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

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

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

Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span

I. MAIN CHARACTERISTIC: involuntary, physical symptoms without demonstrable organic findings or identifiable physiological bases; involve psychological factors or nonspecific conflicts.

II. GENERAL ASSESSMENT:

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

  • Precipitant: major emotional, interpersonal stress.
  • Occurrence of secondary gain from illness.

III. GENERAL ANALYSIS/NURSING DIAGNOSIS:

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

  • Fear related to loss of dependent relationships.
  • Powerlessness related to chronic resentment over frustration of dependency needs.
  • Altered feeling states: inhibition of anger, which is discharged physiologically and is related to control of anxiety.
  • Impaired judgment related to denial of existence of any conflicts or relationship to physical symptoms.
  • Altered role performance: regression related to not having dependency needs met.

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

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

Repeated, multiple, vague or exaggerated physical complaints of several years’ duration without identifiable physical cause; clients constantly seek medical attention, undergo numerous tests; at risk for unnecessary surgery or drug abuse.

A. Assessment:

  • Onset and occurrence—teen years, more common in women.
  • Reports illness most of life.
    a. Neuromuscular symptoms—fainting, seizures, dysphagia, difficulty walking, back pain, urinary retention.
    b. Gastrointestinal symptoms—nausea, vomiting, flatus, food intolerance, constipation or diarrhea.
    c. Female reproductive symptoms—dysmenorrhea, hyperemesis gravidarum.
    d. Psychosexual symptoms—sexual indifference, dyspareunia.                         e. Cardiopulmonary symptoms—palpitations, shortness of breath, chest pain.
    f. Rule out: multiple sclerosis, systemic lupus erythematosus (SLE), porphyria, hyperparathyroidism.
  • Appears anxious and depressed.

B. Analysis/nursing diagnosis:

  • Anxiety (severe) related to threat to security, unmet dependency needs, and inability to meet role expectations.
  • Self-care deficit related to development of physical symptoms to escape stressful situations.
  • Impaired social interaction related to inability to accept that physical symptoms lack a physiological basis; preoccupation with self and physical symptoms, chronic pain; rejection by others.
  • Body-image disturbance and altered role performance related to passive acceptance of disabling symptoms.

Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span: Conversion Disorder (Hysterical Neuroses, Conversion Type)

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

Sudden symptoms of symbolic nature developed under extreme psychological stress (e.g., war, loss, natural disaster) that disappear through hypnosis.

A. Assessment:

  • Neurological symptoms—paralysis, aphonia, tunnel vision, seizures, blindness, paresthesias, anesthesias.
  • Endocrinological symptoms—pseudocyesis.
  • Hysterical, dependent personality profile: exhibitionistic dress and language; self-indulgent; suggestible; impulsive and global impressions and hunches; little capacity to concentrate, integrate, and organize thoughts or plan action or outcomes; little concern for symptoms, despite severe impairment (“la belle indifference”).

B. Analysis/nursing diagnosis:

  • Prolonged loss or alteration of physiological processes related to severe psychological stress and conflict that results in disuse, atrophy, contractures. Primary gain—internal conflict or need is kept out of awareness; there is a close
    relationship in time between stressor and occurrence of symbolic symptoms.
  • Impaired social interaction: chronic sick role related to attention seeking.
  • Noncompliance with expected routines related to secondary gain—avoidance of upsetting situation, with support obtained from others.
  • Impaired adjustment related to repression of feelings through somatic symptoms, regression, denial and isolation, and externalization.
  • Ineffective individual coping (e.g., daydreaming, fantasizing, superficial warmth and seductiveness related to inability to control symptoms voluntarily or to explain them by known physical disorder).

Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span: Hypochondriasis (Hypochondriacal Neurosis)

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

Exaggerated concern for one’s physical health; unrealistic interpretation of signs or sensations as abnormal; preoccupation with fear of having serious disease, despite medical reassurance of no diagnosis of physical disorder.

A. Assessment:

  • Preoccupation with symptoms: sweating, peristalsis, heartbeat, coughing, muscular soreness, skin eruptions.
  • Occurs in both men and women in adolescence, 30s or 40s, and elders.
  • History of long, complicated shopping for doctors and refusal of mental health care.
  • Organ neurosis may occur (e.g., cardiac neurosis).
  • Personality trait: compulsive.
  • Prevalence of anxiety and depression.
  • Controls relationships through physical complaints.

B. Analysis/nursing diagnosis:

  • Personal identity disturbance related to perception of self as ill in order to meet needs for dependency, attention, affection.
  • Displaced anxiety related to inability to verbalize feelings.
  • Fear related to not being believed.
  • Powerlessness related to feelings of insecurity.
  • Altered role performance: disruption in work and interpersonal relations related to regression and need gratification through preoccupation with fantasized illness; and related to control over others through physical complaints.

IV. GENERAL NURSING CARE PLANS/ IMPLEMENTATION for somatoform disorders:

A. Long-term goals:

  • Develop interests outside of self. Introduce to new activities and people.
  • Facilitate experiences of increased feelings of independence.
  • Increase reality perception and problem-solving ability.
  • Emphasize positive outlook and promote positive thinking. Reassure that symptoms are anxiety related, not a result of physical disease.
  • Develop mature ways for meeting affection needs.

B. Short-term goals:

  • Prevent anxiety from mounting and becoming uncontrollable by recognizing symptoms, for early intervention.
  • Environment: warm, caring, supportive interactions; instill hope that anxiety can be mastered.
  • Encourage client to express somatic concerns
    verbally. Encourage awareness of body processes.
  • Provide diversional activities.
  • Develop ability to relax rather than ruminate or worry. Help find palliative relief through anxiety reduction (slower breathing, exercise).

C. Health teaching:

  • Relaxation training as self-help measures.
  • Increase knowledge of appropriate and correct information on physiological responses that accompany anxiety.

V. GENERAL EVALUATION/OUTCOME CRITERIA:

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

  • Does not isolate self.
  • Discusses fears, concerns, conflicts that are self-originated and not likely to be serious.
  • Decides which aspects of situation can be overcome and ways to meet conflicting obligations.
  • Looks for things of importance and value.
  • Deliberately engages in new activities other than ruminating or worrying.
  • Talks self out of fears.
  • Decrease in physical symptoms; is able to sleep, feels less restless.
  • Makes fewer statements of feeling helpless.
  • Can freely express angry feelings in overt way and not through symptoms.

Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span: Other Conditions in which Psychological Factors Affect Medical Conditions (Psychophysiological Disorders)

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

This group of disorders occurs in various organs and systems, whereby emotions are expressed by affecting body organs.

I. CONCEPTS AND PRINCIPLES RELATED TO PSYCHOLOGICAL FACTORS AFFECTING PHYSICAL CONDITIONS:

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

A. Majority of organs involved are usually under control of autonomic nervous system.

B. Defense mechanisms

  • Repression or suppression of unpleasant emotional experiences.
  • Introjection—illness seen as punishment.
  • Projection—others blamed for illness.
  • Conversion—physical symptoms rather than underlying emotional stresses are emphasized.

C. Clients often exhibit the following underlying needs in excess:

  • Dependency.
  • Attention.
  • Love.
  • Success.
  • Recognition.
  • Security.

D. Need to distinguish between:

  • Factitious disorders—deliberate, conscious exhibit
    of physical or psychological illness to avoid an
    uncomfortable situation.
  • Conversion disorder—affecting sensory and skeletal-muscular systems that are usually under voluntary control; generally non–life-threatening; symptoms are symbolic solution to anxiety; no demonstrable organic pathology.
  • Psychological factors affecting physical condition (e.g., psychophysiological disorders); under autonomic nervous system control; structural organic changes; may be life threatening.

E. A decrease in emotional security tends to produce an increase in symptoms.

F. When treatment is confined to physical symptoms, emotional problems are not usually relieved.

II. ASSESSMENT OF PHYSIOLOGICAL FACTORS:

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

A. Persistent psychological factors may produce structural organic changes resulting in chronic diseases, which may be life-threatening if untreated.

B. All body systems are affected:

  • Skin (e.g., pruritus, acne, dermatitis, herpes,
    psoriasis).
  • Musculoskeletal (e.g., backache, muscle cramps).
  • Respiratory (e.g., asthma, hiccups, hay fever).
  • Gastrointestinal (e.g., obesity, ulcers, ulcerative colitis, irritable bowel syndrome, gastroesophageal reflux disease, constipation, diarrhea, nausea and vomiting).
  • Cardiovascular (e.g., cardiospasm, angina, paroxysmal tachycardia, migraines, palpitations, hypertension, coronary heart disease).
  • Genitourinary (e.g., impotence, enuresis, amenorrhea, dysuria, dysmenorrhea).
  • Endocrine (e.g., hypoglycemia, hyperglycemia, hyperthyroidism).
  • Nervous system (e.g., general fatigue, anorexia, exhaustion).
  • Cancer.
  • Autoimmune disease (e.g., multiple sclerosis, systemic lupus erythematosus, rheumatoid arthritis).

III. ANALYSIS/NURSING DIAGNOSIS: ineffective individual coping related to inappropriate need gratification through illness (actual illness used as means of meeting needs for attention and affection). Absence of life experiences that gratify needs for attention and affection.

IV. NURSING CARE PLAN/IMPLEMENTATION in disorders in which psychological factors affect physical conditions:

A. Long-term goal: release of feelings through verbalization.
B. Short-term goals:

  • Take care of physical problems during acute phase.
  • Remove client from anxiety-producing stimuli.

C. Prompt attention in meeting clients’ basic needs, to gratify appropriate needs for dependency, attention, and security.

D. Maintain an attitude of respect and concern; clients’ pains and worries are very real and upsetting to them; do not belittle the symptoms. Do not say, “There is nothing wrong with you” because emotions do in fact cause somatic disabilities.

E. Treat organic problems as necessary, but without undue emphasis (i.e., do not reinforce preoccupation with bodily complaints).

F. Help clients express their feelings, especially anger, hostility, guilt, resentment, or humiliation, which may be related to such issues as sexual difficulties, family problems, religious conflicts, and job difficulties. Help clients recognize that, when stress
and anxiety are not released through some channel such as verbal expression, the body will release the tension through “organ language.”

G. Provide outlets for release of tensions and diversions from preoccupation with physical complaints.

  • Provide social and recreational activities to decrease time for preoccupation with illness.
  • Encourage clients to use physical and intellectual capabilities in constructive ways.

H. Protect clients from any disturbing stimuli; help the healing process in the acute phase of illnesses (e.g., myocardial infarct).

I. Help clients feel in control of situations and be as independent as possible.

J. Be supportive; assist clients to bear painful feelings through a helping relationship.

K. Health teaching:

  • Teach how to express feelings.
  • Teach more effective ways of responding to stressful life situations.
  • Teach the family supportive relationships.

V. EVALUATION/OUTCOME CRITERIA: can verbalize feelings more fully.

Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span: Schizophrenia and Other Psychotic Disorders

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

Schizophrenia is a group of interrelated symptoms with a number of common features involving disorders of mood, thought content, feelings, perception, and behavior. The term means “splitting of the mind,” alluding to the discrepancy between the content of thought processes and their emotional expression; this should not be confused with “multiple personality” (dissociative reaction).

Half of the clients in mental hospitals are diagnosed as schizophrenic; many more with schizophrenic disorder live in the community. The onset of symptoms for this disorder generally occurs between 15 and 27 years of age.

Genetics and neurochemical imbalances of dopamine and serotonin play a significant role in the etiology of schizophrenia. Clients with schizophrenia have larger brain ventricles, and the prefrontal cortex and limbic cortex are not fully developed. Whether the brain structure changes cause the disorder or are a result of the chemical changes that occur with schizophrenia remains unclear. Other causal theories include prenatal exposure to the influenza virus.

I. COMMON SUBTYPES OF SCHIZOPHRENIA (without clear-cut differentiation):

disorganized type disordered, thinking (“word salad”), inappropriate affect (blunted, silly), regressive behavior, incoherent speech, preoccupied and withdrawn.

catatonic type disorder of muscle tension, with rigidity, waxy flexibility, posturing, mutism, violent rage outbursts, negativism, and frenzied activity. Marked decrease in involvement with environment and in spontaneous movement.

paranoid type disturbed perceptions leading to disturbance in thought content of persecutory, grandiose, or hostile nature; projection is key mechanism, with religion a common preoccupation.

residual continued difficulty in thinking, mood, perception, and behavior after schizophrenic episode.

undifferentiated type unclassifiable schizophreniclike disturbance with mixed symptoms of delusions, hallucinations, incoherence, gross disorganization.

II. CONCEPTS AND PRINCIPLES RELATED TO SCHIZOPHRENIC DISORDERS:

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

A. General:

  • Symbolic language used expresses life, pain, and progress toward health; all symbols used have meaning.
  • Physical care provides media for relationship; nurturance may be initial focus.
  • Consistency, reliability, and empathic understanding build trust.
  • Denial, regression, and projection are key defense mechanisms.
  • Felt anxiety gives rise to distorted thinking.
  • Attempts to engage in verbal communication may result in tension, apprehensiveness, and defensiveness.
  • Person rejects real world of painful experiences and creates fantasy world through illness.

B. Withdrawal:

  • Withdrawal from and resistance to forming relationships are attempts to reduce anxiety related to:
    a. Loss of ability to experience satisfying human relationships.
    b. Fear of rejection.
    c. Lack of self-confidence.
    d. Need for protection and restraint against potential destructiveness of hostile impulses (toward self and others).
  • Ambivalence results from need to approach a relationship and need to avoid it.
    a. Cannot tolerate swift emotional or physical closeness.
    b. Needs more time than usual to establish a relationship; time to test sincerity and interest of nurse.
  • Avoidance of client by others, especially staff, will reinforce withdrawal, thereby creating problem of mutual withdrawal and fear.

C. Hallucinations:

  • It is possible to replace hallucinations with satisfying interactions.
  • Person can relearn to focus attention on real things and people.
  • Hallucinations originate during extreme emotional stress when unable to cope.
  • Hallucinations are very real to client.
  • Client will react as the situation is perceived, regardless of reality or consensus.
  • Concrete experiences, not argument or confrontation, will correct sensory distortion.
  • Hallucinations are substitutes for human relations.
  • Purposes served by or expressed in falsification of reality:
    a. Reflection of problem in inner life.
    b. Statement of criticism, censure, self-punishment.
    c. Promotion of self-esteem.
    d. Satisfaction of instinctual strivings.
    e. Projection of unacceptable unconscious content in disguised form.
  • Perceptions not as totally disturbed as they seem.
  • Client attempts to restructure reality through hallucinations to protect remaining ego integrity.
  • Hallucinations may result from a variety of psychological and biological conditions (e.g., extreme fatigue, drugs, pyrexia, organic brain disease).
  • Person who hallucinates needs to feel free to describe his or her perceptions if he or she is to be understood by the nurse.

III. ASSESSMENT OF SCHIZOPHRENIC DISORDERS:

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

A. Some clinicians prefer to describe signs and symptoms of schizophrenia as “positive” or “negative.”

1. “Positive” symptoms: reflect an excess or distortion of normal functions; are associated with normal brain structures on CT scans, with relatively good responses to treatment.

  • Delusions (see definitions in B. following)
    (1)Persecution.
    (2)Grandeur.
    (3) Ideas of reference.
    (4)Somatic.
  • Hallucinations (see descriptions in B. following)
    (1)Auditory.
    (2)Visual.
    (3)Olfactory.
    (4)Gustatory.
    (5)Tactile.
  • Disorganized thinking/speech (see descriptions in B. following; see also Glossary)
    (1) Associative looseness.
    (2) Clang associations.
    (3)Word salad.
    (4) Incoherence.
    (5)Neologisms.
    (6)Concrete thinking.
    (7)Echolalia.
    (8)Tangentiality.
    (9) Circumstantiality.
  • Disorganized behavior
    (1)Appearance: disheveled.
    (2)Behavior: restless agitated; inappropriate sexual behavior.
    (3)Waxy flexibility.

2. “Negativesymptoms: four A’s reflect a loss or diminution of normal functions; CT scans often show structural brain abnormalities, with poor response to treatment.

Affective flattening
(1)Facial expression: unchanged.
(2)Eye contact: poor.
(3)Body language: reduced.
(4)Emotional expression: diminished.
(5) Affect: inappropriate.

Alogia (poverty of speech)
(1)Responses: brief, empty.
(2)Speech: decreased content and fluency.

Avolition/Apathy
(1)Grooming/hygiene: impaired.
(2)Activities: little or no interest (in work or other activities).
(3) Inability to initiate goal-oriented actions.

Anhedonia
(1)Absence of pleasure in social activities.
(2)Diminished interest in intimacy/sexual activities.

Social withdrawal (see C. following)

B. Eugene Bleuler described four classic and primary symptoms as the “four A’s”:

  • Associative looseness—impairment of logical thought progression, resulting in confused, bizarre, and abrupt thinking. Neologisms— making up new words or condensing words into one.
  • Affect—exaggerated, apathetic, blunt, flat, inappropriate, inconsistent feeling tone that is communicated through face and body posture.
  • Ambivalence—simultaneous, conflicting feelings or attitudes toward person, object, or situation; need-fear dilemma.
    a. Stormy outbursts.
    b. Poor, weak interpersonal relations.
    c. Difficulty even with simple decisions.
  • Autism—withdrawal from external world; preoccupation with fantasies and idiosyncratic thoughts.
    a. Delusions—false, fixed beliefs, not corrected by logic; a defense against intolerable feeling. The two most common delusions are:
    (1)Delusions of grandeur—conviction in a belief related to being famous, important, or wealthy.
    (2)Delusions of persecution—belief that one’s thoughts, moods, or actions are controlled or influenced by strange forces or by others.                                      b. Hallucinations—false sensory impressions without observable external stimuli.
    (1)Auditory—affecting hearing (e.g., hears voices).
    (2) Visual—affecting vision (e.g., sees snakes).
    (3) Tactile—affecting touch (e.g., feels electric charges in body).
    (4)Olfactory—affecting smell (e.g., smells rotting flesh).
    (5)Gustatory—affecting taste (e.g., food tastes like poison).
    c. Ideas of reference—clients interpret cues in the environment as having reference to them. Ideas symbolize guilt, insecurity, and alienation; may become delusions, if severe.
    d. Depersonalization—feelings of strangeness and unreality about self or environment or both; difficulty in differentiating boundaries between self and environment.

C. Prodromal or residual symptoms:

  • Social isolation, withdrawal; regression: extreme withdrawal and social isolation.
  • Marked impairment in role functioning (e.g., as student, employee).
  • Markedly peculiar behavior (e.g., collecting garbage).
  • Marked impairment in personal hygiene.
  • Affect: blunt, inappropriate.
  • Speech: vague, overelaborate, circumstantial, metaphorical.
  • Thinking: bizarre ideation or magical thinking (e.g., ideas of reference, “others can feel my feelings”).
  • Unusual perceptual experiences (e.g., sensing the presence of a force or person not physically there).

D. Rule out general medical conditions/substances that may cause psychotic symptoms.

  • Neurological conditions: neoplasms, cardiovascular disease, epilepsy, Huntington’s disease, deafness, migraine headaches, CNS infections.
  • Endocrine conditions: hypothyroidism or hyperthyroidism, hypoparathyroidism or hyperparathyroidism, hypoadrenocorticism.
  • Metabolic conditions: hypoxia, hypoglycemia, hypercarbia.
  • Autoimmune disorders: SLE.
  • Other conditions: hepatic or renal disease.
  • Substances: drugs of abuse (alcohol, amphetamines, cannabis, cocaine, hallucinogens, inhalants); anesthetics; chemotherapeutic agents; corticosteroids; toxins (nerve gases, carbon monoxide, carbon dioxide, fuel or paint, insecticides).

IV. ANALYSIS/NURSING DIAGNOSIS:

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

  • Sensory/perceptual alterations related to inability to define reality and distinguish the real from the unreal (hallucinations, illusions) and misinterpretation of stimuli, disintegration of ego boundaries.
  • Altered thought processes related to intense anxiety and blocking (delusions), ambivalence or conflict.
  • Risk for violence to self or others related to fear and distortion of reality.
  • Altered communication process with inability to verbally express needs and wishes related to difficulty with processing information and unique patterns of speech.
  • Self-care deficit with inappropriate dress and poor physical hygiene related to perceptual or cognitive impairment or immobility.
  • Altered feeling states related to anxiety about others (inappropriate emotions).
  • Altered judgment related to lack of trust, fear of rejection, and doubts regarding competence of others.
  • Altered self-concept related to feelings of inadequacy in coping with the real world.
  • Body-image disturbance related to inappropriate use of defense mechanisms.
  • Disorganized behaviors: impaired relatedness to others, related to withdrawal, distortions of reality, and lack of trust.
  • Diversional activity deficit related to personal ambivalence.

V. NURSING CARE PLAN/IMPLEMENTATION IN SCHIZOPHRENIC DISORDERS:

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

A. General:

  • Set short-term goals, realistic to client’s levels of functioning.
  • Use nonverbal level of communication to demonstrate concern, caring, and warmth, because client often distrusts words.
  • Set climate for free expression of feelings in whatever mode, without fear of retaliation, ridicule, or rejection.
  • Seek client out in his or her own fantasy world.
  • Try to understand meaning of symbolic language; help client to communicate less symbolically.
  • Provide distance, because client needs to feel safe and to observe nurses for sources of threat or promises of security.
  • Help client tolerate nurses’ presence and learn to trust nurses enough to move out of isolation and share painful and often unacceptable (to client) feelings and thoughts.
  • Anticipate and accept negativism; do not personalize.
  • Avoid joking, abstract terms, and figures of speech when client’s thinking is literal.
  • Give antipsychotic medications.

B. Withdrawn behavior:

  • Long-term goal: develop satisfying interpersonal relationships.
  • Short-term goal: help client feel safe in one-to-one relationship.
  • Seek client out at every chance, and establish some bond.
    a. Stay with client, in silence.
    b. Initiate talk when he or she is ready.
    c. Draw out, but do not demand, response.
    d. Do not avoid the client.
  • Use simple language, specific words.
  • Use an object or activity as medium for relationship; initiate activity.
  • Focus on everyday experiences.
  • Delay decision making.
  • Accept one-sided conversation, with silence from the client; avoid pressuring to respond.
  • Accept the client’s outward attempts to respond and inappropriate social behavior, without remarks or disdain; teach social skills.
  • Avoid making demands on client or exposing client to failure.
  • Protect from persons who are aggressive and from impulsive attacks on self and others.
  • Attend to nutrition, elimination, exercise, hygiene, and signs of physical illness.
  • Add structure to the day; tell him or her, “This is your 9 a.m. medication.”
  • Health teaching: assist family to understand client’s needs, to see small sign of progress; teach client to perform simple tasks of self-care to meet own biological needs.

C. Hallucinatory behavior:

  • Long-term goal: establish satisfying relationships with real persons.
  • Short-term goal: interrupt pattern of hallucinations.
  • Provide a structured environment with routine activities. Use real objects to keep client’s interest or to stimulate new interest (e.g., in painting or crafts).
  • Protect against injury to self and others resulting from “voices” client thinks he or she hears.
  • Short, frequent contacts initially, increasing social interaction gradually (one person → small groups).
  • Ask person to describe experiences as hallucinations occur.
  • Respond to anything real the client says (e.g., with acknowledgment or reflection). Focus more on feelings, not on delusional, hallucinatory content.
  • Distract client’s attention to something real when he or she hallucinates.
  • Avoid direct confrontation that voices are coming from client himself or herself; do not argue, but listen.
  • Clarify who “they” are:
    a. Use personal pronouns, avoid universal and global pronouns.
    b. Nurse’s own language must be clear and unambiguous.
  • Use one sentence, ask only one question, at a time.
  • Encourage consensual validation. Point out that experience is not shared by you; voice doubt.
  • Health teaching:
    a. Recommend more effective ways of coping (e.g., consensual validation).
    b. Advise that highly emotional situations be avoided.
    c. Explain the causes of misperceptions.
    d. Recommend methods for reducing sensory stimulation.

VI. EVALUATION/OUTCOME CRITERIA:

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

  • Small behavioral changes occur (e.g., eye contact, better grooming).
  • Evidence of beginning trust in nurse (keeping appointments).
  • Initiates conversation with others; participates in activities.
  • Decreases amount of time spent alone.
  • Demonstrates appropriate behavior in public places.
  • Articulates relationship between feelings of discomfort and autistic behavior.
  • Makes positive statements.

Psychosocial Integrity Behavioral/Mental Health Care Throughout the Life Span: Delusional (Paranoid) Disorders

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

Paranoid disorders have a concrete and pervasive delusional system, usually persecutory. Projection is a chief defense mechanism of this disorder.

I. CONCEPTS AND PRINCIPLES RELATED TO PARANOID DISORDERS:

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

  • Delusions are attempts to cope with stresses and problems.
  • May be a means of allegorical or symbolic communication and of testing others for their trustworthiness.
  • Interactions with others and activities interrupt delusional thinking.
  • To establish a rational therapeutic relationship, gross distortions, mis-orientation, misinterpretation, and mis-identification need to be overcome.
  • People with delusions have extreme need to maintain self-esteem.
  • False beliefs cannot be changed without first changing experiences.
  • A delusion is held because it performs a function.
  • When people who are experiencing delusions become at ease and comfortable with people, delusions will not be needed.
  • Delusions are misjudgments of reality based on a series of mental mechanisms: (a) denial, followed by (b) projection and (c) rationalization.
  • There is a kernel of truth in delusions.
  • Behind the anger and suspicion in a person who is paranoid, there is a person who is lonely and terrified and who feels vulnerable and inadequate.

II. ASSESSMENT of paranoid disorders:

  • Chronically suspicious, distrustful (thinks “people are out to get me”).
  • Distant, but not withdrawn.
  • Poor insight; blames others (projects).
  • Misinterprets and distorts reality.
  • Difficulty in admitting own errors; takes pride in intelligence and in being correct (superiority).
  • Maintains false persecutory belief despite evidence or proof (may refuse food and medicine, insisting he or she is poisoned).
  • Literal thinking (rigid).
  • Dominating and provocative.
  • Hypercritical and intolerant of others; hostile, quarrelsome, and aggressive.
  • Very sensitive in perceiving minor injustices, errors, and contradictions.
  • Evasive.
[sociallocker]

III. ANALYSIS/NURSING DIAGNOSIS:

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

  • Altered thought processes related to lack of insight, conflict, increased fear and anxiety.
  • Severe anxiety related to projection of threatening, aggressive impulses and misinterpretation of stimuli.
  • Ineffective individual coping (misuse of power and force) related to lack of trust, fear of close human contact.
  • Impaired cognitive functioning related to rigidity of thought.
  • Chronic low self-esteem related to feelings of inadequacy, powerlessness.
  • Impaired social interaction related to lack of tender, kind feelings, feelings of grandiosity or persecution.

IV. NURSING CARE PLAN/IMPLEMENTATION in paranoid disorders:

A. Long-term goals: gain clear, correct perceptions and interpretations through corrective experiences.
B. Short-term goals:

  • Help client recognize distortions, misinterpretations.
  • Help client feel safe in exploring reality.

C.Help client learn to trust self; help to develop self-confidence and ego assets through positive reinforcement.

D. Help to trust others.

  • Be consistent and honest at all times.
  • Do not whisper, act secretive, or laugh with others in client’s presence when he or she cannot hear what is said.
  • Do not mix medicines with food.
  • Keep promises.
  • Let client know ahead of time what he or she
    can expect from others.
  • Give reasons and careful, complete, and repetitive explanations.
  • Ask permission to contact others.
  • Consult client first about all decisions concerning him or her.

E. Help to test reality.

  • Present and repeat reality of the situation.
  • Do not confirm or approve distortions.
  • Help client accept responsibility for own behavior rather than project.
  • Divert from delusions to reality-centered focus.
  • Let client know when behavior does not seem appropriate.
  • Assume nothing and leave no room for assumptions.
  • Structure time and activities to limit delusional thought, behavior.
  • Set limit for not discussing delusional content.
  • Look for underlying needs expressed in delusional content.

F. Provide outlets for anger and aggressive drives.

  • Listen matter-of-factly to angry outbursts.
  • Accept rebuffs and abusive talk as symptoms.
  • Do not argue, disagree, or debate.
  • Allow expression of negative feelings without fear of punishment.

G. Provide successful group experience.

  • Avoid competitive sports involving close physical contact.
  • Give recognition to skills and work well done.
  • Use managerial talents.
  • Respect client’s intellect and engage him or her in activities with others requiring intellect (e.g., chess, puzzles, Scrabble).

H. Limit physical contact.
I. Health teaching: teach a more rational basis for deciding whom to trust by identifying behaviors characteristic of trusting and people who are trustworthy.

V. EVALUATION/OUTCOME CRITERIA: able to differentiate people who are trustworthy from untrustworthy; growing self-awareness, and able to share this awareness with others; accepting of others without need to criticize or change them; is open to new experiences; able to delay gratification.

[/sociallocker]

FURTHER READING/STUDY:

Resources:

 

 

 

Leave a Reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.