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

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

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

Subtypes of personality disorders include borderline, paranoid, schizoid, schizotypal, obsessive-compulsive, antisocial, histrionic, narcissistic, avoidant, and dependent personalities. A personality disorder is a syndrome in which the person’s inner difficulties are revealed through general behaviors and by a pattern of living that seeks immediate gratification of impulses and instinctual needs without regard to society’s
laws, mores, and customs and without censorship of personal conscience. Borderline and antisocial personality disorders are the most significant in interactions with the nurse.

Borderline personality disorder is a subtype in which the client is unstable in many areas: she or he has unstable but intense interpersonal relationships, impulsive and unpredictable behavior, wide mood swings, chronic feelings of boredom or emptiness, intolerance of being alone, and uncertainty about identity, and is physically self-damaging.

I. CONCEPTS AND PRINCIPLES RELATED TO ANTISOCIAL PERSONALITY DISORDERS:

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

  • One defense against severe anxiety is “acting out,” or dealing with distressful feelings or issues through action.
  • Faulty or arrested emotional development in preoedipal period has interfered with development of adequate social control or superego.
  • Because there is a malfunctioning or weakened superego, there is little internal demand and therefore no tension between ego and superego to evoke guilt feelings.
  • The defect is not intellectual; person shows lack of moral responsibility, inability to control emotions and impulses, and deficiency in normal feeling responses.
  • “Pleasure principle” is dominant.
  • Initial stage of treatment is most crucial; treatment situation is very threatening because it mobilizes client’s anxiety, and client ends treatment abruptly. Key underlying emotion: fear of closeness, with threat of exploitation, control, and abandonment.

II. ASSESSMENT of antisocial personality disorders:

  • Onset before age 15.
  • History of behavior that conflicts with society: truancy, expulsion, or suspension from school for misconduct; delinquency, thefts, vandalism, running away from
    home; persistent lying; repeated substance abuse; initiating fights; fire starting and cruelty to animals; chronic violation of rules at home or school; school grades below IQ level.
  • Inability to sustain consistent work behavior (e.g., frequent job changes or absenteeism).
  • Lack of ability to function as parent who is responsible (evidence of child’s malnutrition or illness due to lack of minimal hygiene standards; failure to obtain medical care for child who is seriously ill; failure to arrange for caregiver when parent is away from home).
  • Failure to accept social norms with respect to lawful behavior (e.g., thefts, multiple arrests).
  • Inability to maintain enduring intimate relationship (e.g., multiple relations, desertion, multiple divorces); lack of respect or loyalty.
  • Irritability and aggressiveness (spouse, child abuse; repeated physical fights).
  • Failure to honor financial obligations.
  • Failure to plan ahead.
  • Disregard for truth (lying, “conning” others for personal gain).
  • Recklessness (driving while intoxicated, recurrent speeding).
  • Violating rights of others.
  • Does not appear to profit from experience; repeats same punishable or antisocial behavior; usually does not feel guilt or depression.
  • Exhibits poor judgment; may have intellectual, but not emotional, insight to guide judgments. Inadequate problem-solving and reality testing.
  • Uses manipulative behavior patterns in treatment setting.
    1. Demands and controls.
    2. Pressures and coerces, threatens.
    3. Violates rules, routines, procedures.
    4. Requests special privileges.
    5. Betrays confidences and lies.
    6. Ingratiates.
    7. Monopolizes conversation.

III. ANALYSIS/NURSING DIAGNOSIS in personality disorders:

A. Ineffective individual coping related to:

  • Inability to tolerate frustration (altered conduct/ impulse processes).
  • Verbal, nonverbal manipulation (lying).
  • Destructive behavior toward self (e.g., in borderline personality disorder) or others.
  • Cognitive distortions (e.g., overuse of denial, projection, rationalization, intellectualization, persecutory thoughts).
  • Inability to learn from experience.

B. Personal identity disturbance related to:

  • Self-esteem disturbance as evidenced by grandiosity, depression, extreme mood changes.
  • Lack of: responsibility, accountability, commitment, tolerance of rejection.
  • Distancing relationships.

C. Social intrusiveness related to fear of real or potential loss.

D. Noncompliance related to excess need for independence.

IV. NURSING CARE PLAN/IMPLEMENTATION in personality disorders:

  • Long-term goal: help person accept responsibility
    and consequences of own actions.
  • Short-term goal: minimize manipulation and acting out.
  • Set fair, firm, consistent limits and follow through on consequences of behavior; let client know what she or he can expect from staff and what the unit’s
    regulations are, as well as the consequences of violations. Be explicit.
  • Avoid letting staff be played against one another by a particular client; staff should present a unified approach.
  • Nurses should control their own feelings of anger and defensiveness aroused by any person’s manipulative behavior.
  • Change focus when client persists in raising inappropriate subjects (such as personal life of a nurse).
  • Encourage expression of feelings as an alternative to acting out.
  • Aid client in realizing and accepting responsibility for own actions and social responsibility to others.
  • Use group therapy as a means of peer control and multiple feedback about behavior.
  • Health teaching: teach family how to use behavior modification techniques to reward client’s acceptable behavior (i.e., when he or she accepts responsibility for own behavior, is responsive to rights of others, adheres to social and legal norms).

V. EVALUATION/OUTCOME CRITERIA: less use of lying, blaming others for own behavior; more evidence of following rules; less impulsive, explosive behavior.

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

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

Mood disorders include (1) depressive disorders and (2) bipolar disorders. Bipolar disorders are further divided into (a) manic, (b) depressed, (c) mixed, or (d) cyclothymia. The mood disturbance may occur in a number of patterns of severity and duration, alone or in combination, where client feels extreme sadness and guilt, withdraws socially, expresses self-deprecatory thoughts (major depression), or experiences an elevated, expansive mood with hyperactivity, pressured speech, inflated self-esteem, and decreased need for sleep (manic episode or disorder).

Another specific mood disorder is dysthymic disorder (depressive neuroses), in which there is a chronic mood disturbance involving a depressed mood or loss of interest
and pleasure in all usual activities, but not of sufficient severity or duration to be classified as a major depressive episode.

These affective disorders should be distinguished from grief. Grief is realistic and proportionate to what has been specifically lost and involves no loss of self-esteem.

Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span

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

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

I. CONCEPTS AND PRINCIPLES:

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

A. Self-limiting factors—most depressions are self-limiting disturbances, making it important to look for a change in functioning and behavior.

B. Theories of cause of depression:

  • Aggression turned inward—self-anger.
  • Response to separation or object loss.
  • Genetic or neurochemical basis—impaired neurotransmission system, especially serotonin regulation.
  • Cognitive—negative mindset of hopelessness toward self, world, future; overgeneralizes; focuses on single detail rather than whole picture; draws conclusions on inadequate evidence.
  • Personality—negative self-concept, low self-esteem affects belief system and appraisal of stressors; ambivalence, guilt, feeling of failure.
  • Learned helplessness—dependency; environment cannot be controlled; powerlessness.
  • Behavioral—loss of positive reinforcement; lack of support system.
  • Integrated—interaction of chemical, experiential, and behavioral variables acting on diencephalon.

II. GENERAL ASSESSMENT:

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

  • Physical: early-morning awakening, insomnia at night, increased need for sleep during the day, fatigue, constipation, anorexia with weight loss, loss of sexual interest, psychomotor retardation, physical complaints, amenorrhea.
  • Psychological: inability to remember, decreased concentration, slowing or blocking of thought, all-or-nothing thinking, less interest in and involvement
    with external world and own appearance, feeling worse at certain times of day or after any sleep, difficulty in enjoying activities, monotonous voice, repetitive discussions, inability to make decisions due to ambivalence, impaired coping with practical problems.
  • Emotional: loss of self-esteem, feelings of hopelessness and worthlessness, shame and self-derogation due to guilt, irritability, despair and futility (leading
    to suicidal thoughts), alienation, helplessness, passivity, avoidance, inertia, powerlessness, denied anger; uncooperative, tense, crying, demanding, dependent behavior, and negativistic.

III. ANALYSIS/NURSING DIAGNOSIS:

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

  • Risk for violence toward self (suicide) related to inability to verbalize emotions.
  • Sleep pattern disturbance (insomnia or excessive sleep) related to unresolved fears and anxieties, biochemical alterations (decreased serotonin).
  • Impaired social interaction/social isolation/withdrawal related to decreased energy/inertia, inadequate personal resources, absence of significant purpose in life.
  • Altered nutrition (anorexia) related to lack of interest in food.
  • Self-care deficit related to disinterest in activities of daily living.
  • Chronic low self-esteem with self-reproaches and blame related to feelings of inadequacy.
  • Altered feeling states and meaning patterns (sadness, loneliness, apathy) related to overwhelming feeling of unworthiness, hopelessness, and dysfunctional grieving.

IV. NURSING CARE PLAN/IMPLEMENTATION:

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

A. Promote sleep and food intake: take nursing measures to ensure the physical well-being of the client.

B. Provide steady company to assess suicidal tendencies and to diminish feelings of loneliness and alienation.

  • Build trust in a one-to-one relationship.
  • Interact with client on a nonverbal level if that is his or her immediate mode of communication; this will promote feelings of being recognized, accepted, and understood.
  • Focus on today, not the past or far into the future.
  • Reassure that present state is temporary and that he or she will be protected and helped.

C. Make the environment non-challenging and nonthreatening.

  • Use a kind, firm attitude, with warmth.
  • See that client has favorite foods; respond to other wishes and likes.
  • Protect from over stimulation and coercion.

D. Postpone client’s decision making and resumption of duties.

  • Allow more time than usual to complete activity (dressing, eating) or thought process and speech.
  • Structure the environment for client to help reestablish a set schedule and predictable routine during ambivalence and problems with decisions.

E. Provide nonintellectual activities (e.g., sanding wood); avoid activities such as chess and crossword puzzles, because thinking capacity at this time tends to be circular.

Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span

F. Encourage expression of emotions: denial, hopelessness, helplessness, guilt, regret; provide outlets for anger that may be underlying the depression; as client becomes more verbal with anger and recognizes the origin and results of anger, help client resolve feelings—allow client to complain and be demanding in initial phases of depression.

G. Discourage redundancy in speech and thought: redirect focus from a monologue of painful recounts to an appraisal of more neutral or positive attributes and aspects of situations.

H. Encourage client to assess own goals, unrealistic expectations, and perfectionist tendencies.

  • May need to change goals or give up some goals that are incompatible with abilities and external situations.
  • Assist client to recapture what was lost through substitution of goals, sublimation, or relinquishment of unrealistic goals—reanchor client’s selfrespect to other aspects of his or her existence; help him or her free self from dependency on one person or single event or idea.

I. Indicate that success is possible and not hopeless.

  • Explore what steps client has taken to achieve goals and suggest new or alternative ones.
  • Set small, immediate goals to help attain mastery.
  • Recognize client’s efforts to mobilize self.
  • Provide positive reinforcement for client through exposure to activities in which client can experience a sense of success, achievement, and completion to build self-esteem and self-confidence.
  • Help client experience pleasure; help client start good relationships in social setting.

J. Long-term goal: to encourage interest in external surroundings, outside of self, to increase and strengthen social relationships.

  • Encourage purposeful activities.
  • Let client advance to activities at own pace (graded task assignments).
  • Gradually encourage activities with others.
  • Cognitive restructuring: changing negative thoughts to positive ones.

K. Health teaching: explain need to recognize highly stressful situation and fatigue as stress factor; advise that negative responses from others be regarded with minimum significance; explain need to maintain positive self-attitude; advise occasional respite from responsibilities; emphasize need for realistic expectation of others.

V. EVALUATION/OUTCOME CRITERIA: performs self-care; expresses increased self-confidence; engages in activities with others; accepts positive statements from others; identifies positive attributes and skills in self.

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.

I. CONCEPTS AND PRINCIPLES RELATED TO BIPOLAR DISORDERS:

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

  • The psychodynamics of manic and depressive episodes are related to hostility and guilt.
  • The struggle between unconscious impulses and moral conscience produces feelings of hostility, guilt, and anxiety.
  • To relieve the internal discomfort of these reactions, the person projects long-retained hostile feelings onto others or onto objects in the environment during manic phase; during depressive phase, hostility and guilt are introjected toward self.
  • Demands, irritability, sarcasm, profanity, destructiveness, and threats are signs of the projection of hostility; guilt is handled through persecutory delusions and accusations.
  • Feelings of inferiority and fear of rejection are handled by being light and amusing.
  • Both phases, though appearing distinctly different, have the same objective: to gain attention, approval, and emotional support. These objectives and behaviors are unconsciously determined by the client; this behavior may be either biochemically determined or both biochemically and unconsciously determined.

II. ASSESSMENT of bipolar disorders:

A. Manic and depressed types are opposite sides of the same disorder.

  • Both are disturbances of mood and selfesteem.
  • Both have underlying aggression and hostility.
  • Both are intense.
  • Both are self-limited in duration.

B. Comparison of behaviors associated with mania and depression.

III. ANALYSIS/NURSING DIAGNOSIS:

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

  • Risk for violence directed at others/self related to poor judgment, impulsiveness, irritability, manic excitement.
  • Altered nutrition, less than body requirements, related to inability to sit down long enough to eat, metabolic expenditures.
  • Sleep pattern disturbance: lack of sleep and rest related to restlessness, hyperactivity, emotional dysfunctioning, lack of recognition of fatigue.
  • Self-care deficits related to altered motor behavior due to anxiety.
  • Sensory/perceptual alterations (overload) related to endogenous chemical alteration, sleep deprivation.
  • Altered feeling state (anger), judgment, thought content (magical thinking), thought processes (altered concentration and problem-solving) related to disturbance in self-concept.
  • Altered feeling processes (mood swings).
  • Altered attention: hyperalertness.
  • Impaired social interaction related to internal and external stimuli (overload, under load).
  • Impaired verbal communication: flight of ideas and racing thoughts.

Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span

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IV. NURSING CARE PLAN/IMPLEMENTATION:

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

A. Manic:

  • Prevent physical dangers stemming from suicide and exhaustion—promote rest, sleep, and intake of nourishment.
    a. Use suicide precautions.
    b. Reduce outside stimuli or remove to quieter area.
    c. Diet: provide high-calorie beverages, finger foods within sight and reach.
  • Attend to client’s personal care.
  • Absorb with understanding and without reproach behaviors such as talkativeness, provocativeness, criticism, sarcasm, dominance, profanity, and dramatic actions.
    a. Allow, postpone, or partially fulfill demands and freedom of expression within limits of ordinary social rules, comfort, and safety of client and others.
    b. Do not cut off manic stream of talk, because this increases anxiety and need for release of hostility.
  • Constructively utilize excessive energies with activities that do not call for concentration or follow-through.
    a. Outdoor walks, gardening, putting, and ball tossing are therapeutic.
    b. Exciting, disturbing, and highly competitive activities should be avoided.
    c. Creative occupational therapy activities promote release of hostile impulses, as does creative writing.
  • Give benzodiazepines and/or atypical antipsychotics (e.g., aripiprazole [Abilify]) for rapid stabilization of acute mania, as ordered until lithium affects symptoms (3 weeks); then give lithium carbonate as ordered. An anticonvulsant (e.g., valproic acid [Depakote]) may be used as an alternative treatment for mood stabilization.
  • Help client to recognize and express feelings (denial, hopelessness, anger, guilt, blame, helplessness).
  • Encourage realistic self-concept.
  • Health teaching: how to monitor effects of lithium; instructions regarding salt intake.

B. Depressed:

  • Take routine suicide precautions.
  • Give attention to physical needs for food and sleep and to hygiene needs. Prepare warm baths and hot beverages to aid sleep.
  • Initiate frequent contacts:
    a. Do not allow long periods of silence to develop or client to remain withdrawn.
    b. Use a kind, understanding, but emotionally neutral approach.
  • Allow dependency in severe depressive phase. Because dependency is one of the underlying concerns with persons who are depressed, if nurse allows dependency to occur as an initial response, he or she must plan for resolution of the dependency toward himself or herself as an example for the client’s other dependent relationships.
  • Slowly repeat simple, direct information.
  • Assist in daily decision making until client regains self-confidence.
  • Select mild exercise and diversionary activities instead of stimulating exercise and competitive games, because they may overtax physical and emotional endurance and lead to feelings of inadequacy and frustration.
  • Give anti-depressive drugs.
  • Health teaching: how to make simple decisions related to health care.

V. EVALUATION/OUTCOME CRITERIA:

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

  • Manic: speech and activity are slowed down; affect is less hostile; able to sleep; able to eat with others at the table.
  • Depressed: takes prescribed medications regularly. Does not engage in self-destructive activities. Able to express feelings of anger, helplessness, hopelessness.
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FURTHER READING/STUDY:

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