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: Crisis Intervention

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

Crisis intervention is a type of brief psychiatric treatment in which individuals or their families are helped in their efforts to forestall the process of mental decompensation in reaction to severe emotional stress by direct and immediate supportive approaches.

I. DEFINITION OF CRISIS: sudden event in one’s life that disturbs homeostasis, during which usual coping mechanisms cannot resolve the problem. Types of crisis:

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

  • Maturational (internal): see Erik Erikson’s eight stages of developmental crises anticipated in the development of the infant, child, adolescent, and adult.
  • Situational (external): occurs at any time (e.g., loss of job, loss of income, death of significant person, illness, hospitalization).
  • Catastrophic (external): can occur at anytime (e.g., natural disasters and terrorist attacks).

II. CONCEPTS AND PRINCIPLES RELATED TO CRISIS INTERVENTION:

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

  • Crises are turning points where changes in behavior patterns and lifestyles can occur; individuals in crisis are most amenable to altering old and unsuccessful coping mechanisms and are most likely to learn new and more functional behaviors.
  • Social milieu and its structure are contributing factors in both the development of psychiatric symptoms and eventual recovery from them.
  • If crisis is handled effectively, the person’s mental stability will be maintained; individual may return to a precrisis state or better.
  • If crisis is not handled effectively, individual may progress to a worse state with exacerbations of earlier conflicts; future crises may not be handled well.
  • There are a number of universal developmental crisis periods (maturational crises) in every individual’s life.
  • Each person tries to maintain equilibrium through use of adaptive behaviors.
  • When individuals face a problem they cannot solve, tension, anxiety, narrowed perception, and disorganized functioning occur.
  • Immediate relief of symptoms produced by crisis is more urgent than exploring their cause.

III. CHARACTERISTICS OF CRISIS INTERVENTION:

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

  • Acute, sudden onset related to a stressful precipitating event of which individual is aware but which immobilizes previous coping abilities.
  • Responsive to brief therapy with focus on immediate problem.
  • Focus shifted from the psyche in the individual to the individual in the environment; deemphasis on intrapsychic aspects.
  • Crisis period is time limited (usually up to 6 weeks).

 

IV. NURSING CARE PLAN/IMPLEMENTATION IN CRISES:

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

A. General goals:

  • Avoid hospitalization if possible.
  • Return to precrisis level and preserve ability to function.
  • Assist in problem-solving, with here-and-now focus.

B. Assess the crisis:

  • Identify stressful precipitating events: duration, problems created, and degree of significance.
  • Assess suicidal and homicidal risk.
  • Assess amount of disruption in individual’s life and effect on significant others.
  • Assess current coping skills, strengths, and general level of functioning.

C.Plan the intervention:

  • Consider past coping mechanisms.
  • Propose alternatives and untried coping methods.

D. Implementation:

  • Help client relate the crisis event to current feelings.
  • Encourage expression of all feelings related to disruption.
  • Explore past coping skills and reinforce adaptive ones.
  • Use all means available in social network to take care of client’s immediate needs (e.g., significant others, law enforcement agencies, housing, welfare, employment, medical, and school).
  • Set limits.
  • Health teaching: teach additional problem solving approaches.

V. EVALUATION/OUTCOME CRITERIA:

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

  • Client returns to precrisis level of functioning.
  • Client learns new, more effective coping skills.
  • Client can describe realistic plans for future in terms of own perception of progress, support system, and coping mechanisms.

Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span: Selected Specific Crisis Situations: Problems Related to Abuse/Violence

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

I. DOMESTIC VIOLENCE*:

A. Characteristics:

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

  • Victims: feel helpless, powerless to prevent assault; blame themselves; ambivalent about leaving the relationship.
  • Abusers: often blame the victims; have poor impulse control; use power (physical strength or weapon) to threaten and subject victims to their assault.
  • Cycle of stages, with increase in severity of the battering:
    a. Buildup of tension (through verbal abuse): abuser is often drinking or taking other drugs; victim blames self.
    b. Physical abuse: abuser does not remember brutal beating; victim is in shock and detached (“honeymoon” phase).
    c. Calm: abuser “makes up,” apologizes, and promises “never again”; victim believes and forgives the abuser, and feels loved.

B. Risk factors:

  • Learned responses: abuser and victim have had past experience with violence in family; victim has “learned helplessness.”
  • Women who are pregnant and those with one or more preschool children, who see no alternative to staying in the battering relationship.
  • Women who fear punishment from the abuser.

C. Assessment:

  • Injury to parts of body, especially face, head, genitals (e.g., welts, bruises, fracture of nose).
  • Presents in the emergency department with report of “accidental injury.”
  • Severe anxiety.
  • Depression.

D. Analysis/nursing diagnosis:

  • Risk for injury related to physical harm.
  • Post traumatic response related to assault.
  • Fear related to threat of death or change in health status.
  • Pain related to physical and psychological harm.
  • Powerlessness related to interpersonal interaction.
  • Ineffective individual coping related to situational crisis.
  • Spiritual distress related to intense suffering and challenged value system.

E. Nursing care plan/implementation:

  • Provide safe environment; refer to community resources for shelter.
  • Treat physical injuries.
  • Document injuries.
  • Supportive, nonjudgmental approach: identify woman’s strengths; help her to accept that she cannot control the abuser; encourage description of home situation; help her to see choices.
  • Encourage individual and family therapy for victim and abuser.

F. Evaluation/outcome criteria:

  • Physical symptoms have been treated.
  • Discusses plans for safety (for self and any children) to protect against further injury.

II. RAPE-TRAUMA SYNDROME:

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

A. Definition: forcible perpetration of an act of sexual intercourse on the body of an unwilling person.

B. Assessment:

  • Signs of physical trauma—physical findings of entry.
  • Symptoms of physical trauma—verbatim statements regarding type of sexual attack.
  • Signs of emotional trauma—tears, hyperventilation, extreme anxiety, withdrawal, self-blame, anger, embarrassment, fears, sleeping and eating disturbances, desire for revenge.
  • Symptoms of emotional trauma—statements regarding method of force used and threats made.

C. Analysis/nursing diagnosis: rape-trauma syndrome related to phases of response to rape:

  • Acute response: volatility, disorganization, disbelief, shock, incoherence, agitated motor activity, nightmares, guilt (feels that should have been able to protect self), phobias (crowds, being alone, sex).
  • Outward coping: denial and suppression of anxiety and fear (silent rape syndrome), feelings appear controlled.
  • Integration and resolution: confronts anger with attacker; realistic perspective.

D. Nursing care plan/implementation in counseling victims of rape.

1. Overall goals:

  • Protect legal (forensic) evidence.
  • Acknowledge feelings.
  • Face feelings.
  • Resolve feelings.
  • Maintain and restore self-respect, dignity, integrity, and self-determination.

2. Work through issues:

  • Handle legal matters and police contacts.
  • Clarify facts.
  • Assist medical examiner in collecting DNA evidence.
  • Get medical attention if needed.
  • Notify family and friends.
  • Understand emotional reaction.
  • Attend to practical concerns.
  • Evaluate need for psychiatric consultations.

3. Acute phase:

  • Decrease victim’s stress, anxiety, fear.
  • Seek medical care.
  • Increase self-confidence and self-esteem.
  • Identify and accept feelings and needs (to be in control, cared about, to achieve).
  • Reorient perceptions, feelings, and statements about self.
  • Help resume normal lifestyle.

4. Outward coping phase:

  • Remain available and supportive.
  • Reflect words, feelings, and thoughts.
  • Explore real problems.
  • Explore alternatives regarding contraception, legal issues.
  • Evaluate response of family and friends to victim and rape.

5. Integration and resolution phase:

  • Assist exploration of feelings (anger) regarding attacker.
  • Explore feelings (guilt and shame) regarding self.
  • Assist in making own decisions regarding health care.

6. Maintain confidentiality and neutrality— facilitate person’s own decision.

7. Search for alternatives to giving advice.

8. Health teaching:

  • Explain procedures and services to victim.
  • Counsel to avoid isolated areas and being helpful to strangers.
  • Counsel where and how to resist attack (scream, run unless assailant has weapon).
  • Teach what to do if pregnancy or STI is outcome.

E. Evaluation/outcome criteria: little or no evidence of possible long-term effects of rape (guilt, shame, phobias, denial).

Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span

III. CHILD WHO IS VICTIM OF VIOLENCE:

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

A. Assessment—clues to the identification of a child who is a victim of violence.*

1. Clues in the history:

  • Significant delay in seeking medical care.
  • Major discrepancies in the history:
    (1)Discrepancy between different people’s versions of the story.
    (2)Discrepancy between the history and the observed injuries.
    (3)Discrepancy between the history and the child’s developmental capabilities.
  • History of multiple emergency department visits for various injuries.
  • A story that is vague and contradictory.

2. Clues in the physical examination:

  • Child who seems withdrawn, apathetic, and does not cry despite the injuries.
  • Child who does not turn to parents for comfort; or unusual desire to please parent; unusual fear of parent(s).
  • Child who is poorly nourished and poorly cared for.
  • The presence of bruises: multiple bruises, welts, and abrasions, especially around the trunk and buttocks; lesions resembling bites or fingernail
    marks; old bruises in addition to fresh ones.
  • The presence of suspicious burns:
    (1) Cigarette burns.
    (2) Scalds without splash marks or involving the buttocks, hands, or feet but sparing skin folds.
    (3)Rope marks.
  • Clues in parent behavior—exaggerate care and concern.
  • X-rays: old fractures or dislocation, especially in child under 3 years.
Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span

B. Analysis/nursing diagnosis:

  • Same as for domestic violence.
  • Altered parenting related to poor role model/identity, unrealistic expectations, presence of stressors and lack of support.
  • Low self-esteem related to deprivation and negative feedback.

C. Nursing care plan/implementation:

  • Same as for domestic violence.
  • Report suspected child abuse to appropriate source.
  • Conduct assessment interview in private, with child and parent separated.
  • Be supportive and nonjudgmental.

D. Evaluation/outcome criteria:

  • Same as domestic violence.
  • Child safety has been ensured.
  • Parent(s) or caregivers have agreed to seek help.

IV. SEXUAL ABUSE OF CHILDREN:

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

A. Assessment—characteristic behaviors:

  • Relationship of offender to victim: many filling paternal role (uncle, grandfather, cousin) with repeated, unquestioned access to the child.
  • Methods of pressuring victim into sexual activity: offering material goods, misrepresenting moral standards (“it’s OK”), exploiting need for human contact and warmth.
  • Method of pressuring victim to secrecy (to conceal the act) is inducing fear of punishment, not being believed, rejection, being blamed for the activity, abandonment.
  • Disclosure of sexual activity via:
    a. Direct visual or verbal confrontation and observation by others.
    b. Verbalization of act by victim.
    c. Visible clues: excess money and candy, new clothes, pictures, notes; enlarged vaginal or rectal orifice; stains and/or blood on underwear.
    d. Signs and symptoms: bed wetting, excessive bathing, tears, avoiding school, somatic distress (GI and urinary tract pains). Genital irritation (itching, bruised, bleeding, pain); unusual sexual behavior.
    e. Overly solicitous parental attitude toward child.

B. Analysis/nursing diagnosis:

  • Altered protection related to inflicted pain.
  • Risk for injury related to neglect, abuse.
  • Personal identity disturbance related to abuse as child and feeling guilty and responsible for being a victim.
  • Ineffective individual coping related to high stress level.
  • Sleep pattern disturbance related to traumatic sexual experiences.
  • Ineffective family coping.
  • Altered family processes related to use of violence.
  • Altered parenting related to violence.
  • Powerlessness related to feelings of being dependent on abuser.
  • Social isolation/withdrawal related to shame about family violence.
  • Risk for altered abuse response patterns.

C. Nursing care plan/implementation:

  • Establish safe environment and the termination of trauma.
  • Encourage child to verbalize feelings about incident to dispel tension built up by secrecy.
  • Ask child to draw a picture or use dolls and toys to show what happened.
  • Observe for symptoms over a period of time.
    a. Phobic reactions when seeing or hearing offender’s name.
    b. Sleep pattern changes, recurrent dreams, nightmares.
  • Look for silent reaction to being an accessory to sex (i.e., child keeping burden of the secret activity within self); help deal with unresolved issues.
  • Establish therapeutic alliance with parent who is abusive.
  • Health teaching:
    a. Teach child that his or her body is private and to inform a responsible adult when someone violates privacy without consent.
    b. Teach adults in family to respond to victim with sensitivity, support, and concern.

D. Evaluation/outcome criteria:

  • Child’s needs for affection, attention, personal recognition, or love met without sexual exploitation.
  • Perpetrator accepts therapy.
  • Conspiracy of silence is broken.

E. Summary: signs that are common to both physical and sexual abuse:

1. Parental behaviors:

  • Blaming child or sibling for injury.
  • Anger (rather than providing comfort) toward child for injury.
  • Hostility toward health-care providers.
  • Exaggeration or absence of response from parent regarding child’s injury.

2. Child (toddler or preschooler):

  • No protest when parent leaves.
  • Shows preference for health-care provider over parent.
  • Signs of “failure to thrive” syndrome.

3. Other signs:

  • History: inconsistent with stages of growth and development.
  • Inconsistent details of injury between one person and another.

V. ELDER ABUSE/NEGLECT:

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

A. Definition: battering, psychological abuse, sexual assault, or any act or omission by personal caregiver, family, or legal guardian that results in harm or threatened harm.

B. Concepts, principles, and characteristics:

  • Elders who are currently being abused often abused their abusers—their offspring. Violence is a learned behavior.
  • Victim characteristics: diminished self-esteem, feeling responsibility for the abuse, isolated.
  • Abuser characteristics: usually has physical or psychosocial stressors related to marital or fiscal difficulties; substance abuse.
  • Legal: most states have mandatory laws to report elder abuse, although many cases are not reported because of shame, fear of more abuse, cultural/religious beliefs, optimism, loyalty, financial dependency.
  • Types of abuse:
    a. Financial abuse (e.g., fraudulent monetary schemes, theft [money, property, or both]).
    b. Neglect (e.g., withholding food, water, medications; no provision for assistive devices [dentures, hearing aids, glasses, canes], adequate heating).
    c. Psychological abuse (e.g., verbal abuse, yelling, harsh commands, insults, threats, ignoring, social isolation, and withholding affection).
    d. Physical abuse (e.g., beating, shoving, bruising, subconjunctival hemorrhage; physical restraints, rape).

C. Assessment:

  • Risk factors:
  • Behavioral clues: agitation, anger, denial, fear, poor eye contact; confusion, depression, withdrawal, unbelievable stories about causes of injuries.
  • Physical indicators: weight loss; dehydration; unexplained cuts, welts, burns, bruises, puncture wounds; untreated injuries, fractures, contractures; unkempt; noncompliance with medical plan of care; severe skin breakdown.
  • Financial matters (e.g., recent changes in will; unusual banking activity; missing checks, personal belongings; forged signatures; unwillingness to spend money on the elder).

D. Analysis/nursing diagnosis:

  • Risk for injury related to neglect, abuse.
  • Fear.
  • Powerlessness related to dependency on abuser.
  • Unilateral neglect.
  • Spiritual distress.
  • Altered family processes related to use of violence.
  • Caregiver role strain.

E. Nursing care plan/implementation:

1. Primary prevention:

  • Early case-finding; early treatment.
  • Referral to community services for caregiver (e.g., respite care) before serious abuse occurs.

2. Secondary prevention:

  • Report case to law enforcement agencies.
  • Provide elder with phone number for confidential hotline.
  • Plan for safety of elder (e.g., shelter).

3. Tertiary prevention:

  • Counseling, support, and self-help groups for victim.
  • Legal action against abuser.

F. Evaluation/outcome criteria:

  • Elder develops trust in caregivers, without fear of further abuse.
  • Spiritual well-being is enhanced, with diminished feelings of guilt, hopelessness, and powerlessness.

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

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

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

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

Milieu therapy consists of treatment by means of controlled modification of the client’s environment to promote positive living experiences.

I. CONCEPTS AND PRINCIPLES RELATED TO MILIEU THERAPY:

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

A. Everything that happens to clients from the time they are admitted to the hospital or treatment setting has a potential that is either therapeutic or antitherapeutic.

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

  • Not only the therapists but all who come in contact with the clients in the treatment setting are important to the clients’ recovery.
  • Emphasis is on the social, economic, and cultural dimension, the interpersonal climate, and the physical environment.

B. Clients have the right, privilege, and responsibility to make decisions about daily living activities in the treatment setting.

II. CHARACTERISTICS of milieu therapy:

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

  • Friendly, warm, trusting, secure, supportive, comforting atmosphere throughout the unit.
  • An optimistic attitude about prognosis of illness.
  • Attention to comfort, food, and daily living needs; help with resolving difficulties related to tasks of daily living.
  • Opportunity for clients to take responsibility for themselves and for the welfare of the unit in gradual steps.
    1. Client government.
    2. Client-planned and client-directed social activities.
  • Maximum individualization in dealing with clients, especially regarding treatment and privileges in accordance with clients’ needs.
  • Opportunity to live through and test out situations in a realistic way by providing a setting that is a microcosm of the larger world outside.
  • Opportunity to discuss interpersonal relationships in the unit among clients and between clients and staff (decreased social distance between staff and clients).
  • Program of carefully selected resocialization activities to prevent regression.

III. NURSING CARE PLAN/IMPLEMENTATION in milieu therapy:

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

  • New structured relationships—allow clients to develop new abilities and use past skills; support them through new experiences as needed; help build liaisons with others; set limits; help clients modify destructive behavior; encourage group solutions to daily living problems.
  • Managerial—inform clients about expectations; preserve orderliness of events.
  • Environmental manipulation—regulate the outside environment to alter daily surroundings.
    1. Geographically move clients to units more conducive to their needs.
    2. Work with families, clergy, employers, etc.
    3. Control visitors for the benefit of the client.
  • Team approach uses the milieu to meet each client’s needs.

IV. EVALUATION/OUTCOMES CRITERIA:

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

  • Physical dimension: order, organization.
  • Social dimension: clarity of expectations, practical orientation.
  • Emotional dimension: involvement, support, responsibility, openness, valuing, accepting.

FURTHER READING/STUDY:

Resources:

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