Sad Person Scale

Sex (males are more likely)

Age (younger than 19 or older than 45)
Depression
Previous suicide attempt
Ethanol (alcohol) abuse
Rational thinking (impaired)
Social support is lacking (including recent loss of loved one)
Organized plan
No spouse
Sickness (especially chronic)

1
B. Suicide danger signs
1. The presence of suicide plan
2. Change in established patterns of routines
3. Anticipation of failure
4. Change in behavior, presence of panic, agitation or calmness, usually, as
depression is lifted.
5. Hopelessness: feelings of impending doom, futility and entrapment.
6. Withdrawal and rejection of help.

2
Clients at risk
1. Adolescents and elderly; males usually complete the suicide act.
2. Clients experiencing recent stress of a maturational or situational crisis
3. Clients with chronic or painful illnesses
4. Clients with previous suicide attempts or suicide behavior
5. Withdrawn, depressed or hallucinating clients
6. Clients with sexual identity conflicts and those who abuse alcohol and drugs.

3
Adolescent Suicide
Characteristics
1. History of suicide
2. Previous suicide attempts
3. Long-term use of drugs
4. Acting-out behaviors; delinquency, stealing, vandalism, academic failure,
promiscuity, loss of boyfriend/girlfriend

4
Family Characteristics
1. Unproductive, conflictual communication
2. Impaired problem-solving ability
3. Inconsistent positive reinforcement plus a
greater number of negative reinforcement.
4. Unstabel home environment

5
Key concepts
Positive Symptoms focus on the distortion of normal functions
Negative symptoms- focus on a loss of normal functions
Thought broadcasting believe that their thoughts are broadcast to the external
world
Disorganized thinking or looseness of association
Common themes Delusional themes can be persecutory somatic, erotomanic,
jealous or grandiose.

6
Schizophrenia
A maladaptive disturbance characterized by a number of
common behaviors involving disorders
of thought content, mood, feeling, perception, communication, and
interpersonal relationships.

7
Schizophrenia
One of a cluster of related psychotic brain disorders of unknown
etiology

A combination of disordered thinking, perceptual disturbances,

behavioral abnormalities, affective disruptions and impaired social
competency
History
1856 Morel used the phrase dementia praecox while treating an
adolescent boy, to describe the group of symptoms he observed.

1868 Kahlbaum and Hecker (1870) added to the psychiatric

nomenclature with their diagnostic categories catatonia and
hebephrenia
 1902- Kraeplin added the term paranoia and engaged in rigorous
study of what is we now call schizophrenia.

He found commonalities of the 3 conditions. He envisioned

progressive deteriorating course resulting in disabling mental
impairment with little hope of recovery.

1900s Bleuler coin the term schizophrenia

Etiology
Genetic Predisposition
- Theory suggests:
- Increased risk of development in families with positive family history of
schizophrenia

-10% in those who have immediate family with the disease and

- Approximately 40% if the disease affects both parents or an identical twins

- 60% of people with schiz. have no close relatives with the illness.
 22q1 deletion syndrome
-First true etiologic subtype:
-consequence of chromosome deletion
-Persons have distinct facial appearance, abnormalities of the palate,
heart defects, and immunologic deficits.
-Risk of developing schiz. is approx. 25%
 Genetic locations of schiz
- believed to be in human chromosomes 13 and 8.

-One study indicates mothers of clients with schiz. had a high

incidence of the gene type H6A- B44
 Biochemical and Neurostructural Theory
-Dopamine hypothesis
excessive amount allows the nerve impulses
to bombard the mesolimbic pathway (arousal and
motivation) resulting to hallucination and
delusions.
-Low levels of GABA
 Structural
- (circuits filters information entering the brain and sends relevant info
to other parts for determining action).
- Defective circuits bombardment of unfiltered information
positive and negative symptoms compensatory mechanism
withdrawal and negative symptoms
 Enlarge ventricles, cerebral atrophy, decreased cerebral blood flow,
decreased and reduced glucose metabolism in the frontal and
temporal lobes as on imaging studies
 Organic or Psychophysiologic Theory
- Theories suggest that schizophrenia is a functional deficit occuring in
the brain due to stressors (virus, toxins, trauma, abnormal
substances)
- Metabolic disorder is also proposed
 Environmental or Cultural Theory
- Faulty reaction to the environment, unable to respond selectively to
numerous stimuli.

- Persons coming from low socioeconomic areas or single-parent

homes in deprived areas are not exposed to situations in which they
can become successful in life.
 Perinatal Theory
- Risks exists if the developing fetus or newborn is deprived of oxygen during
pregnancy or if the mother suffers from malnutrition or starvation during 1st
trimester of pregnancy

- Development may occur during fetal life at critical points in brain

development:34th or 35th week AOG.

- .
- Trauma and injury in the 2nd trimester and birth are also considered in
the development of schizophrenia.

- Short gestation periods and low birthweights

 Psychological or Experiential Theory
- Prefrontal lobes of the brain are extremely responsive to environmental stress.

- negative response from family and acquaintances to emotional needs can

intensify neurologic state, triggering and exacerbating symptoms.

- Poor mother-child relationships

- Deeply disturbed family rel.

- Impaired sexual identity and body image

- Rigid concepts of reality and repeated exposure to double-bind

situations.
 Age occurrence
-
Vast majority of individuals develop the disorder in adolescence or
young adulthood, with only 10 per cent of cases first diagnosed in
people over the age of 45.
 Vitamin Deficiency
- Vit. B deficiency as well as in Vitamin C may cause development of
schizophrenia.
Onset
Usually occurs in adolescence and early adulthood (19-21) with a
duration of symptoms of at least 6 months.

25
General Concepts
A. Loss of Ego Boundaries
B. May result from many other factors
1. Organic or physiological:
Genetic-
Biochemical - (overactivity of dopamine, norepinephrine insufficiency, or
an imbalance of both, decreased monoamine oxidase activity)
Immunological imbalance-
Structural deviation of brain tissue or enlarged brain ventricles

26
2. Psychosocial

Individual adaptive pattern to stress

Double-bind communication pattern
Poor family relationships
Past traumatic relationships
Lack of ego strength
1. Deficit in cognitive development caused by perinatal, nutritional, and
maturational factors.

27
C. Primary Mental Mechanisms are repression, regression, projection,
and denial.
D. Failure or inability to trust self or others.
E. Security and identity are threatened, prompting the client to
withdraw from reality.

28
Prepsychotic Personality Characteristics
A. Aloof and indifferent
B. Social withdrawal, peculiar behavior
C. Relatives and friends note a change in personality
D. Unusual perceptual experiences and disturbed communication
patterns
E. Lack of personal grooming

29
Psychodynamics of Maladaptive Disturbances
A. Disturbed thought processes
1. Confused, chaotic, and disorganized thinking
2. Communicates in symbolic language in which all symbols have special meaning.
3. Belief that thought or wishes can control other people (i.e. magical thinking).
4. Retreats to a fantasy world, rejecting the real world of painful experience while
responding to reality in a bizarre or autistic manner

30
B. Disturbed Affect
1. Difficulty expressing emotions
2. Absent, flat, blunted, or inappropriate affect
3. Inappropriate affect makes it difficult to form a close relationships

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C. Disturbance in Psychomotor Behavior
1. Display of disorganized, purposeless activity
2. Behavior may be uninhibited and bizarre; abnormal posturing
(agitated or retardation catatonia); waxy flexibility
3. Often appears aloof, disinterested, apathetic, and lacking in
motivation

32
D. Disturbance in perception
1. Hallucinations and delusions; auditory forms are most common
2. Abnormal bodily sensations and hypersensitivity in sound, sight and
smell

33
E. Disturbance in Interpersonal relationships

1. Establishment of interpersonal relationship is difficult because

of inability to communicate clearly and react appropriately.

34
2. Difficulty relating to others
a. Unable to form close relationships
b. Has difficulty trusting others and experiences ambivalence, fear and
dependency.
c. Need-fear dilemma; withdraws to protect self from further hurt
and consequently experiences lack of warmth, trust, and intimacy

35
d. As if phenomenon: feels rejected by others which leads to
increased isolation, perpetuating further feelings of rejection.

36
Clinical Symptoms and Diagnostic Characteristics
Typical Symptoms
- Delusional ideation false belief brought about without appropriate external
stimulation and inconsistent with the individuals own knowledge and
experience.
- Hallucination false sensory perceptions that may involve any of the five senses
- Disorganized speech patterns

- Bizzare behaviors

- At least 2 of these symptoms must be present for a significant portion

of the time during a 1-month period.
The Blueler 4 As
Affective disturbance
Autistic Thinking
Ambivalence
Associative looseness
Added currently: Auditory Hallucination
3 Broad categories
Positive symptoms
- presence of overt psychotic or distorted behavior ( hallucinations,
delusions, or suspiciousness due to increased dopamine affecting the
cortical areas of the brain.

Negative symptoms
- a diminution or loss of normal functions (affect, motivation or ability
to enjoy activities) due to cerebral atrophy
 Disorganized symptoms
- Presence of confused thinking, incoherent or disorganized speech and behavior.

Type I Schizophrenia acute onset of positive symptoms which generally

responds to typical neuroleptics.

Type II Schizophrenia slow onset of negative symptoms caused by viral

infections, abnormalities in cholecystokinin. Enlarged ventricles is present.
Negative symptoms generally respond to atypical antipsychotic
Positive Symptoms

Excess or distortion of normal functions

Delusions (persecutory or grandiose)
Conceptual disorganization
Hallucination (visual, auditory, or other sensory mode)
Excitement or agitation
Hostility or aggressiveness
Suspiciousness, ideas of reference
Pressured speech
Bizarre dress or behavior
Possible suicidal tendencies
Negative Symptoms
Diminution or loss of normal functions
Anergia
Anhedonia
Emotional withdrawal
Poor eye contact
Blunted affect
Avolition
Difficulty in abstract thinking
Alogia
Dysfunctional relationship with others
Disorganized symptoms
Cognitive defects/confusion
Incoherent speech
Disorganized speech
Repetitive rhythmic gestures
Attention deficits
Diagnostic Characteristics

Evidence of 2 or more of the ff:

delusions, hallucinations, disorganized speech, grossly organized or catatonic
behavior, negative symptoms

Above symptoms are present for a major portion of the time during a 1-month
period.

Significant impairment in work or interpersonal relations, or self-care below the

level of previous functions.
 Demonstration of problems continuously for at least 6-month
interval.

Symptoms unrelated to schizoaffective disorder and mood disorder

with psychotic symptoms and not the result of a substance-related
disorder of medical condition.
Types of Schizophrenia
A. Schizophrenia, disorganized
1.Cognitive impairment
2. Disorganized speech
Displacement
Fantasy
Grimacing
Hallucinations
Lack of coherence
Loose association

47
5. Inappropriate affect, giggling and silly laughter
6. Usually have flat or inappropriate affect and incoherent thoughts.
7. Regressive behavior
8. Severe thought disturbance, incoherent speech, word salad.
9. Withdrawn, fragmentary hallucinations and delusions
10. Magical thinking (believes his thought can control others)
11. Word salads

48
Positive Symptoms

Excess or distortion of normal functions

Delusions (persecutory or grandiose)
Conceptual disorganization
Hallucination (visual, auditory, or other sensory mode)
Excitement or agitation
Hostility or aggressiveness
Suspiciousness, ideas of reference
Pressured speech
Bizarre dress or behavior
Possible suicidal tendencies

49
Negative Symptoms
Diminution or loss of normal functions
Anergia
Anhedonia
Emotional withdrawal
Poor eye contact
Blunted affect
Avolition
Difficulty in abstract thinking
Alogia
Dysfunctional relationship with others

50
Contributing Factors
Fragile ego, cant withstand external reality
Brain abnormalities
Developmental involvement
Genetic factors
Neurotransmitter abnormalities
Social or environmental, interactive with persons inherited biological makeup

51
Diagnostic test results
MRI shows possible enlargement of ventricles and prominent cortical
sulci
Neuropsychological and cognitive tests indicate impaired
performance.

52
Nursing Diagnosis
1. Altered thought process
2. Social isolation
3. Sensory or perceptual alterations (auditory)

53
Treatment
1. Family therapy
2. Milieu therapy
3. Psychoeducational programs
4. Social skills training
5. Stress management
6. Supportive psychotherapy

54
Drug therapy
Neuroleptics: chlorpromazine (thorazine), fluphenazine (prolixin),
haloperidol (haldol), olanzapine (Zyprexa), risperidone (Risperdal),
Thioridazine (Mellaril).
Antiparkinson agents: Benztropine(Cogentin)

55
Interventions
1. Help patient meet basic needs for food, comfort, and a sense of safety
2. During an acute psychotic episode, remove potentially hazardous items, from
the patients environment to promote safety
3. Briefly explain procedures, routines, and tests
4. Protect patient from self-destructive tendencies or aggressive impulses to
ensure safety
5. Convey sincerity and understanding when communicating to promote a
trusting relationship

56
6. Formulate realistic goals with the patient
7. If the patient experiences hallucinations, dont attempt to reason with him or
challenge his perception of hallucinations. Instead ensure safety and provide
comfort.
8. Encourage the patient with auditory hallucinations to reveal what the voices are
telling him
9. First, encourage the patient to participate in one-on-one interactions, and then
progress to small groups

57
10. Provide positive reinforcement for socially acceptable behavior such as efforts
to improve hygiene and table manners
11. Encourage the patient to express feelings related to experiencing hallucinations.

58
B. Schizophrenia, Catatonic
1. Shows little reaction to the environment
2. Stupor and excitement phases of catatonia, bizarre posturing, waxy flexibility
3. Negativism, rigidity and mutism
4. Displacement (switching emotions from their original object to a more
acceptable substitute)
5. Dissociation (separation of things from their emotional significance)

59
5. Echolalia
6. Echopraxia
7. Behavior can last for hours at a time
8. Childlike regressed behavior
9. Ritualistic mannerism
8. The least common type of schiz.

60
Contributing factors
1. Fragile ego, which cant withstand the demands of reality
2. Brain abnormalities
3. Developmental abnormalities
4. Genetic factors
5. Hyperactivity of the neurotransmitter dopmine.
6. An infectious agent or autoimmune response (unproven cause).
7. Social or environmental stress, interacting with the persons inherited biological
makeup.

61
Diagnostic test results
1. Magnetic resonance imaging shows enlargement of lateral
ventricles, enlarged third ventricle and sulci.
2. Patient show impaired performance on neuropsychological and
cognitive tests

62
Nursing diagnosis
1. Altered thought processes
2. Ineffective individual coping
3. Hygiene self-care deficit

63
Treatment
ECT
Family therapy
Milieu therapy
Outpatient group therapy
Psychoeducational program
Social skills training
Stress management
Supportive psychotherapy

64
Interventions
1. Provide skin care
2. Monitor for adverse effects of neuroleptics (dystonic reactions and tardive
dyskinesias)
3. Be aware of the patients personal space; use gestures and touch judiciously
4. Provide appropriate measures to ensure patient safety and explain to the patient
why it is done.
5. Collaborate with the patient to identify anxious behavior as well as probable
causes.
6. Monitor intake and output

65
7. When discussing care, give short, simple explanations at the patients level of
understanding to increase cooperation.
8. Promote trusting relationship to create a safe environment
9. Briefly explain procedures, routines, and tests to allay anxiety.
10. Provide opportunities for patient to learn adaptive social skills in a
nonthreatening environment.

66
Teaching topics
Accepting that feelings are valid
Recognizing extrapyramidal effects of antipsychotic medications.
Preventing photosensitivity reactions to drugs to avoid exposure to
sunlight.

67
C. Schizophrenia, paranoid
1. Delusions of persecution and grandeur
2. Extreme suspiciousness
3. Anger, argumentativeness, and violence
4. Doubts about gender identity
5. Often display bizarre behavior, are easily angered and are at high risk for
violence.
6. The prognosis for independent functioning is often better than for other types
of schizophrenia

68
Other assessment findings
Anxiety
Argumentativeness
Delusions and auditory hallucinations
Displacement
Dissociation
Easily angered
Inability to trust
Potential for violence
Projection
Withdrawal or aloofness

69
Diagnostic test results
1. MRI shows possible enlargement of ventricles, and enlarged sulci.
Enlarged sulci suggest cortical loss, particularly in the frontal lobe
2. Neuropsychological and cognitive test indicate impaired
performance.

70
Nursing Diagnosis
Altered thought processes
Social isolation
Sensory or perceptual alteration (auditory)

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Treatment therapy
Family therapy
Group therapy
Milieu therapy
Psychoeducational program
Social skills training
Stress management
Supportive psychotherapy

72
Drug therapy
Antipsychotics
Antiparkinsonism

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Interventions
Inform the patient that you will help him control his behavior to promote feelings
of safety
Set limits on aggressive behavior and communicate your expectations to the
patient to prevent injury to the patient and others
Designate one nurse to communicate with the patient and to direct other staff
members who care for the patient to foster trust and a stable environment and to
minimize opportunities for the patient to exhibit hostility

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4. Maintain a low level of stimuli to minimize the patients anxiety, agitation and
suspiciousness
5. Be flexible- allow patient some control. Approach in a clam, unhurried manner. Let
patient talk about anything he wishes, but keep the conversation light and social to
avoid entering into power struggle.
6. Dont let patient put you on the defensive, and dont take his remarks personally. If
he tells you to leave him alone, do leave but return soon. Brief contacts with patients
may be useful at first.

75
7. Dont make attempts to combat the patients delusions with
logic. Instead, respond to feeling themes, or underlying
needs.
8. If the patient is taking clozapine, stress the importance of
returning weekly to the facility or an outpatient setting to
have his blood checked
9. Teach patient the importance of complying with the
medication regimen. Tell him to report adverse reactions
instead of discontinuing the drugs
10. If he takes a slow-release formulation, make sure that he
understands when to return for his next dose to promote
compliance.

76
Teaching topics
Avoiding exposure to sunlight
Reporting any adverse effects of antipsychotic medications
Visiting the hospital weekly to have blood chemistry monitored.

77
D. Schizophrenia, undifferentiated
1. Mixed psychotic symptom
2. Unclassifiable, either does not meet the criteria of one of the
subtypes or meets the criteria of more than one.

78
E. Schizophrenia, residual
1. History of exhibited psychotic symptoms of schizophrenia but not
psychotic at present
2. Continued difficulty in thinking, mood and perception.

79
General Assessment
A. Four As: Eugene Bleulers Classic symptoms
1. Associative looseness
Lack of logical thought progression, resulting to disorganized and chaotic
thinking.
2. Affect
emotion or feeling tone is one of indifference or is flat, blunted, exaggerated or
socially inappropriate.

80
3. Ambivalence
Conflicting strong feelings that neutralize each other,
leading to psychic immobilization and difficulty in
expressing emotions.

4. Autism
Fantasies, preoccupation with daydreams, and
psychotic thought processes of delusion and
hallucination,
Ideas of reference- actions and speech of others have
reference to oneself; ideas symbolize feelings of guilt,
insecurity, and alienation.

81
 Depersonalization feeling alienated from oneself; difficulty
distinguishing self from others; loss of boundaries between self and
environment.

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Additional Characteristics
Regression
Negativism
Religiosity
Lack of social awareness

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Nursing Diagnosis
Disturbed thought processes r/t the presence of persecutory delusion
Disturbed sensory perceptions r/t the presence of visual
hallucinations
Self-care deficit related to poor personal hygiene
Impaired verbal communication r/t thought disturbance (looseness of
association).

84
 Noncompliance r/t refusal to take prescribed psychotropic meds
Disturbed sleep pattern r/t the presence of auditory hallucinations
Social isolation r/t homelessness
Ineffective coping r/t fear

85
Nursing Objectives
The client will communicate with members of the treatment team
The client will verbalize her physical needs
The client will exhibit compliance with medication management
The client will verbalize a decrease presence of persecutory delusions

86
General Interventions
Goal: To Build Trust
1. Encourage free expression of feelings without fear of rejection, ridicule, or
retaliation.
2. Use nonverbal level of communication to demonstrate warmth, concern and
empathy because clients often distrust words.
3. Consistency, reliability, acceptance, and persistence build trust
4. Allow client to set pace; proceed slowly in planning social contacts.

87
Goal: to provide a safe and secure environment
1. Maintain familiar routines.
2. Avoid stressful situations or increasing anxiety

Goal: To clarify and reinforce reality

1. Involve client in reality-0riented activities
2. Help client find satisfaction in the external environment and ways or relating to
others.
3. Focus on clear communication and the immediate situation.

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Goal: To promote and build self-esteem
1. Encourage simple activities with limited concentration and no competition
2. Provide successful experiences with short-range goals. Realistic for clients level
of functioning
3. Relieve client of decision making until he or she is ready
4. Avoid making demands

89
Goal: To encourage independent behavior
1. Anticipate and accept negativism
2. Avoid fostering dependency
3. Encourage client to make his or her own decisions, using positive
reinforcements
Goal: To provide care to meet basic human needs.
1. Determine clients ability to meet responsibilities of daily living
2. Attend to nutrition, elimination, exercise, hygiene and signs of physical illness

90
Goal: To assist in medical treatment
1. Assist with ECT; may be useful in some instances to modify behavior
Goal: To deal effectively with withdrawn behavior.
A. Establish one-to-one relationship.
1. Initiate interaction by seeking out client at every opportunity
2. Maintain a nonjudgmental, accepting manner in what is said and done.
3. Attempt to draw client into conversation without demanding a response.

91
B. Promote social skills by helping client feel more secure with other people.
1. Accept one-sided conversation
2. Accept clients negativism without comments

C. Attend to physical needs of the client as necessary

D. Have client focus on reality
E. Protect and restrain client from potential destructiveness to self and others.

92
Goal: to deal effectively with hallucination
A. Clarify and reinforce reality
1. Help client recognize hallucination as a manifestation of anxiety
2. Provide a safe and secure environment
3. Avoid denying or arguing with client when he or she is experiencing
hallucinations
4. Acknowledge clients experience but point out that you do not share the same
experience.
5. Do not give attention to content of hallucination

93
6. Direct clients attention to real situation, such as singing along with music
7. Protect client from injury to self or others when he or she is prompted by
voices or visions.

B. Encourage social interaction to help client find satisfactory ways of relating with
others.
1. Increase interactions gradually
2. Respond verbally to anything real that client talks about.

94
Schizophrenia-like disorders
Schizoaffective disorder
Uninterrupted illness during which, at some time, the client experiences
major depressive, manic, or mixed episode along with the negative symptoms
of schiz. In the absence of mood symptoms, the individual exhibits delusions,
hallucinations for at least 2 weeks

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 Schizophreniform disorder
- The client exhibits features of schiz for than 1 month but fewer than 6
months. Impaired social or occupational functioning does not
necessarily occur.

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 Brief Psychotic Disorder
- disturbance that involves the sudden onset of at least one of the
positive symptoms of psychosis such as hallucinations, delusions,
disorganized speech, or grossly disorganized or catatonic behavior

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 - occurs for at least 1 day but for less than 1 month, as the individual
eventually exhibits a full recovery or return to the former level of
functioning

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 Psychotic disorder due to a general medical condition
- presence of prominent hallucinations/delusions due to the direct
physiologic effects of a specific medical condition.
- Evidence from history, physical exam, or laboratory findings is
necessary to confirm diagnosis.
5. Check for any abnormal body movements, disturbance of gait, or
unusual behavior.
6. Document any hallucinations or delusions, and other disorders such
as anxiety, substance abuse, or depression that are assessed.
Delusional Disorders
Patients hold firm beliefs despite contradictory information.
Tends to be intelligent and can have a high level of competence, but
have impaired social and personal relationshisps.
One indication of delusional disorder is the absence of hallucination

101
characteristics
Antagonism
Brushes with the law
Delusions that are visual, auditory or tactile
Denial
Ideas of reference
Inability to trust
Irritable or depressed mood
Marked anger and violence
Projection
Stalking behavior

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Diagnostic test results
Blood and urine tests eliminate organic or chemical cause
Endocrine function test rule out hyperadrenalism, pernicious anemia,
and thyroid disorders
Neurologic evaluation rule out organic cause

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Nursing Process
Assessment
1. Obtain subjective data from family
-Focus on the medications taken and presence of adverse effects, if any.
-Check ADL patterns, presence of bizarre eating habits such as pica or compulsive
overeating.

2. Check for presence of depression and risk for suicide which is 10-13% in schiz.

3.Check for psychogenic polydipsia

4. Document clients physical condition comorbid medical problems such as

hypertension, type II D.M., and hepatitis may be present.
Nursing Diagnosis
Disturbed thought processes r/t the presence of persecutory delusion
Disturbed sensory perceptions r/t the presence of visual hallucinations
Self-care deficit related to poor personal hygiene
Impaired verbal communication r/t thought disturbance (looseness of
association).
 Noncompliance r/t refusal to take prescribed psychotropic meds

Disturbed sleep pattern r/t the presence of auditory hallucinations

Social isolation r/t homelessness

Ineffective coping r/t fear

Nursing Objectives
The client will communicate with members of the treatment team
The client will verbalize her physical needs
The client will exhibit compliance with medication management
The client will verbalize a decrease presence of persecutory delusions.
Nursing Interventions
Interventions vary as biologic, cognitive, perceptual, behavioral, and emotional
disturbances are considered.
Establish trusting relationship; clear, consistent and open communication
Alleviate positive, negative and disorganized symptoms
Maintain biologic integrity
 Encourage clients verbalization of feelings
Communicate in simple, easy-to-understand terms directed at
the clients level of functioning.

Provide safe, structured environment

Limit-setting, physical restraints may be necessary
Interventions on Agitation
Remove clients from, or avoid situations known to cause
agitation

Decrease stimulants such as caffeine, bright lights and loud noise

or music.

Avoid display of anger, discouragement, or frustration when

interacting with the client
.
 Avoid criticism and do not argue with the client.
Set limits and follow through with consequences if a violation
occurs.
Monitor for physical discomfort such as pain or physical illness.
Administer prescribed medications as ordered
Interventions on Hallucinations
Decrease environmental stimuli such as loud music, extremely bright
colors, flashing lights.
Attempt to identify precipitating factors by asking client what
happened prior to the onset of hallucinations.
 Monitor t.v. programs to minimize external stimuli

Monitor for command hallucinations that may precipitate aggressive

or violent behaviors.

Administer prescribed medications as ordered.

Interventions on delusions
Do not whisper or laugh in the presence of the client.
Do not argue with the client or attempt to disprove delusional
or suspicious thoughts.
Explain all procedures and interventions, including medication
management.
.
 Provide for personal space and do not touch the client without
warning.
Maintain eye contact during interactions with the client.
Provide consistency in care and assigned caregivers to establish
rapport
Somatoform Disorders
Characteristics
1. Complains of symptoms and typically travels from doctor to doctor in search of
sympathetic and enthusiastic treatment
2. Physical exams and laboratory tests fail to uncover an organic basis
3. Usually unable to accept that his illnes has a psychological cause.

116
Psychosomatic conditions in which a psychologic state contributes to the
development of a physical illness.
Somatization manifestation of physical symptoms that result from psychological
distress.
Anyone who feels the pain of a sore throat or the ache of flu has a somatic
symptom, but it isnt considered somatization unless the physical symptoms are
an expression of emotional stress.

117
Internalization refers to the condition in which a patients anxiety, and
frustration are expressed through physical symptoms rather than
confronted directly.

118
Major Somatoform Disorders
1. Conversion disorders
2. Hypochondrasis
3. Pain disorder
4. Sleep disorders
5. Parasomnias

119
Conversion Disorder
Patient exhibits symptoms that suggest a physical disorder, but
evaluations and observation cant determine a physiologic cause.
The onset of symptom is preceded by psychological symptoms are a
manifestation of conflict.

120
Contributing Factors
Psychological conflict
Overwhelming stress

121
Assessment Findings
Aphonia
Blindness
Deafness
Dysphagia
Impaired balance and impaired coordination
La belle Indifference (lack of concern about the symptoms or
limitation on functioning).

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 Loss of touch sensation
Lump in the throat
Paralysis
Seizures
Urinary retention

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Diagnostic Test Results
Test results are inconsistent with physical findings
The absence of expected diagnostic findings can confirm the disorder.

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Treatment
Individual Therapy

Drug Therapy
Benzodiazepine: lorazepam (Ativan), alprazolam (xanax)

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Interventions
1. Ensure and maintain safe environment to protect the patient
2. Establish supportive relationship that communicates acceptance of the patient
but keeps the focus away from symptoms to help patient learn and recognize
anxiety.
3. Review all laboratory and diagnostic study results to ascertain whether any
physical problems are present.

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4. Encourage the patient to identify any emotional
conflicts occurring before the onset of physical symptoms to make the
relationship between the conflict and the symptoms more clear.
5. Promote social interaction to decrease the patients level of self-involvement
6. Identify constructive coping mechanisms to encourage the patient to use
practical coping skills and relinquish the role of being sick.

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Teaching Topics
1. Teach the family members how to set limits on the patients sick role behavior
while continuing to provide support.
2. Teach the stress-reduction methods.

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Hypochondriasis
Patient is preoccupied by fears of a serious illness, despite medical assurance of
good health.
Interprets all physical sensations as indication of illness, impairing his ability to
function normally.

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Contributing factors
Death of someone close to the individual
Family member with a serious illness
Previous serious illness

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Assessment findings
Abnormal focus on bodily functions and sensations
Anger, frustration, depression
Frequent visits to doctors and specialists despite assurance from health care providers
that the patient is healthy
Intensified physical symptoms around sympathetic people.
Rejection of idea that the symptoms are stress related
Use of symptoms to avoid difficult situations
Vague physical symptoms

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Diagnostic test results
Test results are inconsistent with patients complaints and physical findings

Nursing Diagnosis
Knowledge deficit
Ineffective individual coping
Altered health maintenance
Treatment
Individual therapy

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Drug therapy
Benzodiazepine: lorazepam (ativan), alprazolam (xanax)
Tricyclic antidepressants: amitriptylline (Elavil), imipramine(tofranil),
doxepin(sinequan), phenelzine(nardil)

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Interventions
Assess the patients level of knowledge about how emotional issues can impact
physiologic functioning to promote understanding of the condition.
Encourage emotional expression to discourage emotional repression, which can
have physical consequences.
Respond to the patients symptoms in a matter-of-fact way

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Teaching topics
Relaxation and assertiveness techniques
Initiating conversations that focus on something other than physical
maladies

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Pain Disorder
Patient experiences pain in which psychological factors play a significant role in
the onset, severity, exacerbation, or maintenance of pain.
Pain isnt intentionally produced or feigned by patient
Pain becomes the major focus of life and there is impaired social and work
functioning
May have ailment but shouldnt be experiencing such intense pain.

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Contributing factors
Traumatic, stressful, or humiliating experience
Assessment Findings
Acute and chronic pain not associated with a physiologic cause
Anger, frustration, depression
Drug-seeking behavior in an attempt to relieve pain
Frequent visits to multiple doctors to seek pain relief
Insomnia

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Nursing Diagnosis
Pain
Ineffective individual coping
Anxiety
Therapy
Individual therapy
Drug therapy
Anxiolytics (benzodiazepines): lorazepam (ativan), alprazolam(xanax).
TCAs: amitriptylline (elavil), imipramine(tofranil), doxepin(sinequan).

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Interventions
Ensure safe, accepting environment
Acknowledge patients pain
Teaching Topic
Promoting social interaction
Establishing constructive coping mechanisms
Problem-solving techniques
Nonpharmacologic: pain management (guided imagery,
massage, therapeutic touch, relaxation, heat and cold)

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Parasomnias

Characterized by abnormal behavior that occurs during sleep.

Includes nightmare disorder, sleep terror, and sleepwalking
disorder.

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Contributing Factors
Severe psychosocial stressors
Genetic predispositions
Sleep deprivation
Fever

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Nightmare disorder
Recurrence of frightening dreams that cause the patient to awaken
from sleep.
When the patient awakens, he is fully alert and experiences persistent
anxiety or fear.
Typically the patient is able to recall details of the dream that involves
physical danger.

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Assessment findings
Anxiety
Depression
Dream recall
Excessive sleepiness
Irritability
Mild autonomic arousal upon awakening
Poor concentration

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Diagnostic test
Polysomnography demonstrates abrupt awakening from REM sleep that
corresponds to the individuals report or nightmares
The awakenings usually occur during the second half of the nght.
Heart rate and respiratory rate may increase or show increased variability before
the awakening.

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Sleep terror disorder
Episodes of sleep terrors causing distress or impairment of social or occupational
functioning.
May sit up in bed screaming or crying with frightened expression and intense
anxiety.
The patient is difficult to awaken and if he does, hes generally confused or
disoriented.
Patient has no record of the dream content.

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 Autonomic signs of intense anxiety(tachycardia, tachypnea, flushing,
sweating, increased muscle tone, dilated pupils)
Inability to recall dream content
Screaming or crying

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 Polysomnography: deep NREM sleep characterized by slow frequency
EEG activity.

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Sleepwalking disorder
Amnesia of the episode or limited recall
Episode may include sitting up, talking, walking, or engaging in inappropriate
behavior.

Diagnostic test
Polysomnography: episodes of sleepwalking that begin within the 1st few hours of
sleep usually during the NREM stage 3 or 4 sleep.

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Nursing Diagnosis
Sleep pattern disturbances
Fatigue
Altered role performance

Treatment
Hypnosis
Drug therapy
Benzodiazepines : lorazepam (ativan), alprazolam(xanax)

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Interventions
Assess patient and document symptoms of sleep disturbance
Lock windows and doors
Provide emotional support
Establish sleep routine
Schedule regular sleep and awakening
Administer medication as prescribed

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Teaching topics
Safety measures for the patient with sleep-walking disorder
Ways to identify and reduce stressors

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