NCLEX-RN: Psychiatric Nursing

Psychiatric Nursing: Anxiety Disorders

Focus topic: Psychiatric Nursing

Definition: Anxiety disorders are those disorders in which the predominant disturbance is one of anxiety. Anxiety may be manifested as panic, generalized anxiety, phobias, obsessive–compulsive behavior, or post traumatic stress. Although there is overlap of symptoms, there are also variances by disorder. Anxiety is usually evaluated in context of medical diagnosis when it interferes with social, occupational, or other important areas of functioning and/ or is out of proportion to a situation.

Psychiatric Nursing: Generalized Anxiety Disorder

Focus topic: Psychiatric Nursing

A. Client has unrealistic, diffuse persistent anxiety about two or more life experiences.
B. Client cannot control anxiety.
C. The individual’s worry is out of proportion to the true impact of the worried event or situation; anxiety has been present for several months and is not attributable to a specific physiological cause.
D. Psychological symptoms.

  •  Difficulty concentrating, “going blank.”
  •  Feelings of depression and guilt.
  •  Harbored fear of sudden death or loss of control.
  •  Dread of being alone.
  •  Confusion.
  •  Rumination.
  •  Agitation and restlessness—motor tension.
  •  Impatience or irritability.
  •  Difficulty making decisions.

E. Physiological symptoms.

  •  Tremors.
  •  Dyspnea.
  •  Palpitations.
  •  Tachycardia.
  •  Numbness of extremities.
  • Sleep disturbance.

A. Recognize behavior in client that denotes anxiety.
B. Maintain calm approach because nurse’s anxiety reinforces client’s anxiety. Provide for safety.
C. Help client to develop conscious awareness of anxiety, reorient to situation as needed.
D. Help client identify and describe feelings and source of anxiety, if identifiable. Support realistic view of the situation and evaluation strategies.
E. Provide physical outlet for anxiety.
F. Remain with client, provide reassurance.
G. Decrease environmental stimuli.
H. Avoid reinforcing secondary gains (attention, sympathy).
I. Utilize medication if available and indicated. Provide medication education.

Psychiatric Nursing

Psychiatric Nursing: Panic Disorder

Focus topic: Psychiatric Nursing

A. Panic attacks are characterized by recurrent, expected, and unpredictable attacks of severe anxiety lasting minutes to a few hours.

  • Intense physical symptoms include palpitations, sweating, shaking, dyspnea, chest pain, dizziness, chills or hot flashes, nausea, or abdominal distress.
  • Fear of losing control, choking. Fear of losing his or her mind or dying are also present.
  • People with panic disorder have a significantly higher incidence of mitral valve disorder (57%, versus 5–7% in the general population). The exact relationship between the two is unclear.

B. Attacks appear suddenly with no warning. May become associated with specific situations.
C. Interventions: Implement actions as you would for generalized anxiety disorder.

Psychiatric Nursing: Phobic Disorders

Focus topic: Psychiatric Nursing

A. Fear is recognized by individual as excessive or unreasonable in proportion to reality.
B. A compelling desire exists to avoid object or situation; fight or flight response may be exhibited.
C. Client has unrealistic, irrational fear of object or situation that presents no actual danger.
D. Client uses projection, displacement, repression, avoidance, and sublimation.
E. Client may transfer anxiety or fear from its source to a symbolic idea or situation.
F. Phobic disorders are classified into many different types. Examples are

  •  Agoraphobia intense, excessive anxiety or fear about being in places or situations from which escape might be difficult or embarrassing.
  •  Acrophobia fear of high places.
  • Social phobia desire to avoid social situations in which individuals fear they will behave in an embarrassing way.
  •  Simple phobia persistent or irrational fear of simple objects or situations.
  •  Claustrophobia fear of enclosed spaces (elevators).
  •  Belonephobia fear of needles.

A. Draw client’s attention away from phobia.
B. Have client focus on awareness of self.
C. Do not force client into situation feared.
D. Slowly develop sound, therapeutic relationship with client.

E. Assist client to go through desensitizing process.

  • New studies indicate that high-tech virtual reality programs enable the client to become desensitized to the phobia.
  •  Fear of elevators and flying are programs currently available as examples of in vivo desensitization.

Psychiatric Nursing: Obsessive–Compulsive Disorder

Focus topic: Psychiatric Nursing

A. Client has anxiety associated with persistent, undesired ideas, thoughts, or images that are experienced as senseless, unreasonable, or undesirable.
B. Client releases anxiety through repetitive, ritualistic, stereotyped acts.
C. Personality characteristics.

  • Insecure, guilt-ridden.
  •  Sensitive, shy.
  •  Straight-laced.
  • Fussy and meticulous.

D. Client uses repression, isolation, and undoing to reduce anxiety.
E. Client is unable to control feelings of hostility and aggression.
F. Behavior interferes with social or role functioning.
G. Symptoms are distressing to client.
H. Most common obsessions are thoughts of violence, contamination, and doubt.
I. Most common compulsions involve hand washing, counting, checking, and touching. Ritualistic body movements such as tapping or shrugging are also common and sometimes classified as tics.

A. Avoid punishment or criticism.
B. Allow episodes of compulsive acts, setting limits only to prevent harmful acts.
C. Engage in alternative activities with client.
D. Limit decision making for client.
E. Provide for client’s physical needs, provide a safe environment, and prevent complications such as skin breakdown.
F. Convey acceptance of client (nonjudgmental) regardless of behavior.
G. Establish routine to avoid anxiety-producing changes.
H. Gear assignments to those that are routine and can be done with perfection, such as straightening linen or cleaning.
I. Plan therapy, any change in routine, or one to one contact after completion of a compulsive episode.
J. Positive feedback for successful attempts to decrease compulsive activities.

Psychiatric Nursing: Post traumatic Stress Disorder

Focus topic: Psychiatric Nursing

Definition: Condition follows a traumatic event that is outside the range of common experience (military combat, rape, assault, etc.). Symptoms persist for longer than a month and there is significant social, occupational, and other distress as a result of the symptoms. In the DSM-V, posttraumatic stress disorder (PTSD) is classified in a new category, Trauma and Stressor- Related Disorders.

A. Intrusive recollections of the trauma.
B. As event is reexperienced, client suffers behavioral and emotional symptoms (Abreaction occurs: vivid recall of painful experience with emotion consistent with the original situation.)
C. Individual is not able to adjust to the event.
D. Persistent avoidance of stimuli associated with trauma occurs including isolation and modification of daily activities.
E. Persistent symptoms of increased arousal, such as difficulty falling/staying asleep, irritability, and/or negative cognition and mood symptoms, such as anhedonia, anger, impulsivity, negative thoughts, and self-destructive activities.

A. Assess for symptoms:

  •  Anxiety and depression.
  •  Comorbidities.
  •  Frequency/quality of intrusive recollections.
  •  Emotional instability.
  •  Feelings of detachment or guilt.
  •  Nightmares, difficulty sleeping.
  •  Withdrawal, isolation, and anhedonia
  • Self-destructive behavior such as use of drugs and alcohol and risk for injury.
  •  Level of functioning.

B. Aggressive or acting-out behavior.

  • Explosive or unpredictable behavior.
  •  Impulsive behavior; change in lifestyle.

A. Assist client to go through recovery process.

  • Deal with conscious awareness of traumatic experience.
  •  Adjust to acceptance of experience.

B. Protect client from self-destructive behaviors or acting-out behaviors.
C. Administration of prescribed medication as needed.
D. Encourage participating in treatment and access of supportive resources.
E. Recovery process follows four stages.

  •  Recovery—reassure client that he or she is safe following experience of the traumatic event.
  • Avoidance—client will avoid thinking about traumatic event; support client.
  •  Reconsideration—client deals with event by confronting it, talking about it, and working through feelings.
  •  Adjustments—client rehabilitates and adjusts to environment following event; functions and is able to view future positively.

Psychiatric Nursing: Somatoform Disorders

Focus topic: Psychiatric Nursing

Definition: Somatoform behaviors are physical symptoms that may involve any organ system, and whose etiologies are in part precipitated by psychological factors. There are three main types: psychosomatic, conversion disorder, and hypochondriasis. In the DSM-V, is classified in a new category, Somatic Symptoms and Related Disorders.

A. An individual must adapt and adjust to stresses in life.

  •  The way a person adapts depends on the individual’s characteristics.
  •  Emotional stress may exacerbate or precipitate an illness.

B. Psychosocial stress is an important factor in symptom formation.

 Psychiatric Nursing: Psychosomatic Disorders

Focus topic: Psychiatric Nursing

A. Determine which body systems are involved that resulted in somatoform disorder. Some possible examples are gastrointestinal (GI) disorders, skin disorders, and sexual dysfunction.
B. Evaluate history for physical symptoms of several years’ duration.
C. Observe closely and assess client’s present condition.

  • Collect data about physical illness—symptoms (multiple sources).
  •  Life situations and psychosocial adjustment.
  •  Coping mechanisms that work for client.
  •  Strengths of client.
  •  Problem-solving abilities.

D. Note if symptoms are intermittent.
E. Assess what kinds of things aggravate or relieve symptoms.

A. Provide restful, supportive environment.

  •  Balance therapy and recreation.
  •  Decrease stimuli.
  •  Provide activities that deemphasize the client’s physical symptoms.

B. Care for the “total” person—physical and emotional.
C. Realize physical symptoms are real and that person is not “faking.”
D. Recognize that treatment of physical problems does not relieve emotional problems.
E. Reduce demands on client.
F. Develop nurse–client relationship.

  •  Respect the person and the person’s problems.
  •  Help client to express his or her feelings.
  •  Help client to express anxiety and explore new coping mechanisms.
  • Allow client to meet dependency needs.
  •  Allow client to feel in control.

G. Help client to work through problems and learn new methods of responding to stress.

Psychiatric Nursing: Conversion Disorder

Focus topic: Psychiatric Nursing

A. Establish psychosomatic origin by assessing physical condition and ruling out any organic basis for symptoms (e.g., neurological examinations, laboratory tests).
B. Identify conversion behavior/symptoms. Conversion behavior is the development of a physical symptom (blindness, paralysis, deafness) with no physical etiology identified.
C. Evaluate client’s attitude toward condition: “la belle indifference” (French term describing client’s lack
of concern or indifference toward physical symptom  a definite clue that condition is a conversion disorder).
D. Identify primary gain.

  •  Keeps internal conflict or need out of awareness (repression).
  •  Symptom has symbolic value to client.

E. Identify secondary gain.

  •  Provides additional advantages that result from particular behaviors that are not connected to the primary gain, such as avoidance, attention, or sympathy.
  •  Reinforces maladjusted behavior.

F. Assess whether symptoms disappear under hypnosis.

A. Establish therapeutic nurse–client relationship.
B. Reduce pressure on client.
C. Control environment.
D. Provide recreational and social activities.
E. Do not confront client with his or her illness.
F. Divert client’s attention from symptom.
G. Do not feed into secondary gains through anticipating client needs.

Psychiatric Nursing: Hypochondriasis

Focus topic: Psychiatric Nursing

A. Preoccupation with an imagined illness for which no observable symptoms or organic changes exist.
B. Evaluate severe, morbid preoccupation with body functions or fear of serious disease.
C. Assess whether client shows lack of interest in environment.
D. Assess whether client shows severe regression.
E. Determine if client goes from doctor to doctor to find cure or enjoys recounting medical history.
F. Differentiate from malingering deliberately making up illness to prolong hospitalization.

A. Accept client; recognize and understand that physiological complaints are not in client’s conscious awareness.
B. Provide diversionary activities in which client can succeed in building self-esteem.
C. Use friendly, supportive approach but do not focus on physical condition (i.e., avoid asking, “How are you today?”).
D. Help client to refocus interest on topics other than physical complaints.
E. Provide for client’s physical needs; give accurate information and correct any misinformation.
F. Assist client to understand how he or she uses illness to avoid dealing with life’s problems.
G. Be aware of staff ’s negativity, as it may lead to exacerbation of client’s symptoms.

Psychiatric Nursing: Eating Disorders

Focus topic: Psychiatric Nursing

Psychiatric Nursing: Anorexia Nervosa

Focus topic: Psychiatric Nursing

Definition: A potentially life-threatening (results in death 10% of the time) eating disorder characterized by an intense fear of gaining weight or becoming fat. In pursuit of thinness, adopts extreme restriction on intake. The psychological aversion to food results in emaciation, physical problems, and possible death.

A. Almost exclusively female—6:1 to 10:1 female:male ratio.
B. Most common in adolescent girls and young adults (age 12 to mid-30s).
C. Often unnoticed in early stages; female “goes on diet to lose weight.”
D. Dynamics of disorder.

  •  History of a “model child”—extreme perfectionism.
  •  Overprotected by parents in rigid, enmeshed family structure.
  •  Conflict erupts at adolescence between poor involvement and family loyalty.
  • Becomes negative due to power struggles with family over pressure to eat.
  •  Intense fear of obesity leads anorectic to report feeling fat.
  •  Not a disturbance in appetite but distorted body image perceptions; related to disturbance in sense of self, identity, and autonomy.
  •  Hormones altered whether cause or effect is yet to be determined.
  •  Anorectics do not want treatment. Potentially lethal disease: mortality up to 20% often due to cardiac complications or suicide.
  •  Many anorectics have a single episode, then recover. Factors associated with positive prognosis include onset of problem before age 15 and weight gain within 2 years.

A. Assess weight: refusal to maintain body weight at or above a normal weight for age and height (loss of 15% or greater average body weight; calculate body mass index [BMI]).
B. No menstrual period for 3 months.
C. Assess for physical symptoms.

  • Malnutrition.
  •  Fractures calcium leaked from bones.
  • Teeth enamel eroded and poor gums.
  •  Hypotension, hypothermia.
  •  Anemia and decreased white blood cells.
  •  Hypoproteinemia.
  •  Sleep disturbances.
  •  Cold intolerance (cyanosis and numbness of extremities).

D. Monitor for potential complications.

  •  Electrolyte imbalance (cardiac dysrythmia).
  •  Kidney failure, multiorgan failure.
  • Heart failure and coma, possible death.

A. Actions to improve nutritional status (to stabilize medical condition).

  •  Diet.
    a. High protein, high carbohydrate, vitamins, and amino acids.
    b. Identify foods client prefers.
    c. Small, nutritious, attractive feedings.
  • Nasogastric feedings: if client refuses to eat, administer tube feedings as ordered.
  •  Total parenteral nutrition (TPN)/peripheral parenteral nutrition (PPN).
  •  Dietary/nutrition consult.

B. Psychological and physical care.

  •  Care plan.
    a. Formulate plan that all staff agree on. Do not allow manipulation. Do not engage in power struggle. Matter of-fact approach.
    b. Do not focus on food, taste, recipes, etc.
    c. Remain with client when eating or monitor when client eats with others.
    d. Do not accept excuses to leave eating area (to vomit).
    e. Set limits on amount client must eat. Reward when client adheres to plan.
    f. Ensure that weight is taken same time every day with client dressed in only a hospital gown. Evaluate weight in context of diet ordered/caloric intake.
    g. Be supportive in approach to client.
    h. Symptom management.
    i. Facilitate family involvement.
  •  Treatment.
    a. Medications: antidepressants—selective serotonin reuptake inhibitor (SSRI).
    b. Focused on behavior therapy.
    (1) Develop and implement individualized behavioral therapy treatment plan with reinforcement. Set limits.
    (2) Establish contract that specifies weight gain or loss correlated with privileges/restrictions.
    c. Insight-oriented therapy: correcting client’s body perceptions and misconceptions about feelings, needs, self-worth, autonomy.
    d. Family therapy: important focus as issues of control and autonomy are connected to eating.
    e. Dietary/nutrition consult.
    f. Recreational therapy consult to promote appropriate level of activity; monitor activity levels.

Psychiatric Nursing: Bulimia Nervosa

Focus topic: Psychiatric Nursing

Definition: Eating disorder characterized by loss of control during binge eating, frequently followed by self induced vomiting, use of laxatives, or other compensatory measures to avoid weight gain.

A. Etiology is unknown but this disorder is often accompanied by an underlying psychopathology and comorbidities.
B. More common in women than men.
C. Begins in adolescence or early adulthood and often follows a chronic course over many years.
D. Generally aware that eating patterns are abnormal (in contrast to anorectics).
E. Typically evidences impaired impulse control, low self-esteem, and depression.

A. Assess degree of disruption in life caused by eating disorder.
B. Assess degree of depression: often due to guilt over eating binges. (Studies suggest link between bulimia and affective disorder.)
C. Assess weight fluctuation and potential danger of weight loss.
D. Assess for physical symptoms and complications.

  •  Enlarged parotid glands.
  •  Dental erosion and caries, esophagitis.
  •  Electrolyte imbalance (hypokalemia), hypoglycemia, low protein.
  •  Fluid retention.
  •  Constipation.
  •  Bradycardia, orthostatic blood pressure changes.

A. Client is hospitalized if weight loss is severe or there are serious abnormal findings such as electrolyte imbalance, hematemesis, inability to maintain body weight, kidney dysfunction, or vital sign changes.
B. Symptom management.
C. Behavior-modification and insight-oriented therapy used with limited success.
D. Care plan is similar to anorexia nervosa with focus on interrupting binge/purge cycle and altering attitudes toward food and self.
E. Combination of cognitive-behavioral therapy and psychopharmacology (SSRI antidepressants) more effective.
F. Nutritional rehabilitation to promote controlled weight gain and adequate nutrition.

Psychiatric Nursing: Sleep Disorders

Focus topic: Psychiatric Nursing

Definition: Sleep disorders or sleep pattern disturbance can be categorized into four different groups: primary sleep disorders (dyssomnias and parasomnias), sleep disorders related to mental conditions, a medical condition, or substance-induced disorder.

A. Dyssomnias.

  •  Primary insomnia.

a. Assess difficulty falling asleep or continuing sleep.
b. Assess problems with nonrestorative sleep.

  •  Primary hypersomnia.
    a. Assess for prolonged sleep and excessive sleepiness that interferes with daily functioning.
    b. Excessive sleepiness is not caused by insomnia and is not accounted for by inadequate sleep.
  •  Breathing-related sleep disorders.
    a. Assess for sleep apnea, obstructive type (upper airway partially collapses and opening it involves at least partial arousal).
    b. Assess for predisposing factors: obese, middle-aged men with a history of snoring.
  •  Narcolepsy.
    a. Assess for a pattern of brief episodes of deep sleep, occurring daily.
    b. May be accompanied by cataplexy ( sudden collapse of muscle tone or recurrent episodes of rapid eye movement).
  •  Circadian rhythm sleep disorders.
    a. Assess for a recurrent pattern of sleep disruption due to mismatched sleep wake schedules.
    (1) Disturbance causes stress or impairment of functioning.
    (2) Disturbance is not connected to other sleep disorders or a substance abuse.
    b. Assess for specific types: delayed sleep phase, jet lag, shift work phase or unspecified.

B. Parasomnias.

  •  Somnambulism—sleep walking, nightmares, sleep terrors.
  •  Bruxism—teeth grinding.
  •  Enuresis—bed-wetting.

A. Intervention is based on thorough identification of the type of sleep disturbance.

  • Diagnostic sleep tests (polysomnography) assists in confirming the diagnosis.
  •  Treatment is based on subjective analysis unless specific symptoms suggest other disorders.

B. Interventions may include principles of sleep hygiene, coping mechanisms, medication, reduction or removal of an obstruction (sleep apnea), continuous positive airway pressure (CPAP) by nasal mask; in general, treatment is specific to each individual’s problem.


Psychiatric Nursing: Dissociative Disorders

Focus topic: Psychiatric Nursing

Definition: These disorders involve disruptions in the usually integrated functions of consciousness, identity, memory, or perception of the environment. Methods of disruption are involuntary and often create risk for safety.

A. Client attempts to deal with anxiety through various disturbances or by blocking certain areas out of the mind from conscious awareness.
B. Client has a psychological retreat from reality.
C. Repression is used to block awareness of traumatic event.
D. Manifestations.

  •  Amnesia—circumscribed, selective or generalized, and continuous loss of memory.
  •  Fugue—condition experienced as a transient disorientation—client is unaware he or she has traveled to another location. Client does not remember period of fugue.
  •  Dissociative identity disorder (DID)— dominated by two or more personalities, each of which controls the behavior while in the consciousness.
  •  Depersonalization—alteration in perception or experience of self; sense of detachment from self.

A. Determine that symptoms are not of organic origin.
B. Assess in which form the dissociative disorder is manifesting.
C. Evaluate degree of interference in lifestyle and interpersonal relationships.
D. Assess presence of accompanying symptoms such as depression, suicide ideation, use of alcohol and drugs, etc.
E. Note inconsistencies in elapsed time.
F. Note complaints of voices “inside” the head talking to one another, as opposed to hallucinations that are “outside” the head.

A. Support therapeutic modality as established by treatment team.
B. Provide for safety.
C. Reduce anxiety-producing stimuli.
D. Redirect client’s attention away from self.
E. Avoid sympathizing with client.
F. Increase socialization activities.
G. Therapy.

  •  Hypnosis.
  •  Abreaction (assisting client to recall past, painful experiences).
  •  Cognitive restructuring.
  •  Behavioral therapy.
  • Psychopharmacology (anti-anxiety and antidepressants).





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