psychiatric nursing- foundations

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Psychiatric Psychiatric Nursing Nursing The Heart of the Nursing The Heart of the Nursing Profession Profession

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Page 1: Psychiatric Nursing- Foundations

Psychiatric Psychiatric NursingNursing

The Heart of the Nursing The Heart of the Nursing ProfessionProfession

Page 2: Psychiatric Nursing- Foundations

Outline of Psychiatric Outline of Psychiatric NursingNursing Fundamental Concepts of Psychiatric Fundamental Concepts of Psychiatric

nursingnursing The Definition of Psychiatric NursingThe Definition of Psychiatric Nursing The Scope of Psychiatric Nursing PracticeThe Scope of Psychiatric Nursing Practice Self-AwarenessSelf-Awareness Theoretical FrameworkTheoretical Framework

FreudFreud EriksonErikson PiagetPiaget SullivanSullivan FowlerFowler

Page 3: Psychiatric Nursing- Foundations

Outline of Psychiatric Outline of Psychiatric NursingNursing The Therapeutic Nursing The Therapeutic Nursing

RelationshipRelationship The Therapeutic CommunicationThe Therapeutic Communication Modalities of Psychiatric CareModalities of Psychiatric Care

Psychiatric Settings- Therapeutic Psychiatric Settings- Therapeutic Environment Environment

Overview of Psychotherapy- therapeutic Overview of Psychotherapy- therapeutic modalitiesmodalities

PsychopharmacologyPsychopharmacology Psychiatric Diagnostic TestsPsychiatric Diagnostic Tests

Page 4: Psychiatric Nursing- Foundations

Outline of Psychiatric Outline of Psychiatric NursingNursing The Psychiatric Nursing ProcessThe Psychiatric Nursing Process

Psychiatric Assessment: History and Psychiatric Assessment: History and PEPE

Diagnostic ExaminationDiagnostic Examination Psychiatric Nursing DiagnosisPsychiatric Nursing Diagnosis Nursing PlanningNursing Planning Nursing ImplementationNursing Implementation Nursing EvaluationNursing Evaluation

Page 5: Psychiatric Nursing- Foundations

Outline of Psychiatric Outline of Psychiatric NursingNursing Client Responses to illnessClient Responses to illness

Anxiety and CrisisAnxiety and Crisis AngerAnger HostilityHostility DepressionDepression Abuse Abuse ViolenceViolence SuicideSuicide Grief and LossGrief and Loss

Page 6: Psychiatric Nursing- Foundations

Outline of Psychiatric Outline of Psychiatric NursingNursing

Psychiatric Disorders: AdultPsychiatric Disorders: Adult

1.1. Anxiety and Anxiety DisordersAnxiety and Anxiety Disorders

2.2. SchizophreniaSchizophrenia

3.3. Mood disorders Mood disorders

4.4. Personality DisordersPersonality Disorders

5.5. Eating DisordersEating Disorders

6.6. Substance abuseSubstance abuse

7.7. Somatoform disordersSomatoform disorders

Page 7: Psychiatric Nursing- Foundations

Outline of Psychiatric Outline of Psychiatric NursingNursing

Psychiatric Disorders: Children and Psychiatric Disorders: Children and adolescentsadolescents

1.1. AutismAutism

2.2. ADHDADHD

3.3. Mental RetardationMental Retardation

4.4. Other disordersOther disorders

Page 8: Psychiatric Nursing- Foundations

Outline of Psychiatric Outline of Psychiatric NursingNursing

Psychiatric Disorders: OthersPsychiatric Disorders: Others

1.1. DementiaDementia

2.2. DeliriumDelirium

Page 9: Psychiatric Nursing- Foundations

Ready Ready Colleagues?Colleagues?BY: Prof Joan A. OcampoBY: Prof Joan A. Ocampo

Page 10: Psychiatric Nursing- Foundations

Nature of Psychiatric Nature of Psychiatric Nursing Nursing

Let us first review Let us first review terms related to terms related to

Psychiatric Psychiatric NursingNursing

Page 11: Psychiatric Nursing- Foundations

Nature of Psychiatric Nature of Psychiatric Nursing Nursing

Mental HealthMental Health A state of emotional, psychological A state of emotional, psychological

and social wellness evidenced by and social wellness evidenced by satisfying interpersonal satisfying interpersonal relationships, effective behavior and relationships, effective behavior and coping, positive self-concept and coping, positive self-concept and emotional stability (Videbeck)emotional stability (Videbeck)

lifelong process of successful lifelong process of successful adaptation to a changing internal adaptation to a changing internal and external environments and external environments

Page 12: Psychiatric Nursing- Foundations

Nature of Psychiatric Nature of Psychiatric Nursing Nursing

Mental DisorderMental Disorder A clinically significant behavioral or A clinically significant behavioral or

psychological syndrome or pattern that psychological syndrome or pattern that occurs in an individual and that is occurs in an individual and that is associated with present distress, associated with present distress, increased risk of suffering, death, increased risk of suffering, death, disability and loss of freedom (Videbeck)disability and loss of freedom (Videbeck)

Loss of ability to respond to environment Loss of ability to respond to environment in ways that are in accord with oneself in ways that are in accord with oneself and society and society

Page 13: Psychiatric Nursing- Foundations

Mentally Healthy PersonMentally Healthy Person

Accepts himselfAccepts himself Perceives realityPerceives reality Mastery of self and environmentMastery of self and environment AutonomyAutonomy Unifying, integrated outlook in lifeUnifying, integrated outlook in life

Page 14: Psychiatric Nursing- Foundations

Nature of Psychiatric Nature of Psychiatric Nursing Nursing

The DSM-TR IV The DSM-TR IV A taxonomy that describes all A taxonomy that describes all

mental disorders, outlining specific mental disorders, outlining specific diagnostic criteria for each based diagnostic criteria for each based on clinical experience and researchon clinical experience and research

Clinicians utilize this to diagnose Clinicians utilize this to diagnose psychiatric disorderspsychiatric disorders

Purpose of DSM-TR: Purpose of DSM-TR: 1.1. Standard nomenclatureStandard nomenclature2.2. Defining characteristicsDefining characteristics3.3. Underlying cause of disordersUnderlying cause of disorders

Page 15: Psychiatric Nursing- Foundations

Nature of Psychiatric Nature of Psychiatric Nursing Nursing

The DSM-TR IV : Multi Axis The DSM-TR IV : Multi Axis ClassificationClassification

AXIS I- Major Psychiatric DisordersAXIS I- Major Psychiatric Disorders

AXIS II- Mental Retardation and AXIS II- Mental Retardation and Personality DisordersPersonality Disorders

AXIS III- Current Medical ConditionAXIS III- Current Medical Condition

AXIS IV- Psychosocial and AXIS IV- Psychosocial and Environmental ProblemsEnvironmental Problems

AXIS V- Global Assessment of FunctionAXIS V- Global Assessment of Function

Page 16: Psychiatric Nursing- Foundations

Nature of Psychiatric Nature of Psychiatric Nursing Nursing

Historical People Worth Historical People Worth MentioningMentioning

1.1. Aristotle- the HumorsAristotle- the Humors

2.2. Freud- -Psychosexual theoryFreud- -Psychosexual theory

3.3. Kraeplin- symptomatic Kraeplin- symptomatic classification of mental disordersclassification of mental disorders

4.4. Bleuler- coined “schizophrenia”Bleuler- coined “schizophrenia”

Page 17: Psychiatric Nursing- Foundations

Nature of Psychiatric Nature of Psychiatric Nursing Nursing

Psychiatric Nursing in the Psychiatric Nursing in the PhilippinesPhilippines

GO and NGOs GO and NGOs Mental health programsMental health programs

Page 18: Psychiatric Nursing- Foundations

Nature of Psychiatric Nature of Psychiatric Nursing Nursing

Psychiatric Nursing in the PhilippinesPsychiatric Nursing in the Philippines

Mental Health= Mental Health= State of well beingState of well being, , where a person can realize his potential where a person can realize his potential

Mental Ill Health= Mental Ill Health= disturbancedisturbance of of thought, feelings and behaviorthought, feelings and behavior

Mental Disorder= Mental Disorder= medically medically diagnosablediagnosable illness illness

Mental Hygiene= Mental Hygiene= ScienceScience which deals which deals with measures employed to promote with measures employed to promote mental healthmental health

Page 19: Psychiatric Nursing- Foundations

Nature of Psychiatric Nature of Psychiatric Nursing Nursing

Scope of Nursing PracticeScope of Nursing Practice Individual, family and Individual, family and

communitycommunity Healthy and ill person Healthy and ill person

Page 20: Psychiatric Nursing- Foundations

Nature of Psychiatric Nature of Psychiatric Nursing Nursing

Self AwarenessSelf Awareness The process by which the nurse The process by which the nurse

gains recognition of his/her own gains recognition of his/her own feelings, beliefs and attitudes feelings, beliefs and attitudes (Videbeck)(Videbeck)

Initial nursing activity to do Initial nursing activity to do before practicing psychiatric before practicing psychiatric nursingnursing

Page 21: Psychiatric Nursing- Foundations

Nature of Psychiatric Nature of Psychiatric Nursing Nursing

Self AwarenessSelf Awareness This is accomplish through This is accomplish through

reflection, spending time reflection, spending time deliberately focusing on how one deliberately focusing on how one feels and what one values or feels and what one values or believesbelieves

Page 22: Psychiatric Nursing- Foundations
Page 23: Psychiatric Nursing- Foundations

Theoretical FoundationsTheoretical Foundations

Mental health-Psychiatric Mental health-Psychiatric treatment integrates concepts treatment integrates concepts and strategies from theories.and strategies from theories.

Theoretical Models are used as Theoretical Models are used as guides for treatments guides for treatments

These theories attempt to explain These theories attempt to explain human behavior, health and human behavior, health and mental illnessmental illness

Page 24: Psychiatric Nursing- Foundations

Theoretical FoundationsTheoretical Foundations Theoretical frameworks Theoretical frameworks

allow the systematic organization of allow the systematic organization of knowledgeknowledge

guide data collectionguide data collection provide explanations for assessed provide explanations for assessed

behaviorsbehaviors guide care plan developmentguide care plan development provides rationales for interventions andprovides rationales for interventions and determine evaluation criteriadetermine evaluation criteria Guide research by providing Guide research by providing

assumptions to be tested. assumptions to be tested.

Page 25: Psychiatric Nursing- Foundations

Theoretical FoundationsTheoretical Foundations

Psychosexual- Psychosexual- Psychoanalytical Psychoanalytical TheoryTheory

Sigmund FREUDSigmund FREUD

Psychosocial Psychosocial TheoryTheory

Erik ERIKSONErik ERIKSON

Cognitive TheoryCognitive Theory Jean PIAGETJean PIAGET

Interpersonal Interpersonal TheoryTheory

Harry Stack Harry Stack SullivanSullivan

Moral TheoryMoral Theory KOHLBERGKOHLBERG

Spiritual TheorySpiritual Theory FOWLERFOWLER

Page 26: Psychiatric Nursing- Foundations

Theoretical FoundationsTheoretical Foundations

Behavioral Behavioral TheoriesTheories

Pavlov and SkinnerPavlov and Skinner

Humanistic Humanistic Theories Theories

Maslow and Carl Maslow and Carl RogersRogers

Psychobiology Psychobiology theorytheory

Neuroanatomy and Neuroanatomy and physiologyphysiology

Page 27: Psychiatric Nursing- Foundations

Theories of Personality Theories of Personality developmentdevelopment

Freud’s Psychoanalytic theoryFreud’s Psychoanalytic theory Erikson’s Psychosocial theoryErikson’s Psychosocial theory Sullivan’s interpersonal theorySullivan’s interpersonal theory Piaget’s Cognitive theoryPiaget’s Cognitive theory Fowler’s Spiritual theoryFowler’s Spiritual theory Kohlberg’s Moral theoryKohlberg’s Moral theory

Page 28: Psychiatric Nursing- Foundations

Psychosexual/Psychosexual/PsychoanalyticalPsychoanalytical

This theory supports the notion This theory supports the notion that EVERY human behavior is that EVERY human behavior is caused and can be explainedcaused and can be explained

Freud believes that “repressed” Freud believes that “repressed” sexual urges, desires, impulses sexual urges, desires, impulses or drives motivated much human or drives motivated much human behaviorbehavior

Page 29: Psychiatric Nursing- Foundations

Psychosexual/Psychosexual/PsychoanalyticalPsychoanalytical

Components of PersonalityComponents of Personality

1.1. ID- part of a person that reflects ID- part of a person that reflects BASIC or innate DESIRES, BASIC or innate DESIRES, INSTINCT and SURVIVAL impulsesINSTINCT and SURVIVAL impulses

2.2. EGO- represents the REALITY EGO- represents the REALITY aspectaspect

3.3. SUPER-EGO- part that reflects SUPER-EGO- part that reflects MORALITY and ethical concepts, MORALITY and ethical concepts, and values and values

Page 30: Psychiatric Nursing- Foundations

Psychosexual/Psychosexual/PsychoanalyticalPsychoanalytical

Personality Stages and Functional Personality Stages and Functional AwarenessAwareness

1.1. Conscious – perceptions, thoughts Conscious – perceptions, thoughts and emotion that exist in the person’s and emotion that exist in the person’s awarenessawareness

2.2. Pre-conscious/Subconscious- Pre-conscious/Subconscious- Thoughts and emotions not currently Thoughts and emotions not currently in awareness but can be recalled with in awareness but can be recalled with efforteffort

3.3. Unconscious- thoughts, drives and Unconscious- thoughts, drives and emotions totally a person is Unaware emotions totally a person is Unaware

Page 31: Psychiatric Nursing- Foundations

Psychosexual/Psychosexual/PsychoanalyticalPsychoanalytical

According to this theory, According to this theory, much of our behavior is much of our behavior is

motivated by our motivated by our SUBCONSCIOUS SUBCONSCIOUS

thoughts orthoughts or

feelingsfeelings

Page 32: Psychiatric Nursing- Foundations

Psychosexual/Psychosexual/PsychoanalyticalPsychoanalytical

Five Stages of psychosexual Five Stages of psychosexual development development

1.1. Oral Oral

2.2. AnalAnal

3.3. Phallic or OedipalPhallic or Oedipal

4.4. LatencyLatency

5.5. GenitalGenital

Page 33: Psychiatric Nursing- Foundations

Psychosexual/Psychosexual/PsychoanalyticalPsychoanalytical

PhasePhase AgeAge FocusFocus

OralOral 0-18 0-18 monthsmonths

Site of gratification: MouthSite of gratification: Mouth

AnalAnal 1 ½ - 3 1 ½ - 3 yearsyears

Site of gratification: AnusSite of gratification: Anus

PhalliPhallicc

3- 5 3- 5 yearsyears

Site of gratification: GenitalsSite of gratification: Genitals

LatenLatencycy

6- 12 6- 12 yearsyears

Site of gratification: (School Site of gratification: (School Activities)Activities)

GenitGenital al

12 & 12 & aboveabove

Site of gratification: GenitalsSite of gratification: Genitals

Page 34: Psychiatric Nursing- Foundations

Psychosexual/Psychosexual/PsychoanalyticalPsychoanalytical

PhasePhase AgeAge FocusFocus

OralOral 0-18 0-18 monthsmonths

Major task: WeaningMajor task: Weaning

AnalAnal 1 ½ - 3 1 ½ - 3 yearsyears

Major task: Toilet trainingMajor task: Toilet training

PhalliPhallicc

3- 5 3- 5 yearsyears

Major task: Oedipal & Major task: Oedipal & Electra complexElectra complex

LatenLatencycy

6- 12 6- 12 yearsyears

Major task : School activitiesMajor task : School activities

GenitGenital al

12 & 12 & aboveabove

Major task: Sexual intimacy Major task: Sexual intimacy

Page 35: Psychiatric Nursing- Foundations

1. Oral1. Orala. 0-18 monthsa. 0-18 monthsb. Pleasure and gratification through b. Pleasure and gratification through

mouthmouthc. c. BehaviorsBehaviors: dependency, : dependency, eatingeating, ,

cryingcrying, , bitingbitingd. Distinguishes between self and d. Distinguishes between self and

mothermothere. Develops body image, e. Develops body image, aggressive aggressive

drivesdrives

Psychosexual model Psychosexual model (Freud)(Freud)

Page 36: Psychiatric Nursing- Foundations

2. Anal2. Anal

a. 18 months - 3 yearsa. 18 months - 3 years

b. Pleasure through elimination or b. Pleasure through elimination or retention of retention of fecesfeces

c. c. BehaviorsBehaviors: : controlcontrol of holding on or of holding on or letting goletting go

d. Develops d. Develops concept of powerconcept of power, , punishment, ambivalence, concern punishment, ambivalence, concern with with cleanlinesscleanliness or being dirty or being dirty

Psychosexual model Psychosexual model (Freud)(Freud)

Page 37: Psychiatric Nursing- Foundations

3. Phallic/Oedipal3. Phallic/Oedipala. 3 - 6 yearsa. 3 - 6 years

b. Pleasure through b. Pleasure through genitalsgenitals

c. c. BehaviorsBehaviors: : touching of genitalstouching of genitals, , erotic attachment to parent of erotic attachment to parent of opposite sexopposite sex

d. Develops d. Develops fear of punishment by by parent of parent of same sexsame sex, , guiltguilt, sexual , sexual identityidentity

Psychosexual model Psychosexual model (Freud)(Freud)

Page 38: Psychiatric Nursing- Foundations

4. Latency4. Latencya. 6 - 12 yearsa. 6 - 12 years

b. Energy used to gain new skills in b. Energy used to gain new skills in social relationshipssocial relationships and knowledge and knowledge

c. c. BehaviorsBehaviors: sense of : sense of industryindustry and and masterymastery

d. Learns control over aggressive, d. Learns control over aggressive, destructive impulsesdestructive impulses

e Acquires e Acquires friendsfriends

Psychosexual model Psychosexual model (Freud)(Freud)

Page 39: Psychiatric Nursing- Foundations

Psychosexual model Psychosexual model (Freud)(Freud)

5. Genital5. Genitala. 12 - 20 yearsa. 12 - 20 years

b. Sexual pleasure through b. Sexual pleasure through genitalsgenitals

c. c. BehaviorsBehaviors: becomes : becomes independent independent of parentsof parents, responsible for self, responsible for self

d. Develops sexual identity, d. Develops sexual identity, ability to ability to lovelove and work and work

Page 40: Psychiatric Nursing- Foundations

Psychosexual/Psychosexual/PsychoanalyticalPsychoanalytical

Ego Defense MechanismsEgo Defense Mechanisms

Page 41: Psychiatric Nursing- Foundations

Unconscious Ego defense Unconscious Ego defense mechanismmechanism

These are PSYCHOLOGIC adaptive These are PSYCHOLOGIC adaptive mechanismsmechanisms

Mental mechanisms that develop as Mental mechanisms that develop as the personality attempts to DEFEND the personality attempts to DEFEND itself, establishes compromises itself, establishes compromises among conflicting impulses and among conflicting impulses and allays inner tensionsallays inner tensions

Page 42: Psychiatric Nursing- Foundations

Unconscious Ego defense Unconscious Ego defense mechanismmechanism

The unconscious mind working to The unconscious mind working to protect the person from anxiety protect the person from anxiety

Releases tension Releases tension

Page 43: Psychiatric Nursing- Foundations

Ego Defense MechanismsEgo Defense Mechanisms

CompensationCompensation

DenialDenial

Covering up Covering up weaknesses by weaknesses by emphasizing a emphasizing a more desirable more desirable traittrait

Attempt to ignore Attempt to ignore unacceptable unacceptable realities by realities by refusing to refusing to acknowledge themacknowledge them

Page 44: Psychiatric Nursing- Foundations

Ego Defense MechanismsEgo Defense Mechanisms

DisplacementDisplacement

IdentificationIdentification

Discharging Discharging emotional emotional reactions from reactions from one object to a one object to a LESS threatening LESS threatening object/personobject/person

Imitation of Imitation of someone feared someone feared or respectedor respected

Page 45: Psychiatric Nursing- Foundations

Ego Defense MechanismsEgo Defense Mechanisms

IntellectualizatioIntellectualizationn

IntrojectionIntrojection

Use of rational Use of rational explanations that explanations that remove from the remove from the event any personal event any personal significance and significance and feelingsfeelings

Acceptance of Acceptance of other’s norms as other’s norms as oneselfoneself

Page 46: Psychiatric Nursing- Foundations

Ego Defense MechanismsEgo Defense Mechanisms MinimizationMinimization

Projection Projection

Not Not acknowledging the acknowledging the significance of significance of one’s behaviorone’s behavior

Blame is attached Blame is attached to others or to to others or to environment for environment for unacceptable unacceptable thoughts, thoughts, mistakes, etcmistakes, etc

Page 47: Psychiatric Nursing- Foundations

Ego Defense MechanismsEgo Defense Mechanisms

RationalizationRationalization

Reaction Reaction FormationFormation

JUSTIFICATION JUSTIFICATION of certain of certain BEHAVIORS by BEHAVIORS by faulty faulty logic/reasonslogic/reasons

Acting Acting OPPOSITELY to OPPOSITELY to the way they feelthe way they feel

Page 48: Psychiatric Nursing- Foundations

Ego Defense MechanismsEgo Defense Mechanisms RegressionRegression

RepressionRepression

Resorting to an Resorting to an earlier, more earlier, more comfortable level of comfortable level of functioning that is functioning that is less demandingless demanding

Unconscious Unconscious mechanism of mechanism of keeping keeping threatening desires threatening desires or thoughts from or thoughts from becoming becoming CONSCIOUSCONSCIOUS

Page 49: Psychiatric Nursing- Foundations

Ego Defense MechanismsEgo Defense Mechanisms SublimationSublimation

SubstitutionSubstitution

Re-channeling of Re-channeling of aggressive aggressive energies into energies into socially acceptable socially acceptable activitiesactivities

Replacement of a Replacement of a highly valued highly valued object by a LESS object by a LESS valuable or valuable or acceptable and acceptable and available objectavailable object

Page 50: Psychiatric Nursing- Foundations

Ego Defense MechanismsEgo Defense Mechanisms

UndoingUndoing Actions or words Actions or words designed to designed to cancel some cancel some disapproved disapproved thoughts, thoughts, impulses , or acts impulses , or acts in which the in which the person relieves person relieves GUILT by making GUILT by making reparationreparation

Page 51: Psychiatric Nursing- Foundations

Psychosexual/Psychosexual/PsychoanalyticalPsychoanalytical

Transference and Counter-Transference and Counter-transference transference

TRANSFERENCE is the clients TRANSFERENCE is the clients feeling toward nurse arising from feeling toward nurse arising from unconscious experiences with early unconscious experiences with early significant otherssignificant others

COUNTER TRANSFERENCE is the COUNTER TRANSFERENCE is the nurse’s feelings toward the patient nurse’s feelings toward the patient arising also form previous arising also form previous experiencesexperiences

Page 52: Psychiatric Nursing- Foundations

Psychosexual/Psychosexual/PsychoanalyticalPsychoanalytical

The Freudian View of Mental IllnessThe Freudian View of Mental Illness All behavior has meaningAll behavior has meaning Mental illness and manifestations Mental illness and manifestations

are caused by unconscious are caused by unconscious INTERNAL conflict arising from INTERNAL conflict arising from unresolved issues in early childhoodunresolved issues in early childhood

Ego defenses are utilized to relieve Ego defenses are utilized to relieve inner tensioninner tension

Page 53: Psychiatric Nursing- Foundations

Psychosocial TheoryPsychosocial Theory

Theory that focuses on Theory that focuses on developmental task, focuses on EGO developmental task, focuses on EGO as this develops from social as this develops from social interactioninteraction

The developmental tasks are The developmental tasks are sequential and depend on prior sequential and depend on prior successful masterysuccessful mastery

An individual who fails to “master” An individual who fails to “master” the task at appropriate age may the task at appropriate age may return to work on masteryreturn to work on mastery

Page 54: Psychiatric Nursing- Foundations

Psychosocial TheoryPsychosocial Theory

Use of the theory in NursingUse of the theory in Nursing Assessment can be done focusing Assessment can be done focusing

on the psychosocial development on the psychosocial development at specific age at specific age

Appropriate interventions can be Appropriate interventions can be selected based on taskselected based on task

Nurses can promote healthy Nurses can promote healthy behaviors and encourages hope behaviors and encourages hope that re-learning is possible that re-learning is possible

Page 55: Psychiatric Nursing- Foundations

Erikson’s Psychosocial Erikson’s Psychosocial theorytheory

Trust versus mistrustTrust versus mistrust Autonomy versus shame and doubtAutonomy versus shame and doubt Initiative versus guiltInitiative versus guilt Industry versus inferiorityIndustry versus inferiority Identity versus role confusionIdentity versus role confusion Intimacy versus isolationIntimacy versus isolation Generativity versus stagnationGenerativity versus stagnation Ego integrity versus despairEgo integrity versus despair

Page 56: Psychiatric Nursing- Foundations

Psychosocial Model Psychosocial Model (Erikson)(Erikson)

1. Trust vs mistrust1. Trust vs mistrust a. 0 - 18 monthsa. 0 - 18 monthsb. Learn to b. Learn to trusttrust others and self others and self vsvs

withdrawalwithdrawal, estrangement, estrangement

2. Autonomy vs shame and doubt2. Autonomy vs shame and doubta. 18 months - 3 yearsa. 18 months - 3 yearsb. Learn b. Learn self-controlself-control and the degree to and the degree to

which one has control over the which one has control over the environment environment vsvs compulsive compulsive compliance or compliance or defiancedefiance

Page 57: Psychiatric Nursing- Foundations

Psychosocial Model Psychosocial Model (Erikson)(Erikson)

3. Initiative vs guilta. 3 - 5 yearsb. Learn to influence environment,

evaluate own behavior vs fear of doing wrong, lack of self-confidence, over restricting actions

4. Industry vs inferioritya. 6 - 12 yearsb. Creative; develop sense of

competency vs sense of inadequacy

Page 58: Psychiatric Nursing- Foundations

Psychosocial Model Psychosocial Model (Erikson)(Erikson)

5. Identity vs role confusiona. 12 - 20 yearsb. Develop sense of self; preparation,

planning for adult roles vs doubts relating to sexual identity, occupational career

6. Intimacy vs isolationa. 18 - 25 yearsb. Develop intimate relationship with

another; commitment to career vs avoidance of choices in relationships, work, or life-style

Page 59: Psychiatric Nursing- Foundations

Psychosocial Model Psychosocial Model (Erikson)(Erikson)

7. Generativity vs stagnationa. 21 - 45 yearsb. Productive; use of energies to guide

next generation vs lack of interests, concern with own needs

8. Integrity vs despair a. 45 years to end of lifeb. Relationships extended, belief that

own life has been worthwhile vs lack of meaning of one’s life, fear of death

Page 60: Psychiatric Nursing- Foundations

Interpersonal theory Interpersonal theory

This concept focuses on This concept focuses on interaction between an individual interaction between an individual and his environment and his environment

Personality is shaped through Personality is shaped through “interaction” with significant “interaction” with significant others others

We internalize approval or We internalize approval or disapproval form our parents disapproval form our parents

Page 61: Psychiatric Nursing- Foundations

Interpersonal theory Interpersonal theory

Personality has three SELF-SYSTEMPersonality has three SELF-SYSTEM

1. “Good Me” develops in response to 1. “Good Me” develops in response to behaviors receiving approval by behaviors receiving approval by parents/SOparents/SO

2. “Bad Me” develops in response to 2. “Bad Me” develops in response to behaviors receiving disapproval by behaviors receiving disapproval by parents/SOparents/SO

3. “Not Me” develops in response to 3. “Not Me” develops in response to behaviors generating extreme anxiety in behaviors generating extreme anxiety in parents/SO and this is denied as part of parents/SO and this is denied as part of oneselfoneself

Page 62: Psychiatric Nursing- Foundations

Interpersonal theory Interpersonal theory

Mental Health is Viewed as:Mental Health is Viewed as:

1.1. Related to conflict or Related to conflict or problematic interpersonal problematic interpersonal relationshipsrelationships

2.2. Past relationships, Past relationships, inappropriate communication inappropriate communication and current relationship crisis and current relationship crisis are etiologic factors of mental are etiologic factors of mental illnessillness

Page 63: Psychiatric Nursing- Foundations

Interpersonal theory Interpersonal theory

Treatment of Mental illness:Treatment of Mental illness: Focuses on anxiety and its causesFocuses on anxiety and its causes Therapeutic relationship with Therapeutic relationship with

client that is active and client that is active and participativeparticipative

Feelings and emotions are Feelings and emotions are verbalized by the clients to verbalized by the clients to modify problematic relationships modify problematic relationships

Page 64: Psychiatric Nursing- Foundations

Interpersonal theory Interpersonal theory

Usefulness in NursingUsefulness in Nursing Nurse and client can participate Nurse and client can participate

in and contribute to the in and contribute to the relationship that is therapeuticrelationship that is therapeutic

This relationship can be used as This relationship can be used as a corrective interpersonal a corrective interpersonal experienceexperience

Anxiety management Anxiety management

Page 65: Psychiatric Nursing- Foundations

Interpersonal Model Interpersonal Model (Sullivan)(Sullivan)

1. Infancy1. Infancya. 0 - 18 months a. 0 - 18 months b. b. OthersOthers will satisfy will satisfy needsneeds

2. Childhood2. Childhooda. 18 months - 6 years a. 18 months - 6 years b. Learn to b. Learn to delaydelay need need gratificationgratification

3. Juvenile3. Juvenilea. 6 - 9 years a. 6 - 9 years b. Learn to b. Learn to relate to peersrelate to peers

Page 66: Psychiatric Nursing- Foundations

Interpersonal Model Interpersonal Model (Sullivan)(Sullivan)

4. Preadolescence a. 9—12 yearsa. 9—12 yearsb. Learn to b. Learn to relaterelate to friends of to friends of same sexsame sex5. Early adolescence5. Early adolescencea. 12—14 yearsa. 12—14 yearsb. Learn independence and how to b. Learn independence and how to relaterelate to to

opposite sexopposite sex6. Late adolescence6. Late adolescencea. 14—21 yearsa. 14—21 yearsb. Develop b. Develop intimate relationshipintimate relationship with person with person

of of opposite sexopposite sex

Page 67: Psychiatric Nursing- Foundations

Cognitive TheoryCognitive Theory

This theory focuses on the inborn This theory focuses on the inborn development of thinking ability development of thinking ability from infancy to adulthoodfrom infancy to adulthood

A person is born with a tendency A person is born with a tendency to organize and to adapt to their to organize and to adapt to their environment environment

Mental illness is not directly Mental illness is not directly discussed discussed

Page 68: Psychiatric Nursing- Foundations

Cognitive TheoryCognitive Theory

Usefulness of Cognitive theory in Usefulness of Cognitive theory in NursingNursing

1.1. This provides an understanding how This provides an understanding how an individual think and communicate. an individual think and communicate. Nurse can provide intervention Nurse can provide intervention accordingly accordingly

2.2. Nursing interventions should be Nursing interventions should be congruent to the age-specific congruent to the age-specific cognitive levelcognitive level

3.3. Teaching strategies are modified Teaching strategies are modified according to cognitive processaccording to cognitive process

Page 69: Psychiatric Nursing- Foundations

PiagetPiaget

Sensori-motor (birth to 2 )Sensori-motor (birth to 2 ) Pre-operational (2-7)Pre-operational (2-7)

Preoperational preconceptual (2-4)Preoperational preconceptual (2-4) Preoperational intuitive (4-7)Preoperational intuitive (4-7)

Concrete operational (7-12)Concrete operational (7-12) Formal operational (12 to adulthood)Formal operational (12 to adulthood)

Page 70: Psychiatric Nursing- Foundations

Cognitive Theory Cognitive Theory (Piaget)(Piaget)

A. 0 - 2 years: A. 0 - 2 years: sensorimotorsensorimotor

--reflexesreflexes, repetition of acts, repetition of acts

B. 2 - 4 years: B. 2 - 4 years: preoperational/preconceptualpreoperational/preconceptual

-no cause and effect reasoning; -no cause and effect reasoning; egocentrism; egocentrism; use of symbolsuse of symbols; ; magical thinkingmagical thinking

C. 4 - 7 years: C. 4 - 7 years: intuitive/preoperational intuitive/preoperational

-beginning of -beginning of causationcausation

Page 71: Psychiatric Nursing- Foundations

Cognitive Theory Cognitive Theory (Piaget)(Piaget)

D. 7 - 11 years: D. 7 - 11 years: concrete concrete operationsoperations

- uses memory to learn - uses memory to learn

- aware of - aware of reversibilityreversibility

E. 11 - 15 years: E. 11 - 15 years: formal operationsformal operations

-reality, -reality, abstract thoughtabstract thought

-can deal with the -can deal with the past, present past, present and futureand future

Page 72: Psychiatric Nursing- Foundations

Behavioral TheoryBehavioral Theory

This concept describes a person’s This concept describes a person’s function in terms of identified function in terms of identified BEHAVIORSBEHAVIORS

People learn to be who they arePeople learn to be who they are Behavior can be observed, described Behavior can be observed, described

and recordedand recorded Behavior is subject to reward or Behavior is subject to reward or

punishmentpunishment Behavior can be modified by changing Behavior can be modified by changing

environment environment

Page 73: Psychiatric Nursing- Foundations

Behavioral TheoryBehavioral Theory

The Classical Conditioning by The Classical Conditioning by PavlovPavlov Learning can occur when a stimulus Learning can occur when a stimulus

is paired with an unconditioned is paired with an unconditioned response response

Conditioned responses happens when Conditioned responses happens when stimulus is presentstimulus is present

Acquisition – gain of learned Acquisition – gain of learned responseresponse

Extinction – loss of learned responseExtinction – loss of learned response

Page 74: Psychiatric Nursing- Foundations

Behavioral TheoryBehavioral Theory

The Operant Conditioning by The Operant Conditioning by SkinnerSkinner Rewards and punishments are Rewards and punishments are

utilizedutilized Positive reinforcement- rewardsPositive reinforcement- rewards Negative reinforcement- Negative reinforcement- Positive punishmentPositive punishment Negative punishment- withdrawing Negative punishment- withdrawing

reward reward

Page 75: Psychiatric Nursing- Foundations

Behavioral TheoryBehavioral Theory

Mental Illness is viewed as:Mental Illness is viewed as: Mal-adaptive BEHAVIORS are Mal-adaptive BEHAVIORS are

learned through classical and learned through classical and operant conditioningoperant conditioning

Mal-adaptive behaviors can be Mal-adaptive behaviors can be changed by altering environment changed by altering environment

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Behavioral TheoryBehavioral Theory

Application to NursingApplication to Nursing

1.1. The nurse assess both adaptive and The nurse assess both adaptive and ,al-adaptive behaviors,al-adaptive behaviors

2.2. The nurse and client collaborate in The nurse and client collaborate in identifying behaviors that need to identifying behaviors that need to change change

3.3. Behavioral modification techniques Behavioral modification techniques are utilized by the nurse in the are utilized by the nurse in the treatment of mental illnesstreatment of mental illness

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Humanistic theoryHumanistic theory

Human nature is positive and Human nature is positive and growth centered and existence growth centered and existence involves search for meaning and involves search for meaning and truthtruth

Maslow’s theory of Needs are Maslow’s theory of Needs are organized in a hierarchy organized in a hierarchy

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Humanistic theoryHumanistic theory

Mental illness in this frameworkMental illness in this framework

1.1. The failure to develop one’s FULL The failure to develop one’s FULL potential leads to poor copingpotential leads to poor coping

2.2. Lack of self awareness and unmet Lack of self awareness and unmet needs interfere with feelings of needs interfere with feelings of securitysecurity

3.3. Fundamental human anxiety is Fundamental human anxiety is fear of death which leads to fear of death which leads to existential anxiety existential anxiety

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Humanistic theoryHumanistic theory

Application of the theory to NursingApplication of the theory to Nursing1.1. NCR is based on positive regard, NCR is based on positive regard,

respect and empathyrespect and empathy2.2. Nurses assess the spiritual Nurses assess the spiritual

aspects of the client including aspects of the client including religion, love and relationshipsreligion, love and relationships

3.3. Through reflective listening and Through reflective listening and emphatic responses, the nurse emphatic responses, the nurse helps the client gain self-helps the client gain self-understanding understanding

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KOHLBERG’S KOHLBERG’S STAGES OF STAGES OF

MORAL MORAL DEVELOPMENTDEVELOPMENT

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PRECONVENTIONAL PRECONVENTIONAL LEVELLEVEL

Stage 1Stage 1 Age Age 2-32-3

Description:Description: Punishment or obediencePunishment or obedience

(heteronomous morality)(heteronomous morality) A child does the right things A child does the right things

because a parent tells him or because a parent tells him or her to avoid punishmenther to avoid punishment

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PRECONVENTIONAL PRECONVENTIONAL LEVELLEVEL

Stage 2Stage 2 Age : 4-7Age : 4-7 Description:Description:

IndividualismIndividualism Child carries out actions to Child carries out actions to satisfy satisfy

own needsown needs rather than society’s. rather than society’s. The child The child does something for does something for anotheranother if that person does if that person does something for him in returnsomething for him in return

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CONVENTIONAL LEVEL CONVENTIONAL LEVEL level 2level 2

Stage 3Stage 3 Age : Age : 7-107-10

Description:Description: Orientation to interpersonal Orientation to interpersonal

relations of relations of mutualitymutuality A child follows rules because of A child follows rules because of

a need to be a a need to be a good persongood person in in own eyes and in the eyes of own eyes and in the eyes of othersothers

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CONVENTIONAL LEVEL CONVENTIONAL LEVEL level 2level 2

Stage 4 Stage 4 Age : Age : 10-1210-12

Description:Description: Maintenance of social order, Maintenance of social order,

fixed rules and authorityfixed rules and authority Child Child follows rulesfollows rules of authority of authority

figures as well as parents figures as well as parents to to keep the system workingkeep the system working

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POSTCONVENTIONAL LEVEL POSTCONVENTIONAL LEVEL level 3level 3

Stage 5Stage 5 Age :older than 12 Age :older than 12

Description:Description: social contract, utilitarian law social contract, utilitarian law

making perspectivemaking perspective child child follows standardsfollows standards of of

society society for the good of all for the good of all peoplepeople

Page 86: Psychiatric Nursing- Foundations

POSTCONVENTIONAL LEVEL level POSTCONVENTIONAL LEVEL level 33

Stage 6Stage 6 Age :older than 12 Age :older than 12

Descriptions:Descriptions: universal ethical principleuniversal ethical principle

orientationorientation child follows internalized child follows internalized

standards of conductstandards of conduct

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Therapeutic Therapeutic RelationshipsRelationships

This is a nurse-client interaction This is a nurse-client interaction that is directed toward that is directed toward enhancing the client’s well-being enhancing the client’s well-being (Isaacs) (Isaacs)

A relationship established A relationship established between a health care between a health care professional and a client for the professional and a client for the purpose of assisting the client to purpose of assisting the client to solve his problems solve his problems

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Therapeutic Therapeutic RelationshipsRelationships

The nurse- patient relationship is The nurse- patient relationship is characterized by a helping characterized by a helping processprocess The nurse and client work together The nurse and client work together

for his benefit for his benefit The nurse uses herself The nurse uses herself

therapeutically and this is achieved therapeutically and this is achieved by self-awarenessby self-awareness

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Therapeutic Therapeutic RelationshipsRelationships

The nurse- patient relationshipThe nurse- patient relationship Respect the client and vale as Respect the client and vale as

individualindividual Holistic careHolistic care Maintain appropriate limitsMaintain appropriate limits Covey empathy not sympathyCovey empathy not sympathy Maintain honest and therapeutic Maintain honest and therapeutic

communicationcommunication Encourage expression of feelingsEncourage expression of feelings

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Therapeutic Therapeutic RelationshipsRelationships

ELEMENTS OF THE ELEMENTS OF THE THERAPEUTIC RELATIONSHIPTHERAPEUTIC RELATIONSHIP

Contract Boundaries Confidentiality Therapeutic Behaviors

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Therapeutic Therapeutic RelationshipsRelationships

ELEMENTS OF THE THERAPEUTIC ELEMENTS OF THE THERAPEUTIC RELATIONSHIPRELATIONSHIP

Therapeutic BehaviorsTherapeutic Behaviors1.1. Genuineness = sincerity and honestyGenuineness = sincerity and honesty2.2. Concreteness= ability to identify Concreteness= ability to identify

client’s feelingsclient’s feelings3.3. Respect= shown through Respect= shown through

consideration of patient as unique consideration of patient as unique beingbeing

4.4. Self- exploration and self disclosure Self- exploration and self disclosure

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Therapeutic Therapeutic RelationshipsRelationships

PHASES OF THE THERAPEUTIC PHASES OF THE THERAPEUTIC RELATIONSHIPRELATIONSHIP

1. Pre-Interaction- Pre-orientation2. Orientation- Interaction3. Working4. Termination

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Therapeutic Therapeutic RelationshipsRelationships

PhasePhase Nursing Activities Nursing Activities

Pre-interactionPre-interaction Nurse obtains data Nurse obtains data from secondary from secondary sourcessources

Interaction- Interaction- OrientationOrientation

Nurse establishes Nurse establishes trust, assess client, trust, assess client, establishes mutual establishes mutual agreement agreement

WorkingWorking Nurse assists the Nurse assists the client to meet goals client to meet goals and resolve problems and resolve problems

TerminationTermination Nurse and client Nurse and client express feelings about express feelings about termination, observes termination, observes regressive behaviors regressive behaviors and evaluates NCR and evaluates NCR

Page 95: Psychiatric Nursing- Foundations

OrientationOrientation

Establishment of goals, rules, Establishment of goals, rules, boundaries etc..boundaries etc..

Rapport is builtRapport is built Identify expectationsIdentify expectations Trust is gained Trust is gained Assessment is done Assessment is done Goals are definedGoals are defined Contract is madeContract is made

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Working/Exploration/Working/Exploration/IdentificationIdentification

Problems are identified Problems are identified Solutions are explored, applied Solutions are explored, applied

and evaluatedand evaluated Nurse assists the client to Nurse assists the client to

develop coping skills, positive develop coping skills, positive self concept and independenceself concept and independence

Promote insight and the use of Promote insight and the use of adaptive coping mechanisms adaptive coping mechanisms

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Termination/ResolutionTermination/Resolution

Nurse terminates the relationship Nurse terminates the relationship based on mutually agreed goals when based on mutually agreed goals when these are already achievedthese are already achieved

Focus of this stage is growth that has Focus of this stage is growth that has occurred occurred

Client may become anxious and Client may become anxious and reactsreacts

Nurses must help patient resolve the Nurses must help patient resolve the anxiety and ends the relationship anxiety and ends the relationship professionallyprofessionally

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Therapeutic Therapeutic CommunicationCommunication

Therapeutic communication Therapeutic communication Dynamic process of exchanging Dynamic process of exchanging

informationinformation Composed of verbal and non-verbal Composed of verbal and non-verbal

techniques that the nurse uses to techniques that the nurse uses to focus on the client’s needsfocus on the client’s needs

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Therapeutic Therapeutic RelationshipsRelationships

Therapeutic communication : Therapeutic communication : ELEMENTSELEMENTS

1.1. Sender- the source of messageSender- the source of message

2.2. Message- the information Message- the information transmittedtransmitted

3.3. Receiver- recipient of messageReceiver- recipient of message

4.4. Feedback- receiver’s response Feedback- receiver’s response to the message to the message

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Therapeutic Therapeutic RelationshipsRelationships

NON VERBAL COMMUNICATIONNON VERBAL COMMUNICATION

1.1. Proxemics- the physical space Proxemics- the physical space between the sender and receiverbetween the sender and receiver

2.2. Kinetics- the body movements Kinetics- the body movements such as gestures, facial such as gestures, facial expressions and mannerismsexpressions and mannerisms

3.3. Touch- intimate physical Touch- intimate physical contactcontact

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Therapeutic Therapeutic RelationshipsRelationships

NON VERBAL COMMUNICATIONNON VERBAL COMMUNICATION

4. Silence4. Silence

5. Paralanguage- voice quality 5. Paralanguage- voice quality (tone, inflection) or how a (tone, inflection) or how a message is delivered message is delivered

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Therapeutic Therapeutic RelationshipsRelationships

VERBAL COMMUNICATIONVERBAL COMMUNICATION Use of therapeutic Use of therapeutic

communication techniques communication techniques Effective communication should Effective communication should

be therapeutic, appropriate, be therapeutic, appropriate, simple, adaptive, concise and simple, adaptive, concise and credible credible

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Therapeutic Therapeutic CommunicationCommunication

Open ended questionsOpen ended questions

Focus on FEEELINGSFocus on FEEELINGS

State behaviors observedState behaviors observed

Reflect, restate, rephraseReflect, restate, rephrase

Neutral responses Neutral responses

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Therapeutic Therapeutic CommunicationCommunication

Offering selfOffering self I am here to help I am here to help youyou

Active listeningActive listening Eye to eye contactEye to eye contact

ExploringExploring Tell me more Tell me more about…,.about…,.

Broad OpeningsBroad Openings What do you want What do you want to talk aboutto talk about

Making Making observationobservation

You seemed You seemed depresseddepressed

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Therapeutic Therapeutic CommunicationCommunication

SummarizingSummarizing A few minutes ago, we A few minutes ago, we were talking about.. were talking about.. Then…Then…

Voicing doubtVoicing doubt I find it hard to believe I find it hard to believe

Encouraging Encouraging description of description of perceptionperception

What are these voices What are these voices telling youtelling you

Presenting realityPresenting reality The sound is produced The sound is produced by the carby the car

No one is in the roomNo one is in the room

Seeking clarificationSeeking clarification I am not sure of what I am not sure of what you meanyou mean

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Therapeutic Therapeutic CommunicationCommunication

Verbalizing the Verbalizing the impliedimplied

Are you saying you Are you saying you want to kill yourself?want to kill yourself?

ReflectingReflecting Do you think you Do you think you should?should?

Restating Restating P: I cant sleep at nightP: I cant sleep at night

N: You cant sleep at N: You cant sleep at night ?night ?

General leadsGeneral leads GO on… then…. GO on… then…. Hmm….you were Hmm….you were saying….saying….

FocusingFocusing Lets talk more about Lets talk more about what you think of your what you think of your problemsproblems

Page 107: Psychiatric Nursing- Foundations

Non-therapeutic Non-therapeutic communicationcommunication

These are blocks to communication These are blocks to communication Usually, these are the common Usually, these are the common

pitfalls of communicating non-pitfalls of communicating non-therapeutically:therapeutically: Giving adviseGiving advise Talking about selfTalking about self Telling client is wrongTelling client is wrong False reassuranceFalse reassurance Cliché’Cliché’ Asking ‘Why’Asking ‘Why’

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Non-therapeutic Non-therapeutic communicationcommunication

Making judgment Making judgment You are wrongYou are wrong

False reassuranceFalse reassurance It’s going to be alright It’s going to be alright

InvalidationInvalidation I cannot talk now, I’m I cannot talk now, I’m busybusy

Focusing on selfFocusing on self I am the best nurse to I am the best nurse to care for youcare for you

Changing the subject Changing the subject P: I’m afraid of the P: I’m afraid of the surgerysurgery

N: Ho many children N: Ho many children do you havedo you have

Giving adviceGiving advice If I were you, I willIf I were you, I will

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Non-therapeutic Non-therapeutic communicationcommunication

Agreeing Agreeing Yes I think you are Yes I think you are rightright

Disapproving Disapproving I don’t want you to do I don’t want you to do thatthat

DefendingDefending This hospital is the This hospital is the bestbest

Requesting Requesting explanationexplanation

““why”why”

ClichéCliché There is the sun after There is the sun after the rainthe rain

Belittling feelingsBelittling feelings P: I’m so depressed P: I’m so depressed todaytoday

N: everyone feels sad N: everyone feels sad at timesat times

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ProxemicsProxemics

DistancesDistancesINTIMATE=INTIMATE= Touching to 1 ½ ftTouching to 1 ½ ft

PERSONAL= PERSONAL= 1 ½ to 4 ft1 ½ to 4 ft

SOCIAL= SOCIAL= 4 to 12 ft4 to 12 ft

PUBLIC= PUBLIC= 12 to 15 ft12 to 15 ft

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Psychiatric Nursing Psychiatric Nursing ProcessProcess

Applies to all clients Applies to all clients Utilizes unique process for Utilizes unique process for

psychological assessment psychological assessment Similar to other types of nursing Similar to other types of nursing

process approachesprocess approaches

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Psychiatric Nursing Psychiatric Nursing ProcessProcess

Nursing ASSESSMENTNursing ASSESSMENT

Nursing History Nursing History

Physical Examination including Physical Examination including the Neurological examinationthe Neurological examination

Laboratory Examination Laboratory Examination

Page 113: Psychiatric Nursing- Foundations

Psychiatric Nursing Psychiatric Nursing ProcessProcess

Nursing ASSESSMENTNursing ASSESSMENT Refers to the scientific process of Refers to the scientific process of

identifying a patient’s psychosocial identifying a patient’s psychosocial problems, strengths an concerns problems, strengths an concerns

Interview is done to acquires broad Interview is done to acquires broad information about a client information about a client

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Psychiatric Nursing Psychiatric Nursing ProcessProcess

MENTAL STATUS ASSESSMENTMENTAL STATUS ASSESSMENT Level of consciousnessLevel of consciousness General appearanceGeneral appearance BehaviorBehavior SpeechSpeech Mood and affectMood and affect Judgment Judgment Memory Memory insight insight

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Psychiatric Nursing Psychiatric Nursing ProcessProcess

MENTAL STATUS ASSESSMENTMENTAL STATUS ASSESSMENT Observation of mood and affectObservation of mood and affect Assessment of thought, sensorium Assessment of thought, sensorium

and intelligence and intelligence Speech and content Speech and content Assess developmental status and Assess developmental status and

family-cultural-spiritual family-cultural-spiritual backgroundbackground

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Psychiatric Nursing Psychiatric Nursing ProcessProcess

MENTAL STATUS ASSESSMENTMENTAL STATUS ASSESSMENT Emotional statusEmotional status Cognitive assessmentCognitive assessment Socio-cultural assessment Socio-cultural assessment

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Psychiatric Nursing Psychiatric Nursing ProcessProcess

Physical ExaminationPhysical Examination Observation for key signsObservation for key signs

Diagnostic TestsDiagnostic Tests CT, MRI, PET, EEGCT, MRI, PET, EEG Laboratory tests= CBC, Electrolytes, Laboratory tests= CBC, Electrolytes,

Drug levelsDrug levels

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Psychiatric Nursing Psychiatric Nursing ProcessProcess

Other diagnostic testsOther diagnostic tests Beck depression inventoryBeck depression inventory Minnesota multiphasic personality Minnesota multiphasic personality

inventoryinventory Draw-a person test Draw-a person test Sentence completion testSentence completion test Thematic aperception testThematic aperception test

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Psychiatric Nursing Psychiatric Nursing ProcessProcess

Nursing DiagnosesNursing Diagnoses AnxietyAnxiety Ineffective coping- individual, Ineffective coping- individual,

familyfamily FatigueFatigue FearFear Sleep pattern disturbanceSleep pattern disturbance Altered thought processAltered thought process Etcetera Etcetera

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Psychiatric Nursing Psychiatric Nursing ProcessProcess

Nursing ObjectivesNursing Objectives Short term goals are set for Short term goals are set for

immediate problems, feasible immediate problems, feasible and within client's capabilitiesand within client's capabilities

Long term goals are related to Long term goals are related to discharge planning and discharge planning and prevention of recurrence of prevention of recurrence of symptomssymptoms

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Psychiatric Nursing Psychiatric Nursing ProcessProcess

Nursing Objectives: The client Nursing Objectives: The client will:will: Participate in treatment programParticipate in treatment program Becomes oriented to three spheres Becomes oriented to three spheres

and exhibit reality-based behaviorsand exhibit reality-based behaviors Recognize reasons for behavior Recognize reasons for behavior Maintain self-care activitiesMaintain self-care activities

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Psychiatric Nursing Psychiatric Nursing ProcessProcess

Nursing InterventionsNursing Interventions Use of therapeutic communicationUse of therapeutic communication Therapeutic GroupsTherapeutic Groups Psychotherapy: Family, Milieu, Psychotherapy: Family, Milieu,

Behavioral modification, Crisis Behavioral modification, Crisis intervention, Psychopharmacologyintervention, Psychopharmacology

Electroconvulsive therapyElectroconvulsive therapy

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Psychiatric Nursing Psychiatric Nursing ProcessProcess

Nursing EvaluationNursing Evaluation Determine if goals are met by Determine if goals are met by

collecting data and comparing them collecting data and comparing them to baselineto baseline

Clients’ behavior should Clients’ behavior should demonstrate optimal orientation to demonstrate optimal orientation to reality and interaction with others reality and interaction with others appropriately appropriately

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Treatment ModalitiesTreatment Modalities

1.1. Therapeutic Environment- Milieu Therapeutic Environment- Milieu

2.2. Therapeutic GroupsTherapeutic Groups

3.3. Crisis interventionCrisis intervention

4.4. Family therapyFamily therapy

5.5. Behavioral modificationBehavioral modification

6.6. Cognitive therapyCognitive therapy

7.7. PsychotherapyPsychotherapy

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Therapeutic environmentTherapeutic environment

Research has documented that Research has documented that the environment in which the the environment in which the mentally ill person is treated is a mentally ill person is treated is a major factor in enhancing or major factor in enhancing or impeding the therapeutic effects impeding the therapeutic effects of other treatment modalities of other treatment modalities

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Therapeutic environmentTherapeutic environment

Characteristics of a Therapeutic Characteristics of a Therapeutic environmentenvironment

1.1. The clients’ physical needs are The clients’ physical needs are metmet

2.2. The client is respectedThe client is respected

3.3. Decision making authority is Decision making authority is clearly definedclearly defined

4.4. Client is protected from injury Client is protected from injury (self and others)(self and others)

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Therapeutic environmentTherapeutic environment

Characteristics of a Therapeutic Characteristics of a Therapeutic environmentenvironment

5. Clients are allowed freedom of 5. Clients are allowed freedom of choice commensurate to his ability choice commensurate to his ability to decideto decide

6. Nursing Personnel remain constant 6. Nursing Personnel remain constant and assignments are stableand assignments are stable

7. Emphasis is placed on social 7. Emphasis is placed on social interaction between clients and staffinteraction between clients and staff

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Therapeutic ModalitiesTherapeutic Modalities

Milieu therapyMilieu therapy Total environment has an effect on the Total environment has an effect on the

person’s behavior- physical, emotional, person’s behavior- physical, emotional, relationshipsrelationships

Purposes of therapyPurposes of therapy1.1. Improve client’s behaviorImprove client’s behavior2.2. Involve client in decision makingInvolve client in decision making3.3. Increase autonomy and Increase autonomy and

communicationcommunication4.4. Set structure of unit and behavioral Set structure of unit and behavioral

limitslimits

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Therapeutic ModalitiesTherapeutic Modalities

Milieu therapyMilieu therapy The surrounding is made positive The surrounding is made positive

to effect behavioral changes in to effect behavioral changes in the prescribed directionsthe prescribed directions

Goals of milieu therapy: to help Goals of milieu therapy: to help patient develop sense of self-patient develop sense of self-esteem, personal growth, esteem, personal growth, improve ability to relate to others improve ability to relate to others and return to the community and return to the community better preparedbetter prepared

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Therapeutic modalitiesTherapeutic modalities

Milieu therapyMilieu therapy The nurse involves the client in The nurse involves the client in

decision makingdecision making The nurse promotes the The nurse promotes the

involvement of staff in careinvolvement of staff in care Social skills are developed and Social skills are developed and

sense of community is fostered sense of community is fostered

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Therapeutic GroupsTherapeutic Groups

A treatment approach in which the A treatment approach in which the entire milieu is used as treatment entire milieu is used as treatment

This includes the physical This includes the physical environment and the others clientsenvironment and the others clients

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Therapeutic GroupsTherapeutic Groups

Group TherapyGroup Therapy Involves meaningful interaction Involves meaningful interaction

between members of a group as between members of a group as they relate their personal they relate their personal experiences to each otherexperiences to each other

The main objective is for each group The main objective is for each group member to examine his own member to examine his own behavior and relationship. The behavior and relationship. The group can influence to change his group can influence to change his behavior and relationshipsbehavior and relationships

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Therapeutic GroupsTherapeutic Groups

Groups of clients meet with one Groups of clients meet with one or more therapists to work or more therapists to work together to solve client problems together to solve client problems

Page 135: Psychiatric Nursing- Foundations

Therapeutic GroupsTherapeutic Groups

PurposesPurposes To increase self-awarenessTo increase self-awareness To improve interpersonal To improve interpersonal

relationshipsrelationships To make changes in behavior To make changes in behavior To enhancing group teaching and To enhancing group teaching and

learning learning

Page 136: Psychiatric Nursing- Foundations

Therapeutic GroupsTherapeutic Groups

Structure of the Therapeutic Structure of the Therapeutic GroupGroup One leader chosen by the groupOne leader chosen by the group MembersMembers Size is usually 10 Size is usually 10 Physical arrangementPhysical arrangement Time and place of meetingTime and place of meeting

Page 137: Psychiatric Nursing- Foundations

Therapeutic GroupsTherapeutic Groups

Phases of group developmentPhases of group development1.1. Beginning phaseBeginning phase

Info given, anxiety heightened Info given, anxiety heightened

2.2. Middle phaseMiddle phase Confrontation, cohesiveness, trust Confrontation, cohesiveness, trust

and self-relianceand self-reliance

3.3. Termination phaseTermination phase Goals of the group are achievedGoals of the group are achieved Individuals leave the group when Individuals leave the group when

work is done work is done

Page 138: Psychiatric Nursing- Foundations

Therapeutic modalitiesTherapeutic modalities

CRISISCRISIS A disturbance caused by a A disturbance caused by a

precipitating event such as precipitating event such as perceived loss, a threat of loss or perceived loss, a threat of loss or a challenge that is perceived as a a challenge that is perceived as a threat to self. threat to self.

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Therapeutic modalitiesTherapeutic modalities

CRISISCRISIS

Can be classified as to maturational Can be classified as to maturational crisis, situational crisis or adventitious crisis, situational crisis or adventitious crisiscrisis Maturational= role changesMaturational= role changes Situational= loss of job, deathSituational= loss of job, death Adventitious= fires, earthquakes and Adventitious= fires, earthquakes and

floodsfloods In a crisis, the person’s usual methods of In a crisis, the person’s usual methods of

coping are INEFFECTIVE, resulting in coping are INEFFECTIVE, resulting in increasingly greater levels of anxiety.increasingly greater levels of anxiety.

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Therapeutic Modalities Therapeutic Modalities

Characteristics of Crisis: Characteristics of Crisis: It is suddenIt is sudden It is short term may last for 4-6 It is short term may last for 4-6

weeksweeks IndividualizedIndividualized The person becomes dependent and The person becomes dependent and

overwhelmedoverwhelmed

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Therapeutic Modalities Therapeutic Modalities

Factors that can produce crisisFactors that can produce crisis 1. Hazardous EVENTS1. Hazardous EVENTS 2. Threat to the individual’s 2. Threat to the individual’s

equilibriumequilibrium 3. Inadequate coping skills3. Inadequate coping skills

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Therapeutic Modalities Therapeutic Modalities

There are four PHASES of Crisis There are four PHASES of Crisis (DIDA)(DIDA) DenialDenial Increased Tension-Increased Tension- when the person when the person

knows the existence of crisis and still knows the existence of crisis and still continues ADLcontinues ADL

DisorganizationDisorganization= pre-occupied and = pre-occupied and unable to perform functionunable to perform function

Attempts to ReorganizeAttempts to Reorganize= by mobilizing = by mobilizing previous coping mechanismsprevious coping mechanisms

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Therapeutic ModalitiesTherapeutic Modalities

CRISIS INTERVENTIONCRISIS INTERVENTION A technique of helping the person A technique of helping the person

go through the crisisgo through the crisis To mobilize his resourcesTo mobilize his resources To help him deal with the here and To help him deal with the here and

nownow A five step problem solving A five step problem solving

technique designed to promote a technique designed to promote a more adaptive outcome including more adaptive outcome including improved abilities to cope with improved abilities to cope with future crisesfuture crises

Page 144: Psychiatric Nursing- Foundations

Therapeutic modalitiesTherapeutic modalitiesGoal of Crisis intervention: help the patient go Goal of Crisis intervention: help the patient go

back to his state of optimum level of back to his state of optimum level of functioningfunctioning IDENTIFY the problem- A solution is not IDENTIFY the problem- A solution is not

possible unless the problem be identified.possible unless the problem be identified. LIST alternatives- all possible solutions to LIST alternatives- all possible solutions to

the problem need to be listed. the problem need to be listed. CHOOSE from among the alternatives- each CHOOSE from among the alternatives- each

options is carefully considered, and the options is carefully considered, and the alternative chosen is usually highly alternative chosen is usually highly individualized, based on priorities and individualized, based on priorities and values of the personvalues of the person

IMPLEMENT the plan- the alternative is put IMPLEMENT the plan- the alternative is put into action. The nurse may need to support into action. The nurse may need to support and encourage patient to take actionand encourage patient to take action

EVALUATE the outcome- the effectiveness EVALUATE the outcome- the effectiveness of the plan is evaluated. of the plan is evaluated.

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Therapeutic modalitiesTherapeutic modalities

Family therapyFamily therapy An approach in which the An approach in which the

therapist focuses on the therapist focuses on the behavior of the entire family as behavior of the entire family as a system instead of focusing on a system instead of focusing on the pathology of one memberthe pathology of one member

Page 146: Psychiatric Nursing- Foundations

Therapeutic modalitiesTherapeutic modalities

Family therapyFamily therapy Focuses on the client as a ‘family”Focuses on the client as a ‘family” Involvement of family membersInvolvement of family members

Purposes of family therapyPurposes of family therapy

1.1. Improve relationships among family Improve relationships among family membersmembers

2.2. Promote family functionsPromote family functions

3.3. Resolve family problems Resolve family problems

4.4. Help family find ways to cope with Help family find ways to cope with problemsproblems

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Therapeutic modalitiesTherapeutic modalities

Family therapyFamily therapy Problems are identified by each Problems are identified by each

family members and each family members and each discusses his/her involvement in discusses his/her involvement in the problemthe problem

Members discuss how problems Members discuss how problems affect them and they explore affect them and they explore how to solve them how to solve them

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Therapeutic ModalitiesTherapeutic Modalities

Family therapyFamily therapy The nurse functions to assess The nurse functions to assess

the family interactions, makes the family interactions, makes observations and encourages observations and encourages expression of feelingsexpression of feelings

Helping the family resolve the Helping the family resolve the problem is the goalproblem is the goal

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Therapeutic ModalitiesTherapeutic Modalities

Behavioral ModificationBehavioral Modification Therapy to change the unacceptable Therapy to change the unacceptable

behavior to acceptable behavior to acceptable The nurse determines the The nurse determines the

unacceptable behaviors and she unacceptable behaviors and she identifies adaptive behaviorsidentifies adaptive behaviors

Punishment is given to unacceptable Punishment is given to unacceptable behaviorbehavior

Reward is given to acceptable Reward is given to acceptable behaviorbehavior

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Therapeutic ModalitiesTherapeutic Modalities

Behavioral ModificationBehavioral Modification Other Behavioral therapiesOther Behavioral therapies

1. Self-control therapy1. Self-control therapy

2. Aversion therapy2. Aversion therapy

3. Desensitization3. Desensitization

4. Modeling4. Modeling

5. Operant conditioning 5. Operant conditioning

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Therapeutic ModalitiesTherapeutic Modalities

Cognitive therapyCognitive therapy An active, directive, time-limited An active, directive, time-limited

approach approach Therapeutic techniques are used Therapeutic techniques are used

to identify reality testing to identify reality testing The nurse helps the patient think The nurse helps the patient think

and act more realistically and and act more realistically and adaptively about his problemsadaptively about his problems

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Therapeutic ModalitiesTherapeutic Modalities

Play therapyPlay therapy Therapy with children in which Therapy with children in which

they are helped to express they are helped to express themselves or their behavior themselves or their behavior through play through play

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Therapeutic Modality: Therapeutic Modality: PsychotherapyPsychotherapy

A method of treating mental A method of treating mental illness in which verbal and illness in which verbal and expressive techniques are used expressive techniques are used to help the person resolve inner to help the person resolve inner conflict and modify behaviorsconflict and modify behaviors

Page 154: Psychiatric Nursing- Foundations

Therapeutic Modality: Therapeutic Modality: PsychotherapyPsychotherapy

1.1. PsychoanalysisPsychoanalysis

2.2. Client centered therapyClient centered therapy

3.3. Rational emotive therapyRational emotive therapy

4.4. Gestalt therapyGestalt therapy

5.5. Reality therapyReality therapy

6.6. Transactional analysisTransactional analysis

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Therapeutic Modality: Therapeutic Modality: PsychotherapyPsychotherapy

1.1. PsychoanalysisPsychoanalysis THE therapist obtains information THE therapist obtains information

about the past and present about the past and present experiences that have repressed in experiences that have repressed in the person’s subconscious mindthe person’s subconscious mind

By learning the source of the By learning the source of the problem, the problems can be problem, the problems can be brought to the conscious where brought to the conscious where the therapist helps the individual the therapist helps the individual dealt with them dealt with them

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Therapeutic Modality: Therapeutic Modality: PsychotherapyPsychotherapy

2. Client Centered therapy2. Client Centered therapy The therapist work with one client The therapist work with one client Accepting, non-judgmental Accepting, non-judgmental

environment aimed at reducing the environment aimed at reducing the anxiety and reducing negative defensesanxiety and reducing negative defenses

The patient is encouraged to express The patient is encouraged to express his feelings and increase self-his feelings and increase self-awarenessawareness

When the person is aware of what he When the person is aware of what he feels, he can work on improving feels, he can work on improving behaviorbehavior

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Therapeutic Modality: Therapeutic Modality: PsychotherapyPsychotherapy

3. Rational-Emotive therapy3. Rational-Emotive therapy This is based in the assumption This is based in the assumption

that a person’s behavior is due to that a person’s behavior is due to his own thinkinghis own thinking

Problems arise as the person Problems arise as the person believes about eh eventsbelieves about eh events

The therapy aims to change the The therapy aims to change the person’s belief systemperson’s belief system

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Therapeutic Modality: Therapeutic Modality: PsychotherapyPsychotherapy

4. Gestalt Therapy4. Gestalt Therapy The mind receives experiences as a The mind receives experiences as a

wholewhole When the experience is complete, When the experience is complete,

the problem will arisethe problem will arise The goal of the therapy is to help The goal of the therapy is to help

patients complete the experience patients complete the experience through awareness through awareness

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Therapeutic Modality: Therapeutic Modality: PsychotherapyPsychotherapy

5. Transactional Analysis5. Transactional Analysis A group therapy methodA group therapy method Helps people “analyze” their Helps people “analyze” their

transaction or interaction with transaction or interaction with others and guides them to the others and guides them to the conclusion: I’m OK you are OKconclusion: I’m OK you are OK

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Responses to Illness Responses to Illness

StressStress AnxietyAnxiety CrisisCrisis Anger and hostilityAnger and hostility

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Importance of studying Importance of studying stressstress

It provides a way of It provides a way of understanding the person as a understanding the person as a holistic beingholistic being

Nurses must also learn to cope Nurses must also learn to cope with stress in their work and with stress in their work and life as they are subjected to life as they are subjected to the demands of their career. the demands of their career.

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Stress and AdaptationStress and Adaptation

STRESSSTRESS A condition in which the person A condition in which the person

responds to changes in the normal responds to changes in the normal balanced statebalanced state

Selye: non specific response of the Selye: non specific response of the body to any kind of demand made body to any kind of demand made upon itupon it

Any event – environmental / internal Any event – environmental / internal demands or both tax or exceed the demands or both tax or exceed the adaptive resources of an individual, adaptive resources of an individual, social system or tissue systemssocial system or tissue systems

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Stress and AdaptationStress and Adaptation STRESSORSTRESSOR

Any event or stimulus that causes an Any event or stimulus that causes an individual to experience stressindividual to experience stress

They may They may neither positive or neither positive or negativenegative, but they have positive or , but they have positive or negative effects negative effects

Internal Stressor (illness, hormonal Internal Stressor (illness, hormonal change, fear)change, fear)

External Stressor (loud noise, cold External Stressor (loud noise, cold temperature)temperature)

Developmental StressorDevelopmental Stressor Situational StressorSituational Stressor

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Stress and AdaptationStress and Adaptation

COPING- a problem COPING- a problem solving process that the solving process that the person uses to manage the person uses to manage the stresses or events with stresses or events with which he/she is presented.which he/she is presented.

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Stress and AdaptationStress and Adaptation

ADAPTATION- the process ADAPTATION- the process by which human system by which human system modifies itself to conform modifies itself to conform to the environment. It is a to the environment. It is a change that results from change that results from response to stress.response to stress.

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Stress and AdaptationStress and Adaptation

SOURCES OF STRESSSOURCES OF STRESS

1.1. InternalInternal

2.2. ExternalExternal

3.3. DevelopmentalDevelopmental

4.4. SituationalSituational

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Stress CharacteristicsStress Characteristics

It is a universal phenomenon.It is a universal phenomenon. It is an individual experience. It is an individual experience. It provides stimulus for It provides stimulus for

growth and change.growth and change. It affects all dimension of It affects all dimension of

life. life. It is not a nervous energy. It is not a nervous energy.

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Effects of Stress on the Effects of Stress on the BodyBody

PhysicalPhysical- affects physiologic - affects physiologic homeostasishomeostasis

EmotionalEmotional- affects feeling towards self - affects feeling towards self IntellectualIntellectual- influences perception and - influences perception and

problem solving abilitiesproblem solving abilities SocialSocial – can alter relationships with – can alter relationships with

othersothers SpiritualSpiritual- affects one’s beliefs and - affects one’s beliefs and

valuesvalues

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Effects of Stress on the Effects of Stress on the BodyBody

Metabolic DisordersMetabolic Disorders Hyper/Hyper/

hypothyroidismhypothyroidism DiabetesDiabetes

CancerCancer Accident pronenessAccident proneness Skin disordersSkin disorders

EczemaEczema PruritusPruritus UrticariaUrticaria PsoriasisPsoriasis

Respiratory disordersRespiratory disorders AsthmaAsthma Hay feverHay fever TuberculosisTuberculosis

CVDCVD Coronary artery diseaseCoronary artery disease Essential hypertensionEssential hypertension CHFCHF

GIT disordersGIT disorders ConstipationConstipation DiarrheaDiarrhea Duodenal ulcerDuodenal ulcer Anorexia nervosaAnorexia nervosa ObesityObesity Ulcerative colitisUlcerative colitis

Menstrual irregularitiesMenstrual irregularities Musculoskeletal disordersMusculoskeletal disorders

RARA LBPLBP Migraine HeadacheMigraine Headache Muscle tensionMuscle tension

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GENERAL THEORETICAL GENERAL THEORETICAL FRAMEWORKS FOR FRAMEWORKS FOR

UNDERSTANDING STRESSUNDERSTANDING STRESSStress can be defined differently Stress can be defined differently

by the three modelsby the three models STIMULUSSTIMULUS RESPONSERESPONSE TRANSACTIONTRANSACTION

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Stress and AdaptationStress and Adaptation

Models of StressModels of Stress

1.1. STIMULUS based modelsSTIMULUS based models

2.2. RESPONSE based modelsRESPONSE based models

3.3. TRANSACTION based TRANSACTION based modelsmodels

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Stress as a StimulusStress as a Stimulus

When viewed as a stimulus, When viewed as a stimulus, stress is defined as an event stress is defined as an event or set of events causing a or set of events causing a disrupted response (Lyon disrupted response (Lyon and Werner, 1987) and Werner, 1987)

Life events or Life events or circumstances causing a circumstances causing a disrupted response on an disrupted response on an individualindividual

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Stress as a StimulusStress as a Stimulus Holmes and Rahe 1967: They Holmes and Rahe 1967: They

studied the relationship between studied the relationship between specific life changes such as specific life changes such as divorce or death, and the divorce or death, and the subsequent onset of illness.subsequent onset of illness.

Focus: disturbing events within the Focus: disturbing events within the environmentenvironment

Advantage: the scale identifies Advantage: the scale identifies events stressful for most peopleevents stressful for most people

Disadvantage: does not provide Disadvantage: does not provide individual differences in perception individual differences in perception and response to stressors; the and response to stressors; the degree of stress of a life event degree of stress of a life event varies from one person to anothervaries from one person to another

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Stress as a TransactionStress as a Transaction

Views the person and Views the person and environment in a dynamic, environment in a dynamic, reciprocal and interactive reciprocal and interactive relationships (Lazarus, 1966 )relationships (Lazarus, 1966 )

Mental and physiologic Mental and physiologic (adaptive and affective) (adaptive and affective) responses to stressresponses to stress

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Stress as a TransactionStress as a Transaction The transactional stress theory includes The transactional stress theory includes

cognitive, affective, and adaptive cognitive, affective, and adaptive responses from person and environment responses from person and environment interaction. The person responds to interaction. The person responds to perceived environmental changes by perceived environmental changes by coping mechanisms.coping mechanisms.

Transactional theory of stress emphasizes Transactional theory of stress emphasizes that people & groups differ in their that people & groups differ in their sensitivity & vulnerability to certain types sensitivity & vulnerability to certain types of events, as well as in their of events, as well as in their interpretations & reactionsinterpretations & reactions

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Stress as a TransactionStress as a Transaction Includes mental & psychologic Includes mental & psychologic

components or responses as part of his components or responses as part of his concept of stressconcept of stress

takes into account cognitive processes takes into account cognitive processes that intervene between the encounter & that intervene between the encounter & the reactionthe reaction

encompasses a set of cognitive, affective encompasses a set of cognitive, affective & adaptive (coping) responses that arise & adaptive (coping) responses that arise out of person-environment transactions.out of person-environment transactions.

Cognitive appraisalCognitive appraisal: evaluative process : evaluative process determines why & to what extent a determines why & to what extent a particular/series transaction between the particular/series transaction between the person & the environment is stressfulperson & the environment is stressful

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Stress As a ResponseStress As a Response

Disruptions caused by harmful Disruptions caused by harmful stimulus or stressorsstimulus or stressors

Specifies particular response or Specifies particular response or pattern of responses that may pattern of responses that may indicate a stressorindicate a stressor

Selye (1976): developed models Selye (1976): developed models of stress, that defines stress as of stress, that defines stress as a non-specific response of the a non-specific response of the body to any demand made on itbody to any demand made on it

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Stress As a ResponseStress As a Response

Focus:Focus: reactions of the BODY reactions of the BODY Selye used the term “stressor’ Selye used the term “stressor’

as as the stimulus or agents that the stimulus or agents that evokes a stress response in the evokes a stress response in the person . person .

A stressor may be anything that A stressor may be anything that places a demand on the person for places a demand on the person for change or adaptation.change or adaptation.

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Stress As a ResponseStress As a Response Hans Selye (1976) “ non-specific Hans Selye (1976) “ non-specific

response of the body to any kind of response of the body to any kind of demand made upon itdemand made upon it

He called it “non-specific” because the He called it “non-specific” because the body goes through a number of body goes through a number of biochemical changes and re-biochemical changes and re-adjustments without regard to the adjustments without regard to the nature of the stress producing agents.nature of the stress producing agents.

Any type of stressor may produce the Any type of stressor may produce the same responses in the human bodysame responses in the human body

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Stress As a ResponseStress As a Response

Advantage : response to Advantage : response to stress is purely physiologic; stress is purely physiologic; determines physiological determines physiological response to stressresponse to stress

Disadvantage: does not Disadvantage: does not consider individual differences consider individual differences in response patternin response pattern

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Stress as a responseStress as a response

SELYE proposed two Stress SELYE proposed two Stress adaptation responsesadaptation responses

1.1. General Adaptation General Adaptation SyndromeSyndrome

2.2. Local Adaptation Local Adaptation SyndromeSyndrome

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General Adaptation General Adaptation SyndromeSyndrome

Physiologic responses of the Physiologic responses of the whole whole body to stressorsbody to stressors

Involves the Involves the Autonomic Nervous Autonomic Nervous System, and Endocrine SystemSystem, and Endocrine System

Occurs with the release of adaptive Occurs with the release of adaptive hormones and subsequent changes hormones and subsequent changes in the WHOLE bodyin the WHOLE body

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General Adaptation General Adaptation SyndromeSyndrome

Stressor

Alarm reaction

Shock phase

Epinephrine Cortisone

Stages of resistance

Stages of exhaustion

Three stages adaptation to stress for both GAS/LAS:

Counter-shock Phase

Rest Death

Normal state

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General Adaptation General Adaptation SyndromeSyndrome

I. ALARM REACTIONI. ALARM REACTION Initial reaction of the body; “ fight OR Initial reaction of the body; “ fight OR

flight” responsesflight” responses Mobilizing of the defense mechanisms of Mobilizing of the defense mechanisms of

the body and mind to cope with stressors.the body and mind to cope with stressors. SHOCK PHASE- the autonomic nervous SHOCK PHASE- the autonomic nervous

system reacts; release of Epinephrine and system reacts; release of Epinephrine and CortisolCortisol

COUNTERSHOCK PHASE- reversal of the COUNTERSHOCK PHASE- reversal of the changes produced in the shock phasechanges produced in the shock phase

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General Adaptation General Adaptation SyndromeSyndrome

II. STAGE OF RESISTANCE:II. STAGE OF RESISTANCE: The BODY stabilizes, hormonal levels The BODY stabilizes, hormonal levels

return to normal, heart rate, blood return to normal, heart rate, blood pressure and cardiac output return to pressure and cardiac output return to normalnormal

2 things may occur:2 things may occur: Either the person successfully adapts to Either the person successfully adapts to

the stressors and returns to normal, thus the stressors and returns to normal, thus resolving and repairing body damage; orresolving and repairing body damage; or

The stressor remains present, and The stressor remains present, and adaptation fails (ex. Long-term terminal adaptation fails (ex. Long-term terminal illness, mental illness, and continuous illness, mental illness, and continuous blood loss)blood loss)

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General Adaptation General Adaptation SyndromeSyndrome

III. STAGE OF EXHAUSTION:III. STAGE OF EXHAUSTION: Occurs when the body can no Occurs when the body can no

longer resist stress and body longer resist stress and body energy is depleted. energy is depleted.

The body’s energy level is The body’s energy level is compromised and adaptation compromised and adaptation diminishes. diminishes.

Body may not be able to defend Body may not be able to defend self that may end to death.self that may end to death.

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General Adaptation General Adaptation SyndromeSyndrome

Stage 1 Stage 1 ALARM REACTIONALARM REACTIONEnlargement of adrenal cortexEnlargement of adrenal cortexEnlargement of lymphatic systemEnlargement of lymphatic system

Increase in hormone levelsIncrease in hormone levels

Stage 2Stage 2 RESISTANCE PHASERESISTANCE PHASE Shrinkage of adrenal gland to normal sizeShrinkage of adrenal gland to normal size

Lymph nodes closer to normal sizeLymph nodes closer to normal sizeHormone levels sustainedHormone levels sustained

Stage 3Stage 3 EXHAUSTION PHASEEXHAUSTION PHASERest or deathRest or deathIncrease in hormone levelsIncrease in hormone levelsDepletion of adaptive hormonesDepletion of adaptive hormones

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Stress and AdaptationStress and Adaptation

A-R-EA-R-EALARM:ALARM: sympathetic system is sympathetic system is

mobilized!mobilized!

RESISTANCE: RESISTANCE: adaptation takes adaptation takes placeplace

EXHAUSTIONEXHAUSTION: adaptation cannot : adaptation cannot be maintained be maintained

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GASGAS

HypothalamusHypothalamus

Anterior Pituitary GlandAnterior Pituitary Gland

Adrenal GlandAdrenal Gland

Adrenal CortexAdrenal Cortex Adrenal medullaAdrenal medulla

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Adrenal glandAdrenal gland

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Adrenal GlandAdrenal Gland

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Adrenal GlandAdrenal Gland

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Hormonal ChangesHormonal Changes

Adrenal Adrenal CortexCortex

MINERALOCORTICOIDSMINERALOCORTICOIDS AldosteroneAldosterone Na+ retentionNa+ retention WATER retentionWATER retention Protein anabolismProtein anabolism

GLUCOCORTICOIDSGLUCOCORTICOIDS CortisolCortisol (Anti-inflammatory)(Anti-inflammatory) Protein catabolismProtein catabolism GluconeogenesisGluconeogenesis

Adrenal MedullaAdrenal Medulla NOREPINEPHRINENOREPINEPHRINE

Peripheral Peripheral vasoconstrictionvasoconstriction

Decreased blood to Decreased blood to kidneykidney

Increased renin Increased renin (angiotensin)(angiotensin)

EPINEPHRINEEPINEPHRINE TachycardiaTachycardia Increased myocardial Increased myocardial

activityactivity Increased Bronchial Increased Bronchial

dilatationdilatation Increased Blood clottingIncreased Blood clotting Increased MetabolismIncreased Metabolism Increased Fat MetabolismIncreased Fat Metabolism

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Local Adaptation Local Adaptation SyndromeSyndrome

Localized responses to stressLocalized responses to stress

Ex. Wound healing, blood Ex. Wound healing, blood clotting, vision, response to clotting, vision, response to pressurepressure

Adaptive:Adaptive: a stressor is necessary to a stressor is necessary to stimulate itstimulate it

Short- termShort- term Restorative:Restorative: assist in homeostasis assist in homeostasis

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Local Adaptation Local Adaptation SyndromeSyndrome

Reflex Pain response:Reflex Pain response: Localized response of the CNS to painLocalized response of the CNS to pain Adaptive response and protects tissue Adaptive response and protects tissue

from further damage from further damage Involves a sensory receptor, a sensory Involves a sensory receptor, a sensory

serve to the spinal cord, a connector serve to the spinal cord, a connector neuron, motor nerve, effector’s muscles. neuron, motor nerve, effector’s muscles. Example: unconscious removal of hand Example: unconscious removal of hand from a hot surface, sneezing, etc. from a hot surface, sneezing, etc.

Inflammatory Response:Inflammatory Response: Stimulated by trauma or infection, thus Stimulated by trauma or infection, thus

preventing it to spread; also promotes preventing it to spread; also promotes healinghealing

Pain, heat, redness, swellingPain, heat, redness, swelling

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FACTORS INFLUENCING FACTORS INFLUENCING RESPONSE TO STRESSRESPONSE TO STRESS

Age, SexAge, Sex Nature of StressorsNature of Stressors Physiological functioningPhysiological functioning PersonalityPersonality Behavioral CharacteristicsBehavioral Characteristics Level of personal controlLevel of personal control

Availability of support systemAvailability of support system Feelings of competenceFeelings of competence Cognitive appraisal, Economic StatusCognitive appraisal, Economic Status

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The MANIFESTATIONS OF The MANIFESTATIONS OF STRESSSTRESS

INDICATORS OF STRESSINDICATORS OF STRESS PhysiologicPhysiologic PsychologicalPsychological CognitiveCognitive Verbal-MotorVerbal-Motor

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Physiological IndicatorsPhysiological Indicators Dilated pupilsDilated pupils DiaphoresisDiaphoresis Tachycardia, tachypnea, Tachycardia, tachypnea,

HYPERTENSION, increased blood flow HYPERTENSION, increased blood flow to the musclesto the muscles

Increased blood clottingIncreased blood clotting BronchodilationBronchodilation Skin pallorSkin pallor Water retention, Sodium retentionWater retention, Sodium retention OliguriaOliguria Dry mouth, decrease peristalsisDry mouth, decrease peristalsis HyperglycemiaHyperglycemia

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Remember these Physiologic Remember these Physiologic Manifestations of Stress Manifestations of Stress

Pupils dilate to increase visual Pupils dilate to increase visual perception when serious threats perception when serious threats to the body ariseto the body arise

Sweat production (diaphoresis) Sweat production (diaphoresis) increases to control elevated increases to control elevated body heat due to increased body heat due to increased metabolismmetabolism

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Remember these Physiologic Remember these Physiologic Manifestations of Stress Manifestations of Stress

Heart rate or pulse rate increases Heart rate or pulse rate increases to transport nutrients & to transport nutrients & byproducts of metabolism more byproducts of metabolism more effectivelyeffectively

Skin becomes pale (Pallor) Skin becomes pale (Pallor) because of constriction of because of constriction of peripheral blood vessels to shunt peripheral blood vessels to shunt blood to the vital organs. blood to the vital organs.

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Remember these Physiologic Remember these Physiologic Manifestations of Stress Manifestations of Stress

BP increases due to BP increases due to vasoconstriction of vessels in vasoconstriction of vessels in blood reservoir (skin, kidneys, blood reservoir (skin, kidneys, lungs), due to secretion of renin, lungs), due to secretion of renin, Angiotensin I and IIAngiotensin I and II

Increased rate/depth of respiration Increased rate/depth of respiration

with dilation of bronchioles, with dilation of bronchioles, promoting hyperventilation and promoting hyperventilation and increased oxygen uptakeincreased oxygen uptake

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Remember these Physiologic Remember these Physiologic Manifestations of Stress Manifestations of Stress

Mouth may become dry, urine Mouth may become dry, urine output may decrease. The output may decrease. The peristalsis of the intestines peristalsis of the intestines decreases leading to constipationdecreases leading to constipation

For serious threats, there is For serious threats, there is improved mental alertnessimproved mental alertness

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Remember these Physiologic Remember these Physiologic Manifestations of Stress Manifestations of Stress

Increased muscle tension to Increased muscle tension to prepare for rapid motor prepare for rapid motor activity/defenseactivity/defense

Increased blood sugar Increased blood sugar (glucocorticoids & (glucocorticoids & gluconeogenesis) to supply gluconeogenesis) to supply

energy source to the body.energy source to the body.

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Psychological indicatorsPsychological indicators

This includes anxiety, This includes anxiety, fear, anger, depression fear, anger, depression and unconscious ego and unconscious ego defense mechanismsdefense mechanisms

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AnxietyAnxiety

A state of mental A state of mental uneasiness, apprehension, uneasiness, apprehension, or helplessness, related to or helplessness, related to anticipated unidentified anticipated unidentified stressstress

Occurs in the Conscious, Occurs in the Conscious, subconscious, or subconscious, or unconscious levelsunconscious levels

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Levels of AnxietyLevels of Anxiety

4 Levels of Anxiety:4 Levels of Anxiety: MildMild ModerateModerate SevereSevere PanicPanic

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Levels of AnxietyLevels of Anxiety

Mild-Mild- increased alertness, increased alertness, motivation and attentivenessmotivation and attentiveness

Moderate-Moderate- perception narrowed, perception narrowed, selective inattention and physical selective inattention and physical discomfortdiscomfort

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Levels of AnxietyLevels of Anxiety

Severe-Severe- behaviors become automatic, behaviors become automatic, details are not seen, senses are details are not seen, senses are drastically reduced, very narrow focus drastically reduced, very narrow focus on specific details, impaired learning on specific details, impaired learning ability.ability.

Panic-Panic- overwhelmed, unable to function overwhelmed, unable to function

or to communicate, with possible bodily or to communicate, with possible bodily harm to self and others, loss of strong harm to self and others, loss of strong displeasuredispleasure

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AnxietyAnxiety

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ANXIETYANXIETYCATEGORCATEGORYY

MILDMILD MODERATMODERATEE

SEVERSEVEREE

PANICPANIC

PerceptiPerception and on and attentionattention

IncreasIncreased ed arousalarousal

NarroweNarrowed focusd focus

Inability Inability to focusto focus

Distorted Distorted perceptioperceptionn

CommunicationCommunication IncreaseIncreased d questioniquestioningng

Voice Voice tremorstremors

Focus on Focus on particular particular objectobject

Difficult Difficult to to understaunderstandnd

Easily Easily distractedistractedd

Trembling Trembling unpredictaunpredictable ble responseresponse

VS VS changeschanges

NONENONE Slight Slight IncreaseIncrease

TachycarTachycardia, dia, HypervenHyperventilationtilation

PalpitationPalpitation, choking, , choking, chest painchest pain

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FearFear

It is a mild to severe feeling of It is a mild to severe feeling of apprehension about some apprehension about some perceived threat.perceived threat.

The Object of fear may or may not The Object of fear may or may not be based on reality.be based on reality.

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Anxiety versus fearAnxiety versus fearANXIETY FEAR

State of mental uneasiness

Emotion of apprehension

Source may not be identifiable

Source is identifiable

Related to the future Related to the present

Vague Definite

Result of psychological or emotional conflict

Result of discrete physical or psychological entity, definite and concrete events

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AngerAnger

Subjective feeling of strong Subjective feeling of strong displeasuredispleasure

It is an emotional state It is an emotional state consisting of subjective consisting of subjective feeling of animosity or feeling of animosity or strong displeasurestrong displeasure

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Other terms related Other terms related AngerAnger

Hostility = marked by overt Hostility = marked by overt antagonismantagonism & harmful or & harmful or destructive behavior destructive behavior

Aggression = Aggression = unprovoked unprovoked attackattack or a hostile, injurious, or a hostile, injurious, or destructive action or outlookor destructive action or outlook

Violence = exertion of Violence = exertion of physical physical forceforce to injure or abuse to injure or abuse

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DepressionDepression

An extreme feeling of An extreme feeling of sadness, despair, sadness, despair, dejection, lack of worth dejection, lack of worth or emptinessor emptiness

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DepressionDepression

Emotional Emotional Symptoms:Symptoms:

TirednessTiredness

emptinessemptiness numbnessnumbness

Physical signsPhysical signs loss of appetiteloss of appetite weight lossweight loss constipationconstipation headacheheadache dizzinessdizziness

Behavioral signs:Behavioral signs: irritabilityirritability inability to inability to

concentrateconcentrate difficulty making difficulty making

decisiondecision loss of sexual loss of sexual

desiredesire cryingcrying sleep disturbancesleep disturbance social withdrawalsocial withdrawal

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COGNITIVE COGNITIVE MANIFESTATIONSMANIFESTATIONS

Thinking responses that include Thinking responses that include problem solving, prayer, problem solving, prayer, structuring, self control, structuring, self control, suppression and fantasysuppression and fantasy

Thinking responses of the Thinking responses of the individual toward stressindividual toward stress

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COGNITIVE COGNITIVE MANIFESTATIONSMANIFESTATIONS

PROBLEM SOLVING:PROBLEM SOLVING: Use of Use of specific steps to arrive at a solutionspecific steps to arrive at a solution

STRUCTURING:STRUCTURING: manipulation of a manipulation of a situation so that threatening events situation so that threatening events do not occurdo not occur

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COGNITIVE COGNITIVE MANIFESTATIONSMANIFESTATIONS

SELF CONTROL / DISCIPLINE:SELF CONTROL / DISCIPLINE: assuming a sense of being in control assuming a sense of being in control or in charge of whatever situationor in charge of whatever situation

SUPPRESSION:SUPPRESSION: willfully putting a willfully putting a thought / feeling out of one’s mindthought / feeling out of one’s mind

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COGNITIVE COGNITIVE MANIFESTATIONSMANIFESTATIONS

FANTASY / DAYDREAMING:FANTASY / DAYDREAMING: “ “ make believe” or imagination of make believe” or imagination of unfulfilled wishes as fulfilledunfulfilled wishes as fulfilled

PRAYER:PRAYER: identification, description identification, description of the problem, suggestion of of the problem, suggestion of solution, then reaching out for help solution, then reaching out for help or support to the supreme beingor support to the supreme being

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VERBAL / MOTOR VERBAL / MOTOR MANIFESTATIONSMANIFESTATIONS

First hand responses to stressFirst hand responses to stress

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VERBAL / MOTOR VERBAL / MOTOR MANIFESTATIONSMANIFESTATIONS

CRYING:CRYING: feelings of pain, joy, sadness feelings of pain, joy, sadness are releasedare released

VERBAL ABUSE:VERBAL ABUSE: release mechanism release mechanism toward non living objects, and stress toward non living objects, and stress producing eventsproducing events

LAUGHING:LAUGHING: anxiety reducing response anxiety reducing response that leads to constructive problem solvingthat leads to constructive problem solving

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VERBAL / MOTOR VERBAL / MOTOR MANIFESTATIONSMANIFESTATIONS

SCREAMING:SCREAMING: response to fear or response to fear or intense frustration and angerintense frustration and anger

HITTING AND KICKING:HITTING AND KICKING: spontaneous response to physical spontaneous response to physical threats or frustrationsthreats or frustrations

HOLDING AND TOUCHING:HOLDING AND TOUCHING: responses to joyful, painful or sad eventsresponses to joyful, painful or sad events

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FACTORS INFLUENCING FACTORS INFLUENCING STRESSSTRESS

DEPEND ON THEDEPEND ON THE Nature of the stressorNature of the stressor Perception of the stressorPerception of the stressor Number of simultaneous stressorNumber of simultaneous stressor Duration of exposure to the stressorDuration of exposure to the stressor Experiences with a comparable Experiences with a comparable

stressorstressor Age of the individualAge of the individual Support peopleSupport people

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Personality TypesPersonality Types

TYPE ATYPE A

impatient, competitive, impatient, competitive, aggressive, and insecure, aggressive, and insecure, always in a hurry, always in a hurry, inability to relaxinability to relax

Prone to cardiovascular Prone to cardiovascular illness.illness.

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Personality TypesPersonality Types

TYPE BTYPE B more relaxed, unhurried, more relaxed, unhurried,

able to enjoy both work and able to enjoy both work and play without guiltplay without guilt

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Personality TypesPersonality Types

TYPE C:TYPE C: ““coping personality” experiences coping personality” experiences

considerable stress but learns to cope considerable stress but learns to cope with it (with it (challenge, commitment,& challenge, commitment,& controlcontrol) , uses personality ) , uses personality characteristics to cope with stress characteristics to cope with stress

Coping Characteristics of Type C:Coping Characteristics of Type C: Challenge Challenge Commitment Commitment ControlControl

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COPINGCOPING

A problem solving process or A problem solving process or strategy that the person uses to strategy that the person uses to manage the out-of-ordinary events manage the out-of-ordinary events or situations with which he/she is or situations with which he/she is presented. presented.

Successfully dealing with problemsSuccessfully dealing with problems A cognitive and behavioral effort to A cognitive and behavioral effort to

manage specific external and manage specific external and internal demands that are appraised internal demands that are appraised as exceeding the person’s resourcesas exceeding the person’s resources

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Coping related terms Coping related terms

Coping strategy- is a coping Coping strategy- is a coping mechanism, way of responding to mechanism, way of responding to problemsproblems

Problem focused coping- efforts to Problem focused coping- efforts to improve a situation by making improve a situation by making changeschanges

Emotion focused coping- includes Emotion focused coping- includes thoughts and actions that relieve thoughts and actions that relieve emotional stressemotional stress

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Coping related terms Coping related terms Long term coping- involves Long term coping- involves

constructive and realistic changesconstructive and realistic changes Short term coping- involves stress Short term coping- involves stress

reduction to tolerable levels reduction to tolerable levels temporarilytemporarily

Adaptive coping- helps person deal Adaptive coping- helps person deal effectively with stresseffectively with stress

Maladaptive coping- results in Maladaptive coping- results in unnecessary distress for the person unnecessary distress for the person and stressful eventsand stressful events

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MODES OF ADAPTATIONMODES OF ADAPTATION1. Physiologic mode (biologic 1. Physiologic mode (biologic

adaptation)adaptation) Occurs in response to increased or Occurs in response to increased or

altered demands placed on the body & altered demands placed on the body & results in compensatory physical results in compensatory physical changes.changes.

2. Psychological Mode2. Psychological Mode Involves a change in attitude & behavior Involves a change in attitude & behavior

toward emotionally stressful situations. toward emotionally stressful situations. (Ex. Stopping smoking)(Ex. Stopping smoking)

3. Socio-cultural Mode3. Socio-cultural Mode Changing persons behavior in accordance Changing persons behavior in accordance

with the norms, conversions, & beliefs of with the norms, conversions, & beliefs of various groups (leaving in new country) various groups (leaving in new country)

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CHARACTERISTICS OF ADAPTIVE CHARACTERISTICS OF ADAPTIVE RESPONSESRESPONSES

All attempts to maintain homeostasisAll attempts to maintain homeostasis Whole body or total organism responseWhole body or total organism response Have limits (Physiologic, Have limits (Physiologic,

Psychologic/Social) Psychologic/Social) Requires timeRequires time Varies from person to personVaries from person to person Maybe inadequate or excessive Maybe inadequate or excessive

(infection/allergy(infection/allergy

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MANIFESTATIONS OF MANIFESTATIONS OF ALTERED COPINGALTERED COPING

Addictive behaviorsAddictive behaviors Physical illnessPhysical illness Anxiety and depressionAnxiety and depression Violent behaviorsViolent behaviors

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Applying the Nursing Applying the Nursing ProcessProcess

AA DD PP II EE

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AssessmentAssessment

It is important that the nurse have an It is important that the nurse have an understanding of the methods or understanding of the methods or strategies used by the patient so that strategies used by the patient so that nursing care can be appropriately nursing care can be appropriately individualized. individualized.

1. Utilize the Nursing History1. Utilize the Nursing History Subjective data- such as the Subjective data- such as the

functional pattern, risk pattern and functional pattern, risk pattern and dysfunctional pattern.dysfunctional pattern.

2. Physical Examination – centered on 2. Physical Examination – centered on the changes in the ANS and NES. the changes in the ANS and NES. Objective data- Physical assessment, Objective data- Physical assessment, Diagnostic tests and proceduresDiagnostic tests and procedures

3. Laboratory Examination3. Laboratory Examination

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DiagnosesDiagnoses

Utilize those accepted by NANDAUtilize those accepted by NANDA

1.1. AnxietyAnxiety 7. Fear7. Fear

2.2. Caregiver role strainCaregiver role strain 8. Impaired 8. Impaired adjustmentadjustment

3.3. Compromised family coping 9. Ineffective Compromised family coping 9. Ineffective coping coping

4.4. Decisional conflictDecisional conflict 10. Ineffective Denial10. Ineffective Denial

5.5. Defensive copingDefensive coping 11. Post-trauma Syn11. Post-trauma Syn

6.6. Disabled Family coping Disabled Family coping 12. Relocation 12. Relocation Stress SynStress Syn

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PlanningPlanningThe goals for the patient with ineffective The goals for the patient with ineffective

individual coping need to be individual coping need to be individualized, taking into consideration individualized, taking into consideration the patient’s history, areas of risk, the patient’s history, areas of risk, evidence of dysfunction and related evidence of dysfunction and related objective dataobjective data. .

There are four important guidelines to be There are four important guidelines to be followed in choosing nursing goals. The nurse followed in choosing nursing goals. The nurse must choose goals geared : must choose goals geared : To eliminate as many stressors as possibleTo eliminate as many stressors as possible To teach about the effects of stress to the bodyTo teach about the effects of stress to the body To teach how to cope with stressTo teach how to cope with stress To teach on how to adjust to stressTo teach on how to adjust to stress

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PlanningPlanningOverall client goals are the following: Overall client goals are the following: To decrease or resolve anxietyTo decrease or resolve anxiety To increase ability to manage or cope with To increase ability to manage or cope with

stressstress To improve role performanceTo improve role performanceExamples of Patient Goals are: Examples of Patient Goals are: After After

___hours/days: ___hours/days: 1. The patient will identify sources of stress 1. The patient will identify sources of stress

in his/her lifein his/her life2. The patient will identify usual personal 2. The patient will identify usual personal

coping strategies for stressful situationscoping strategies for stressful situations3. The patient will define the effect of stress 3. The patient will define the effect of stress

and coping strategies on activities of daily and coping strategies on activities of daily livingliving

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ImplementationImplementation Once the diagnosis is made, the nurse can Once the diagnosis is made, the nurse can

intervene independently and intervene independently and collaboratively to help restore functioncollaboratively to help restore function

The nurse can assist the patient in The nurse can assist the patient in recognizing signs and symptoms of stress, recognizing signs and symptoms of stress, identifying the sources of distress, and identifying the sources of distress, and choosing an appropriate course of action. choosing an appropriate course of action.

The nurses can assist the patient in The nurses can assist the patient in finding techniques that are most effective.finding techniques that are most effective.

The nurse also has significant role in The nurse also has significant role in identifying people at risk for ineffective identifying people at risk for ineffective coping and initiating appropriate teaching coping and initiating appropriate teaching to promote optimum health. to promote optimum health.

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ImplementationImplementation

There are essentially three ways There are essentially three ways to manage Stress: to manage Stress:

Eliminate the causes/sources Eliminate the causes/sources of stressof stress

Produce a relaxation response Produce a relaxation response in the bodyin the body

Suggest a change in lifestyle, Suggest a change in lifestyle, if possibleif possible

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ImplementationImplementationStress reduction techniques:Stress reduction techniques: Proper nutritionProper nutrition Regular exercise, physical activity & Regular exercise, physical activity &

recreationrecreation Meditation, Breathing exercises, creative Meditation, Breathing exercises, creative

imagery, YOGAimagery, YOGA Communication, time management, Communication, time management,

expression of feeling, talking it out, expression of feeling, talking it out, organizing timeorganizing time

BiofeedbackBiofeedback Therapeutic touchTherapeutic touch Relaxation response , Problem Solving Relaxation response , Problem Solving

TechniquesTechniques

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ImplementationImplementation1.1. Minimize anxietyMinimize anxiety

2.2. Mediate angerMediate anger

3.3. MassageMassage

4.4. Progressive relaxationProgressive relaxation

5.5. Guided imagery Guided imagery

6.6. BiofeedbackBiofeedback

7.7. Therapeutic touchTherapeutic touch

8.8. CRISIS INTERVENTIONCRISIS INTERVENTION

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ImplementationImplementationMinimize anxietyMinimize anxiety Support the client and the familySupport the client and the family Orient the client to the hospital or agency.Orient the client to the hospital or agency. Give the client in a hospital some way of Give the client in a hospital some way of

maintaining identity.maintaining identity. Provide information when the client has Provide information when the client has

insufficient information.insufficient information. Repeat information when the client has Repeat information when the client has

difficulty remembering.difficulty remembering. Encourage the client to participate in the Encourage the client to participate in the

plan of care.plan of care. Give the client the time to express feelings Give the client the time to express feelings

and thoughts.and thoughts.

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ImplementationImplementationMediating AngerMediating Anger Responses that reduce the client’s anger & Responses that reduce the client’s anger &

stressstress offering helpoffering help asking relevant questionsasking relevant questions conveying understandingconveying understanding

Guidelines: to provide understanding responsesGuidelines: to provide understanding responses focus on the feeling words of the clientfocus on the feeling words of the client note the general content of the messagenote the general content of the message restate the feeling & content of what the restate the feeling & content of what the

client has communicatedclient has communicated observe the client’s body languageobserve the client’s body language Ask, “If I were in the client’s shoes, what Ask, “If I were in the client’s shoes, what

would I be feeling?”would I be feeling?”

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ImplementationImplementation

MassageMassage These include These include effleurageeffleurage (stroking), (stroking),

friction, pressure, friction, pressure, petrissagepetrissage (kneading or (kneading or large, quick pinches of the skin, large, quick pinches of the skin, subcutaneous tissue and muscle), vibration subcutaneous tissue and muscle), vibration and percussion. and percussion.

PurposesPurposes --enhances or induces relaxation before enhances or induces relaxation before

sleepsleep -stimulates skin circulation-stimulates skin circulation

Duration: 5-20 minutesDuration: 5-20 minutes

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ImplementationImplementation

Progressive RelaxationProgressive Relaxation Jacobson (1930),Jacobson (1930), the originator of the originator of

the Progressive relaxation techniquethe Progressive relaxation technique

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ImplementationImplementation

Guided ImageryGuided Imagery Imagery is Imagery is "the formation of a mental "the formation of a mental

representation of an object that is usually representation of an object that is usually only perceived through the senses" only perceived through the senses" (Sodergren 1985)(Sodergren 1985). . Example:Example:

VisualVisual -A valley scene with its many greens -A valley scene with its many greens

Auditory Auditory -Ocean waves breaking -Ocean waves breaking rhythmically rhythmically

OlfactoryOlfactory -Freshly baked bread -Freshly baked bread

GustatoryGustatory -A Juicy hamburger -A Juicy hamburger

Tactile-proprioceptive -Stroking a soft, furry catTactile-proprioceptive -Stroking a soft, furry cat

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ImplementationImplementation

Biofeedback is a technique that brings Biofeedback is a technique that brings under conscious control bodily processes under conscious control bodily processes normally thought to be beyond voluntary normally thought to be beyond voluntary command. muscle tension, heartbeat, command. muscle tension, heartbeat, blood flow, peristalsis, & skin blood flow, peristalsis, & skin temperature – can be voluntarily temperature – can be voluntarily controlled controlled feedback provided through:feedback provided through: a. temperature meters (that indicate temp. a. temperature meters (that indicate temp.

changes) changes) b. EMG (electromyogram) that shows electric b. EMG (electromyogram) that shows electric

potential created by contraction the musclespotential created by contraction the muscles

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ImplementationImplementationTherapeutic TouchTherapeutic Touch ““a healing meditation, because the a healing meditation, because the

primary act of the nurse (healer) is to primary act of the nurse (healer) is to "center" the self and to maintain that "center" the self and to maintain that center (mental concentration and center (mental concentration and focusing) throughout the process.focusing) throughout the process.

The process consists of the following four The process consists of the following four steps:steps:

Centering (sense of detachment, Centering (sense of detachment, sensitivity & balance)sensitivity & balance)

Assessing (head to toe scanning process)Assessing (head to toe scanning process) Unruffling (to enhance the transfer of Unruffling (to enhance the transfer of

energy from nurse to client)energy from nurse to client) Transferring energyTransferring energy

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ImplementationImplementation

Therapeutic TouchTherapeutic Touch

The form of energy has different The form of energy has different effects and is related to colors:effects and is related to colors:

Blue energy is sedatingBlue energy is sedating Yellow energy is stimulating and Yellow energy is stimulating and

energizingenergizing Green energy is harmonizing.Green energy is harmonizing.

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EvaluationEvaluation

The evaluation of the plan of care is The evaluation of the plan of care is based on the mutually established based on the mutually established expected outcomes. expected outcomes.

It is important to observe BOTH It is important to observe BOTH verbal and non-verbal cues when verbal and non-verbal cues when evaluating the usefulness of the evaluating the usefulness of the plan. plan.

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EvaluationEvaluation

The nurse must be able to determine the The nurse must be able to determine the success of her action by: success of her action by:

Observing the client for absence or Observing the client for absence or reduction of manifestations of fear and / or reduction of manifestations of fear and / or anxiety.anxiety.

Measuring BP and Pulse RateMeasuring BP and Pulse Rate Asking the client’s personal strengths or Asking the client’s personal strengths or

coping resources identifiedcoping resources identified Determining Effective and ineffective Determining Effective and ineffective

coping responses and consequences.coping responses and consequences. Identifying Situations that use specific Identifying Situations that use specific

adaptive coping method’s and the client’s adaptive coping method’s and the client’s perception of their effectivenessperception of their effectiveness

Observing Support persons involvedObserving Support persons involved

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Stress Management for Stress Management for NursesNurses Plan daily relaxation programPlan daily relaxation program

Establish a regular pattern of exercise Establish a regular pattern of exercise Study assertive techniques. Learn to Study assertive techniques. Learn to

say “no”say “no” Learn to accept failuresLearn to accept failures Accept what cannot be changedAccept what cannot be changed Develop collegial supportDevelop collegial support Participate in professional Participate in professional

organizationorganization Seek counselingSeek counseling

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AnxietyAnxiety

This is the most universal of all This is the most universal of all emotions that cannot be observed emotions that cannot be observed directly BUT must be inferred from directly BUT must be inferred from behavior behavior

This is defined as a “Sense of This is defined as a “Sense of impending doom” , an apprehension impending doom” , an apprehension of dread that seemingly has no basis of dread that seemingly has no basis in reality in reality

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Characteristics of Characteristics of AnxietyAnxiety

Always perceived as a negative Always perceived as a negative feelingfeeling

Extremely communicableExtremely communicable Cannot be distinguished from fear Cannot be distinguished from fear

easilyeasily Occurs in degrees: mild, moderate, Occurs in degrees: mild, moderate,

severe, panicsevere, panic

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Origin of anxietyOrigin of anxiety

The PSYCHOSEXUAL theory The PSYCHOSEXUAL theory believes that anxiety is a response to believes that anxiety is a response to the emergence of the ID impulses the emergence of the ID impulses that are NOT acceptable to that are NOT acceptable to SUPEREGOSUPEREGO

The EGO detects a real or potential The EGO detects a real or potential conflict between the ID and the conflict between the ID and the SUPEREGO resulting to the SUPEREGO resulting to the development of ANXIETYdevelopment of ANXIETY

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Origin of anxietyOrigin of anxiety

BIRTH is the prototypical separation BIRTH is the prototypical separation anxiety- the threat to life and the anxiety- the threat to life and the separation from the mother.separation from the mother.

In subsequent developmental In subsequent developmental changes, unconscious conflicts are changes, unconscious conflicts are perceived as life threatening perceived as life threatening associated with separation associated with separation

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Origin of anxietyOrigin of anxiety SULLIVAN views anxiety as always SULLIVAN views anxiety as always

occurring in an interpersonal contextoccurring in an interpersonal context ANXIETY is generated when the ANXIETY is generated when the

individual anticipates or actually individual anticipates or actually receives cues that signal disapproval receives cues that signal disapproval from othersfrom others

Human being experiences anxiety Human being experiences anxiety during infancy when either his need during infancy when either his need for satisfaction or his need for for satisfaction or his need for security is NOT met by the security is NOT met by the MOTHERING ONEMOTHERING ONE

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Adaptation to anxietyAdaptation to anxiety Use of unconscious ego defense Use of unconscious ego defense

mechanismsmechanisms Utilized when the person experiences Utilized when the person experiences

conflict between the id and superegoconflict between the id and superego Use of security operationsUse of security operations

Identified by SullivanIdentified by Sullivan Apathy, Somnolent detachment, Apathy, Somnolent detachment,

selective inattention and selective inattention and preoccupation preoccupation

Use of coping mechanismsUse of coping mechanisms This is adaptation to anxiety based on This is adaptation to anxiety based on

conscious acknowledgement of a conscious acknowledgement of a problemproblem

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GRIEF AND LOSSGRIEF AND LOSS

Loss is a universal experience Loss is a universal experience that occurs throughout life spanthat occurs throughout life span

Grief is a form of sorrow Grief is a form of sorrow involving feelings, thoughts, and involving feelings, thoughts, and behaviors caused by bereavementbehaviors caused by bereavement

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GRIEF AND LOSSGRIEF AND LOSS

Responses to loss are strongly Responses to loss are strongly influenced by one’s cultural influenced by one’s cultural backgroundbackground

The grief process involves a The grief process involves a sequence of affective, cognitive, sequence of affective, cognitive, and psychological states as a and psychological states as a person responds to, and finally person responds to, and finally accepts a loss.accepts a loss.

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Loss and grievingLoss and grieving

LOSS= something valuable is LOSS= something valuable is gonegone GRIEF= GRIEF= totaltotal response to emotional response to emotional

experience related to lossexperience related to loss BEREAVEMENT= BEREAVEMENT= SubjectiveSubjective

response by loved-onesresponse by loved-ones MOURNING=MOURNING= behavioral behavioral response response

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GRIEF AND LOSSGRIEF AND LOSSStages of Grieving (Kubler-Ross)Stages of Grieving (Kubler-Ross) Denial- refuses to believe that the loss Denial- refuses to believe that the loss

has occurredhas occurred Anger- the individual resists the loss Anger- the individual resists the loss

and may “act out” feelings.and may “act out” feelings. Bargaining- the individual attempts to Bargaining- the individual attempts to

make a deal in an attempt to postpone make a deal in an attempt to postpone the reality of loss.the reality of loss.

Depression- overwhelming feeling of Depression- overwhelming feeling of loneliness and withdrawal from othersloneliness and withdrawal from others

Acceptance- the individual comes to Acceptance- the individual comes to terms with loss, or impending loss, terms with loss, or impending loss, psychological reactions to loss to the psychological reactions to loss to the loss cease, and the interaction to loss cease, and the interaction to other people resumedother people resumed..

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Loss and grievingLoss and grieving

Stages of Grieving (Kubler-Ross)Stages of Grieving (Kubler-Ross)DABDADABDADENIAL= refusal to believeDENIAL= refusal to believeANGER= hostilityANGER= hostilityBARGAINING= feeling of guilt, fear of BARGAINING= feeling of guilt, fear of

punishmentpunishmentDEPRESSION= withdrawn behaviorDEPRESSION= withdrawn behaviorACCEPTANCE= comes to terms with ACCEPTANCE= comes to terms with

lossloss

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Loss and grievingLoss and grievingStages Stages BehaviorsBehaviors

DD Refuses to Refuses to believe that loss believe that loss is happeningis happening

AA RetaliationRetaliation

BB Feelings of guilt, Feelings of guilt, punishment for punishment for sinssins

DD Laments over Laments over what has what has happened happened

AA Begins to plan Begins to plan like wills, like wills, prosthesisprosthesis

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Death and Dying (Kozier)Death and Dying (Kozier)AGEAGE BeliefsBeliefs

Infancy to 5 Infancy to 5 years oldyears old

NO clear concept of NO clear concept of DeathDeath

It isIt is Reversible Reversible, temporary , temporary sleepsleep

5 to 9 years5 to 9 years Understands Understands DEATH is DEATH is FINALFINAL but can be but can be AVOIDEDAVOIDED

9-12 years9-12 years Death is Death is INEVITABLE, INEVITABLE, everyone will die somedayeveryone will die someday

Understands own Understands own mortalitymortality

12-18 years12-18 years Fears a lingering DeathFears a lingering Death

18-4518-45 Attitude is influenced by Attitude is influenced by religionreligion

45-65 years45-65 years Experiences peak of death Experiences peak of death anxietyanxiety

65 and above65 and above Death as multiple meaningsDeath as multiple meanings

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Nursing responsibilities Nursing responsibilities In Death and dyingIn Death and dying

Nurses need to take time to Nurses need to take time to analyze their own feelings analyze their own feelings about death before they can about death before they can effectively help others with effectively help others with terminal illnessterminal illness

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Nursing responsibilities Nursing responsibilities In Death and dyingIn Death and dying

The major goals for the dying The major goals for the dying clients are:clients are:

1.1. To maintain PHYSIOLOGIC To maintain PHYSIOLOGIC and PSYCHOLOGIC supportand PSYCHOLOGIC support

2.2. To Achieve a dignified and To Achieve a dignified and peaceful deathpeaceful death

3.3. To maintain personal control To maintain personal control

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Loss and Death Loss and Death RESPONSIBILITIESRESPONSIBILITIES

Provide Relief from loneliness, Provide Relief from loneliness, fear and depressionfear and depression

Help clients maintain sense of Help clients maintain sense of securitysecurity

Help clients accept lossesHelp clients accept losses Provide physical comfortProvide physical comfort

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LOSS ,GRIEVING AND LOSS ,GRIEVING AND DEATHDEATH

DEATH CONCEPTSDEATH CONCEPTS 1-5 – IMMOBILITY AND INACTIVITY 1-5 – IMMOBILITY AND INACTIVITY

Wishes and unrelated action Wishes and unrelated action responsible for actionresponsible for action

5-10 – final but can be avoided5-10 – final but can be avoided 9-12 – understands own mortality and 9-12 – understands own mortality and

fears deathfears death 12 – 18 – fears and fantasizes avoidance12 – 18 – fears and fantasizes avoidance 18-45 – increased attitude awareness18-45 – increased attitude awareness 45-65 – accepts mortality45-65 – accepts mortality Above 65 – multiple meanings, Above 65 – multiple meanings,

encounters and fearsencounters and fears

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KUBLER ROSS – STAGES KUBLER ROSS – STAGES OF GRIEF OF GRIEF

D – SUPPORTIVE D – SUPPORTIVE

A- PROVIDE STRUCTURE AND CONTINUITYA- PROVIDE STRUCTURE AND CONTINUITY

B – LISTEN AND ENCOURAGEB – LISTEN AND ENCOURAGE

D- ALLOW EXPRESSION AND PROVIDE FOR D- ALLOW EXPRESSION AND PROVIDE FOR SAFETYSAFETY

A- ENCOURAGE PARTICIPATIONA- ENCOURAGE PARTICIPATION

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NeurosisNeurosis any long term mental or behavioral any long term mental or behavioral

disorder in which disorder in which contact with realitycontact with reality is is retained the condition is recognized by retained the condition is recognized by the patient as abnormal. Essentially the patient as abnormal. Essentially features features anxietyanxiety or behavior exaggerated or behavior exaggerated designed to avoid anxiety designed to avoid anxiety

( anxiety disorder ; hysteria to conversion ( anxiety disorder ; hysteria to conversion d/o, amnesia, fugue, multiple personality d/o, amnesia, fugue, multiple personality and depersonalization- Dissociative d/oand depersonalization- Dissociative d/o;oc d/o);oc d/o)

Result of inappropriate early Result of inappropriate early programming (psychoanalysis little value)programming (psychoanalysis little value)

Benefits from Benefits from Behavior TherapyBehavior Therapy

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PsychosisPsychosis Mental or behavioral disorder Mental or behavioral disorder

wherein patient wherein patient looses contact with looses contact with realityreality

Presence of delusions, Presence of delusions, hallucinations, severe thought hallucinations, severe thought disturbances, alteration of mood, disturbances, alteration of mood, poverty of thought and abnormal poverty of thought and abnormal behaviorbehavior

(schizophrenia , major disorder of (schizophrenia , major disorder of affect ( mania – depression), affect ( mania – depression), major paranoid states and organic major paranoid states and organic mental disordermental disorder

Benefits from Benefits from psychoanalysispsychoanalysis and and antipsychotic medications antipsychotic medications

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Mental disordersMental disordersNeurosisNeurosis Does not require Does not require

hospitalizationhospitalization Considered moderate Considered moderate

reaction to stressreaction to stress Reality testing Reality testing

remains soundremains sound Patient feels suffering Patient feels suffering

and wants to get welland wants to get well Ignores realityIgnores reality Exploits symptoms for Exploits symptoms for

secondary gainsecondary gain Desires are not Desires are not

externalizedexternalized Personality remains Personality remains

organizedorganized

PsychosisPsychosis Requires hospitalizationRequires hospitalization MAJOR reaction to MAJOR reaction to

stressstress Reality testing is Reality testing is

GREATLY impairedGREATLY impaired Patient does not Patient does not

recognize he is ILLrecognize he is ILL Patient denies reality Patient denies reality

and substitute and substitute something elsesomething else

NO secondary gain is NO secondary gain is derived from the derived from the symptomssymptoms

Desires and motives are Desires and motives are often PROJECTEDoften PROJECTED

Personality is Personality is DISTORTEDDISTORTED

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Normal Anxiety Versus Normal Anxiety Versus Abnormal AnxietyAbnormal Anxiety

Normal AnxietyNormal Anxiety A protective response and innate A protective response and innate

form of communication that the body form of communication that the body uses to mobilize its coping resources uses to mobilize its coping resources to maintain homeostasis.to maintain homeostasis.

Arises from a realistic apprehension Arises from a realistic apprehension of a previously un-encountered of a previously un-encountered situation that has symbolic meaning situation that has symbolic meaning to the person to the person

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Normal Anxiety Versus Normal Anxiety Versus Abnormal AnxietyAbnormal Anxiety

PATHOLOGIC AnxietyPATHOLOGIC Anxiety A response to thoughts, feelings, A response to thoughts, feelings,

desires that if Conscious would be desires that if Conscious would be UNACCEPTABLE to the individual; UNACCEPTABLE to the individual; that if known, would cause the loss that if known, would cause the loss of approval or love from othersof approval or love from others

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Anxiety DisordersAnxiety Disorders

The MOST common of all The MOST common of all psychiatric disorderspsychiatric disorders

Cause an individual to feel Cause an individual to feel frightened, distressed an uneasy frightened, distressed an uneasy mostly without a specific cause mostly without a specific cause

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Anxiety DisordersAnxiety Disorders

Panic disorder (with or without Panic disorder (with or without agoraphobia)agoraphobia)

Specific phobiaSpecific phobia Social phobiaSocial phobia Obsessive-compulsive disorderObsessive-compulsive disorder Post traumatic stress disorderPost traumatic stress disorder Acute stress disorderAcute stress disorder Generalized anxiety disorderGeneralized anxiety disorder

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Anxiety DisordersAnxiety Disorders

Major manifestations for all Major manifestations for all types:types:

1.1. Autonomic nervous arousalAutonomic nervous arousal2.2. Sense of doomSense of doom3.3. DepersonalizationDepersonalization4.4. Avoidant behaviorsAvoidant behaviors5.5. ParesthesiasParesthesias6.6. Recurrent attacks of intense fear Recurrent attacks of intense fear

or discomfortor discomfort

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Anxiety DisordersAnxiety Disorders

Global Manifestations of Anxiety Global Manifestations of Anxiety disordersdisorders

1.1. Biological- tachypnea, tachycardia, Biological- tachypnea, tachycardia, diaphoresisdiaphoresis

2.2. Behavioral- rituals, avoidance, Behavioral- rituals, avoidance, increased dependence, clingingincreased dependence, clinging

3.3. Motor- tension, pacing, tremors, Motor- tension, pacing, tremors, restlessnessrestlessness

4.4. Cognitive- Sense of doom, Confusion, Cognitive- Sense of doom, Confusion, Helplessness, Intense fear, Helplessness, Intense fear, powerlessness powerlessness

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Anxiety Disorders: Anxiety Disorders: EpidemiologyEpidemiology

Affects 15% of the population Affects 15% of the population Most common reason for seeking Most common reason for seeking

medical helpmedical help Highest in adultsHighest in adults Cultural factors may influence Cultural factors may influence

anxiety disordersanxiety disorders

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Anxiety Disorders: Anxiety Disorders: EtiologyEtiology

Psychodynamic theoryPsychodynamic theory Existential theoryExistential theory Behavioral theoryBehavioral theory Developmental theoryDevelopmental theory Biological theory- Biological theory-

neurotransmitter and genetic neurotransmitter and genetic causescauses

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Anxiety Disorders: Anxiety Disorders: EtiologyEtiology

TheoryTheory Explanation Explanation

Psychodynamic Psychodynamic theorytheory

Anxiety occurs Anxiety occurs when the ego when the ego attempts to deal attempts to deal with psychic with psychic conflict or conflict or emotional tensionemotional tension

If ego defense If ego defense mechanisms will mechanisms will fail to protect the fail to protect the ego, immature ego, immature defenses will evolve defenses will evolve predisposing to predisposing to mental illnessmental illness

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Anxiety Disorders: Anxiety Disorders: EtiologyEtiology

TheoryTheory Explanation Explanation

Existential theoryExistential theory Human existence Human existence and its relationship and its relationship to God is the to God is the concept of this concept of this theorytheory

Sense of Sense of nothingness results nothingness results in inadequate in inadequate coping and mal-coping and mal-adaptive coping adaptive coping causes anxietycauses anxiety

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Anxiety Disorders: Anxiety Disorders: EtiologyEtiology

TheoryTheory Explanation Explanation

Behavioral theoryBehavioral theory Anxiety occurs Anxiety occurs when there is when there is danger perceived. danger perceived. Intense anxiety is a Intense anxiety is a learned learned maladaptive maladaptive response to stress response to stress and anxietyand anxiety

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Anxiety Disorders: Anxiety Disorders: EtiologyEtiology

TheoryTheory Explanation Explanation

Developmental Developmental theorytheory

Anxiety initially Anxiety initially occurs with occurs with separation from separation from early primary care early primary care giversgivers

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Anxiety Disorders: Anxiety Disorders: EtiologyEtiology

TheoryTheory Explanation Explanation

Biological theoryBiological theory Very high cortisol Very high cortisol levellevel

Dysregulation of Dysregulation of benzodiazepine benzodiazepine receptors in the receptors in the CNSCNS

HereditaryHereditary

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Anxiety Disorders: Anxiety Disorders: related termsrelated terms

Phobia= a specific pathological fear Phobia= a specific pathological fear reaction out of proportion to the reaction out of proportion to the stimulus , irrational fear stimulus , irrational fear

Simple phobia= persistent fear of a Simple phobia= persistent fear of a specific object/situationspecific object/situation

Agoraphobia= fear of open spacesAgoraphobia= fear of open spaces

Social phobia= fear of embarrassing Social phobia= fear of embarrassing situation in public placessituation in public places

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Anxiety Disorders: Anxiety Disorders: related termsrelated terms

Phobias and related disordersPhobias and related disorders The individuals recognize the fear as The individuals recognize the fear as

irrational but they feel inadequate or irrational but they feel inadequate or powerless to control the fearpowerless to control the fear

There may be genetic componentThere may be genetic component Behavioral theory suggests that a Behavioral theory suggests that a

phobia results form a conditioned phobia results form a conditioned response in which a person learns to response in which a person learns to associate a phobic object with associate a phobic object with uncomfortable feelings: the avoidance uncomfortable feelings: the avoidance of the object will reduce anxiety and of the object will reduce anxiety and reinforce the phobiareinforce the phobia

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Anxiety Disorders: Anxiety Disorders: related termsrelated terms

Obsession= an undesirable BUT Obsession= an undesirable BUT persistent thought or intrusive idea persistent thought or intrusive idea that is forced into conscious that is forced into conscious awarenessawareness

Compulsion= performance of an Compulsion= performance of an unwanted act or ritual that is unwanted act or ritual that is contrary to the person’s wishes or contrary to the person’s wishes or standard. The behavior is done in a standard. The behavior is done in a stereotypical and repetitive mannerstereotypical and repetitive manner

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Anxiety Disorders: Anxiety Disorders: related termsrelated terms

Obsessive -Compulsive disorderObsessive -Compulsive disorder Recurrent obsession and compulsion that Recurrent obsession and compulsion that

are severe enough to be time consuming are severe enough to be time consuming causing marked distress or impairment of causing marked distress or impairment of functionsfunctions

Proposed etiology: Biologic vulnerability, Proposed etiology: Biologic vulnerability, striatum dysfunction theory and genetic striatum dysfunction theory and genetic vulnerabilityvulnerability

The most common obsessions are repeated The most common obsessions are repeated thoughts about contamination, repeated thoughts about contamination, repeated doubtsdoubts

The most common compulsion involve The most common compulsion involve repeated hand-washing, counting, checkingrepeated hand-washing, counting, checking

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Anxiety Disorders: Anxiety Disorders: related termsrelated terms

Obsessive -Compulsive disorderObsessive -Compulsive disorder The client is WEL aware of his The client is WEL aware of his

unrealistic and inappropriate nature unrealistic and inappropriate nature of obsession and compulsionof obsession and compulsion

He uses the defense mechanisms of : He uses the defense mechanisms of : UNDOING and SYMBOLIZATION UNDOING and SYMBOLIZATION

Indulgence in obsessive thoughts and Indulgence in obsessive thoughts and performance of the behaviors causes performance of the behaviors causes temporary anxiety relief ( a primary temporary anxiety relief ( a primary gain) gain)

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Anxiety disordersAnxiety disorders

Post-traumatic stress disorders Post-traumatic stress disorders (PTSD) = characterized by the re-(PTSD) = characterized by the re-experiencing of the terror experiencing of the terror associated with a psychologically associated with a psychologically distressing event that was actually distressing event that was actually experienced at an earlier time. experienced at an earlier time.

Former names: hysteria, war shock, Former names: hysteria, war shock, battle fatiguebattle fatigue

The event is usually beyond the The event is usually beyond the breath of normal human experiencebreath of normal human experience

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Anxiety disordersAnxiety disorders

Post-traumatic stress disordersPost-traumatic stress disorders Major characteristics:Major characteristics:

1.1. Persistent recurrent and intrusive Persistent recurrent and intrusive thoughts, flashbacks, dreams and thoughts, flashbacks, dreams and intense psychological distressintense psychological distress

2.2. Avoidance behaviors Avoidance behaviors (depersonalization)(depersonalization)

3.3. Emotional numbing, hyper Emotional numbing, hyper vigilance and ANS arousal vigilance and ANS arousal

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Anxiety disordersAnxiety disorders

Generalized anxiety disorder= Generalized anxiety disorder= characterized by unrealistic or characterized by unrealistic or excessive anxiety, worry about excessive anxiety, worry about life circumstances life circumstances Chronic anxiety, apprehensive Chronic anxiety, apprehensive

worrying, about 6 monthsworrying, about 6 months Prevalence is 5 % in the general Prevalence is 5 % in the general

populationpopulation Women affected more than menWomen affected more than men

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Anxiety disordersAnxiety disorders

Panic Disorder= sudden, Panic Disorder= sudden, unanticipated intense anxiety unanticipated intense anxiety persisting for at least 1 monthpersisting for at least 1 month Profound fear and urge to escapeProfound fear and urge to escape Women more than men Women more than men With agoraphobia= anxiety attacks With agoraphobia= anxiety attacks

when in places or situation which when in places or situation which can be embarrassing can be embarrassing

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Nursing Process for Nursing Process for patients with Anxiety patients with Anxiety

DisordersDisorders AssessmentAssessment DiagnosisDiagnosis PlanningPlanning ImplementationImplementation EvaluationEvaluation

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Nursing Process for Nursing Process for patients with Anxiety patients with Anxiety

DisordersDisorders AssessmentAssessment

Process begins with a complete Process begins with a complete medical and physical examination to medical and physical examination to RULE out underlying physical and RULE out underlying physical and substance – related conditions substance – related conditions

Utilize the mental status Utilize the mental status examination examination

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Assessment: Anxiety Assessment: Anxiety DisordersDisorders

Assess activity process: Motor Assess activity process: Motor restlessness, ritualistic behavior, restlessness, ritualistic behavior, pacing, sleep pattern disturbances, pacing, sleep pattern disturbances, staying at home, avoidant behaviorsstaying at home, avoidant behaviors

Assess cognitive processes: Assess cognitive processes: maintains reality testing, maintains reality testing, verbalization of persistent thoughts, verbalization of persistent thoughts, nightmares nightmares

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Assessment: Anxiety Assessment: Anxiety DisordersDisorders

Assess Emotional process: fearful, Assess Emotional process: fearful, feeling of anxiety, nervousnessfeeling of anxiety, nervousness

Assess Interpersonal process: Assess Interpersonal process: strained relationshipsstrained relationships

Assess perception process: hyper-Assess perception process: hyper-alertness, low self-esteemalertness, low self-esteem

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Assessment: Anxiety Assessment: Anxiety DisordersDisorders

Physiologic AssessmentPhysiologic Assessment Tightness of stomachTightness of stomach TachycardiaTachycardia AnorexiaAnorexia PalpitationPalpitation Shortness of breathShortness of breath Feelings of exhaustion Feelings of exhaustion Motor restlessnessMotor restlessness AlertnessAlertness

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Nursing Diagnoses: Anxiety Nursing Diagnoses: Anxiety DisordersDisorders

Ineffective individual copingIneffective individual coping Altered role performanceAltered role performance Impaired social interactionImpaired social interaction Defensive copingDefensive coping Sleep pattern disturbancesSleep pattern disturbances Altered thought processAltered thought process AnxietyAnxiety FearFear PowerlessnessPowerlessness

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Planning: Anxiety Planning: Anxiety DisordersDisorders

The general nursing goals are to The general nursing goals are to help patients lower their anxiety, help patients lower their anxiety, develop functional pattern of develop functional pattern of adaptations and develop awareness adaptations and develop awareness of the effects of the disordersof the effects of the disorders

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Implementation: Anxiety Implementation: Anxiety DisordersDisorders

Foster Activity processFoster Activity process Allow the patient to carry out the Allow the patient to carry out the

anxiety-releasing rituals for them to anxiety-releasing rituals for them to develop securitydevelop security

Provide time-limit to individual rituals. Provide time-limit to individual rituals. Rituals may e schedule earlier so as not Rituals may e schedule earlier so as not

to disrupt any hospital activity to disrupt any hospital activity Help patient develop interests outside Help patient develop interests outside

himself by encouraging involvement in himself by encouraging involvement in activitiesactivities

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Implementation: Anxiety Implementation: Anxiety DisordersDisorders

Establish therapeutic relationship Establish therapeutic relationship with the clientwith the client Teach the patient about the Teach the patient about the

etiology, course and treatment of etiology, course and treatment of anxiety disordersanxiety disorders

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Implementation: Anxiety Implementation: Anxiety DisordersDisorders

Encourage verbalization of Encourage verbalization of concerns and feelingsconcerns and feelings Utilize appropriate communication Utilize appropriate communication

techniquestechniques Convey warm, friendly and emphatic Convey warm, friendly and emphatic

attitudeattitude Introduce relaxation techniques and Introduce relaxation techniques and

other positive anxiety management other positive anxiety management strategiesstrategies

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Implementation: Anxiety Implementation: Anxiety DisordersDisorders

Assist in Therapeutic modalities:Assist in Therapeutic modalities:

Cognitive and behavioral Therapy: Cognitive and behavioral Therapy: desensitizationdesensitization

Pharmacotherapy: use of the Pharmacotherapy: use of the anxiolytic drugs like anxiolytic drugs like benzodiazepinesbenzodiazepines

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Implementation: Anxiety Implementation: Anxiety DisordersDisorders

Cognitive-Behavioral Cognitive-Behavioral TherapyTherapyPsycho-Psycho-

educationeducationTeaching the client and Teaching the client and family about anxiety family about anxiety disordersdisorders

Continuous Continuous symptoms symptoms monitoringmonitoring

Utilizing a diary or Utilizing a diary or recording of symptomsrecording of symptoms

Breathing Breathing retrainingretraining

Teaching client how to Teaching client how to do abdominal breathing do abdominal breathing to control body to control body physiologic responsesphysiologic responses

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Implementation: Anxiety Implementation: Anxiety DisordersDisorders

Cognitive-Behavioral Cognitive-Behavioral TherapyTherapyCognitive- Cognitive-

restructuringrestructuringTeaching the client to Teaching the client to challenge the challenge the exaggerated worries and exaggerated worries and fears. fears.

Exposure to Exposure to triggering triggering anxiety anxiety

(desensitizati(desensitization)on)

Involves gradual Involves gradual exposure of the anxiety exposure of the anxiety provoking or fearful provoking or fearful event event

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Interventions for the client Interventions for the client with OCD with OCD

Convey acceptance of the clientConvey acceptance of the client Allow time to perform rituals because Allow time to perform rituals because

ANXIETY will increase if the client ANXIETY will increase if the client cannot perform the compulsive cannot perform the compulsive behaviorsbehaviors

Encourage LIMIT setting on Encourage LIMIT setting on ritualistic behaviorsritualistic behaviors

The best time to interact with client The best time to interact with client is AFTER completing the ritualistic is AFTER completing the ritualistic behaviorbehavior

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Interventions for the client Interventions for the client with OCD with OCD

Assist the client in listing all of Assist the client in listing all of the objects and places that the objects and places that trigger anxietytrigger anxiety

Introduce coping techniques to Introduce coping techniques to deal with the anxiety situationsdeal with the anxiety situations

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Interventions for the client Interventions for the client with PHOBIA with PHOBIA

DO NOT force the client to approach DO NOT force the client to approach the specific object or situationthe specific object or situation

Allow clients to verbalize feelings Allow clients to verbalize feelings prior to exposure to objectprior to exposure to object

HELP client identify coping HELP client identify coping measures to utilize whenever the measures to utilize whenever the object/ situation is encountered object/ situation is encountered

Practice relaxation with the clients Practice relaxation with the clients Participate in the desensitization Participate in the desensitization

therapytherapy

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Interventions for the client Interventions for the client with PTSD with PTSD

Validate with the client that the Validate with the client that the traumatic event can be experienced traumatic event can be experienced with a high anxiety responsewith a high anxiety response

Allow VERBALIZATION of feelings in Allow VERBALIZATION of feelings in all aspects of the traumatic eventsall aspects of the traumatic events

Teach the patient coping strategies Teach the patient coping strategies to manage symptoms of anxiety that to manage symptoms of anxiety that accompanies the memories of traumaaccompanies the memories of trauma

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EvaluationEvaluation

Client identifies own anxiety Client identifies own anxiety responsesresponses

Identifies stressors in past and Identifies stressors in past and current life situationscurrent life situations

Utilizes coping strategies rather Utilizes coping strategies rather than symptomatic behaviorsthan symptomatic behaviors

Identifies and actively participates Identifies and actively participates in continued treatment plan in continued treatment plan

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Anxiety-related DisordersAnxiety-related Disorders

Dissociative disordersDissociative disorders Somatoform disordersSomatoform disorders

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Anxiety-related DisordersAnxiety-related Disorders

Dissociative disordersDissociative disorders Alteration in conscious awareness Alteration in conscious awareness

which includes periods of which includes periods of forgetfulness, memory loss for past forgetfulness, memory loss for past stressful events and feelings stressful events and feelings disconnected form daily eventsdisconnected form daily events

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Anxiety-related DisordersAnxiety-related Disorders

Dissociative Dissociative disordersdisorders

CharacteristicsCharacteristics

Dissociative Dissociative amnesiaamnesia

Sudden inability to Sudden inability to recall important recall important personal personal informationinformation

Dissociative fugueDissociative fugue Sudden Sudden unexplained flight unexplained flight form home with an form home with an inability to recall inability to recall events from the events from the pastpast

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Anxiety-related DisordersAnxiety-related Disorders

Dissociative Dissociative disordersdisorders

CharacteristicsCharacteristics

Depersonalization Depersonalization disorderdisorder

Feeling detached Feeling detached from one’s from one’s thoughts and bodythoughts and body

Dissociative Dissociative identity disorderidentity disorder

Presence of two or Presence of two or more distinct more distinct personalities, each personalities, each with its own with its own pattern of pattern of perceiving, relating perceiving, relating to and thinking to and thinking about the about the environment environment

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Anxiety-related DisordersAnxiety-related Disorders

Dissociative Dissociative disordersdisorders

CharacteristicsCharacteristics

Dissociative Dissociative disorders not disorders not specifiedspecified

Disorder that does Disorder that does not fit the criterianot fit the criteria

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Dissociative DisordersDissociative Disorders

Etiology:Etiology:

1.1. Trauma= these disorders are Trauma= these disorders are generally associated with traumatic generally associated with traumatic events that the individual deals events that the individual deals with them by “splitting” or with them by “splitting” or dissociating self from the memorydissociating self from the memory

2.2. Abuse- severe traumatic abusive Abuse- severe traumatic abusive event during childhoodevent during childhood

More common in women than menMore common in women than men

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Dissociative DisordersDissociative Disorders

NURSING MANAGEMENTNURSING MANAGEMENT Establish a trusting relationship Establish a trusting relationship

and provide support during times and provide support during times of depersonalization and amnesiaof depersonalization and amnesia

Encourage client to disclose and Encourage client to disclose and discuss feelingsdiscuss feelings

Teach client to perform anxiety-Teach client to perform anxiety-reducing techniques when the reducing techniques when the painful events are re-experienced painful events are re-experienced

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Dissociative DisordersDissociative Disorders

NURSING MANAGEMENTNURSING MANAGEMENT

3. Pharmacotherapy: usually not 3. Pharmacotherapy: usually not employedemployed

4. Psychotherapy: psychodynamic 4. Psychotherapy: psychodynamic therapy with hypnosis to bring therapy with hypnosis to bring the conscious awareness of the the conscious awareness of the traumatic eventstraumatic events

5. Group therapy 5. Group therapy

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Psychosomatic DisordersPsychosomatic Disorders

Disorders characterized by somatic Disorders characterized by somatic complaints for which no organic complaints for which no organic cause could be demonstrated cause could be demonstrated

Usually result from emotional Usually result from emotional factorsfactors

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Psychosomatic DisordersPsychosomatic DisordersCharacteristics:Characteristics:

1.1. Involve the organ system innervate by Involve the organ system innervate by the autonomic nervous systemthe autonomic nervous system

2.2. Physiologic changes accompany Physiologic changes accompany emotional responses that are intenseemotional responses that are intense

3.3. Symptoms are physiological rather Symptoms are physiological rather than symbolic, the emotions beings than symbolic, the emotions beings expressed through the visceraexpressed through the viscera

4.4. Persistent psychosomatic reactions Persistent psychosomatic reactions may produce structural organic may produce structural organic changes over timechanges over time

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Psychosomatic DisordersPsychosomatic DisordersCharacteristics:Characteristics:

5. The somatic symptoms afford 5. The somatic symptoms afford generous secondary gains for generous secondary gains for the for the patients in terms of the for the patients in terms of attentionattention

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Somatoform disordersSomatoform disorders

Refer to a group of psychiatric Refer to a group of psychiatric disorders whose symptoms are disorders whose symptoms are severe enough to cause global severe enough to cause global impairmentimpairment

The clients often present with The clients often present with multiple, recurrent clinically multiple, recurrent clinically significant somatic complaints, significant somatic complaints, usually colorful and exaggerated usually colorful and exaggerated hut lacking in factual basis hut lacking in factual basis

Page 337: Psychiatric Nursing- Foundations

Somatoform disordersSomatoform disorders The condition is characterized by The condition is characterized by

PRIMARY GAIN (relief of anxiety) PRIMARY GAIN (relief of anxiety) and SECONDARY gain (special and SECONDARY gain (special attention)attention)

The individual becomes totally The individual becomes totally focused on the physical symptoms focused on the physical symptoms which can severely restrict activitieswhich can severely restrict activities

The person visits MULTIPLE health The person visits MULTIPLE health care providers and may undergo care providers and may undergo unnecessary proceduresunnecessary procedures

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Somatoform disordersSomatoform disorders

ETIOLOGIESETIOLOGIES

1. Psychodynamic theory= 1. Psychodynamic theory= utilization of the mechanism to utilization of the mechanism to convert psychic energy to convert psychic energy to physical manifestations. physical manifestations. Conversion represents the Conversion represents the symbolic resolution of the symbolic resolution of the anxietyanxiety

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Somatoform disordersSomatoform disorders

ETIOLOGIESETIOLOGIES

2. Neurobiologic theory- 2. Neurobiologic theory- neurotransmitter dysregulation. neurotransmitter dysregulation. There is deficient communication There is deficient communication between the brain hemisphere between the brain hemisphere resulting to difficult expression resulting to difficult expression of emotions, and distress is of emotions, and distress is expressed as physical symptomsexpressed as physical symptoms

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Somatoform disordersSomatoform disorders

ETIOLOGIESETIOLOGIES

3. SOCIO-cultural factors- higher 3. SOCIO-cultural factors- higher among low SESamong low SES

Page 341: Psychiatric Nursing- Foundations

Types of Somatoform Types of Somatoform disordersdisorders

TypesTypes CharacteristicsCharacteristics

Somatization Somatization DisorderDisorder

History of multiple History of multiple physical physical complaints without complaints without organic basisorganic basis

HypochondriasisHypochondriasis Unrealistic fear of Unrealistic fear of having a serious having a serious diseasedisease

Body dysmorphic Body dysmorphic disorderdisorder

Pre-occupation Pre-occupation with an imagined with an imagined defect in the defect in the normal appearing normal appearing person person

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Types of Somatoform Types of Somatoform disordersdisorders

TypesTypes CharacteristicsCharacteristics

Pain disorderPain disorder Chronic pain in Chronic pain in many anatomic many anatomic sitessites

Conversion Conversion disorderdisorder

Loss or change in Loss or change in physical physical functioning that functioning that cannot be cannot be associated with any associated with any organic cause and organic cause and seems to be seems to be associated with associated with psychosocial psychosocial stressorsstressors

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Somatoform disordersSomatoform disorders

NURSING MANAGEMENTNURSING MANAGEMENT

1.1. Mainstay treatment is a long term Mainstay treatment is a long term relationship with a health care relationship with a health care provider to prevent the patient provider to prevent the patient from seeking multiple providers from seeking multiple providers with multiple recommendationswith multiple recommendations

2.2. Assist in psychotherapy as part of Assist in psychotherapy as part of the treatment plan the treatment plan

3.3. Family EducationFamily Education