NCLEX: Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span

Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span: Bipolar Disorders

Focus topic: Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span

Bipolar disorders are major emotional illnesses characterized by mood swings, alternating from depression to elation, with periods of relative normality between episodes. Most persons experience a single episode of manic or depressed type; some have recurrent depression or recurrent mania or mixed. There is increasing evidence that a biochemical disturbance may exist and that most individuals with manic episodes eventually develop depressive episodes.

Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span: Psychiatric Emergencies*

Focus topic: Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span

I. DEFINITION: sudden onset (days or weeks, not years) of unusual (for that individual), disordered (without pattern or purpose), or socially inappropriate behavior caused by emotional or physiological situation. Examples include: suicidal feelings or attempts, overdose, acute psychotic reaction, acute alcohol withdrawal, acute anxiety.

Focus topic: Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span


Focus topic: Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span

A. Assessment: the presence of great distress without reasonable explanation; extreme behavior in comparison with antecedent event.

Focus topic: Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span

  • Fear—related to a particular person, activity, or place.
  • Anxiety—fearful feeling without any obvious reason, not specifically related to a particular person, activity, or place (e.g., adolescent turmoil).
  • Depression—continual pessimism, easily moved to tears, hopelessness, and isolation (e.g., student despondency around examination time, middleage crisis, elderly who feel hopelessness).
  • Mania—unrealistic optimism.
  • Anger—many events seen as deliberate insults.
  • Confusion—diminished awareness of who and where one is; memory loss.
  • Loss of reality contact—hallucinations or delusion (as in acute psychosis).
  • Withdrawal—neglect or giving away of belongings and neglect of appearance; loss of interest in activities; apathy.

B. Analysis/nursing diagnosis: ineffective individual coping related to degree of seriousness:

Focus topic: Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span

  • Life-threatening emergencies—violence toward self or others (e.g., suicide, homicide).
  • Serious emergencies—confused and unable to care for or protect self from dangerous situations (as in substance abuse).
  • Potentially serious emergencies—anxious and in pain; disorganized behavior; can become worse or better (as in grief reaction).

C. General nursing care plan/implementation:

Focus topic: Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span

  • Remove from stressful situation and persons.
  • Engage in dialogue at a nonthreatening distance, to offer help.
  • Use calm, slow, deliberate approach to relieve stress and disorganization.
  • Explain what will be done about the problem and the likely outcome.
  • Avoid using force, threat, or counter threat.
  • Use confident, firm, reasonable approach.
  • Encourage client to relate.
  • Elicit details.
  • Encourage ventilation of feelings without interruption.
  • Accept distortions of reality without arguing.
  • Give form and structure to the conversation.
  • Contact significant others to gain information and to be with client, including previous therapist.
  • Treat emergency as temporary and readily resolved.
  • Check every half hour if cannot remain with client.

Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span


Focus topic: Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span

A. Acute nonpsychotic reactions, such as acute anxiety attack or panic reaction.

Focus topic: Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span

  • Assessment includes differentiating hyperventilation that is anxiety-connected from asthma, angina, and heart disease.
  • Nursing care plan/implementation in hyperventilation syndrome—goal: prevent paresthesia, tetanic contractions, disturbance in awareness; reassure client that vital organs are not impaired.
    a. Increase CO2 in lungs by rebreathing from paper bag.
    b. Minimize secondary gains; avoid reinforcing behavior.
    c. Health teaching: demonstrate how to slow down breathing rate.
  • Evaluation/outcome criteria: respirations slowed down; no evidence of effect of hyperventilation.

B. Delirium—conditions produced by changes in the cerebral chemistry or tissue by metabolic toxins, direct trauma to the brain, drug effects, or withdrawal.

Focus topic: Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span

  • Acute alcohol intoxication.
    a. Assessment: signs of head or other injury (past and recent), emotional lability, memory defects, loss of judgment, disorientation.
    b. Nursing care plan/implementation:
    (1)Observe, monitor vital signs.
    (2) Prevent aspiration of vomitus by positioning.
    (3)Decrease environmental stimuli:
    (a) Place in quiet area of emergency department.
    (b)Speak and handle calmly.
    (4)Give medication (benzodiazepines) to control agitation.
    c. Evaluation/outcome criteria: oriented to time, place, person; appears calmer.
  • Hallucinogenic drug intoxication—LSD, mescaline, amphetamines (e.g. speed), cocaine, scopolamine, and belladonna.
    a. Assessment:
    (1)Perceptual and cognitive distortions (e.g., feels heart stopped beating).
    (2) Anxiety (apprehension → panic).
    (3)Subjective feelings (omnipotence → worthlessness).
    (4) Interrelationship of dose, potency, setting, expectations and experiences of user.
    (5)Eyes: red—marijuana; dilated—LSD, mescaline, belladonna; constricted—heroin and derivatives.
    b. Nursing care plan/implementation:
    (1) “Talk down.”
    (a) Establish verbal contact, attempt to have client verbally express what is
    being experienced.
    (b)Environment—few people, normal lights, calm, supportive.
    (c) Allay fears.
    (d)Encourage to keep eyes open.
    (e) Have client focus on inanimate objects in room as a bridge to reality contact.
    (f) Use simple, concrete, repetitive statements.
    (g) Repetitively orient to time, place, and temporary nature.
    (h)Do not moralize, challenge beliefs, or probe into lifestyle.
    (i) Emphasize confidentiality.                                                                            (2)Medication (minor tranquilizer or benzodiazepines):
    (a) Allay anxiety.
    (b)Reduce aggressive behavior.
    (c) Reduce suicidal potential; check client every 5 to 15 minutes.
    (d)Avoid anticholinergic crisis (precipitated by use of phenothiazines, belladonna, and scopolamine ingestion) with 2 to 4 mg IM or PO of physostigmine salicylate.
    (3)Hospitalization: if hallucinations, delusions last more than 12 to 18 hours; if client has been injecting amphetamines for extended time; if client is paranoid and depressed.
    c. Evaluation/outcome criteria: less frightened; oriented to time, place, person.
  • Acute delirium—seen in postoperative electrolyte imbalance, systemic infections, renal and hepatic failure, over sedation, metastatic cancer.
    a. Assessment:
    (1)Disorientation regarding time, at night.
    (2)Hallucinations, delusions, illusions.
    (3) Alterations in mood.
    (4) Increased emotional lability.
    (5) Agitation.
    (6)Lack of cooperation.
    (8)Sleep pattern reversal.
    (9) Alterations in food intake.
    b. Nursing care plan/implementation:
    (1) Identify and remove toxic substance.
    (2)Reality orientation—well-lit room; constant attendance to repetitively inform of
    place and time and to protect from injury to self and others.
    (3)Simplify environment.
    (4)Avoid excessive medication and restraints; use low-dose phenothiazines; do not give barbiturates or sedatives (these increase agitation, confusion, disorientation).
    c. Evaluation/outcome criteria: oriented to time, place, person; cooperative; less agitated.

C. Acute psychotic reactions—disorders of mood or thinking characterized by hallucinations, delusions, excessive euphoria (mania), or depression.

Focus topic: Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span

  • Acute schizophrenic reaction.
    a. Assessment:
    (1)History of previous hospitalization, illicit drug ingestion; use of major tranquilizers and recent withdrawal from them or alcohol.
    (2)Auditory hallucinations and delusions.
    (3)Violent, assaultive, suicidal behavior directed by auditory hallucinations.(4)Assault, withdrawal, and panic related to paranoid delusions of persecution; fear of harm.
    (5)Disturbance in mental status (associative thought disorder).
    b. Nursing care plan/implementation:
    (2)Medication: phenothiazines or atypical antipsychotics.
    (3)Avoid physical restraints or touch when fears and delusions of sexual attack exist.
    (4) Allow client to diffuse anger and intensity of panic through talk.
    (5)Use simple, concrete terms, avoid figures of speech or content subject to multiple interpretations.
    (6)Do not agree with reality distortions; point out that client’s thoughts are difficult to understand but you are willing to listen.
    c. Evaluation/outcome criteria: does not hear frightening voices; less fearful and combative behavior.
  • Manic reaction.
    a. Assessment:
    (1)History of depression requiring antidepressants.
    (2) Thought disorder (flight of ideas, delusions of grandeur).
    (3) Affect (elated, irritable, irrational anger).
    (4)Speech (loud, pressured).
    (5) Behavior (rapid, erratic, chaotic).
    b. Nursing care plan/implementation:
    (1)Hospitalization to protect from injury to self and others.
    (2)Medication: lithium carbonate. An atypical antipsychotic may be used as an adjunct medication for acute mania.
    (3)Same as for acute schizophrenic reaction, except do not encourage talk, because of need to decrease stimulation.
    (4)Provide food and fluids that can be consumed while “on the go.”
    c. Evaluation/outcome criteria: speech and activity slowed down; thoughts less disordered.

D. Homicidal or assaultive reaction—seen in acutely drug-intoxicated, delirious, paranoid, acutely excited manic, or acute anxiety-panic conditions.

Focus topic: Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span

  • Assessment: history of obvious antisocial behavior, paranoid psychosis, previous violence, sexual conflict, rivalry, substance abuse, recent moodiness, and withdrawal.
  • Nursing care plan/implementation:
    a. Physically restrain if client has a weapon; use group of trained people to help. b. Allow person to “save face” in giving up weapon.
    c. Separate from intended victims.
    d. Approach: calm, unhurried; one person to offer support and reassurance; use clear, unambiguous statements.
    e. Immediate and rapid admission procedures.
    f. Observe for suicidal behavior that may follow homicidal attempt.
  • Evaluation/outcome criteria: client regains impulse control.

E. Suicidal ideation—seen in anxiety attacks, substance intoxication, toxic delirium, schizophrenic auditory hallucinations, and depressive reactions.

Focus topic: Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span

1. Concepts and principles related to suicide:

  • Based on social theory: suicidal tendency is a result of collective social forces rather than isolated individual motives (Durkheim’s Le Suicide).
    (1)Common factor: increased alienation between person and social group; psychological isolation, called “anomie,” when links between groups are weakened.
    (2)“Egoistic” suicide: results from lack of integration of individual with others.
    (3) “Altruistic” suicide: results from insufficient individualization.
    (4)Implication: increase group cohesiveness and mutual interdependence, making group more coherent and consistent in fulfilling needs of each member.
  • Based on symbolic interaction theory:
    (1)Person evaluates self according to others’ assessment.
    (2) Thus, suicide stems from social rejection and disrupted social relations.
    (3)Perceived failure in relationships with others may be inaccurate but seen as real by the individual.
    (4)Implication: need to recognize difference in perception of alienation between own viewpoint and those of others.
  • Based on psychoanalytic theory:
    (1)Suicide stems mainly from the individual, with external events only as precipitants.
    (2)There is a strong life urge in people.
    (3)Universal death instinct is always present (Freud).
    (4)Person may be balancing life wishes and death wishes. When self-preservation instincts are diminished, death instincts may find direct outlet via suicide.
    (5)When love instinct is frustrated, hate impulse takes over (Menninger).
    (a) Desire to kill → desire to be killed → desire to kill oneself.                             (b)Suicide may be an act of extreme hostility, manipulation, and revenge to elicit guilt and remorse in significant others.
    (c) Suicide may also be act of self punishment to handle own guilt or to control fate.
  • Based on synthesis of social and psychoanalytic theories:
    (1)Suicide is seen as running away from an intolerable situation to interrupt it, rather than running to something more desirable.
    (2)Process defined in operational terms involves:
    (a) Despair over inability to cope.
    (b) Inability to feel hope or adequacy.
    (c) Frustration with others when others cannot fill needs.
    (d)Rage and aggression experienced toward significant other is turned inward.
    (e) Psychic blow acts as precipitant.
    (f) Life seen as harder to cope with, with no chance of improvement in life situation.
    (g) Implication: persons who experience suicidal impulses can gain a certain amount of control over these impulses through the support they gain from meaningful relationships with others.
  • Based on crisis theory (Dublin): concept of emotional disequilibrium:
    (1)Everyone at some point in life is in a crisis, with temporary inability to solve problems or to master the crisis.
    (2)Usual coping mechanisms do not function.
    (3)Person unable to relate to others.
    (4)Person searches consciously and unconsciously for useful coping techniques, with suicide as one of various solutions.
    (5)With inadequate communication of needs and isolation, suicide is possible.
  • Based on the view that suicide is an individual’s personal reaction and decision, a final response to own situation:
    (1) Process of anger turned inward → self-inflicted, destructive action.
    (2)Definition of concept in operational steps:
    (a) Frustration of individual needs → anger.
    (b) Anger turned inward → feelings of guilt, despair, depression, incompetence, hopelessness, and exhaustion.
    (c) Stress felt and perceived as unbearable and overwhelming.
    (d)Attempt to communicate hopelessness and defeat to others.
    (e) Others do not provide hope.                                                                        (f) Sudden change in behavior, as noted when depression appears to lift, may indicate danger, as person has more energy to act on suicidal thoughts and feelings.
    (g)Decision to end life → plan of action → self-induced, self-destructive behavior.                                                                                                         (3)May be pseudosuicide attempts, where there is no actual or realistic desire to achieve finality of death. Intentions or causes may be:
    (a) “Cry for help,” where nonlethal attempt notifies others of deeper intentions.
    (b)Desire to manipulate others.
    (c) Need for attention and pity.
    (e) Symbol of utter frustration.
    (f)Wish to punish others.
    (g) Misuse of alcohol and other drugs.
    (4)Other reasons for self-destruction, where the individual gives his or her life rather than takes it, include:
    (a) Strong parental love that can overcome fear and instinct of self-preservation to save child’s life.
    (b) “Sacrificial death” during war, such as kamikaze pilots in World War II.
    (c) Submission to death for religious beliefs (martyrdom).

2. Assessment of suicide:

Focus topic: Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span

a.Assessment of risk regarding statistical probability of suicide—composite picture: male, older than 45 years, unemployed, divorced, living alone, depressed (weight loss, somatic delusions, sleep disturbance, preoccupied with suicide), history of substance abuse and suicide within family.

b.Eleven factors to predict potential suicide and assess risk:

  • Age, sex, and race—teenage and young adult (ages 15 to 24), older age; more women make attempts; more men complete suicide act. Highest risk: older women rather than young boys; older men rather than young girls. Suicide occurs in all races and socioeconomic groups.
  • Recent stress related to loss—family problems: death, divorce, separation,
    alienation; financial pressures; loss of job; loss of status; failing grades.
  • Clues to suicide: suicidal thoughts are usually time limited and do not last
    forever. Early assessment of behavioral and verbal clues is important.*
    (a) Verbal clues—direct: “I am going to shoot myself.” Indirect: “It’s more than I can bear.” Coded: “This is the last time you’ll ever see me.” “I want you to have my coin collection.”
    (b) Behavioral clues—direct: trial run with pills or razor, for example. Indirect: sudden lifting of depression, buying a casket, giving away cherished belongings,
    putting affairs in order, writing a will.
    (c) Syndromes—dependent-dissatisfied: emotionally dependent but dislikes dependent state, irritable, helpless. Depressed: detachment from life; feels
    life is a burden; hopelessness, futility. Disoriented: delusions or hallucinations,
    confusion, delirium tremens, organic brain syndromes. Willfuldefiant:
    active need to direct and control environment and life situation,
    with low frustration tolerance and rigid mind-set, rage, shame.
  • Suicide plan—the more details about method, timing, and place, and preoccupation with thoughts of suicide plan, the higher the risk.
  • Previous suicidal behavior—history of prior attempt increases risk. Eight out
    of 10 suicide attempts give verbal and behavioral warnings as listed previously.
  • Medical and psychiatric status—chronic ailments, terminal illness, and pain
    increase suicidal risk; people with bipolar disorder, and when emerging from depression.
  • Communication—the more disorganized thinking, anxious, hostile, and withdrawn and apathetic, the greater the potential for suicide, unless extreme
    psychomotor retardation is present.
  • Style of life—high risks include substance abusers, those with sexual identity conflicts, unstable relationships (personal and job related). Suicidal tendencies are not inherited but learned from family and other interpersonal relationships.
  • Alcohol—can reinforce helpless and hopeless feelings; may be lethal if used
    with barbiturates; can decrease inhibitions, result in impulsive behavior.
  • Resources—the fewer the resources, the higher the suicide potential. Examples
    of resources: family, friends, colleagues, religion, pets, meaningful recreational
    outlets, satisfying employment.
  • Stigma—unwilling to seek help because of stigma attached to mental illness, substance abuse, and/or suicidal thoughts.

c. Assess needs commonly communicated by individuals who are suicidal:

  • To trust.
  • To be accepted.
  • To bolster self-esteem.
  • To “fit in” with groups.
  • To experience success and interrupt the failure syndrome.
  • To expand capacity for pleasure.
  • To increase autonomy and sense of self-mastery.
  • To work out an acceptable sexual identity.

3. Analysis/nursing diagnosis: risk for suicide related to:

Focus topic: Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span

  • Feelings of alienation.
  • Feelings of rejection.
  • Feelings of hopelessness, despair.
  • Feelings of frustration and rage.

4. Nursing care plan/implementation:

Focus topic: Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span

a. Long-term goals:

  • Increase client’s self-reliance.
  • Help client achieve more realistic and positive feelings of self-esteem, self-respect, acceptance by others, and sense of belonging.
  • Help client experience success, interrupt failure pattern, and expand views about pleasure.

b. Short-term goals:

  • Medical: assist as necessary with gastric lavage; provide respiratory and vascular support; assist in repair of inflicted wounds.
  • Provide a safe environment for protection from self-destruction until client is able to assume this responsibility.
  • Allow outward and constructive expression of hostile and aggressive feelings.
  • Provide for physical needs.

c. Suicide precautions to institute under emergency conditions:

  • One-to-one supervision at all times for maximum precautions; check whereabouts every 15 minutes, if on basic suicide precautions.
  • Before instituting these measures, explain to client what you will be doing and why; physician must also explain; document this explanation.
  • Do not allow client to leave the unit for tests, procedures.
  • Look through client’s belongings with the client and remove any potentially harmful objects (e.g., pills, knife, gun, matches, belts, razors, glass, tweezers).
  • Allow visitors and phone calls, but maintain one-to-one supervision during visits.
  • Check that visitors do not leave potentially harmful objects in the client’s room.
  • Serve meals in an isolation meal tray that contains no glass or metal silverware.
  • Do not discontinue these measures without an order.

d. General approaches:

  • Observe closely at all times to assess suicide potential.
  • Be available.
    (a) Demonstrate concern, acceptance, and respect for client as a person.
    (b)Be sensitive, warm, and consistent.
    (c) Listen with empathy.
    (d)Avoid imposing your own feelings of reality on client.
    (e) Avoid extremes in your own mood when with client (especially exaggerated cheerfulness).
  • Focus directly on client’s self-destructive ideas.
    (a) Reduce alienation and immobilization by discussing this “taboo” topic.
    (b)Acknowledge suicidal threats with calmness and without reproach—do not ignore or minimize threat.
    (c) Find out details about suicide plan and reduce environmental hazards.
    (d)Help client verbalize aggressive, hostile, and hopeless feelings.
    (e) Explore death fantasies—try to take “romance” out of death.
  • Acknowledge that suicide is one of several options and that there are alternatives.
  • Make a contract with the client, and structure a plan of alternatives for coping
    when next confronted with the need to commit suicide (e.g., the client could
    call someone, express feeling of anger outwardly, or ask for help).
  • Point out client’s self-responsibility for suicidal act.
    (a) Avoid manipulation by client who says, “You are responsible for stopping
    me from killing myself.”
    (b)Emphasize protection against self-destruction rather than punishment.
  • Support the part of the client that wants to live.
    (a) Focus on ambivalence.
    (b)Emphasize meaningful past relationships and events.                                    (c) Look for reasons left for wanting to live. Elicit what is meaningful to the client at the moment.
    (d)Point out effect of client’s death on others.
  • Remove sources of stress.
    (a) Decrease uncomfortable feelings of alienation by initiating one-to-one interactions.
    (b)Make all decisions when client is in severe depression.
    (c) Progressively let client make simple decisions: what to eat, what to watch on TV, etc.
  • Provide hope.
    (a) Let client know that problems can be solved with help.
    (b)Bring in new resources for help.
    (c) Talk about likely changes in client’s life.
    (d)Review past effective coping behaviors.
  • Provide with opportunity to be useful. Reduce self-centeredness and brooding
    by planning diversional activities within the client’s capabilities.
  • Involve as many people as possible.
    (a) Gradually bring in others (e.g., other therapists, friends, staff, clergy, family,
    (b)Prevent staff “burnout,” found when only one nurse is working with client who is suicidal.
  • Health teaching: teach client and staff principles of crisis intervention and resolution. Teach new coping skills.

5. Evaluation/outcome criteria: physical condition is stabilized; client able to verbalize feelings rather than acting them out.




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