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

 Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span: Other Substance-Related Disorders

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

I. CONCEPTS AND PRINCIPLES:

A. Three interacting key factors give rise to dependence—psychopathology of the individual; frustrating environment; and availability of powerful, addicting, and temporarily satisfying drug.

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

B. According to conditioning principles, substance abuse and dependence proceed in several phases:

  • Use of sedatives-hypnotics, CNS stimulants, hallucinogens, and narcotics for relief from daily tensions and discomforts or anticipated withdrawal symptoms.
  • Habit is reinforced with each relief by drug use.
  • Development of dependency—drug has less and less efficiency in reducing tensions.
  • Dependency is further reinforced as addict fails to maintain adequate drug intake—increase in frequency and duration of periods of tension and discomfort.

II. ASSESSMENT:

A. Abuse:

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

  • Hallucinogens (lysergic acid diethylamide [LSD], marijuana, ecstasy, STP, PCP, peyote): euphoria and rapid mood swings, flight of ideas; perceptual impairment, feelings of omnipotence, “bad trip” (panic, loss of control, paranoia), flashbacks, suicide.
  • CNS stimulants (amphetamines and cocaine abuse): euphoria, hyperactivity, hyperalertness, irritability, persecutory delusions; insomnia, anorexia → weight loss; tachycardia; tremulousness; hypertension; hyperthermia → convulsions.
  • Narcotics (opium and its derivatives morphine, heroin, codeine, meperidine HCl [Demerol]): used by “snorting,” “skin popping,” and “mainlining.” May lead to abscesses and hepatitis. Decreased pain response, respiratory depression; apathy, detachment from reality; impaired judgment; loss of sexual activity; pinpoint pupils.
  • Sedatives-hypnotics (barbiturate abuse): similar to alcohol-induced behavior (e.g., euphoria) followed by depression, hostility; decreased inhibitions; impaired judgment; staggering gait; slurred speech; drowsiness; poor concentration; progressive respiratory depression.

B. Withdrawal symptoms:

  • Narcotics (e.g., heroin): begin within 12 hours of last dose, peak in 24 to 36 hours, subside in 72 hours, and disappear in 5 to 6 days.
    a. Pupil dilation.
    b. Muscle: twitches, tremors, aches, pains.
    c. Gooseflesh (piloerection).
    d. Lacrimation, rhinorrhea, sneezing, yawning.
    e. Diaphoresis, chills.
    f. Potential for fever.
    g. Vomiting, abdominal distress.
    h. Dehydration.
    i. Rapid weight loss.
    j. Sleep disturbance.
  • Barbiturates: may be gradual or abrupt (“cold turkey”); latter is dangerous or life-threatening; should be hospitalized.
    a. Gradual withdrawal reaction from barbiturates:
    (1)Postural hypotension.
    (2)Tachycardia.
    (3)Elevated temperature.
    (4) Insomnia.
    (5)Tremors.
    (6) Agitation, restlessness.                                                                               b. Abrupt withdrawal from barbiturates:
    (1)Apprehension.
    (2)Muscular weakness.
    (3)Tremors.
    (4)Postural hypotension.
    (5)Twitching.
    (6)Anorexia.
    (7)Grand mal seizures (a.k.a. generalized seizures).
    (8)Psychosis-delirium.
  • Amphetamines: depression, lack of energy, somnolence.
  • Marijuana: psychological dependency includes craving the “high,” and irritability without the drug. Physical withdrawal occurs with heavy daily use; symptoms include: insomnia, anxiety, and loss of appetite.

C. Difference between alcohol and other abused substances (e.g., opioid).

  • Other abused substances may need to be obtained by illegal means, making it a legal and criminal problem as well as a medical and social problem; not so with alcohol abuse and dependency.
  • Opium and its derivatives inhibit aggression; whereas alcohol releases aggression.
  • As long as the client is on large enough doses to avoid withdrawal symptoms, abuser of narcotics, sedatives, or hypnotics is comfortable and functions well; whereas chronically intoxicated abuser of alcohol cannot function normally.
  • Direct physiological effects of long-term opioid abuse and dependence on other abused substances are much less critical than those with chronic alcohol dependence.

III. ANALYSIS/NURSING DIAGNOSIS:

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

  • Risk for altered physical regulation processes (cardiac, circulatory, gastrointestinal, sleep pattern disturbance) related to use of mind-altering drugs.
  • Risk for injury due to altered judgment related to misinterpretation of sensory stimuli and low frustration tolerance.
  • Altered conduct/impulse processes related to rebellious attitudes toward authority.
  • Altered social interaction (manipulation, dependency) related to hostility and personal insecurity.
  • Altered feeling states (denial) related to underlying self-doubt and personal insecurity.

IV. NURSING CARE PLAN/IMPLEMENTATION: generally the same as in treating antisocial personality and alcohol abuse and dependence.

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

A. Maintain safety and optimum level of physical comfort. Supportive physical care: vital signs, nutrition, hydration, seizure precautions.

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

B. Assist with medical treatment and offer support and reality orientation to reduce feelings of panic.

  • Detoxification (or dechemicalization)—give medications according to detoxification schedule.
  • Withdrawal—may be gradual (barbiturates, hypnotics, tranquilizers) or abrupt (“cold turkey” for heroin). Observe for symptoms and report immediately.
  • Methadone (Dolophine)—person must have been dependent on narcotics at least 2 years and have failed at other methods of withdrawal before admission to program of re-addiction by methadone.
    a. Characteristics:
    (1)Synthetic.
    (2)Appeases desire for narcotics without producing euphoria of narcotics.
    (3)Given by mouth.
    (4)Distributed under federal control (Narcotic Addict Rehabilitation Act).
    (5)Given with urinary surveillance.
    b. Advantages:
    (1)Prevents narcotic withdrawal reaction.
    (2)Tolerance not built up.
    (3)Person remains out of prison.
    (4)Lessens perceived need for heroin or morphine.

C. Participation in group therapy—goals: peer pressure, support, and identification.

D. Rehabilitation phase:

  • Refer to halfway house and group living.
  • Support employment as therapy (work training).
  • Expand client’s range of interests to relieve characteristic boredom and stimulus hunger.
    a. Provide structured environment and planned routine.
    b. Provide educational therapy (academic and vocational).
    c. Arrange activities to include current events discussion groups, lectures, drama, music, and art appreciation.

E. Achieve role of stabilizer and supportive authoritative figure; this can be achieved through frequent, regular contacts with the same client.

F. Health teaching: how to cope with pain, fatigue, and anxiety without drugs.

V. EVALUATION/OUTCOME CRITERIA: replaces addictive lifestyle with self-reliant behavior and a plan formulated to maintain a substance-free life.

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

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

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

Anxiety is a subjective warning of danger in which the specific nature of the danger is usually not known. It occurs when a person faces a new, unknown, or untried situation. Anxiety is also felt when a person perceives threat in terms of past experiences. It is a general concept underlying most disease states. In its milder form, anxiety can contribute to learning and is necessary for problem solving. In its severe form, anxiety can impede a client’s treatment and recovery. The general feelings elicited on all levels of anxiety are nervousness, tension, and apprehension.

It is essential that nurses recognize their own sources of anxiety and behavior in response to anxiety, as well as help clients recognize the manifestations of anxiety in themselves.

I. ASSESSMENT:

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

A. Physiological manifestations:

  • Increased heart rate and palpitations.
  • Increased rate and depth of respiration.
  • Increased urinary frequency and diarrhea.
  • Dry mouth.
  • Decreased appetite.
  • Cold sweat and pale appearance.
  • Increased menstrual flow.
  • Increased or decreased body temperature.
  • Increased or decreased blood pressure.
  • Dilated pupils.

B. Behavioral manifestations—stages of anxiety (Adaptation responses to anxiety):

  • Mild anxiety:
    a. Increased perception (visual and auditory).
    b. Increased awareness of meanings and relationships.
    c. Increased alertness (notice more).
    d. Ability to use problem-solving process.
  • Moderate anxiety:
    a. Selective inattention (e.g., may not hear someone talking).
    b. Decreased perceptual field.
    c. Concentration on relevant data; “tunnel vision.”
    d. Muscular tension, perspiration, GI discomfort.
  • Severe anxiety:
    a. Focus on many fragmented details.
    b. Physical and emotional discomfort (headache, nausea, dizziness, dread, horror, trembling).
    c. Not aware of total environment.
    d. Automatic behavior aimed at getting immediate relief instead of problem-solving.
    e. Poor recall.
    f. Inability to see connections between details.
    g. Drastically reduced awareness.
  • Panic state of anxiety:
    a. Increased speed of scatter; does not notice what goes on.
    b. Increased distortion and exaggeration of details.
    c. Feeling of terror.
    d. Dissociation (hallucinations, loss of reality, and little memory).
    e. Inability to cope with any problems; no self-control.

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

 

C. Reactions in response to anxiety:

  • Fight:
    a. Aggression.
    b. Hostility, derogation, belittling.
    c. Anger.
  • Flight:
    a. Withdrawal.
    b. Depression.
  • Somatization (psychosomatic disorder).
  • Impaired cognition: blocking, forgetfulness, poor concentration, errors in judgment.
  • Learning about or searching for causes of anxiety, and identifying behavior.

II. ANALYSIS/NURSING DIAGNOSIS: Anxiety related to:

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

A. Physical causes: threats to biological well-being (e.g., sleep disturbances, interference with sexual functioning, food, drink, pain, fever).

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

B. Psychological causes: disturbance in self-esteem related to:

  • Unmet wishes or expectations.
  • Unmet needs for prestige and status.
  • Impaired adjustment: inability to cope with environment.
  • Altered role performance: not using own full potential.
  • Altered meaningfulness: alienation.
  • Conflict with social order: value conflicts.
  • Anticipated disapproval from a significant other.
  • Altered feeling states: guilt.

III. NURSING CARE PLAN/IMPLEMENTATION:

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

A. Moderate to severe anxiety:

  • Provide motor outlet for tension energy, such as working at a simple, concrete task, walking, crying, or talking.
  • Help clients recognize their anxieties by talking about how they are behaving and by exploring their underlying feelings.
  • Help clients gain insight into their anxieties by helping them to understand how their behavior has been an expression of anxiety and to recognize the threat that lies behind this anxiety.
  • Help clients cope with the threat behind their anxieties by reevaluating the threats and learning new ways to deal with them.
  • Health teaching:
    a. Explain and offer hope that emotional pain will decrease with time.
    b. Explain that some tension is normal.
    c. Explain how to channel emotional energy into activity.
    d. Explain need to recognize highly stressful situations and to recognize tension within oneself.

B. Panic state:

  • Give simple, clear, concise directions.
  • Avoid decision making by client. Do not try to reason with client, because he or she is irrational and cannot cooperate.
  • Stay with client.
    a. Do not isolate.
    b. Avoid touching.
  • Allow client to seek motor outlets (walking, pacing).
  • Health teaching: advise activity that requires no thought.

IV. EVALUATION/OUTCOME CRITERIA:

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

  • Uses more positive thinking and problem-solving activities and is less preoccupied with worrying.
  • Uses values clarification to resolve conflicts and establish realistic goals.
  • Demonstrates regained perspective, self-esteem, and morale; expresses feeling more in control, more hopeful.
  • Fewer or absent physical symptoms of anxiety.

Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span: Patterns of Adjustment (Defense Mechanisms)

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

Defense mechanisms (ego defense mechanisms or mental mechanisms) consist of all the coping means used unconsciously by individuals to seek relief from emotional conflict and to ward off excessive anxiety.

I. DEFINITIONS

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

blocking a disturbance in the rate of speech when a person’s thoughts and speech are proceeding at an average rate but are suddenly and completely interrupted, perhaps even in the middle of a sentence. The gap may last from several seconds up to a minute. Blocking is often a part of the thought disorder found in schizophrenic disorders.

compensation making up for real or imagined handicap, limitation, or lack of gratification in one area of personality by overemphasis in another area to counter the effects of failure, frustration, and limitation (e.g., the person who is blind compensates by increased sensitivity in hearing; the student who is unpopular compensates by becoming an outstanding scholar; men who are small compensate for short stature by demanding a great deal of attention and respect; a nurse who does not have optimal manual dexterity chooses to go into psychiatric nursing).

confabulating filling in gaps of memory by inventing what appear to be suitable memories as replacements. This symptom may occur in various amnestic disorders but is most often seen in Korsakoff’s syndrome (deterioration due to alcohol) and in dementia.

conversion psychological difficulties are translated into physical symptoms without conscious will or knowledge (e.g., pain and immobility on moving your writing arm the day of the examination).

denial an intolerable thought, wish, need, or reality factor is disowned automatically (e.g., a student, when told of a failing grade, acts as if he never heard of such a possibility).

displacement transferring the emotional component from one idea, object, or situation to another, more acceptable one. Displacement occurs because these are painful or dangerous feelings that cannot be expressed toward the original object (e.g., kicking the dog after a bad day at school or work; anger with a clinical instructor gets transferred to a classmate who was late to meet you for lunch).

dissociation splitting off or separation of differing elements of the mind from each other. There can be separation of ideas, concepts, emotions, or experiences from the rest of the mind. Dissociated material is deeply repressed and becomes encapsulated and inaccessible to the rest of the mind. This usually occurs as a result of some very painful experience (e.g., split of affect from idea in anxiety disorders and schizophrenia).

fixation a state in which personality development is arrested in one or more aspects at a level short of maturity (e.g., “She is anally fixated” [controlling, stingy, holding onto things and memories]).

idealization overestimation of some admired aspect or attribute of another person (e.g., “She was a perfect human being”).

ideas of reference fixed, false ideas and interpretations of external events as though they had direct reference to self (e.g., client thinks that TV news announcer is reporting a story about client).

identification the wish to be like another person; situation in which qualities of another are unconsciously transferred to oneself (e.g., boy identifies with his father and learns to become a man; a woman may fear she will die in childbirth because her mother did; a student adopts attitudes and behavior of her favorite teacher).

introjection incorporation into the personality, without assimilation, of emotionally charged impulses or objects; a quality or an attribute of another person is taken into and made part of self (e.g., a girl in love intro ejects the personality of her lover into herself—his ideas become hers, his tastes and wishes are hers; this is also seen in severe depression following death of someone close—client may assume many of deceased’s characteristics; similarly, working in a psychiatric unit with a suicidal person brings out depression in the nurse).

isolation temporary or long-term splitting off of certain feelings or ideas from others; separating emotional and intellectual content (e.g., talking emotionlessly about a traumatic accident).

projection attributes and transfers own feelings, attitudes, impulses, wishes, or thoughts to another person or object in the environment, especially when ideas or impulses are too painful to be acknowledged as belonging to oneself (e.g., in hallucinations and delusions by people who use/abuse alcohol; or,“I flunked the course because the teacher doesn’t know how to teach”; “I hate him” reversed into “He hates me”; or a student impatiently accusing an instructor of being intolerant).

rationalization justification of behavior by formulating a logical, socially approved reason for past, present, or proposed behavior. Commonly used, conscious or unconscious, with false or real reason (e.g., after losing a class election, a student states that she really did not want all the extra work and is glad she lost).

reaction formation going to the opposite extreme from what one wishes to do or is afraid one might do (e.g., being overly concerned with cleanliness when one wishes to be messy; being a mother who is overly protective through fear of own hostility to child; or showing great concern for a person whom you dislike by going out of your way to do special favors).

regression when individuals fail to solve a problem with the usual methods at their command, they may resort to modes of behavior that they have outgrown but that proved successful at an earlier stage of development; retracing developmental steps; going back to earlier interests or modes of gratification (e.g., a senior nursing student about to graduate becomes dependent on a clinical instructor for directions).

repression involuntary exclusion of painful and unacceptable thoughts and impulses from awareness. Forgetting these things solves the situation by not solving it (e.g., by not remembering what was on the difficult examination after it was over).

sublimation channeling a destructive or instinctual impulse that cannot be realized into a socially acceptable, practical, and less dangerous outlet, with some relation to the original impulse for emotional satisfaction to be obtained (e.g., sublimation of sexual energy into other creative activities [art, music, literature], or hostility and aggression into sports or business competition; or a person who is infertile puts all energies into pediatric nursing).

substitution when individuals cannot have what they wish and accept something else in its place for symbolic satisfaction (e.g., pin-up pictures in absence of sexual object; or a person who failed an RN examination signs up for an LVN/LPN examination).

suppression a deliberate process of blocking from the conscious mind thoughts, feelings, acts, or impulses that are undesirable (e.g., “I don’t want to talk about it,” “Don’t mention his name to me,” or “I’ll think about it some other time”; or willfully refusing to think about or discuss disappointment with examination results).

symbolism sign language that stands for related ideas and feelings, conscious and unconscious. Used extensively by children, people from primitive cultures, and clients who are psychotic. There is meaning attached to this sign language that makes it very important to the individual (e.g., a student wears dark, somber clothing to the examination site).

undoing a mechanism against anxiety, usually unconscious, designed to negate or neutralize a previous act (e.g., Lady Macbeth’s attempt to wash her hands [of guilt] after the murder). A repetitious, symbolic acting out, in reverse of an unacceptable act already completed. Responsible for compulsions and magical thinking.

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II. CHARACTERISTICS of defense mechanisms:

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

A. Defense mechanisms are used to some degree by everyone occasionally; they are normal processes by which the ego reestablishes equilibrium—unless they are used to an extreme degree, in which case they interfere with maintenance of self-integrity.

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

B. Much overlapping:

  • Same behavior can be explained by more than one mechanism.
  • May be used in combination (e.g., isolation and repression, denial and projection).

C. Common defense mechanisms compatible with mental well-being:

  • Compensation.
  • Compromise.
  • Identification.
  • Rationalization.
  • Sublimation.
  • Substitution.

D. Typical defense mechanisms in:

  • Paranoid disorders—denial, projection.
  • Dissociative disorders—denial, repression, dissociation.
  • Obsessive-compulsive behaviors—displacement, reaction formation, isolation, denial, repression, undoing.
  • Phobic disorders—displacement, rationalization, repression.
  • Conversion disorders—symbolization, dissociation, repression, isolation, denial.
  • Major depression—displacement.
  • Bipolar disorder, manic episode—reaction formation, denial, projection, introjection.
  • Schizophrenic disorders—symbolization, repression, dissociation, denial, fantasy, regression, projection, isolation.
  • Dementia—regression.

III. CONCEPTS AND PRINCIPLES RELATED TO DEFENSE MECHANISMS:

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

  • Unconscious process—defense mechanisms are used as a substitute for more effective problem solving behavior.
  • Main functions—increase self-esteem; decrease, inhibit, minimize, alleviate, avoid, or eliminate anxiety;maintain feelings of personal worth and adequacy and soften failures; protect the ego; increase security.
  • Drawbacks—involve high degree of self-deception and reality distortion; may be maladaptive because they superficially eliminate or disguise conflicts, leaving conflicts unresolved but still influencing behavior.

IV. NURSING CARE PLAN/IMPLEMENTATION with defense mechanisms:

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

  • Accept defense mechanisms as normal, but not when overused.
  • Look beyond the behavior to the need that is expressed by the use of the defense mechanism.
  • Discuss alternative defense mechanisms that may be more compatible with mental health.
  • Assist the person to translate defensive thinking into nondefensive, direct thinking; a problem solving approach to conflicts minimizes the need to use defense mechanisms.
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FURTHER READING/STUDY:

Resources:

 

 

 

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