NCLEX-RN: Psychiatric Nursing

Psychiatric Nursing: Personality Disorders

Focus topic: Psychiatric Nursing

Definition: Disorders in which individual exhibits inflexible and maladaptive responses to stress, which produce dysfunctional behavioral problems.

Characteristics
A. Three major categories referred to as clusters: odd– eccentric, dramatic–emotional, and fearful–anxious.
B. Several traits are common to all three clusters.

  •  Lacks understanding of how his or her behavior affects others; lacks insight.
  • Cannot take responsibility for own behavior.
  •  When threatened, cannot change own behavior, but attempts to change environment.

C. Other general traits common to personality disorders:

  •  Experiences inadequate interactions with society and individuals.
    a. Difficulty in forming loving and lasting interpersonal relationships.
    b. Difficulty with authority, laws, and rules.
  •  Assets may be social skills—intelligence, charm, and manipulation.
  •  Experiences low tolerance for anxiety and inability to tolerate frustration—will go to great lengths to avoid increased intellectual and emotional demands that raise anxiety.
  •  A common characteristic is manipulation  influencing others or events to meet own needs without regard for others’ needs.

D. For specific personality types.

Implementation: Manipulative Behavior

A. Recognize characteristics of manipulative behavior—pervasive in all personality disorders.

  •  Uses bargains, threats, demands, or intimidation to get own way.
Psychiatric Nursing
  •  Shows ability to identify and use other people’s weaknesses for own benefit.
  •  Makes continuous, unrealistic demands.
  • Pits one individual against another (e.g., clients against staff) and primitive defense mechanism of splitting.
  •  Pretends to be helpless and sorry for behavior.
  •  Lies to gain sympathy of staff or other clients.
  •  Acts out even when given acceptable behavioral alternatives.
  •  Keeps all relationships on a superficial level.
  •  Uses flattery, charm, and excessive compliments to have needs met.
  •  Exploits the generosity of others.
  •  Identifies with staff or authority figure and acts as if he or she is not confined.
  •  Finds a way around the unit rules and expectations.
  •  Uses sexuality to gain control over others— may even approach the staff sexually.

B. Interventions for manipulative behavior.

  •  Set clear and realistic limits with appropriate consequences. Be consistent and firm in setting behavioral expectations and limits.
  •  Confront client about the manipulative behavior. Do not try to out manipulate client is a master at it.
  •  Reinforce adaptive behavior through positive feedback and realistic praise.
  •  Do not be influenced by client’s charming ways all directed toward manipulating you.
  •  Do not be intimidated by client’s behavior.
  •  Clearly and consistently communicate care plans and client’s behavior to other staff. Present a united front.
  •  Accept no flattery, gifts, or favors.

C. Impulsiveness and not taking responsibility for behavior are common with these disorders.

  •  Assist client to identify consequences of behavior.
  •  Begin a behavior modification plan in which all staff consistently implement consequences of behavior.

D. Poor social/interpersonal relationships.

  •  Form a therapeutic nurse–client relationship in which positive behavior is reinforced.
  •  Help to develop trust in relationship by being consistent and doing what you promise to do.
  •  Point out unrealistic expectations in relationships.

E. Low self-esteem, which may lead to selfdestructive behavior.

  •  Work with client to see assets, strengths, and positive attributes group feedback is useful for this intervention.

Psychiatric Nursing: PERSONALITY DISORDERS

Focus topic: Psychiatric Nursing

Psychiatric Nursing
  •  Use of cognitive behavior techniques (stopping negative thoughts) is useful.
  • Self-destructive behavior may necessitate a stable, safe, secure environment with clear expectations of behavior, firm limits, and strict consequences.

F. Aggressive behavior.

  •  Safe environment with strict limits for any unacceptable behavior.
  •  Anger management so client can differentiate feeling angry from behavioral expression of anger.

Implementation: Paranoia

A. Determine client’s degree of suspiciousness and mistrust of others.

  •  Assess client’s hostility toward others.
  •  Determine if delusions are present. Delusions include persecution, grandeur, and/or hypochondriasis.
    a. Delusions of grandeur: false belief that one is in a position of power, wealth, and prominence.
    b. Delusions of persecution: false belief that one is being pursued, followed, or intimidated by an opposing power.
  •  Evaluate client’s degree of insecurity, inadequate self-concept, and low self-esteem.
  •  Assess anxiety level and its impact on disorder.

B. Establish a trusting relationship.

  •  Be consistent and friendly despite client’s hostility.
  •  Avoid talking and laughing when client can see you but not hear you.
  •  If client is very suspicious, use a one-to-one relationship, not a group situation.
  •  Involve client in the treatment plan.
  • Give support by being nonpunitive.

C. Reduce client’s anxiety associated with interpersonal interactions.

  •  Avoid power struggles—do not argue with the client; arguing increases anxiety and hostility.
  •  Do not proceed too quickly with one to one nurse client relationship. Remember that a paranoid client is suspicious and mistrustful of others.
  • Be consistent and honest in approaches to client.

D. Help differentiate delusion from reality (refer to section on delusions).

  •  Do not explain away false ideas. Ideas are real to the client.
  • Avoid any attempt to disagree with delusion, as this action may reinforce it.
  •  Use reality testing when possible.
  •  Focus on reality situations in the environment.
  • Attempt to engage in activities that require concentration.

Psychiatric Nursing: Mood (Affective) Disorders

Focus topic: Psychiatric Nursing

Psychiatric Nursing: Bipolar Affective Disorders

Focus topic: Psychiatric Nursing

Definition: A group of mood disorders that include manic, hypomanic, and mixed episodes as well as depressed and cyclothymic episodes.

Psychiatric Nursing: Manic Episode of Bipolar Affective Disorder

Focus topic: Psychiatric Nursing

Definition: One manifestation of an affective disorder that involves mood swings of elation, euphoria, and grandiose behavior.

Characteristics
A. Specific etiology is unknown. May be related to a genetic predisposition to illness or to increased levels of dopamine and norepinephrine in the brain. Attempts are now being made to discover why Eskalith (lithium) is therapeutic in hopes of solving the mystery of manic illness.
B. Women experience this illness slightly more frequently than men. The lifetime risk of developing this illness is 1 2% of the population.
C. The first manic episode usually occurs before age 30 and, interestingly, is more common in the higher socioeconomic group.

Cyclothymic Disorder
A. Category of bipolar disorder but a milder form— no severe manic or major depressive episodes.
B. Diagnosis is after client has evidenced chronic
mood swings from hypomanic to depressive episodes for 2 years.

Hypomanic Disorder—Bipolar II
One or more hypomanic episodes and a number of depressive episodes.
A. Mild elation, euphoria, “high” a less extreme form of mania.
B. Mood swings are not severe enough to require hospitalization.
C. Therapeutic intervention and medication usually not necessary unless mood swings interfere with lifestyle.

Mixed Disorder (Manic–Depressive)—Bipolar I
One or more manic episodes and one or more depressive episodes.
A. Both manic and depressive episodes are experienced almost every day for a 3-week period.
B. Episodes are severe and require hospitalization.

Assessment: Manic Episode
A. Assess which stage of mania client is experiencing.

  • Mild elation: difficult to detect, as it may not progress. Persons are often referred to as “hypomanics.”
    a. Affect: feelings of happiness, freedom from worry, confidence, and non-inhibition.
    b. Thought: rapid association of ideas but with little evidence of introspection.
    c. Behavior: increased motor activity (person always “on the go”) and increased sexual drive.
  • Acute manic episode: symptoms more intensified and observable. Client usually requires hospitalization.
    a. Mood disturbance and lability: Mood is one of excessive euphoria. Expansive toward others, enthusiastic, and intrusive. Mood may change to one of irritability, annoyance, and even rage and violence. Mood swings may last for hours or days.
    b. Hyperactivity: motor restlessness and overindulgence in recreational, sexual, and other activities. Engages in sexual indiscretions and poor money management. Client uses poor judgment in planning and starting projects and is overoptimistic and unrealistic. Evidences disturbed sleep patterns, often going without sleep for days.
    c. Flight of ideas and pressured speech: Manic clients jump from one idea to another, using puns, jokes, and nuances in a continuous flow of loose and accelerated speech. Often, speech is loud, rapid, and inappropriate.
    d. Distractibility: Manic clients overly respond to environmental stimuli, switching focus rapidly from one stimulus to another.
    e. Distortion of self-esteem: Grandiose perceptions of one’s importance is common with an inflated self-esteem. Often this characteristic is manifested in delusions of grandeur (special relationship with God or the president).
  •  Delirium: state of extreme excitement. Person is disoriented, incoherent, agitated, and frenetic.
    a. May experience visual or olfactory hallucinations.
    b. Exhaustion, dehydration, injury, and death are real dangers and must be prevented by the nurse.

B. Determine if client requires hospitalization (depends on range of symptoms). C. Assess physical health.

  •  Poor sleep habits and no apparent fatigue.
  •  Poor nutrition.
  •  Poor or even bizarre habits of grooming.

Implementation
A. Maintain a safe environment.

  •  Reduce external stimuli: noise, people, and motion.
  •  Avoid competitive activities. (Mild exercise, group singing, and swimming are examples of therapeutic activities.)
  •  Redirect energy into short, useful activities.

B. Establish a nurse–client relationship.

  •  Maintain accepting, nonjudgmental attitude and create conditions where trust can develop in the relationship.
  •  Avoid entering into client’s playful, joking activity.
  •  Allow client to verbalize feelings, especially hostility.

C. Set realistic limits on behavior.

  •  Provide scope and limitations to behavior for a sense of security.
  •  Anticipate destructive behavior and set limits.
  • Be firm and consistent.
  •  Involve client in setting own limits.
    a. Gives client sense of control.
    b. Client fears inability to control own behavior.

D. Give attention to physical needs.

  •  Provide a high-calorie diet with vitamin supplements.
  •  Ensure adequate rest and sleep.

E. Limit decision making during acute phase.

Psychiatric Nursing: Depressive Disorders

Focus topic: Psychiatric Nursing

Definition: Another manifestation of affective disorder; symptoms range from a dysphoric, sad, or gloomy mood that is mild and only slightly debilitating to a pathological condition of overwhelming intensity and long duration. This disorder may be chronic or episodic but it involves no episodes of elation.

Characteristics
A. The most common of all psychiatric illnesses, and more common in women than men. Depression is a condition affecting up to 7% of the population, with 30% of those cases classified as severe. Lifetime prevalence is up to 16%.
B. Most common age for adult onset is between ages 25 and 44. Average age of onset is 32.
C. One cause is now thought to involve a genetic link; other possible causes are personality traits such as low self-esteem, neurochemical imbalances, and other biological factors. Lack of social support, widowhood, and seasonality are other associated factors.
D. Most acute depressive episodes are self-limiting and last from a few weeks to a few months.
E. More than half of those persons who experience a first episode go on to suffer a recurrence, although individuals seeking treatment often recover.

Major Depression/Unipolar Disorder
A. General characteristics.

  •  May be a single episode or recurrent (two or more) episodes.
  •  Symptoms of a major depressive episode usually develop over a period of days to weeks and represent a change in previous functioning.
  •  Episode may begin at any age and is twice as common in women.
  • The clinical picture of depression varies considerably, with no single symptom present in all clinical profiles.

B. Affective symptoms.

  •  Distinguished from grief reactions: Normal, self-limited reaction to obvious loss is labeled grief. Grief reactions are usually brief and milder than pathological depression.
  •  Majority of depressed people experience prolonged periods of sadness, feeling down, gloomy, or unhappy. This depressed mood tends to color the whole of a person’s life; it is pervasive and dominant.
  •  Loss of motivation: loss of interest in life and activities, feelings of hopelessness and helplessness, and suicidal thoughts.
    a. Suicide is the most serious complication. Suicide is the tenth leading cause of death in the United States.
    b. The highest risk is after some improvement.
  •  Vegetative behavior: Related to physical problems that include loss of energy, loss of libido, psychomotor retardation, or agitation. Individual experiences sleep problems (insomnia is more common) and appetite disturbance, usually anorexia.
  •  Cognitive problems: Persistent low self esteem is present, difficulty in concentrating, poor memory, and apparent occupation with inner thoughts. A pervasive sense of guilt and worthlessness is also present.
  • Physical complaints: A series of bodily complaints often accompany this illness, ranging from headaches and backaches to constipation and chest pain.

Dysthymic Disorder
A. Characterized by a chronic depressive syndrome (mild to moderate in degree) that is usually present for most of the day:

  •  Symptoms are present for at least 2 years.
  •  Depression may be episodic or constant.

B. Psychosis is not present.
C. Significant distress in social and occupational functioning.
D. Several of the following symptoms are usually present with this diagnosis.

  •  Low energy level.
  •  Loss of interest in pleasurable activities.
  • Pessimistic attitude toward the future; thoughts of suicide.
  •  Tearful, crying demeanor.
  •  Feelings of low self-esteem.
  • Decreased ability to concentrate.

Assessment: Depression Episode
A. Assess mood level (affect is sad, gloomy, or unhappy).
B. Evaluate behavior (slowed actions, diminished purposeful movement, decreased participation in usual activities anhedonia), and neglect of personal appearance).
C. Assess thought processes (slowed down until there is a paucity of thinking; content includes hopelessness, decreased ability to concentrate).
D. Evaluate attitudes (pessimistic and self-denigrating; focus is on the problems and uselessness of life).
E. Assess physical symptoms.

  • Usually a preoccupation with body and poor health.
  •  Weight loss, decreased appetite.
  •  Insomnia or excessive sleep.
  •  General malaise.

F. Determine social interaction patterns, which are reduced and inappropriate.

  •  Feelings of isolation.
  •  No contribution to interpersonal relationships.

G. Evaluate potential for suicide and perform suicide lethality assessment. Suicidal ideation, plan, and means should be assessed.

Psychiatric Nursing

Implementation
A. Provide a safe milieu and protect the client from self-injury (prevent suicide).
B. Provide a structured environment to mobilize the client.

  •  Allow time for daily activities.
  •  Stimulate recreational activity.
  • Reactivate interests outside of the client’s concerns.
  •  Motivate client for treatment.
  •  Introduce group and occupational therapy.

C. Build trust through a one-to-one relationship.

  •  Employ a supportive, unchallenging approach.
  •  Use accepting, nonjudgmental attitude and behavior.
  •  Show interest; listen and give positive reinforcement.
  •  Redirect the client’s monologue away from painful depressing thoughts.
  •  Focus on any underlying anger and encourage expression of it.

D. Build the client’s ego assets to increase his or her self-esteem.

  •  Lower standards to create successful experiences.
  •  Limit decision making with the severely depressed.
  •  Support use of defenses to alleviate suffering.

E. Be attentive to the client’s physical needs: Provide adequate nutrition, sleep, and exercise.
F. Monitor ECT treatments if ordered.

Psychiatric Nursing: Suicide

Focus topic: Psychiatric Nursing

Definition: Suicide is an act or instance of intentionally killing oneself. Fifteen percent of clients with mood disorder commit suicide.

Characteristics
A. Suicide is the tenth most common cause of death for all ages in the United States today and a leading cause of death among college and high school-aged youth and young adults.
B. Suicide statistics are probably low because of unknown cases such as car accidents.

  •  Suicide ranks fourth as the cause of death in the 15-to-40 age group.
  •  For every successful suicide, it is believed that there are five to ten attempted suicides.
  •  Women make more suicide attempts than men. Four times as many men as women actually commit suicide. Firearms, suffocation, and overdose are common methods.
  • Suicide is increasing in the adolescent and elderly age groups.

C. Factors that contribute to suicide attempts.

  •  The single most common cause is depression; alcohol is a common contributing factor.
  •  Another common cause is that individuals feel overwhelmed by problems in living.
  •  A final cause may be the attempt to communicate a message of hopelessness, anger, or distress to others.

D. Depressed clients, when severely ill, rarely commit suicide.

  •  They do not have the drive and energy to make a plan and follow it through when severely depressed.
  •  Danger period occurs when depression begins to lift.

E. Many individuals give warnings or messages through direct or indirect means. Many had seen a primary care provider within weeks of the suicide.
F. Accompanying symptoms range from depression, disorientation, and defiance to intense dependence on another.

Assessment
A. Recognize level of depression and potential for suicide (when depression begins to lift).
B. Determine presence of suicide ideation, means, plan, ability to complete plan.
C. Observe behavior closely as clues to potential suicide.
D. Listen to verbalization to determine what is meaningful for client.
E. Observe physical status so you can intervene if necessary (if client is not eating, sleeping, etc.).
F. Recognize ambivalence when client is considering suicide.

Implementation
A. Client safety is the first priority provide a safe environment to protect client from self-destruction.
B. Observe client closely at all times, especially when depression is lifting. If client is not hospitalized,monitor routinely and arrange for hospitalization if acuity increases.
C. Establish a supportive relationship, letting client know you are concerned for his or her welfare.
D. Encourage expression of feelings, especially anger.
E. Ask relevant questions that relate to potential suicide ideation (ideas): “Do you wish you were dead?” “Do you think you might do something about it? What?” “Have you taken any steps to prepare? What are they?”
F. Evaluate the lethality of a suicide plan (specificity of details, lethality of proposed method, and availability of means).
G. Recognize a continued desire to commit suicide by the client.
H. Focus on client’s strengths and successful experiences to increase client’s self-esteem.
I. Provide a structured schedule and involve client in activities with others.
J. Structure a plan for client to use as a means of coping when next confronted with suicidal ideation.
K. Help client plan for continued professional support after discharge.

FURTHER READING/STUDY:

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