Mood DisordersDefinition: Disturbances in mood manifested by extremesadness or extreme elationDepressive DisordersDefinition: Pathologic grief reactions ranging from mild tosevere statesSymptoms of Varying Degrees of DepressionA. Mild1. Feelings of sadness2. Difficulty concentrating and performing usualactivities3. Difficulty maintaining usual activity levelB. Moderate1. Feelings of helplessness and powerlessness2. Decreased energy3. Sleep pattern disturbances4. Appetite and weight changes5. Slowed speech, thought, movement (may also beagitated and hyperactive)6. Rumination on negative feelingsC. Severe1. Feelings of hopelessness, worthlessness, guilt,shame2. Despair3. Flat affect4. Indecisiveness5. Lack of motivation, anergia, and decreased concentration6. Change in physical appearance (slumped posture,unkempt)7. Suicidal thoughts8. Possible delusions and hallucinations9. Sleep and appetite disturbances10. Loss of interest in sexual activity11. ConstipationNursing AssessmentA. Determine type of depression.1. Exogenous: caused by a reaction to environmentalor external factors2. Endogenous: caused by an internal biologic deficiency(biogenic amines at receptor sites in thebrain)B. Determine the degree of depression.C. Determine current suicide risk (see Care of the SuicidalClient).D. Arrange for lab tests.1. Dexamethasone-suppression test (DST)a. It is an indirect marker of depression.b. It is considered positive (abnormal) if post-DSTcortisol level is greater than 5 mg/dL.2. Biogenic aminesa. A decreased serotonin is indicative of depression.b. A decreased norepinephrine level is indicative of

depression.Nursing Plans and InterventionsA. Directly ask client about feelings and plans to harmself.B. Implement suicide precautions if assessment indicatesrisk (see Care of the Suicidal Client).C. Monitor sleep, nutrition, and elimination patterns.D. Assist client with ADLs.E. Initiate interaction with client (use nondemandingapproach).F. Insist on participation in activities. Do not give the clienta choice about participating in activities; (e.g., “It’stime to go to the gym for basketball”).G. Observe for sudden elevation in mood; may indicateincreased risk for suicide.H. Assist client in identifying a support system.I. Encourage discussion of feelings of helplessness, hopelessness,loneliness, and anger.J. Administer antidepressant medication as indicated(Table 7-6).K. Sit in silence if client is nontalkative.L. Spend time with client and return when promised.Care of the Suicidal ClientSuicide PrecautionsA. Obtain history; a previous suicide attempt is a mostsignificant risk factor. Other risk groups include thosewith biologic and organic causes of depression, such assubstance abuse, organic brain disorders, or other medicalproblems.B. Be aware of the major warning signs of an impendingsuicide attempt:1. A client begins giving away his or her possessions.2. A previously depressed client becomes happy. He orshe has made the decision to commit suicide, is nolonger debating the possibility, and has figured outhow to accomplish the suicide.Evaluation of IntentA. Directly ask the client about his or her intent. Example:“Do you ever think about harming yourself?”B. If a client is currently contemplating suicide, ask abouthis or her plans for carrying out the attempt. Example:“Do you have a plan for harming yourself?”C. Identify the method chosen; the more lethal themethod, the higher the probability that an attempt isimminent. “What is your plan for harming yourself?”Example: A client mentions a shotgun and plans to putit to his head and pull the trigger.D. Determine the availability of the method chosen. If themethod is readily available, the attempt is more likely.Example: The client has a loaded shotgun in his room,so it is readily available.Nursing Interventions

A. Express concern for the client. Example: “I am veryconcerned that you are feeling so bad that you want toharm yourself.”B. Tell the client that you will share this information withthe staff. Example: “I need to share this with the staff sothat we can provide for your safety until you are feelingbetter.”C. Offer the client hope. Example: “You’re feeling bad at thismoment, but these feelings will pass. We have medicationsand treatments that can help you through the bad times.”D. Stay with the client. Never leave a suicidal client alone.Legally, the nurse should follow the policy of the institutionregarding suicidal clients and should be able todemonstrate that these policies were carried out. Followthe agency policy regarding the removal of potentiallyhazardous objects such as razors, etc.Bipolar Disorder, or Manic-DepressiveIllnessA. It is an affective disorder that is manifested by moodswings involving euphoria, grandiosity, and an inflatedsense of self-worth. This disorder may or may notinclude sudden swings to depression.B. In order to be diagnosed with a bipolar disorder, accordingto the DSM-IV-TR classification, a client must haveat least one episode of major depression. A client maycycle, going from elevation to depression, with periodsof normal activity in between.Characteristics of Varying Degrees of ManiaA. Mild1. Feeling of being on a high2. Feelings of well-being3. Minor alterations in habits4. Usually does not seek treatment because of pleasurableeffectB. Moderate1. Grandiosity2. Talkativeness3. Pressured speech4. Impulsiveness5. Excessive spending6. Bizarre dress and groomingC. Severe1. Extreme hyperactivity2. Flight of ideas3. Nonstop activity (e.g., running, pacing)4. Sexual acting out; explicit language5. Talkativeness6. Overresponsiveness to external stimuli7. Easily distracted8. Agitation and possibly explosiveness9. Severe sleep disturbance

10. Delusions of grandeur or persecutionNursing AssessmentA. Determine level of depression exhibited (Symptoms ofVarying Degrees of Depression, p. 320).B. Determine level of mania exhibited (Characteristics ofVarying Degrees of Mania, p. 322).C. Assess nutrition and hydration status.D. Assess level of fatigue.E. Assess danger to self and others in relation to level ofimpulse impairment present.Nursing Plans and InterventionsA. Maintain client’s physical health: Provide nutrition,rest, and hygiene.B. Provide safe environment (grandiose thinking and poorimpulse control can result in accidents and/or altercationswith other clients).C. Decrease environmental stimulation (e.g., place in privateroom or seclusion room).D. Implement suicide precautions if assessment indicates risk.E. Use consistent approach to minimize manipulativebehavior.F. Use frequent, brief contacts to decrease anxiety.G. Implement constructive limit setting.H. Avoid giving attention to bizarre behavior (e.g., dressand language).I. Try to meet needs as soon as possible to keep clientfrom becoming aggressive.J. Provide small, frequent feedings of food that can becarried (e.g., small finger sandwiches).K. Engage in simple, active, noncompetitive activities.L. Avoid distracting or stimulating activities in the eveningto help promote sleep and rest.M. Praise self-control, acceptable behavior.N. Promote family involvement in therapy, teaching, andmedication compliance.O. Administer lithium, sedatives, and antipsychotics asprescribed (Table 7-7).

Thought DisordersSchizophreniaDescription: Psychiatric disorder characterized by thoughtdisturbance, altered affect, withdrawal from reality, regressivebehavior, difficulty with communication, and impairedinterpersonal relationships (see Types of Schizophrenia) aswell as an impaired ability to perceive reality.Types of SchizophreniaA. Catatonic1. Stupor (decrease in reaction to the environment) ormutism

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2. Rigidity (maintenance of a posture against efforts tobe moved)3. Posturing (waxy flexibility)4. Negativism (resistance to instructions)5. Excitement (severely agitated, out of control)6. Potential for violence to self or others during stuporor excitementB. Disorganized1. Incoherence2. Flat or inappropriate affect3. Disorganized, uninhibited behavior4. Unusual mannerisms5. Socially withdrawn6. No delusions presentC. Paranoid1. Systematized delusions, hallucinations related to asingle theme, or both2. Ideas of reference (misconstruing trivial events andremarks by giving them personal significance)3. Potential for violence if delusions are acted uponD. Residual1. Socially withdrawn2. Inappropriate affect3. Eccentric or peculiar behavior4. Absence of prominent delusions and hallucinations5. No current psychotic behavior exhibitedE. Undifferentiated1. Prominent delusions and hallucinations2. Incoherence and grossly disorganized behaviors3. Failure to meet any of the criteria for the other typesNursing AssessmentA. Assess for disturbance in thought process.1. Interpret content of internal and external stimuli.a. Symbolism: meaning given to words by client toscreen thoughts and feelings that would be difficultto handle if stated directlyb. Delusions: fixed false beliefs that may be persecutory,grandiose, religious, or somatic in naturec. Ideas of reference: belief that conversations oractions of others have reference to the client2. Note form: construction of verbal communication.a. Looseness of association: lack of clear connectionfrom one thought to the nextb. Tangential or circumstantial speech: failing toaddress the original point, giving many nonessentialdetailsc. Echolalia: constantly repeating what is heardd. Neologism: creating new wordse. Preservation: repeating same word or phrase inresponse to different questionsf. Word salad: speaking a jumbled mixture of realand made-up words3. Note process: flow of thoughts.

a. Blocking: gap or interruption in speech due toabsent thoughtsb. Concrete thinking: thinking based on fact versusabstract and intellectual pointsB. Assess for disturbance in perception.1. Hallucinations: false sensory perception, usuallyauditory or visual in nature2. Illusions: misinterpretation of external environment3. Depersonalization: perceives self as alienated ordetached from real body4. Delusions: false, fixed beliefs that cannot be changedby reasonC. Assess for disturbance in affect (feelings or mood).1. Blunted or flat2. Inappropriate3. Incongruent with context of situation or eventD. Assess for disturbance in behavior.1. Incoherent and disorganized2. Impulsive, uninhibited3. Posturing, unusual mannerisms4. Social withdrawal, neglect of personal hygiene5. Exhibiting echopraxia: repetition of another person’smovementsE. Assess for disturbance in interpersonal relationships.1. Difficulty establishing trust2. Difficulty with intimacy3. Fear and ambivalence toward othersNursing Plans and InterventionsA. Establish trust.B. Sit with mute clients.C. Provide safe and secure environment.D. Assist with physical hygiene and ADLs.E. Use matter-of-fact, nonjudgmental approach.F. Use clear, simple, concrete terms when talking with client.G. Accept and support client’s feelings; use clarification.H. Reinforce congruent thinking. Stress reality.I. Avoid arguing and avoid agreeing with inaccuratecommunications.J. Set limits on behavior.K. Avoid stressful situations.L. Structure time for activities so as to limit time forwithdrawal.M. Encourage client to identify positive characteristicsrelated to self.N. Praise socially acceptable behavior.O. Avoid fostering a dependent relationship.P. Promote family involvement in therapy, teaching, andmedication compliance.Delusional DisordersDescription: Characterized by suspicious, strange behavior,which can be precipitated by a stressful event and can

manifest as an intense hypochondriasisNursing AssessmentA. Determine degree of suspiciousness and mistrust ofothers.B. Assess degree of anxiety.C. Determine whether delusions are present.1. Reference or control2. Persecution3. Grandeur4. Somatic5. JealousyD. Assess degree of insecurity.Substance AbuseDescription: Regular use of substances that affect the centralnervous system, resulting in behavioral changes; thechemicals involved produce physiologic and psychologicaldependence.AlcoholismThis is a drinking pattern that interferes with physical,social, familial, vocational, and emotional functioning.Nursing AssessmentA. Patterns indicative of alcoholism:1. Episodic drinking (binges)2. Continuous drinking3. Morning drinking4. Increase in family fighting about drinking5. Increase in absences from work or school, especiallyMondays6. Blackouts7. Hiding drinking pattern8. Legal problems, such as drinking under the influence(DUI)9. Health problems such as gastritis10. Defense mechanisms: denial, projection, andrationalizationB. Family history of alcoholism or substance abuseC. Dependency, yet resentfulness of authorityD. Impulsive, abusive behaviorE. Impaired judgment, memory lossF. Incoordination, slurred speechG. Mood varying between euphoria and depressionH. Intoxication as determined by blood alcohol level(BAL; 0.10% or greater is considered intoxication.)I. Previous experience with treatment centers or AlcoholicsAnonymous (AA)J. Alcohol withdrawal symptoms:1. Begin shortly after drinking stops, as early as 4 to 6hours after2. Anxiety, nausea, insomnia, tremors, hyperalertness,and restlessness3. Sudden or gradual increase in all vital signs (autonomichyperactivity)

4. Delirium tremens (DTs); may appear 12 to 36 hoursafter last drink:a. Tachycardia, tachypnea, diaphoresisb. Marked tremorsc. Hallucinationsd. Paranoia5. Grand mal seizures (possible)K. Chronic alcohol-related illnesses:1. Chronic gastritis2. Cirrhosis and hepatitis3. Korsakoff syndrome: organic syndrome that frequentlyfollows DTs; associated with chronic alcoholism4. Wernicke syndrome: a severe disorder (encephalopathy)occurring in chronic alcoholics; probably dueto a deficiency of vitamin B1 (thiamine); may escalateKorsakoff syndrome; is treated with thiaminechloride5. Malnutrition and dehydration6. Pancreatitis7. Peripheral neuropathyNursing Plans and InterventionsA. Maintain safety, nutrition, hygiene, and rest.B. Implement suicide precautions if assessment indicatesrisk.C. Provide care during withdrawal.1. Monitor vital signs, I&O, electrolytes.2. Observe for impending DTs.3. Prevent aspiration; implement seizure precautions.4. Reduce environmental stimuli.5. Medicate with antianxiety medication, usually Libriumor Ativan (see Table 7-4).6. Provide high-protein diet and adequate fluid intake(limit caffeine).7. Provide vitamin supplements, especially vitamins B1and B complex.8. Provide emotional support.D. Rehabilitation:1. Use direct, matter-of-fact, nonjudgmental attitude.2. Confront denial and rationalization (main copingstyles used by alcoholics).3. Confront manipulations; set firm limits on behavior.4. Set short-term, realistic goals.5. Help increase self-esteem.6. Explore ways to increase frustration tolerance withoutalcohol.7. Identify ways to decrease loneliness.8. Encourage client to accept responsibility for ownbehavior.9. Identify availability of support systems (family,friends, church, AA).10. Identify activities and friendships not related todrinking.

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11. Provide group and family therapy; refer family toAl-Anon family groups or Alateen.E. Provide client and family teaching regarding the sideeffects of disulfiram (Antabuse) if it is used as a deterrentto drinking (Table 7-11).Drug AbuseDescription: State of dependency produced by repeated useof a substance that causes altered perception or mood, or bothNursing AssessmentA. Pattern of drug use1. What drugs are used?2. What is the drug of choice?3. How much is used and how often?4. How long has the drug been used?B. Physical evidence of drug usage1. Needle track marks2. Cellulitis at puncture site3. Poor nutritional status4. Inflammation of nasal passagesC. Possible causes of drug dependency1. Desire to escape reality and problems2. Low self-esteem3. Peer or culture pressure4. Inherent susceptibility to drug dependenceD. Symptoms of withdrawal and overdose are specific forthe drug used (Table 7-12).Nursing Plans and InterventionsA. Assess level of consciousness and vital signs. (Rapidwithdrawal can be fatal for persons addicted to barbiturates,antianxiety medications, and hypnotics.)B. Monitor I&O and electrolytes.C. Implement suicide precautions if assessment indicatesrisk.D. Provide adequate nutrition, hydration, and rest.E. Administer medications according to detoxificationprotocol of medical unit.F. Phenothiazines may be used to decrease the discomfortof withdrawal.G. Confront denial (main coping style used by substanceabusers).1. Focus on substance abuse problem.2. Confront the placing of blame on external problems.H. Reinforce reality in simple, concrete terms.I. Encourage verbal expression of anger and depression.J. Assist with identification of stressors and areas ofconflict.K. Encourage exploration of alternative coping strategies.L. Positively reinforce insight into behavior patterns.M. Help identify an appropriate support system.

N. Provide support to significant others.O. Teach danger of acquired immune deficiency syndrome(AIDS) and other blood-related diseases.AbuseChild AbuseDescription: Includes physical and mental injury, sexualabuse, and neglectNursing AssessmentA. Most important indicators of child abuse:1. Injuries not congruent with the child’s developmentalage or skills2. Injuries not correlated with the stated cause3. Delay in seeking medical careB. Bruises in unusual places and in various stages ofhealingC. Bruises, welts caused by belts, cords, etc.D. Burns (cigarette, iron); immersion burns (symmetricalin shape)E. Whiplash injuries caused by being shakenF. Bald patches where hair has been pulled outG. Fractures in various stages of healingH. Failure to thrive, unattended-to physical problemsI. Torn, stained, bloody underclothesJ. Lacerations of external genitaliaK. Bedwetting, soilingL. Sexually transmitted diseasesM. Parent seeing child as “different” from other childrenN. Parent using child to meet own needsO. Parent seldom touching or responding to child; may bevery critical of childP. Child appearing frightened and withdrawn in the presenceof parent or other adultQ. Family history of frequent moves, unstable employment,marital discord, and family violenceR. One parent answering all the questionsNursing Plans and InterventionsA. Nurses are legally required to report all cases of suspectedchild abuse to the appropriate local or state agency.B. Take color photographs of injuries.C. Document factual, objective statements about child’sphysical condition, child–family interactions, and interviewswith family.D. Establish trust, and care for the child’s physical problems;these are the primary and immediate needs ofthese children.E. Recognize own feelings of disgust and contempt for theparents.F. Utilize principles of crisis intervention.G. Assist child and family to develop self-esteem.H. Teach basic child development and parenting skills to

family.I. Support the need for family therapy.Intimate-Partner ViolenceA. It is a criminal act of physical, emotional, economic,or sexual abuse between an assailant and a victim whomost commonly are, or were, in an intimate relationship(may be married or dating).B. Abuse is usually a tension-releasing action as well as alack of impulse control.C. Assailant may come from a family in which batteringand physical violence were present.D. Persons act more violently when drinking or usingdrugs.E. The relationship is usually characterized by extremejealousy and issues of power and control.F. Women in a battering relationship may lack self-confidenceand feel trapped. They may be embarrassedabout their situation, which results in isolation anddependency on the abuser.G. Abuse often begins during pregnancy or occurs morefrequently during pregnancy.Nursing AssessmentA. Delay between time of injury and time of treatmentB. Anxious when answering questions about injuryC. Abdominal injuries during pregnancyD. Looks to abuser for answers to questions related toinjuriesE. Depression or suicidal ideationF. Feeling of responsibility for “provoking” partnerG. Low self-esteemH. Abrasions, cuts, lacerations, sprains, black eyesI. Psychosomatic (somatoform) complaintsJ. Concurrent use of alcohol, drugsNursing Plans and InterventionsA. Establish trust; use nonjudgmental approach.B. Treat physical wounds and injuries.C. Document factual, objective statements about client’sphysical condition, injuries, and interaction with partneror family.D. Determine potential for further violence.E. Provide crisis intervention.F. Assist with referral to shelter if necessary or desired,with adult’s consent.G. Assist client with contacting authorities if charges areto be pressed.H. Interview abused partner when the abuser is notpresent.Elder AbuseA. It is an act that causes physical, verbal, financial, or psychosocialinjury or exploitation as well as the physicalneglect of an older adult.

B. Abuse of older adults is underreported; the estimatednumber varies from 1% to 10% of the olderpopulation.C. The majority of the abuse is committed by spouses andchildren but other caregivers are guilty too.Nursing AssessmentA. Bruises on the upper arms (bilateral, resulting frombeing shaken)B. Broken bones caused by falls (resulting from beingpushed)C. Dehydration or malnourishmentD. OvermedicationE. Poor physical hygiene, improper medical careF. Withdrawn behavior, feelings of hopelessness, helplessnessG. Behavior that may be demanding, belligerent, andaggressiveH. Repeated visits to health care agency for injuries andfallsI. Injuries that do not correlate with stated causeJ. Misuse of money by children or legal guardiansNursing Plans and InterventionsA. Establish trust; use nonjudgmental approach.B. Meet physical needs, treat wounds and injuries.C. Document factual, objective statements about client’sphysical condition, injuries, and interaction with significantother and family.D. Report suspected abuse to the appropriate local orstate authorities.E. Arrange community resources to provide “respite care”for the caregiver.F. Arrange visiting nurses, nutrition services, or adult daycare if possible.Rape and Sexual AssaultDefinition: Crime involving lack of consent, force, and sexualpenetration; an act of aggression, not passionNursing AssessmentA. Physical assessment with careful documentation ofinjuriesB. Emotional status: self-blame, anxiety, fear, humiliation,disbelief, and angerC. Coping behaviorsD. Identification of support systemE. Details of the assaultNursing Plans and InterventionsA. Communicate nonjudgmental acceptance.B. Provide physical care to treat injuries.C. Give clear, concise explanations of all procedures to beperformed.D. Document factual objective statements of physical assessment;record client’s exact words in describing the assault.

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E. Notify police and encourage victim to prosecute.F. Collect and label evidence carefully in the presence ofa witness.G. Notify rape crisis team or counselor if available in thecommunity.H. Allow discussion of feelings about the assault.I. Advise of potential for venereal disease, pregnancy, andhuman immunodeficiency virus (HIV).J. Provide information about medical care available.K. Support client, family, and friends.Organic DisordersDescription: Abnormal psychological or behavioral signsand symptoms that occur as a result of cerebral disease,systemic dysfunction, or use of or exposure to exogenoussubstances.Delirium Description: Acute processthat, if treated, is usuallyreversible. It is recognized byits sudden onset.A. It occurs in response to aspecific stressor, such as:1. Infection2. Drug reaction3. Substance intoxicationor withdrawal4. Electrolyte imbalance5. Head trauma6. Sleep deprivationB. The treatment of choiceis the correction of thecausative disorder.DementiaDescription: Cognitiveimpairments characterized bygradual, progressive onset; it isirreversible. Judgment, memory,abstract thinking, and socialbehavior are affected. Someexamples of symptoms areaphasia, apraxia, and agnosia.A. It is most commonlyseen in:1. Alzheimer’s disease(Table 7-13)2. Multi-infarctions(brain)B. It also occurs in:1. Huntington’s chorea2. Parkinson’s disease3. Multiple sclerosis andbrain tumors4. Wernicke-Korsakoff

syndrome (chronicalcoholics)Nursing AssessmentA. Limited attention span, easily distractedB. Confusion and disorientation, impaired judgmentC. Delusions, visual hallucinations, or sensory illusionsD. Labile affect; sudden angerE. Anxiety and depressionF. Loss of recent and remote memoryG. Confabulation (making up responses, stories to fill inlost memory)H. Impaired coordinationI. Increased psychomotor activityJ. Slurring of speechK. Decreased personal hygieneL. Sleep deprivation, day–night reversalM. Incontinence and constipationNursing Plans and InterventionsA. Provide safe, consistent environment.B. Maintain health, nutrition, safety, hygiene, and rest.C. Assist with ADLs.D. Provide support to client and family.E. Provide routine in daily activities.F. Mark the bathroom clearly.G. Reorient the client as needed.H. Use simple, direct statements.I. See Dementia in Gerontologic Nursing, p. 348, foradditional interventions.Childhood and Adolescent DisordersAttention-Deficit (Hyperactivity) Disorder(ADD/ADHD)Description: Developmentally inappropriate attention,impulsiveness, and hyperactivityNursing AssessmentA. Physical assessmentB. More prevalent in boysC. Failure to listen to and follow instructionsD. Difficulty playing quietly and sitting stillE. Disruptive, impulsive behaviorF. Distractibility to external stimuliG. Excessive talkingH. Shifting from one unfinished task to anotherI. Underachievement in school performanceNursing Plans and InterventionsA. Decrease environmental stimuli.B. Set limits on behavior when indicated.C. Provide a safe, comfortable environment.D. Initiate a behavior contract to help child manage ownbehavior.E. Administer medications as prescribed (Table 7-14).Conduct and Oppositional DefiantDisorders

Definition: Conduct disorder is an antisocial behavior characterizedby violation of laws, societal norms, and the basicrights of others without feelings of remorse or guilt.Definition: Oppositional defiant disorder is characterizedby behavior that fails to adhere to established norms butdoes not violate the rights of others.Nursing Assessment: Conduct DisorderA. Physical fightingB. Running away from homeC. Lying, stealingD. Cruelty to animalsE. Frequent truancyF. Vandalism, arsonG. Use of alcohol, drugsNursing Assessment: Oppositional Defiant DisorderA. ArgumentativenessB. Blaming others for own problemsC. Defying rules and authorityD. Using obscene languageE. Acting resentful, vindictiveDefiant DisordersA. Assess verbal and nonverbal cues for escalating behaviorso as to decrease outbursts.B. Use a nonauthoritarian approach.C. Avoid asking “why” questions.D. Initiate a “show of force” with a child who is out ofcontrol.E. Use a “quiet room” when external control is needed.F. Clarify expressions or jargon if meanings are unclear.G. Teach to redirect angry feelings to safe alternative, suchas a pillow or punching bag.H. Implement behavior modification therapy if indicated.I. Role-play new coping strategies with client.

Nurse Joseph Bahian Abang