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

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

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. Definition: feelings of resentment in response to anxiety when threat is perceived; need to discharge tension of anger.

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

  • Degree of anger and frequency: scope of anger ranges on a continuum from everyday mild annoyance → frustration from interference with goal accomplishment → assertiveness (behavior used to deal with anger effectively) → anger related to helplessness and powerlessness that may interfere with functioning → rage and fury, when coping means are depleted or not developed.
  • Mode of expression of anger:
    a. Covert, passive expression of anger: being overly nice; body language with little or no eye contact, arms close to body, soft voice, little gesturing;
    sarcasm through humor; sublimation through art and music; projection onto others; denying and pushing anger out of awareness; psychosomatic illness in response to internalized anger (e.g., headache).
    b. Overt, active expression of anger: physical activity to work off excess physical energy associated with biological response (e.g., hitting a punching bag, taking a walk); aggression, assertiveness.
  • Physiological behaviors—result of secretion of epinephrine and sympathetic nervous system stimulation preparing for fight-flight.
    a. Cardiovascular response: increased blood pressure and pulse, increased free fatty acid in blood.
    b. Gastrointestinal response: increased nausea, salivation; decreased peristalsis.
    c. Genitourinary response: urinary frequency.
    d. Neuromuscular response: increased alertness, increased muscle tension and deep tendon reflexes, electrocardiographic (ECG) changes.
  • Positive functions of anger:
    a. Energizes behavior.
    b. Protects positive image.
    c. Provides ego defense during high anxiety.
    d. Gives greater control over situation.
    e. Alerts to need for coping.
    f. A sign of a healthy relationship.

C. Analysis/nursing diagnosis: defensive coping related to source of stress (stressors):

  • Biological stressors—instinctual drives (Lorenz, on aggressive instincts, and Freud), endocrine imbalances, seizures, tumors, hunger, fatigue.
  • Psychological stressors—inability to resolve frustration that leads to aggression; real or imagined threatened loss of self-esteem; conflict, lack of
    control; anger as a learned expression and a reinforced response. Prolonged stress; an attempt to protect self; a desire for retaliation; a normal part of grief process.
  • Sociocultural stressors—lack of early training in self-discipline and social skills; crowding, personal space intrusion; role modeling of abusive
    behavior by significant others and by media personalities.

D. Nursing care plan/implementationlong-term goals: constructive use of angry energy to accomplish tasks and motivate growth.

  • Prevent and control violence.
    a. Approach unhurriedly.
    b. Provide atmosphere of acceptance; listen attentively, refrain from arguing and criticizing.
    c. Encourage expression of feelings.
    d. Offer feedback of client’s expressed feelings.
    e. Encourage mutual problem-solving.
    f. Encourage realistic perception of others and situation and respect for the rights of others.
  • Limit setting:
    a. Clearly state expectations and consequences of acts.
    b. Enforce consequences.
    c. Encourage client to assume responsibility for behavior.
    d. Explore reasons and meaning of negative behavior.
  • Promote self-awareness and problem-solving abilities. Encourage and assist client to:
    a. Accept self as a person with a right to experience angry feelings.
    b. Explore reasons for anger.
    c. Describe situations where anger was experienced.
    d. Discuss appropriate alternatives for expressing anger (including assertiveness training).
    e. Decide on one feasible solution.
    f. Act on solution.
    g. Evaluate effectiveness.
  • Health teaching:
    a. Explore other ways to express feelings, and provide activities that allow appropriate expression of anger.
    b. Recommend that behavioral limits be set (by the family).
    c. Explain how to set behavioral limits.
    d. Advise against causing defensive patterns in others.

E. Evaluation/outcome criteria:

  • Demonstrates insight (awareness of factors that precipitate anger; identifies disturbing topics, events, and inappropriate use of coping mechanisms).
  • Uses appropriate coping mechanisms.
  • Reaches out for emotional support before stress level becomes excessive.
  • Evidence of increased reality perception and problem-solving ability.


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

A. Definition: acting out feelings of frustration, anger, anxiety, etc., through physical or verbal behavior.

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

B. Assessment: recognize precombative behavior:

  • Demanding, fist clenching.
  • Boisterous, loud.
  • Vulgar, profane.
  • Limited attention span.
  • Sarcastic, taunting, verbal threats.
  • Restless, agitated, elated.
  • Frowning.

C. Analysis/nursing diagnosis: risk for self-injury and violence directed at others related to:

  • Frustration as response to breakdown of self control coping mechanisms.
  • Acting out as customary response to anger (defensive coping).
  • Confusion (sensory/perceptual alterations).
  • Physical restraints, such as when clients are postoperative and discover wrist restraints.
  • Fear of intimacy, intrusion on emotional and physical space (altered thought processes).
  • Feelings of helplessness, inadequacy (situational or chronic low self-esteem).

D. Nursing care plan/implementation:

  • Long-term goal: channel aggression—help person express feelings rather than act them out.
  • Immediate goal: prevent injury to self and others.
    a. Calmly call for assistance; do not try to handle alone.
    b. Approach cautiously. Keep client within eye contact, observing client’s personal space.
    c. Protect against self-injury and injury to others; be aware of your position in relation to the weapon, door, escape route.
    d. Minimize stimuli, to control the environment— clear the area, close doors, turn off TV so person can hear you.
    e. Divert attention from the act; engage in talk and lead away from others.
    f. Assess triggering cause.
    g. Identify immediate problem.
    h. Focus on remedy for immediate problem.
    i. Choose one individual who has a calm, quiet presence to interact with person; non-authoritarian, nonthreatening.
    j. Maintain verbal contact to keep communication open; offer empathetic ear, but be firm and consistent in setting limits on dangerous behavior.

k. Negotiate, but do not make false promises or argue.
l. Restraints may be necessary as a last resort. m. Place person in quiet room so he or she can calm down.

  • Health teaching:
    a. Explain how to obtain relief from stress and how to rechannel emotional energy into acceptable activity.
    b. Advise against causing defensive responses in others.
    c. Explain what is justifiable aggression.
    d. Emphasize importance of how to recognize tension in self.
    e. Explain why self-control is important.
    f. Explain to family, staff, how to set behavioral limits.
    g. Explain causes of maladaptive coping related to anger.
    h. Teach how to use problem-solving method.

E. Evaluation/outcome criteria:

  • Is aware of causes of anger; can recognize the feeling of anger and use alternative methods of expressing anger.
  • Expression of anger is appropriate, congruent with the situation.
  • Replaces aggression and acting out with assertiveness.


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

A. Definition: loss of reality orientation as to person, time, place, events, ideas.

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

B. Assessment: note unusual behavior:

  • Picking, stroking movements in the air or on clothing and linens.
  • Frequent crying or laughing.
  • Alternating periods of confusion and lucidity (e.g., confused at night, when alone in the dark).
  • Fluctuating mood, actions, rationality (argumentative, combative, withdrawn).
  • Increasingly restless, fearful, leading to insomnia, nightmares.
  • Acts bewildered; has trouble identifying familiar people.
  • Preoccupied; irritable when interrupted.
  • Unresponsive to questions; problem with concentration and setting realistic priorities.
  • Sensitive to noise and light.
  • Has unrealistic perception of time, place, and situation.
  • Nurse no longer seen as supportive but as threatening.

C. Analysis/nursing diagnosis: altered thought processes and sensory/perceptual alterations related to:

  • Physical and physiological disturbances—metabolic (uremia, diabetes, hepatic dysfunction), fluid and electrolyte imbalances, cardiac arrhythmias, heart failure; anemia, massive blood loss with low hemoglobin; brain lesions; nutritional deficiency; pain; sleep disturbance; drugs (antidepressants, tranquilizers, sedatives, antihypertensives, diuretics, alcohol, phencyclidine [PCP], street drugs).
  • Unfamiliar environment—unfamiliar routine and people; procedures that threaten body image; noisy equipment.
  • Loss of sensory acuity from partial or incomplete reception of orienting stimuli or information.
  • Disability in screening out irrelevant and excessive sensory input.
  • Memory impairment.

D. Nursing care plan/implementation:

  • Check physical signs (e.g., vital signs, neurological status, fluid and electrolyte balance, and blood urea nitrogen [BUN]).
  • Be calm; make contact to reorient to reality:
    a. Avoid startling if person is alone, in the dark, sedated.
    b. Make sure person can see, hear, and talk to you—turn off TV; turn on light, put on client’s glasses, hearing aids, dentures.
    c. Call by name, clearly and distinctly.
    d. Approach cautiously, close to eye level.
    e. Keep your hands visible; for example, on bed.
  • Take care of immediate problem (e.g., disconnected IV tube or catheter).
    a. Give instructions slowly and distinctly; avoid threatening tone and comments.
    b. Stay with person until reoriented.
    c. Put side rails up.
  • Use conversation to reduce confusion.
    a. Use simple, concrete phrases; language the person can understand; repeat as needed.
    b. Avoid: shouting, arguing, false promises, use of medical abbreviations (e.g., NPO).
    c. Give more time to concentrate on what you said.
    d. Focus on reality-oriented topics or objects in the environment.
  • Prevent confusion by establishing a reality-oriented relationship.
    a. Introduce self by name.
    b. Jointly establish routines to prevent confusion from unpredictable changes and variations. Determine client’s usual routine; attempt to incorporate this to lessen disruption in lifestyle.
    c. Explain what to expect in understandable words—where client is and why, what will happen, noises and activities client will hear and see, people client will meet, tests and procedures client will have.

d. Find out what meaning hospitalization has to client; reduce anxiety related to feelings of apprehension and helplessness.
e. Spend as much time as possible with client.

  • Maintain orientation by providing nonthreatening environment.
    a. Assign to room near nurses’ station.
    b. Surround with familiar objects from home (e.g., photos).
    c. Provide clock, calendar, and radio.
    d. Have flexible visiting hours.
    e. Open curtain for natural light.
    f. Keep glasses, dentures, hearing aids nearby.
    g. Check client often, especially at night.
    h. Avoid using intercom to answer calls.
    i. Avoid low-pitched conversation.
  • Take care of other needs.
    a. Promote sleep according to usual habits and patterns to prevent sleep deprivation.
    b. Avoid sedatives, which may lead to or increase confusion.
    c. Promote independent functions, self-help activities, to maintain dignity.
    d. Encourage nutritional adequacy; incorporate familiar foods, ethnic preferences.
    e. Maintain routine; avoid being late with meals, medication, or procedures.
    f. Have realistic expectations.
    g. Discover hidden fears.
    (1)Do not assume confused behavior is unrelated to reality.
    (2)Look for clues to meaning from client’s background, occupation.
    h. Provide support to family.
    (1)Encourage expression of feelings; avoid being judgmental.
    (2)Check what worked in previous situations.
  • Health teaching: explain possible causes of confusion. Reassure that it is common. Teach family, friends how to react to confused behavior.

E. Evaluation/outcome criteria:

  • Less restlessness, fearfulness, mood lability.
  • More frequent periods of lucidity; oriented to time, place, and person; responds to questions.


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

A. Definition: a strong and persistent struggle to obtain satisfaction of self-oriented needs (e.g., control, self-esteem) or relief from anxiety.

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

B. Assessment:

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

  • Attention-seeking behavior.
  • Multiple requests.
  • Frequency of questions.
  • Lack of reasonableness; irrationality of request.

C. Analysis/nursing diagnosis: defensive coping and impaired social interaction related to:

  • Feelings of helplessness and hopelessness.
  • Feelings of powerlessness and fear.
  • A way of coping with anxiety.

D. Nursing care plan/implementation:

  • Control own irritation; assess reasons for own annoyance.
  • Anticipate and meet client’s needs; set time to discuss requests.
  • Confront with behavior; discuss reasons for behavior.
  • Ignore negative attention seeking and reinforce appropriate requests for attention.
  • Make plans with entire staff to set limits.
  • Set up contractual arrangement for brief, frequent, regular, uninterrupted attention.
  • Health teaching: teach appropriate methods for gaining attention.

E. Evaluation/outcome criteria: fewer requests for attention; assumes more responsibility for self-care.


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

A. Definition: an attempt or refusal to acknowledge some anxiety-provoking aspect of oneself or external reality. Denial may be an acceptable first phase of coping as an attempt to allow time for adaptation.

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

B. Assessment:

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

  • Observe for defense and coping mechanisms such as: dissociation, repression, selective inattention, suppression, displacement of concern to another person.
  • Note behaviors that may indicate denial of diagnosis:
    a. Failure to follow treatment plan.
    b. Missed appointment.
    c. Refusal of medication.
    d. Inappropriate cheerfulness.
    e. Ignoring symptoms.
    f. Use of flippant humor.
    g. Use of second or third person in reference to illness.
    h. Flight into wellness, over activity.
  • Use of earliest and most primitive defense by closing eyes, turning head away to separate from what is unpleasant and anxiety provoking.
  • Note range of denial: explicit verbal denial of obvious facts, disowning or ignoring aspects or minimizing by understatement.
  • Be aware of situations such as long-term physical disability that make people more prone to denial of illness. Denial of illness protects the ego from overwhelming anxiety.

C. Analysis/nursing diagnosis: ineffective denial related to:

  • Untenable wishes, needs, ideas, deeds, or reality factors.
  • Inability to adapt to full realization of painful experience or to accept changes in body image or role perception.
  • Intense stress and anxiety.

D. Nursing care plan/implementation:

  • Long-term goal: understand needs met by denial.
  • Short-term goals: avoid reinforcing denial patterns.
    a. Recognize behavioral cues of denial of some reality aspect; be aware of level of awareness and degree to which reality is excluded.
    b. Determine if denial interferes with treatment.
    c. Support moves toward greater reality orientation.
    d. Determine person’s stress tolerance.
    e. Supportively help person discuss events leading to, and feelings about, hospitalization.
  • Health teaching:
    a. Explain that emotional response is appropriate and common.
    b. Explain to family and staff that emotional adjustment to painful reality is done at own pace.

E. Evaluation/outcome criteria: indicates desire to discuss painful experience.


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

A. Definition: reliance on other people to meet basic needs, usually for love and affection, security and protection, and support and guidance; acceptable in early phases of coping.

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

B. Assessment:

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

  • Excessive need for advice and answers to problems.
  • Lack of confidence in own decision-making ability and lack of confidence in self-sufficiency.
  • Clinging, too-trusting behavior.
  • Gestures, facial expressions, body posture, recurrent themes conveying “I’m helpless.”

C. Analysis/nursing diagnosis:

  • Chronic low self-esteem related to inability to meet basic needs or role expectations.
  • Helplessness and hopelessness related to inadvertent reinforcement by staff’s expectations.
  • Powerlessness related to holding a belief that one’s own actions cannot affect life situations.

D. Nursing care plan/implementation:

  • Long-term goal: increase self-esteem, confidence in own abilities.
  • Short-term goal: provide activities that promote independence.
    a. Limit setting—clear, firm, consistent; acknowledge when demands are made; accept client but refuse to respond to demands.
    b. Break cycle of nurse avoids client when he or she is clinging and demanding → a client’s anxiety increases → demands for attention increase → frustration and avoidance on nurse’s part increase.
    c. Give attention before demand exists.
    d. Use behavior modification approaches:
    (1)Reward appropriate behavior (such as making decisions, helping others, caring for own needs) with attention and praise.
    (2)Give no response to attention-seeking, dependent, infantile behavior; goal is to increase incidence of mature behavior as client realizes little gratification from dependent behavior.
    e. Avoid secondary gains of being cared for, which impede progress toward aforementioned goals.
    f. Assist in developing ability to control panic by responding less to client’s high anxiety level.
    g. Help client develop ways to seek gratification other than excessive turning to others.
    h. Resist urge to act like a parent when client becomes helpless, demanding, and attention seeking.
    i. Promote decision making by not giving advice.
    j. Encourage accountability for own feelings, thoughts, and behaviors.
    (1)Help identify feelings through nonverbal cues, thoughts, recurrent themes.
    (2)Convey expectations that client does have opinions and feelings to share.
    (3)Role model how to express feelings.
    k. Reinforce self-esteem and ability to work out problems independently. (Consistently ask: “How do you feel about . . .”; “What do you think?”)
    3. Health teaching:
    a. Teach family ways of interacting to enforce less dependency.
    b. Teach problem-solving skills, assertiveness.

E. Evaluation/outcome criteria:

  • Performs self-care.
  • Asks less for approval and praise.
  • Seeks less attention, proximity, physical contact.


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

A. Definition: a feeling of intense anger or an attitude of antagonism or animosity, with the destructive component of intent to inflict harm and pain to another or to self; may involve hate, anger, rage, aggression, regression.

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

B. Operational definition:

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

  • Past experience of frustration, loss of self-esteem, unmet needs for status, prestige, or love.
  • Present expectations of self and others not met.
  • Feelings of humiliation, inadequacy, emotional pain, and conflict.
  • Anxiety experienced and converted into hostility, which can be:
    a. Repressed, with result of becoming withdrawn.
    b. Disowned to the point of overreaction and extreme compliance.
    c. Overtly exhibited: verbal, nonverbal.

C. Concepts and principles:

  • Aggression and violence are two outward expressions of hostility.
  • Hostility is often unconscious, automatic response.
  • Hostile wishes and impulses may be underlying motives for many actions.
  • Perceptions may be distorted by hostile outlook.
  • Continuum: from extreme politeness to externalization as murderous rage or homicide or internalization as depression or suicide.
  • Hostility seen as a defense against depression, as well as a cause of it.
  • Hostility may be repressed, dissociated, or expressed covertly or overtly.
  • Normal hostility may come from justifiable fear of real danger; irrational hostility stems from anxiety.
  • Developmental roots of hostility:
    a. Infants look away, push away, physically move away from threat; give defiant look. Role modeling by parents.
    b. Three-year-olds replace overt hostility with protective shyness, retreat, and withdrawal. Feel weak, inadequate in face of powerful person against whom cannot openly ventilate hostility.
    c. Frustrated or unmet needs for status, prestige, or power serve as a basis for adult hostility.

D. Assessment:

  • Fault-finding, scapegoating, sarcasm, derision.
  • Arguing, swearing, abusiveness, verbal threatening.
  • Deceptive sweetness, joking at other’s expense, gossiping.
  • Physical abusiveness, violence, murder, vindictiveness.

E. Analysis/nursing diagnosis:

  • Causes:
    a. Anxiety related to a learned means of dealing with an interpersonal threat.
    b. Risk for violence related to a reaction to loss of self-esteem and powerlessness.
    c. Defensive coping related to intense frustration, insecurity, or apprehension.
    d. Impaired social interaction related to low anxiety tolerance.
  • Situations with high potential for hostility:
    a. Enforced illness and hospitalization cause anxiety, which may be expressed as hostility.
    b. Dependency feelings related to acceptance of illness may result in hostility as a coping mechanism.
    c. Certain illnesses or physical disabilities may be conducive to hostility:
    (1) Client who has preoperative cancer and is displacing hostility onto staff and family.
    (2)Postoperatively, if diagnosis is terminal, the family may displace hostility onto nurse.
    (3)Anger, hostility is a stage of dying the person may experience.
    (4) Client who had amputation may focus frustration on others due to dependency and jealousy.
    (5) Clients on hemodialysis are prone to helplessness, which may be displaced as hostility.

F. Nursing care plan/implementation:

  • Long-term goal: help alter response to fear, inadequacy, frustration, threat.
  • Short-term goal: express and explore feelings of hostility without injury to self or others.
    a. Remain calm, nonthreatening; endure verbal abuse in impartial manner, within limits; speak quietly.
    b. Protect from self-harm, acting out.
    c. Discourage hostile behavior while showing acceptance of client.
    d. Offer support to express feelings of frustration, anger, and fear constructively, safely, and appropriately.
    e. Explore hostile feelings without fear of retaliation, disapproval.
    f. Avoid: arguing, giving advice, reacting with hostility, punitiveness, finding fault.
    g. Avoid joking, teasing, which can be misinterpreted.
    h. Avoid words such as anger, hostility; use client’s words (upset, irritated).
    i. Do not minimize problem or give client reassurance or hasty, general conclusions.
    j. Do not stop verbal expression of anger unless detrimental.
    k. Respond matter-of-factly to attention-seeking behavior, not defensively.
    l. Avoid physical contact; allow client to set pace in “closeness.”
    m. Look for clues to antecedent events and focus directly on those areas; do not evade or ignore.
    n. Constantly focus on here and now and affective component of message rather than on content.
    o. Reconstruct what happened and why, discuss client’s reactions; seek observations, not inferences.
    p. Learn how client would like to be treated.
    q. Look for ways to help client relate better without defensiveness, when ready.

r. Plan to channel feelings into motor outlets (occupational and recreational therapy, physical activity, games, debates).
s. Explain procedures beforehand; approach frequently.
t. Withdraw attention, set limits, when acting out.

  • Health teaching: teach acceptable motor outlets for tension.

G. Evaluation/outcome criteria: identifies sources of threat and experiences success in dealing with threat.


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

A. Definition: process of playing on and using others by unfair, insidious means to serve own purpose without regard for others’ needs; may take many forms; occurs consciously, unconsciously to some extent, in all interpersonal relations.

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

B. Operational definition

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

  • Conflicting needs, goals exist between client and other person (e.g., nurse).
  • Other person perceives need as unacceptable, unreasonable.
  • Other person refuses to accept client’s need.
  • Client’s tension increases, and he or she begins to relate to others as objects.
  • Client increases attempts to influence others to fulfill his or her needs.
    a. Appears unaware of others’ needs.
    b. Exhibits excessive dependency, helplessness, demands.
    c. Sets others at odds (especially staff).
    d. Rationalizes, gives logical reasons.
    e. Uses deception, false promises, insincerity.
    f. Questions and defies nurse’s authority and competence.
  • Nurse feels powerless and angry at having been used.

C. Assessment:

  • Acts out sexually, physically.
  • Dawdles, always last minute.
  • Uses insincere flattery; expects special favors, privileges.
  • Exploits generosity and fears of others.
  • Feels no guilt.
  • Plays one staff member against another.
  • Tests limits.
  • Finds weaknesses in others.
  • Makes excessive, unreasonable, unnecessary demands for staff time.
  • Pretends to be helpless, lonely, distraught, tearful.
  • Cannot distinguish between truth and falsehood.
  • Plays on sympathy or guilt.
  • Offers many excuses, lacks insight.
  • Pursues unpleasant issues without genuine regard for feelings of individuals involved.
  • Intimidates, derogates, threatens, bargains, cajoles, violates rules to obtain reactions or privileges.
  • Betrays information.
  • Uses communication as a medium for manipulation, as verbal, nonverbal means to get others to cooperate, to behave in certain way, to get something from another for own use.
  • May be coercive, illogical, or skillfully deceptive.
  • Unable to learn from experience (i.e., repeats unacceptable behaviors despite negative consequences).

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

D. Analysis/nursing diagnosis: ineffective individual coping and impaired adjustment related to:

  • Mistrust and contemptuous view of others’ motivations.
  • Life experience of rejection, deception.
  • Low anxiety tolerance.
  • Inability to cope with tension.
  • Unmet dependency needs.
  • Need to avoid anxiety when cannot obtain gratification.
  • Need to obtain something that is forbidden, or need for instant gratification.
  • Attempt to put something over on another when no real advantage exists.
  • Intolerance of intimacy, maneuvering effectively to keep others at a safe distance to dilute the relationship by withdrawing and frustrating others or distracting attention away from self.
  • Attempt to demand attention, approval, disapproval.

E. Nursing care plan/implementation:

  • Long-term goal: define relationship as a mutual experience in learning and trust rather than a struggle for power and control.
  • Short-term goals: increase awareness of self and others; increase self-control; learn to accept limitations.
  • Promote use of “3 Cs”—cooperation, compromise, collaboration—rather than exploitation or deception.
  • Decrease level and extent of manipulation.
    a. Set firm, realistic goals, with clear, consistent expectations and limits.
    b. Confront client regarding exploitation attempts; examine, discuss behavior.
    c. Give positive reinforcement with concrete reinforcers for nonmanipulation, to lessen need for exploitive, deceptive, and self-destructive behaviors.
    d. Ignore “wooden-leg” behavior (feigning illness to evoke sympathy).
    e. Allow verbal anger; do not be intimidated; avoid giving desired response to obvious attempts to irritate.
    f. Set consistent, firm, enforceable limits on destructive, aggressive behavior that impinges on others’ health, rights, and interests, and on excessive dependency; give reasons when you cannot meet requests.
    g. Keep staff informed of rules and reasons; obtain staff consensus.
    h. Enforce direct communication; encourage openness about real needs, feelings.
    i. Do not accept gifts, favors, flattery, or other guises of manipulation.
  • Increase responsibility for self-control of actions.
    a. Decide who (client, nurse) is responsible for what.
    b. Provide opportunities for success to increase self-esteem, experience acceptance by others.
    c. Evaluate actions, not verbal behavior; point out the difference between talk and action.
    d. Support efforts to be responsible.
    e. Assist client to increase emotional repertoire; explore alternative ways of relating interpersonally.
    f. Avoid submission to control based on fear of punishment, retaliation, loss of affection.
  • Facilitate awareness of, and responsibility for, manipulative behavior and its effects on others.
    a. Reflect back client’s behavior.
    b. Discourage distortion and misuse of information.
    c. Increase tolerance for differences and delayed gratification through behavior modification.
    d. Insist on clear, consistent staff communication.
  • Avoid:
    a. Labeling client as a “problem.”
    b. Hostile, negative attitude.
    c. Making a public issue of client’s behavior.
    d. Being excessively rigid or permissive, inconsistent or ambiguous, argumentative or accusatory.
  • Health teaching: act as a role model; demonstrate how to deal with mistakes, human imperfections, by admitting mistakes in nonshameful, nonvirtuous ways.

F. Evaluation/outcome criteria: accepts limits; able to compromise, cooperate rather than deceive and exploit; acts responsibly, self-dependent.




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