed and identified as inappropriate and appropriate behavior. Inappropriate behaviors are observed, targeted and stopped while the appropriate ones are identified, developed, strengthened and maintained.

Some Behavioral Theories and Theorists

Theorists such as Ivan Pavlov and Burrhus Frederick Skinner focused on observable behaviors and factors that bring about behavioral changes. Classical Conditioning by Ivan Petrovich Pavlov Ivan Pavlov is a Russian psychologist, physiologist and physician widely known for providing the best example of classical conditioning through experimentation on dogs. Classical conditioning principle states that a behavior can be modified or changed through conditioning of the external stimuli or conditions. Operant conditioning by Burrhus Frederick Skinner B.F. Skinner is an American psychologist who developed the operant conditioning. Operant conditioning states that people learn their behaviors from their past experiences particularly those which as constantly reinforced.

Bipolar

Results from disturbances in the areas of the brain that regulate mood It involves periods of excitability (mania) alternating with periods of depression This may affects men and women equally Usually appears between ages 15 25

Cause

Unknown It occurs more often in relatives of people with bipolar disorder

Symptoms
Manic Phase 1. Agitation or irritation 2. Elevated mood (hyperactivity, increased energy, lack of self-control, racing thoughts) 3. Inflated self-esteem (delusions of grandeur, false beliefs in special abilities) 4. Little need for sleep 5. Over-involvement in activities 6. Poor temper control 7. Reckless behavior (binge eating, drinking, and/or drug use, impaired judgment, sexual promiscuity, spending sprees) 8. Tendency to be easily distracted Depressed Phase 1. Difficulty concentrating, remembering, or making decisions 2. Eating disturbances

3. 4. 5. 6. 7. 8. 9.

Fatigue or listlessness Feelings of worthlessness, hopelessness and/or guilt Loss of self-esteem Persistent sadness and thoughts of death Sleep disturbances Suicidal thoughts Withdrawal from activities that were once enjoyed

Medical Intervention

Proper History Taking and Observation Antipsychotic medications (such as lithium and mood stabilizers or antidepressant for depressive phase) Electroconvulsive therapy (ECT)

Nursing Interventions
1. Provide a calm environment 2. Giving health teachings about regular exercise, and proper diet 3. Explain to patient that getting enough sleep helps keep a stable mood

Unipolar

Another name for major depressive disorder Occurs when a person experiences the symptoms for longer than a two-week period

Causes

The biopsychosocial model proposes that biological, psychological, and social factors all play a role in causing depression The diathesisstress model specifies that depression results when a preexisting vulnerability, or diathesis, is activated by stressful life events

Symptoms
1. 2. 3. 4. 5. 6. 7. Depressed mood A lack of interest in activities normally enjoyed Changes in weight and sleep Fatigue Feelings of worthlessness and guilt Difficulty concentrating Has thoughts of death and suicide

Medical Interventions

Antidepressants Tricyclic antidepressants Monoamine oxidase inhibitors Selective serotonin re-uptake inhibitors Electroconvulsive therapy

Nursing Interventions
1. 2. 3. 4. 5. Interpersonal Therapy Psychotherapy Encourage client to have a regular exercise Cognitive behavioral therapy Behavioral modification therapy

Difference between Bipolar and Unipolar Disorder

Gender and Age of Onset UNIPOLAR BIPOLAR Affects women more often Affects men and than men, appears later woman equally, in life average age of onset suspected to be 18 years Generally insomnia, Generally difficulty falling asleep or hypersomnia, waking repeatedly during excessive tiredness the night and difficulty waking in the morning Often has a loss of Often binge-eating and appetite and diminished cravings for interest in eating carbohydrates, may alternate with loss of appetite Agitated, pacing and Inactivity, somnolence, restlessness are more a slowing down of common movements (psychomotor retardation) more common Sadness, hopelessness, Same as for unipolar, feelings of worthlessness although guilt is often much more prominent Episodes often last Risk of drug abuse and longer, sometimes more suicide higher than in responsive to treatment unipolar depression

Sleep

Appetite

Activity Level

Mood

Other

BIPOLAR DISORDER-A mood disorder, formerly known as manic depression is characterized by recurrent episodes of depression and mania. Either phase may be predominant at any given time or elements of both phases may be present simultaneously.

Risk Factors

1. 2. 3. 4.

Biochemical imbalances Family genetics one parent, child has 25% risk; two parents, 50-75% risk. Environmental factors such as stress, losses, poverty, social isolation. Psychological influences inadequate coping, denial of disordered behavior.

Specific Biological Factors

1. 2. 3. 4. Possible excess of norepinephrine, serotonin, and dopamine. Increased intracellular sodium and calcium Neurotransmitters supersensitive to transmission of impulses Defective feedback mechanism in limbic system.

Signs and Symptoms

1. Risk for self or others 2. Impaired social interactions 3. Mania
o o o o o o o o o o o o o

Persistent elevated or irritable mood Poor judgment Increase in talking and activities, grandiose view of self and abilities. Impulsivity such as spending money, giving away money or possessions. Impairment in social and occupational functioning Decreased sleep Distractibility Delusions, paranoia, and hallucinations Dislike of interference or intolerance of criticism Denial of illness Agitation Attention seeking behavior Depression

Nursing Diagnoses
1. High risk for violence, directed at self or others 2. Impaired verbal communication 3. Anxiety 4. Individual coping, ineffective 5. Disturbance of self-esteem 6. Alteration in though processes 7. Alteration in sensory perceptions 8. Self-care deficits 9. Sleep pattern disturbances 10. Alteration in nutrition

Therapeutic Nursing Management

1. Environment 2. Psychological treatment o Individual Psychotherapy may be used to identify stressors and pattern of behavior. o Group therapy establishes a supportive environment and redirect inappropriate behavior. o Family therapy verbalizes family frustration and establishes a treatment plan for outpatient use.

3. Somatic and Psychopharmacologic treatments o electroconvulsive therapy o Psychopharmacology

Nursing Interventions
1. 2. 3. 4. 5. 6. Assess clients suicidal feelings and intentions and escalating behavior regularly. Set consistent limits on inappropriate behavior to help the client de-escalate. Establish a calm environment for the client. Reinforce and focus on reality. Provide outlets for physical activity but prevent client for escalating. Client may be very likable during high periods. Staff members need to avoid participating in this behavior, at other times, client may be very irritable and staff members should approach client quietly and with limits, if necessary. 7. If the client cannot control self and other methods are not successful, staff may need to provide client protection if a threat of a self-harm or injury to other exist. 8. Monitor clients nutrition, fluid intake and sleep. 9. Discuss with the client and family the possible environment or situational causes, contributing factors and triggers for a mood disorder with recurrent episodes of depression and mania. 10. 11. BULIMIA NERVOSA

The Diet-Binge-Purge Disorder. Is a disorder characterized by alternating dieting, binging and purging through vomiting, enema, and laxatives. The person engages in episodes of starvation and other methods of controlling weight (diet pills, excessive exercise, enemas, diuretics, laxatives), then engages in uncontrolled and rapid eating for about two hours (over 8000 calories in 2 hours and 50,000 in 1 day) then terminates binging by inducing self to vomit, going to sleep or going to social activities. Weight fluctuations are due to alternating fasting and binging. 1. Bulimia means insatiable appetite.

2. Binging means eating an unusually large amount of food over a short period of time. 3. Purging is an attempt to compensate for calories consumed via selfinduced vomiting or abuse of laxatives, diuretics, or enemas.

A chronic disorder that usually manifest first during late adolescence and early adulthood, around the ages 15-24 years. It almost always occurs after a period ofdieting.

The bulimic often belong to a family and society that place great value on external appearance. The person strives to be thin to be accepted because they believe self-worth requires being thin. Usually of normal weight or obese, extrovert, reports self loathing, low selfesteem, has symptoms of depression, of fear of losing control, with selfdestructive tendencies such as suicide. These individuals are known to be perfectionist, achievers scholastically and professionally and highly dependent on the approval of others to maintain selfesteem. They hide their disorder because of fear of rejection. Like anorexia, bulimia can kill. Even though bulimics put up a brave front, they are often depressed, lonely, ashamed, and empty inside. Friends may describe them as competent and fun to be with, but underneath, when they hide their guilty secrets, they are hurting. Feeling unworthy, they suffered from great difficulty talking about their feelings, which almost always include anxiety, depression, self-doubt, and deeply buried anger. Impulse control may be a problem like shoplifting, sexual adventurousness, alcohol and drug abuse, and other kinds of risk taking behavior in which the person acts with little consideration of consequences. The person is aware that the behavior is abnormal, but is unable to stop because she is immobilized by her fear that she cannot stop her behavior voluntarily. The binge episode usually ends when the person becomes exhausted eating, develops GIT discomfort, runs out of food or is noticed by others. After the episode she becomes guilty and depressed that she was unable to control herself, and engages in self-critism. Then she purges her self as a form of cleansing and punishment.

Common Complications Related to the Manner of Purging

Chronic inflammation of the lining of the esophagus due to induced vomiting, acidic gastric secretions irritates esophageal mucosa. Rupture of esophagus and stomach. Electrolyte imbalance causing cardiac arrythmias, hypokalemia due to diarrhea,hypochloremia due to vomiting, hyponatremia due to vomiting and diarrhea. Dehydration. Enlargement of the parotid gland.

Irritable bowel syndrome. Rectal prolapse or abscess. Dental erosion. Chronic edema. Fungal infection of vagina and rectum.

Nursing Diagnosis

Alterations in health maintenance. Altered nutrition: Less than body requirements. Altered nutrition: More than body requirements Anxiety Body image disturbance Ineffective family coping; compromised Ineffective individual coping Self-esteem disturbance

Nursing Interventions
1. Patient with bulimia are aware of their problems and they want to be helped because they feel helpless and unable to control themselves during episodes of binging. But because of their intense desire to please and need to conform they may resort to manipulative behavior and tell half-truths during interview to gain trust and acceptance of nurses. Create an atmosphere of trust. Accept person as

2. 3.

4. 5. 6. 7.

worthwhile individual. If they know that no rejection or punishment is forthcoming they disclose their problem, they will be more open and honest. Develop strength to cope with problems. Encourage patient to discuss positive qualities about themselves to increase self-esteem. Help patient identify feelings and situations associated with or that triggers binge eating. o Assist to explore alternative and positive ways of coping. o Encourage making a journal of incident and feelings before-during and after a binge episode. o Make a contract with the patient to approach the nurse when they feel the urge to binge so that feelings and alternative ways of coping can be explored. Encourage adhering to meal and snack schedule of hospital. This decreases the incidence of binging, which is often precipitated by starvation and fasting. Encourage participating in group activities with other persons having the same eating disorder to gain additional support. For young adolescent living at home, encourage family therapy to correct dysfunctional family patterns. Cognitive behavioral therapy is the ideal therapy to help the bulimic understand the problem and explore appropriate behaviors. Cognitive disorders are characterized by the disruption of thinking, memory, processing, and problem solving. Types of cognitive disorders include: delirium, dementia, and memory loss disorders (amnesia or dissociative fugue).

Risk Factors
1. Physiological changes such as neurological, metabolic, and cardiovascular disease. 2. Cognitive changes 3. Family genetics 4. Infections 5. Tumors 6. Sleep disorders 7. Substance abuse 8. Drug intoxications and withdrawals

Signs and Symptoms

1. 2. 3. 4. Irritability; mood most frequently seen in organic brain disorder. Change in level of consciousness. Difficulty thinking with sudden onset. State of awareness ranging from hyper vigilance to stupor or coma.

5. Impairment in cognition and thought process, particularly short-term memory. 6. Anxiety 7. Confabulation

Therapeutic Nursing Management

1. The nurse plays a primary role in providing a safe environment for the client and others. 2. Exogenous stimuli in the environment can intensify the clients level of orientation. 3. Cognitive changes may often include a period of confusion or forgetfulness. 4. The nurse may encourage family members to bring photographs or familiar items as strategy to orient the client. 5. Psychological treatment may focus more on the family to offer them support during this stressful time. 6. Cognitive changes affect the family and care providers. Cognitive decline often means a change in the family roles and activities of daily living. 7. Pharmacologic therapy is implemented to reduce or alleviate the associated symptoms such as antianxiety medications, antidepressants, and antipsychotics.

Nursing Interventions
1. Determine the cause and treatment of the underlying causes. 2. Remain with the client, monitoring behavior, providing reorientation and assurance. 3. Provide a room with a low level of visual and auditory stimuli. 4. Provide palliative care with the focus on nutritional support. 5. Reinforce orientation to time, place, and person. 6. Establish a routine. 7. Client protection may be required. 8. Have client wear an identification bracelet, in case she or he gets lost. 9. The client should not be left alone at home 10. Break test into small steps, giving one instruction at a time. Crisis is a situation or period in an individuals life that produces an overwhelming emotional response. This event occurs when an individual is confronted by a certain life circumstance or stressor that he or she cannot effectively manage by using his or her usual coping skills. Crisis is an unexpected event that can create uncertainty to an individual and has been viewed as a threat to a persons important goals.

Stages of Crisis

The first stage of crisis occurs when the person is confronted by a stressor. Exposure to this stressor would result to anxiety. The individual then tries to handle things by using his or her customary coping skills. Second stage of crisis occurs when the person realizes that his usual coping ability is ineffective in dealing with anxiety. As the person becomes aware of his unsuccessful effort in dealing with the perceived stressor, he moves on to the next stage of crisis where the individual tries to deal with the crisis using new methods of coping. The fourth stage of crisis takes place when the persons coping attempts of resolving the crisis fail. The individual then experiences disequilibrium and significant distress.

Types of crisis
1. Maturational crisis also called developmental crisis. These are predictable events in a persons life which includes getting married, having a baby and leaving home for the first time. 2. Situational crises unexpected or sudden events that imperils ones integrity. Included in this type of crisis are: loss of a job, death of a loved one or relative and physical and emotional illness of a family member or an individual. 3. Adventitious crisis also called social crisis. Included in this category are: natural disasters like floods, earthquakes or hurricanes, war, terrorist attacks, riots and violent crimes such as rape and murder.

Crisis Intervention
Crisis intervention refers to the methods used to offer immediate, short-term help to individuals who experience an event that produces emotional, mental, physical, and behavioral distress or problems. Guide for an effective crisis intervention: 1. Assist the person to view the event or issue in a different perspective. 2. Assist the individual to use the existing support systems. It is vital to help the person find new sources of support that can help in decreasing the feelings of being alone or overwhelmed. 3. Assist the individual in learning new methods of coping that will help resolve the current crisis and give him or her new coping skills to be used in the future when dealing with another overwhelming situation.

DEFENSE MECHANISM

People use defense, or coping, mechanisms to relieve anxiety. The definitions below will help you determine whether your patient is using one or more of these mechanisms. 1. 1. Acting Out o Acting out refers to repeating certain actions to ward off anxiety without weighing the possible consequences of those action. o Example: A husband gets angry with his wife and starts staying at work later. 2. Compensation o Also called substitution. o It involves trying to make up for feelings of inadequacy or frustration in one area by excelling or overindulging in another. o Example: An adolescent takes up jogging because he failed to make the swimming team. 3. Denial o A person in denial protects himself from reality especially the unpleasant aspects of life by refusing to perceive, acknowledge, or face it. o Example: A woman newly diagnosed with end-stage-cancer says, Ill be okay, its not a big deal. 4. Displacement o In displacement, the person redirects his impulses (commonly anger) from the real target (because that target is too dangerous) to a safer but innocent person. o Example: A patient yells at a nurse after becoming angry at his mother for not calling him. 5. Fantasy o Fantasy refers to creation of unrealistic or improbable images as a way of escaping from daily pressures and responsibilities or to relieve boredom. o Example: A person may daydream excessively, watch TV for hours on end, or imagine being highly successful when he feels unsuccessful. Engaging in such activities makes him feel better for a brief period. 6. Identification o In identification, the person unconsciously adopts the personality characteristics, attitudes, values, and behavior of someone else (such as a hero he emulates and admires) as a way to allay anxiety. He may identify with a group to be more accepted by them. o Example: An adolescent girl begins to dress and act like her favorite pop star.

Intellectualization
o o o

Also called isolation. Intellectualization refers to hiding ones emotional responses or problems under a faade of big words and pretending theres no problem. Example: After failing to obtain a job promotion, a worker explains that the position failed to meet his expectations for climbing the corporate ladder.

7. Introjection o A person introjects when he adopts someone elses values and standards without exploring whether they fit him. o Example: An individual begins to follow a strict vegetarian diet for no apparent reason. 8. Projection o In projection, the person attributes to others his own unacceptable thoughts, feelings, and impulses. o Example: A student who fails a test blames his parents for having the television on too loud when he was trying to study. 9. Rationalization o Rationalization occurs when a person substitutes acceptable reasons for the real or actual reasons that are motivating his behavior. o The rationalizing patient makes excuses for shortcomings and avoids selfcondemnation, displacements, and criticisms. o Example: An individual states that she didnt win the race because she hadnt gotten a good nights sleep. 10. Reaction Formation o In reaction formation, the person behaves the opposite of the way he feels. o Example: Love turns to hate and hate into love. 11. Regression o Under stress, a person may regress by returning to the behaviors he used in an earlier, more comfortable time in his life. o Example: A previously toilet-trained preschool child begins to wet his bed every night after his baby brother is born. 12. Repression o Repression refers to unconsciously blocking out painful or unacceptable thoughts and feelings, leaving them to operate in the subconscious. o Example: A woman who was sexually abused as a young child cant remember the abuse but experiences uneasy feelings when she goes near the place where the abuse occurred. 13. Sublimation o In sublimation, a person transforms unacceptable needs in acceptable ambitions and actions. o Example: He may channel his sex drive into his sports or hobbies. 14. Undoing o In undoing, the person tries to undo the harm he feels he has done to others. o Example: A patient who says something bad about a friend may try to undo the harm by saying nice things about her or by being nice to her and apologizing. Theorists consider that emotional, social, cognitive and moral skills develop in stages.

1. Psychosocial Erik Eriksons theory of psychosocial development is most widely used. At each stage, children confront a crisis that requires the integration of personal needs and skills with social and cultural expectations. Each stage has two possible components, favorable and unfavorable. 2. Psychosexual Sigmund Freud considered sexual instincts to be significant in the development of personality. At each stage, regions of the body assume prominent psychologic significance as source of pleasure. 3. Cognitive Jean Piaget proposed four major stages of development for logical thinking. Each stage arises from and builds on the previous stage in an orderly fashion. 4. Moral Lawrence Kohlbergs theory of moral development is based on cognitive development and consists of three major levels, each containing two stages. Stage Infancy (birth to 1 year) Toddlerhood (1-3 years old) Preschool (3-6 years old) Erikson Trust vs. mistrust Freud Oral Piaget Sensorimotor (birth to 2 years) Sensorimotor (1-2 years); preoperational (preconceptual) (2-4 years) Preoperational (preconceptual) (2-4 years); preoperational (intuitive) (4-7 years) Concrete operations (7-11 years) Formal operations (11-15 years) Kohlberg

Autonomy vs. same and doubt

Anal

Preconventional

Initiative vs. guilt

Phallic

Preconventional

School Age (6-12 years) Adolescence (12-18 years)

Industry vs. inferiority

Latency

Conventional

Identity vs. role diffusion (confusion)

Genital

Postconventional