Medical-Surgical Nursing: An Integrated Approach, 2E Chapter 33 NURSING CARE OF THE CLIENT: MENTAL ILLNESS Mental Illness Mental illness occurs when: an individual is not able to view self clearly or has a distorted view of self. is unable to maintain satisfying personal relationships. is unable to adapt to the environment. Mental Disorder A clinically significant behavior or psychological syndrome or pattern Associated with present distress, disability or with a significantly increased risk of suffering, death, pain, disability. DSM-IV The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (better known as the DMS-IV) is the reference tool used to identify and establish psychiatric disorders. Relationship Development Five components necessary in the therapeutic nurse-client relationship: Trust Rapport Respect Genuineness Empathy Trust The ability to rely on an individual’s character and ability. A nurse promotes trust by demonstrating consistency, respect, and honesty. Essential Factors of Trust CONSISTENCY RESPECT HONESTY Follow through on plans. Call client by name. Ask client about personal preferences. Adhere to schedule. Provide clear explanations. Keep any promises. Seek out client for extra time to interact. Recognize own strengths and limitations. Maintain confidentiality. Be straightforward. Listen to client. Be flexible in responding to requests. Rapport A bond or connection between two people that is based on mutual trust. To establish rapport, the nurse must show that the client is considered important. Respect The acceptance of an individual as is and in a nonjudgmental manner. Genuineness Genuineness (sincerity) is an attribute easily perceived by the client and can be the most significant aspect of the nurseclient relationship. Empathy The ability to perceive and relate to another person’s experience. By perceiving the client’s understanding of his own needs, the nurse is better able to assist the client in determining what will work best. Through empathy, the nurse validates the experiences of the client. Confidentiality Because of the highly personal and sensitive nature of mental disorders, it is vitally important in psychiatric nursing to observe confidentiality, the nondisclosure of the identity of or personal information about an individual. Clients in Crisis A crisis, in psychological terms, is a stressor that forces an individual to respond and/or adapt in some way. The client experiencing crisis may be anxious, angry, aggressive, homicidal, suicidal, psychotic, or any combination of these. Anxiety Feelings of dread frequently accompanied by physical symptoms (increased heart and respiratory rates and elevated blood pressure) in absence of a specific source and reason for these emotions and responses. Common psychiatric diagnoses related to anxiety are Generalized Anxiety Disorder, Panic Disorder and Post-Traumatic Stress Disorder. Generalized Anxiety Disorder Exhibits symptoms of excessive anxiety or dread. Clients usually realize that their symptoms are out of proportion to any real threat. Symptoms include three or more of the following: restlessness, easy fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbance. Panic Disorder A condition wherein the client experiences periods of intense anxiety that begin abruptly and peak within 10 minutes. Characterized by palpitations, sweating, trembling, shortness of breath, sensation of choking, chest pain, nausea, dizziness, fear of losing control, fear of dying, numbness or tingling, chills or hot flashes, and some sense of altered reality. Post-Traumatic Stress Syndrome Client has experienced a serious trauma (e.g. a severe beating or emotional, physical, or sexual abuse or has lived through a catastrophic event or natural disaster). The response is fear or helplessness and the event is persistently re-experienced through recurrent recollections, dreams, or hallucinatory flashbacks. Impairment of social functioning and a numbing of general responsiveness are characteristic. Medical-Surgical Management: Psychotherapy Psychotherapy, the treatment of mental and emotional disorders through psychological rather than physical methods, continues to be widely used in the treatment of anxiety disorders. Psychotherapy can be viewed as falling into two general categories: those based on helping individuals achieve insight into why they feel anxiety and those that emphasize behavioral means of controlling the anxiety. Psychoanalysis Therapy focused on uncovering unconscious memories and processes. Among the best of the insight therapies and has been widely employed to assist persons with anxiety. Cognitive-Behavior Therapy Assumes that clients can learn to identify the common stimuli that give rise to their anxiety, develop plans to respond to those stimuli with nonanxious response, and problem solve when unanticipated anxiety-provoking situations arise. Medical-Surgical Management: Pharmacological The drug of choice for treating clients with anxiety are usually the anxiolytics, or antianxiety agents. Some of the anxiolytics include alprazolam (Xanax) and lorazepam (Ativan). Client Teaching: Antianxiety Medications Do not increase dose or frequency of medication without consulting physician. Tolerance develops quickly and unsupervised used can lead to addiction. Do not drink alcohol while on medication. Do not take any other medications unless prescribed by your physician. Do not stop taking medication abruptly. Do not drive or operate heavy machinery while on the medication. Depression The state wherein an individual experiences feeling of extreme sadness, hopelessness, and helplessness. Symptoms include insomnia or hypersomnia (excessive sleeping); changes in appetite; lethargy; decreased libido (sexual energy); frequent crying spells; racing thoughts; difficulty concentrating; forgetfulness; and suicidal ideations (thoughts of hurting or killing self). Major Depressive Disorder A person experiencing a depressive episode may express feelings of sadness and hopelessness or may express the sense of feeling empty or having no feelings. Some individuals, particularly adolescents, may exhibit irritability rather than sadness. Major depressive episodes frequently develop over a few days or weeks and without treatment commonly last for Dysthmic Disorder A feeling of depression that lasts nearly all the time. The DSM-IV criteria include “depressed mood for most of the day, for more days than not…for at least two years.” Somewhat rarer than Major Depressive Disorder, occurring during a lifetime in approximately 6% of persons. Some Therapies for Depression Brief Dynamic Therapy focuses on core conflicts that derive from personality and living situations. The goal is to resolve depressive symptoms by improving these conflicts and resolving stresses. Electroconvulsive therapy (ECT) is a procedure wherein the client is treated with pulses of electrical energy sufficient to cause a brief convulsion or seizure. Antidepressants Within this classification are several groups including: The tetracyclic and atypical depressants. The selective serotonin reuptake inhibitors. The tricyclic antidepressants. The monoamine oxidase inhibitors. Anger Control Some of the techniques used in anger control include: Limiting access to frustrating situations. Providing physical outlets for expression of anger or tension (such as punching bags, large motor activities, e.g. sports; and anger journals). Ensuring that a client for whom anger is a problem is given enough personal space. Assessing for Risk of Violence Be aware of those clients with past history of violence or poor impulse control. Observe the client’s body language. Notice changes in behavior, words, or dress. Assess for aggressive behaviors, increasing tension, clenched fists, loud or angry tone of voice, narrowed eyes, and pacing. Remember that hostility tends to be contagious. Do not reciprocate with anger and hostility! Suicide Purposefully taking one’s own life is the ultimate form of self-destruction. Clients who are suicidal often feel overwhelmed by life events and decide that the only relief will come from ending their own lives. Intense feelings of fear, loss, anger, or despair can drive individuals to suicide, and the effects of an attempted or completed suicide can be devastating and long-lasting. Suicide is the eighth leading cause of death in the U.S. Assessment of Risk for Suicide Does the client have a plan to commit suicide? The client who has a plan for committing suicide is at increased risk. How specific is the plan to commit suicide? A specific plan increases the risk of completing a suicide. Does the client have access to the means to commit suicide? Easy availability of the means to kill oneself increases the risk of suicide. How lethal is the intended means to commit suicide? Gunshots are the most common cause of completed suicide. Restraints and Seclusion The client who is severely agitated, aggressive, actively suicidal, and/or homicidal may need to be restrained (usually with leather straps serving as physical restraints) or placed in seclusion (confined to a single room that may or may not be locked and may or may not have furnishings). No-Suicide Contract Ask the client whether he is able to make a promise to himself that he will not do anything to harm himself. If the client is unable to commit to the contract for the rest of his life, work with him on establishing a time frame to which he can commit. Ask the client whether he is able to maintain the No-Suicide Contract no matter what happens. Ask the client whether he can make a promise to himself that if thoughts of suicide return, he will talk to someone and let them know before taking any action. Assist the client in developing a detailed plan of action regarding those persons he will contact in event suicidal thoughts return. At the bottom of the list put the name an dpone number of local suicide crisis hotline and/or local emergency number. Assist the client in putting the No-Suicide Contract in writing and in his own words. Psychosis: Defined as: A state wherein an individual loses the ability to recognize reality. A psychotic person may experience hallucinations, wherein he hears voices or sees images of persons or things others cannot see or hear. A psychotic person is frequently unable to care for basic needs of safety, security, nutrition, and so on. Schizophrenia Clients with schizophrenia tend to be tired and lethargic, probably due to multiple factors including the disease process and, possible, the sedative properties associated with some of the antipsychotics, especially some of the older ones like Thorazine and Mellaril. Bipolar Disorder Previously known as manic-depressive disorder, it is a psychiatric diagnosis characterized by wide fluctuations in mood (the way an individual reports feeling, e.g. depressed, elated, happy, sad) and affect (the objective or outward manifestations of the way an individual feels, e.g. avoids eye contact, smiles, etc.). Bipolar Disorder: Mood Swings Individual with bipolar disorder may experience fluctuations between depression and mania (extremely elevated mood with accompanying agitated behavior), sometimes in the same day. The drug of choice for treatment is Lithium carbonate. Attention-Deficit/Hyperactivity Disorder (ADHD) The child with ADHD may exhibit inattention, hyperactivity, and impulsivity. Condition may continue well into adulthood. Neglect and Abuse Neglect (a situation wherein a basic need of the client is not being provided) and abuse (an incident involving some type of violation of the client) can occur among any age group. Abuse can be physical, emotional, psychological, financial, or sexual in nature, or any combination of these. Abuse can also take the form of domestic violence, which is aggression and violence involving family members. Rape Sexual violence to dominate and degrade victims and to express rapist’s own anger. Three basic types of rape: (1) rape by a person known to survivor; (2) gang rape; (3) stranger-to-stranger rape. Interviewing the Survivor of Abuse or Violence Inform the client that it is necessary to ask some very personal questions. Use language appropriate to age and developmental level of survivor. Use conversational or street language. Keep questions simple, nonthreatening, and direct. Pose questions in a manner that permits brief answers. Indicate sensitivity to client’s state of confusion. Avoid using leading statements that can distort the client’s report. Do not criticize the client’s family. Do not promise to report the abuse; indicate that you are required by law to report abuse. Eating Disorders Anorexia nervosa (self-imposed starvation created by restricting caloric intake and compulsive exercising). Bulimia nervosa (characterized by periods of binge eating of up to 10,000 calories at one time followed by self-induced vomiting and others forms of purging such as laxative and diuretic abuse). Both syndromes affect mainly women.