Anger, Hostility, and Aggression

Anger is a normal human emotion.

Hostility and aggression are inappropriate expressions of anger.Anger is a strong, uncomfortable, emotional response to a provocation, either real or perceived.

It results when one is frustrated, hurt, or afraid and energizes the body for defense (fight or flight).

• Denying or suppressing angry feelings can lead to physical or emotional problems

• Anger that is expressed inappropriately can lead to hostility and aggression• Appropriate expression of anger involves assertive communication skills that

lead to problem solving or conflict resolution• Venting angry feelings by engaging in safe but aggressive activities (punching

bag, yelling) is called catharsis. However, research has shown that catharsis may increase rather than alleviate angry feelings

• Clients with depression may have anger attacks when they feel emotionally trapped

Hostility and AggressionHostile and aggressive behavior may occur suddenly without warning, but often stages or phases can be identified:

• Triggering• Escalation• Crisis• Recovery• Postcrisis

Hostility is an emotion expressed by: • Verbal abuse• Lack of cooperation• Violation of rules or norms• Threatening behavior (verbal aggression)

Related DisordersMost psychiatric clients are not aggressive, but some exhibit angry, hostile, or aggressive behavior caused by:

• Paranoid delusions• Auditory (command) hallucinations• Dementia, delirium• Head injury• Intoxication with alcohol or drugs• Antisocial and borderline personality disorders

Intermittent Explosive Disorder: Rare psychiatric diagnosis involving discrete episodes of aggressive impulses

resulting in serious injury or property damageEpisodes are out of proportion to any provocation, and the person is remorseful

and embarrassed afterward.

Acting Out

An immature defense mechanism in which the person deals with emotional conflict or stress by actions rather than reflection or feelings; the person is trying to feel less powerless or helpless by acting out.

Etiology of Hostility and Aggression

• Neurobiologic theories: decreased serotonin, increased dopamine and norepinephrine; structural damage to limbic system, damage to frontal or temporal lobes

• Psychosocial theories: failure to develop impulse control and ability to delay gratification

Cultural ConsiderationsIn certain cultures, expressing anger may be seen as rude or disrespectful; some culture-bound syndromes involve aggressive, agitated, or violent behavior.

Treatments and MedicationsTreatment often focuses on treating the underlying or comorbid psychiatric diagnosis such as schizophrenia or bipolar disorder.

Aggressive Clients• Lithium for bipolar disorder, conduct disorder, or mental retardation• Carbamazepine (Tegretol) or valproate (Depakote) for dementia, psychosis, or

personality disorders• Atypical antipsychotics such as clozapine (Clozaril), risperidone (Risperdal), and

olanzapine (Zyprexa) for dementia, brain injury, mental retardation, and personality disorders

• Benzodiazepines for older adults with dementia• Haloperidol (Haldol) and lorazepam (Ativan) for clients with psychoses

Application of the Nursing ProcessAssessment

• Early assessment and intervention needed when clients are angry or hostile to avoid physically aggressive episodes

• Nurse must assess both individual clients and the therapeutic milieu or environment

• Assessment and intervention are based on five phases of aggressionData AnalysisCommon nursing diagnoses:

• Risk for Other-Directed Violence• Ineffective Coping

Outcome IdentificationThe client will:

• Not harm self or threaten others• Refrain from intimidating or frightening behaviors• Describe feelings and concerns without aggression• Comply with treatment

InterventionInterventions are most effective and least restrictive when implemented early in the cycle of aggression.

• Managing the milieu includes: – Having planned activities; informal discussions

– Scheduled one-to-one interactions; letting clients know what to expect– Helping clients with conflicts to solve their problems, including expression

of angry feelings• Managing aggressive behavior includes:

– Triggering phase: • Approach in nonthreatening, calm manner• Convey empathy• Listen• Encourage verbal expression of feelings• Suggest going to a quieter area, or use of PRN medications• Physical activity such as walking

– Escalation phase: • Take control• Provide directions in firm, calm voice• Direct client to room or quiet area for time out• Offer medication again• Let client know aggression is unacceptable and nurse or staff will

help maintain/regain control if needed• If ineffective to that point, obtain assistance from other staff (show

of force) to get client to take time out or take medication– Crisis phase:

• Staff must take control of situation as determined by facility or agency policy (trained in techniques for behavioral management)

• Use restraint or seclusion only if necessary– Recovery phase as client regains control:

• Talk about the situation or trigger• Help client relax or sleep • Explore alternatives to aggressive behavior• Provide documentation of any injuries• Staff debriefing

– Postcrisis phase: • Client is removed from any restraint or seclusion and rejoins the

milieu• Calm discussion of behavior; no lecturing or chastising; return to

activities, groups, and so forth• Focus is on appropriate expression of feelings, resolution of

problems or conflicts in nonaggressive manner

Evaluation• Was the client’s anger defused in an early stage? • Did the angry, hostile, and potentially aggressive client learn to express feelings

verbally and safely without threats or harm to others or destruction of property?• Was the client’s anger defused in an early stage? • Did the angry, hostile, and potentially aggressive client learn to express feelings

verbally and safely without threats or harm to others or destruction of property?

Community-Based Care

• Regular follow-up appointments, compliance with prescribed medication, and participation in community support programs help the client to achieve stability

• Anger management groups are available to help clients express their feelings and learn problem-solving and conflict-resolution techniques

Self-Awareness Issues• How nurse handles own angry feelings• Comfort with expression of anger from others• Ability to be calm, nonjudgmental• Nurse must have assertive communication skills, conflict resolution skills, ability

to see that client’s behavior/anger is not personal or a sign of nurse’s failure, and ability to deal with own fear when clients are aggressive or threatening

Abuse and Violence

Abuse is the wrongful use and maltreatment of another person……can be child, spouse, partner, or elder parent

Victims of abuse and trauma can have both physical and psychological injuries, including:

• Agitation anxiety, silence• Suppressed anger or resentment• Shame and guilt• Feelings of being degraded or dehumanized; low self-esteem• Relationship problems; mistrust of authority figures

Characteristics of Violent Families• Social isolation• Power and control by abusive person• Alcohol and other drug abuse• Intergenerational transmission process• Domestic violence occurs in families of all ages and from all ethnic, racial,

religious, socioeconomic, and sexual orientation backgrounds• Battered immigrant women face increased legal, social, and economic barriers

Spouse or Partner Abuse• Involves the mistreatment of one person by another in the context of an

intimate relationship

• 90% to 95% of domestic violence victims are women• Pregnancy escalates domestic violence• Abuse can occur in same-sex relationships

Cycle of Abuse and Violence• Initial episode of violence• Honeymoon period: abuser promises it will never happen again, gives gifts and

flowers, is affectionate• Tensions begins to build with arguments, silence, complaints• Violence occurs again• This cycle repeats over and over

Assessment• It is necessary to identify victims of abuse in all settings, since they often do not

seek treatment directly• SAFE questions can be used to assess:

– Stress/Safety– Afraid/Abused– Friends/Family– Emergency plan

Treatment and Intervention• Domestic violence laws vary among states and are not always followed• Women may stay in abusive relationships

for fear of violence to children, fear of increased violence or death, financial dependence

• Identifying women in violent situations is a priority. More health care agencies are beginning to ask routine screening questions of all women

• Providing women with information about shelters, services, and so forth is essential

• The nurse must never indicate that he or she thinks the woman should leave the relationship; need to keep the door open for further communication

Child AbuseChild abuse is intentional injury of a child, including:

– Physical abuse or injuries– Sexual assault or intrusion– Neglect or failure to prevent harm (failure to provide adequate physical or

emotional care or supervision; abandonment)– Psychological abuse

All states have mandatory child abuse reporting laws that include nurses.Parents who abuse children:

• Have minimal parenting knowledge and skills• Are emotionally immature and needy • Are incapable of meeting their own needs, much less those of a child • Often raise their children the way they were raised, including corporal

punishment and abuse• Expect the child to meet all their needs for love and affection

Assessment

Suspect child abuse when there are: • Unusual injuries such as scalding and cigarette burns • Delays in seeking treatment, inconsistent history, or illogical explanation for the

injuries • Urinary tract infections; red, swollen, or bruised genitalia; tears of vagina or

rectum• Old injuries that were not treated • Multiple, unexplained bruises

Treatment and Intervention• Getting the child to a safe place once abuse is identified• Family therapy• Individual therapy for the child• Intensive involvement of social service agencies • Treatment for parents for any substance abuse or psychiatric issues

Elder AbuseElder abuse is maltreatment of older adults by family members or caretakers, including:

– Physical, sexual, or psychological abuse or neglect – Self-neglect– Financial exploitation– Denial of adequate medical treatment

• 60% of perpetrators are spouses, 20% adult children, 20% others• People who abuse elders are almost always in a caretaker role• Elders are reluctant to report abuse because they fear the alternative (nursing

home)• Not all states have mandatory elder abuse reporting laws

AssessmentPossible indicators of physical abuse:

• Malnourished, dehydrated• Rashes, sores, lice• Smell of urine, feces, dirt• Failure to keep needed medical appointments• Untreated medical condition

Possible indicators of emotional or psychological abuse:• Reluctance to talk openly• Helplessness• Withdrawal or depression• Anger or agitation

Possible indicators of self-neglect:• Inability to manage own finances • Inability to perform activities of daily living• Inadequate clothing• Signs of malnutrition or dehydration• Rashes and sores

Possible indicators of financial exploitation:• Inability to manage money• Unusual activity in bank accounts• Different signatures on checks• Recent changes in will that client could not make• Missing valuables

Possible indicators of abuse by caregiver:• Caregiver speaks for the elderly person• Caregiver shows indifference or anger• Caregiver blames elderly person for physical problems• Caregiver shows defensiveness• Caregiver and client give conflicting accounts

Treatment and InterventionTreatment and intervention may involve:

• Providing adequate support and respite for the caregivers• Changing caregiving arrangements• Moving the elderly person to a safe environment

Rape

Rape is a crime of violence and aggression expressed through sexual means. The act is against the victim’s will or against someone who cannot give consent.

• The victim can be any age• Half of rapes are committed by someone known to the victim • Rape is underreported to the police

Male rapists have been categorized as: • Sexual sadists aroused by pain of victim• Exploitative predators• Inadequate men• Those who rape as a displaced expression of anger and rage• Same-sex rape can occur between partners but is most common in institutions

Physical and psychological trauma to rape victims is severe:• Medical problems: victims are significantly less healthy; pregnancy, STDs, HIV

are concerns• Victims may feel frightened, helpless, guilty, humiliated, and embarrassed; may

avoid previously pleasurable activities• Relationship problems may occur

Treatment and Intervention • Immediate support to ventilate fear and rage• Care by persons who believe that the rape happened• Coordination of all needed services in one location• Giving the victim control over choices whenever possible • Prophylactic treatment for STDs • Referral to therapy services; counseling; and groups for longer-term help

Community Violence Of great concern are homicides and suicides associated with schools.Solutions emphasize:

• Problem-solving skills, anger management, and social skills development• Parenting programs that promote strong bonding between parents and children

and conflict management in the home• Mentoring programs for young people

A history of violence, victimization, and witnessing of violence can lead to problems with aggression, depression, relationships, achievement, and abuse of drugs and alcohol

Psychiatric Disorders Related to Abuse and ViolenceTwo psychiatric disorders are associated with histories of violence and abuse:

1. Posttraumatic stress disorder (PTSD)2. Dissociative disorders

PTSDDisturbing behavior resulting after a traumatic event at least 3 months after the trauma occurredUp to 60% of persons at risk (combat veterans, victims of violence and natural disasters) develop PTSD.

Symptoms of PTSD include:• Persistent nightmares• Memories• Flashbacks• Emotional numbness• Insomnia• Irritability• Hypervigilance• Angry outbursts

Dissociative Disorders

Dissociation is a subconscious defense mechanism that helps a person protect the emotional self from recognizing the full impact of some horrific or traumatic event by allowing the mind to forget or remove itself from the painful situation or memory.

Dissociation can occur both during and after the event and becomes easier with repeated use. Dissociative disorders include:

• Amnesia• Fugue• Dissociative identity disorder (formerly multiple personality disorder)• Depersonalization disorder

Treatment and Interventions• Involvement in group and/or individual therapy in the community • Clients with dissociative disorder or PTSD are seen in the acute setting for brief

periods when symptoms are severe or there is concern for their safety

Application of the Nursing ProcessAssessment

• Includes history of trauma or abuse• Client often appears hyperalert, anxious, or agitated • Mood and affect: client is fearful and anxious; needs large personal space; has a

wide range of emotions• Thought processes and content: nightmares, flashbacks, destructive thoughts or

impulses• Sensorium and intellectual processes: disorientation (during flashbacks),

memory gaps• Judgment and insight: impaired decision-making and problem-solving abilities• Self-concept: client has low self-esteem• Roles and relationships: problems with relationships, work, authority figures• Physiologic considerations: difficulty sleeping, under- or overeating, use of

alcohol or drugs for self-medication

Data AnalysisNursing diagnoses include:

• Risk for Self-Mutilation • Ineffective Coping • Post-Trauma Response • Chronic Low Self-Esteem • Powerlessness

Outcome IdentificationThe client will:

• Be physically safe• Distinguish between self-harm ideas and taking action on those ideas• Learn healthy ways to deal with stress• Express emotions nondestructively• Establish social support network in the community

Intervention• Promoting the client’s safety• Helping the client cope with stress and emotions using grounding techniques• Helping to promote the client’s self-esteem• Establishing social support

EvaluationIs the patient:

• Learning to protecting him- or herself?• Learning to manage stress and emotions?• Able to function in their daily lives?

Self-Awareness Issues• Becoming comfortable asking all women about abuse (SAFE questions) • Listening to accounts of abuse from clients and families • Recognizing client’s strengths, not just problems • Working with perpetrators of abuse; dealing with own feelings about abuse and

violence

Grief and Loss

Grief refers to the subjective emotions and affect that are a normal response to loss.

Grieving, also known as bereavement, is the process of experiencing grief.

Anticipatory grief is facing an imminent loss.

Mourning is the outward sign of grief.

Experiences of grief and loss are essential and normal in the course of life; letting go, relinquishing, and moving on happen as we grow and develop.Grief and loss are uncomfortable.

Types of LossesLosses may be planned, expected, or sudden. Loss of a loved one is probably the most devastating type of loss, but there are many other types of losses:

• Physiologic (loss of limb, ability to breathe)• Safety (domestic violence, posttraumatic stress disorder, breach of

confidentiality)• Security/sense of belonging (relationship loss [death, divorce])• Self-esteem (ability to work, children leaving home)• Self-actualization (loss of personal goals, such as not going to college, never

becoming an artist or dancer)

The Grieving Process

Nurses must recognize the signs of grieving to understand and support the client through the grieving process.

The therapeutic relationship and therapeutic communication skills are paramount when assisting grieving clients. Using these skills, nurses may promote the expression and release of emotional as well as physical pain during grieving.

Theories of the Grieving Process

Kubler-Ross’s stages of grieving:• Denial (shock and disbelief)• Anger (toward God, relatives, health care providers)• Bargaining (trying to get more time, prolonging the inevitable loss)• Depression (awareness of the loss becomes acute)• Acceptance (person comes to terms with impending death or loss)

Bowlby’s phases of grieving: • Numbness and denial of the loss• Emotional yearning for lost loved one and protesting permanence of loss• Cognitive disorganization and emotional despair• Reorganizing and reintegrating sense of self

John Harvey’s phases of grieving: • Shock, outcry, and denial• Intrusion of thoughts, distractions, and obsessive reviewing of loss• Confiding in others to emote and cognitively restructure

Rodebaugh’s stages of grieving: • Reeling• Feelings• Dealing• Healing

There are many similarities among theorists about grief. Not all clients follow predictable steps or make steady progress.

Tasks of the Grieving Process• Undoing psychosocial bonds to loved one and eventually creating new ties• Adding new roles, skills, and behaviors• Pursuing a healthy lifestyle• Integrating the loss into life

Dimensions of Grieving• Cognitive responses to grief

– Questioning and trying to make sense of the loss– Attempting to keep the lost one present

• Emotional responses to grief • Spiritual responses to grief• Behavioral responses to grief• Physiologic responses to grief

Cultural ConsiderationsAll cultures grieve for lost loved ones, but the rituals and habits surrounding death vary among cultures, for instance, how shock and sadness are expressed, how long mourning should last, and so forth. Many cultural bereavement rituals have their roots in a major religion. Nurses should be sensitive to cultural differences and ask how the mourners can be assisted.

Nurse’s RoleThe nurse must encourage clients to discover and use effective and meaningful grieving behaviors:

• Praying• Staying with the body• Performing rituals• Attending memorials and public services

Disenfranchised Grief or Complicated Grieving

Disenfranchised grief is grief over a loss that is not or cannot be openly acknowledged, mourned publicly, or supported socially:

• A relationship has no legitimacy• The loss itself is not recognized• The griever is not recognized

Complicated grieving is a response that lies outside the norm of grieving in terms of extended periods of grieving: responses that seem out of proportion or responses that are void of emotion

People who are vulnerable to disenfranchised grieving: • Relationships that may be viewed as having no legitimacy: lovers, friends,

neighbors, foster parents, colleagues, caregivers, same-sex relationships, cohabitation without marriage, and extramarital affairs

• Losses that may not be recognized: prenatal death, abortion, relinquishing a child for adoption, death of a pet, or other losses not involving death such as job loss, separation, divorce, and children leaving home

• Grievers who may not be recognized: older adults, children, nurses

People who are vulnerable to complicated grieving include those with:• Low self-esteem• Low trust in others• A previous psychiatric disorder• Previous suicide threats or attempts• Absent or unhelpful family members• An ambivalent, dependent, or insecure attachment to the deceased person

Experiences increasing the risk for complicated grieving include:• Death of a spouse or child• Death of a parent (particularly in early childhood or adolescence)• Sudden, unexpected, and untimely death• Multiple deaths• Death by suicide or murder

Complicated Grieving as a Unique and Varied Experience • Physical reactions can include:

– Impaired immune system– Increased adrenocortical activity– Increased levels of serum prolactin and growth hormone – Psychosomatic disorders– Increased mortality from heart disease

• Emotional responses can include:– Depression– Anxiety or panic disorders– Delayed or inhibited grief– Chronic grief

Application of the Nursing ProcessAssessment

• Does the client have adequate perception regarding the loss? – What does the client think and feel about the loss?– How is the loss going to affect the client’s life?– What information does the nurse need to clarify or share with the client?

• Does the client have adequate support? • Does the client have adequate coping behaviors?

Data Analysis and Planning• Possible nursing diagnoses:• Grieving• Anticipatory Grieving• Dysfunctional Grieving

Outcome IdentificationGrieving The client will:

• Identify the effects of his or her loss• Seek adequate support• Apply effective coping strategies while expressing and assimilating all

dimensions of human response to loss in his or her life

Anticipatory Grieving The client will:

• Identify the meaning of the expected loss in his or her life• Seek adequate support while expressing grief• Develop a plan for coping with the loss as it becomes a reality

Dysfunctional Grieving The client will:

• Identify the meaning of his or her loss• Recognize the negative effects of the loss on his or her life• Seek or accept professional assistance to promote the grieving process

Intervention• Regarding perception of the loss

– Explore perception and meaning of the loss • Regarding adequate support

– Help the client reach out and accept what others want to give• Regarding adequate coping behaviors

– Shift from an unconscious defense mechanism to conscious coping– Compare and contrast past coping– Encourage the client to care for self

Essential communication and interpersonal skills to assist grieving:• Use simple, nonjudgmental statements • Refer to a loved one or object of loss by name (if acceptable in the client’s

culture)• Appropriate use of touch indicates caring• Respect the client’s unique process of grieving• Respect the client’s personal beliefs• Be honest, dependable, consistent, and worthy of the client’s trust• Offer a welcoming smile and eye contact

EvaluationEvaluation of progress is based on the goals established for the client. Make an evaluation of the client’s status based on the theoretical tasks and phases of grieving.

Self-Awareness Issues• Examining one’s own experiences with grief and loss• Taking a self-awareness inventory and reflecting on the results may be helpful.

Level Psychological Responses Physiological ResponsesMild Wide perceptual field

Sharpened sensesIncreased motivationEffective problem solvingIncreased learning abilityIrritability

RestlessnessFidgetingGI butterfliesDifficulty sleepingHypersensitivity to noise

Moderate Perceptual field narrowed to immediate taskSelectively attentiveCannot connect thoughts or events independentlyIncreased use of automatisms

Muscle tensionDiaphoresisPounding pulseHeadacheDry mouthHigh pitch voiceFast rate of speechGI upsetFrequent urination

Severe Perceptual field reduced to one detail orscattered details

Cannot complete tasksCannot solve problems or learn effectivelyBehavior geared towards anxiety relief and is usually ineffectiveDoesn’t respond to redirectionFeels awe, dread or horrorCriesRitualistic behavior

Severe headacheNausea, vomiting and diarrheaTremblingRigid stanceVertigoPaleTachycardiaChest pain

Panic Perceptual filed reduced to focus on selfCannot process any environmental stimuliDistorted perceptionsLoss of rational thoughtDoesn’t recognize potential dangerCan’t communicate verballyPossible delusions and hallucinationMay be suicidal

May bolt and runorTotally immobile and muteDilated pupilsIncreased blood pressure and pulseFight, flight or freeze

Anxiety and Stress-Related Illness

Anxiety vague feeling of dread unwarranted by the situation with no identifiable stimulus

accompanied by feelings of uneasiness and apprehensiono Fear o there is an identifiable threatening object

has healthy and harmful facets it is an internal warning device produces physiologic and emotional changes at each level

o mildo moderateo severeo panic

WORKING WITH ANXIOUS CLIENTS

Mild anxiety Moderate anxiety Severe anxiety

o an asset

o client can learn and solve problems effectively

o client is receptive to teaching and suggestions

o can cause client’s attention to wander

o nurse must redirect client back to topic

o nurse must validate that client has heard and understood

o causes impairment of many abilities

o client cannot learn or problem solve

o nurse must calm client and focus on lowering anxiety level

CATEGORIES OF ANXIETY DISORDERS Panic, with or without agoraphobia Phobia (social or specific) Obsessive-compulsive disorder (OCD) Posttraumatic stress disorder Acute stress disorder Generalized anxiety disorder Anxiety disorder due to a medical condition Substance-induced anxiety disorder

This chapter focuses on panic disorder, phobic disorder, and OCD.

INCIDENCE Anxiety disorders are the most common psychiatric disorders in the United States,

affecting 15% of adults More prevalent in women More common in divorced and separated persons More common in persons of lower socioeconomic status Onset and clinical course are variable

PHYSIOLOGIC AND PSYCHOSOCIAL RESPONSES TO ANXIETY Anxiety can be communicated nonverbally from one person to another. Defense mechanisms are used to reduce anxiety

when overused, they preclude learning more adaptive coping skills.

Physiologic responses include: sympathetic stimulation (fight or flight) discomfort difficulty thinking clearly agitated motor activity tension headaches

ETIOLOGY Stress: People handle stress in different ways. Stress is part of everyday life.

Selye identified responses to stress on the body in stages: alarm reaction resistance exhaustion

Biologic theories: o Anxiety may have an inherited componento neurotransmitter γ-aminobutyric acid (GABA)o Serotonin plays a part in OCD

Psychodynamic theories: o overuse of defense mechanismso results from problems in interpersonal relationshipso “learned” behavioral response

CULTURAL CONSIDERATIONS People from Asian cultures often somatize anxiety into expressions of pain in the

body. Hispanics may identify illnesses as “hot” or “cold” and eat either “hot” or “cold”

foods to counteract them.

TREATMENT Effective treatment usually involves a combination of medication (anxiolytics and

antidepressants) and therapy. Cognitive-behavioral therapy includes:

o positive reframing - turning negative messages into positive oneso decatastrophizing - making a more realistic appraisal of the situation

Assertiveness training helps the client learn to negotiate interpersonal situations more successfully.

PANIC DISORDERo involves 15- to 30-minute episodes of intense, escalating anxiety with emotional

fear and physiologic discomforto 75% have spontaneous attacks of panic with no environmental triggero Onset peaks: late adolescence and in the mid-30so Treatment:

o Selective serotonin reuptake inhibitors (SSRIs)o cyclic antidepressantso benzodiazepines are used

Application of the Nursing Process for Panic DisorderAssessment

Client feels unreal and detached from self during attack. Fears losing control or going insane Has temporarily disorganized thought process; feels he or she is dying Judgment is poor during an attack. Anticipation of attacks causes the person to limit social activities and may

interfere with work, relationships, and family life Some develop agoraphobia and avoid public places altogether, not leaving their

homes Clients experience:

o primary gain (relief of anxiety by staying at home)o secondary gain (attention received from others due to the disorder; relief

from daily responsibilities).

Data AnalysisNursing diagnoses include:

Risk for Injury Anxiety Fear Social Isolation Situational Low Self-Esteem Ineffective Coping Powerlessness Ineffective Role Performance Disturbed Sleep Pattern

Outcome IdentificationThe client will:

Be free of injury Verbalize feelings Use effective coping techniques Manage own anxiety response Verbalize sense of personal control Sleep at least 6 hours per night

Intervention Promoting safety and comfort Using therapeutic communication Managing anxiety Client and family teaching

PHOBIASo an illogical, intense, persistent fear of a specific object or social situationo cause extreme distress and interferes with normal life functioningo People with phobias understand that their fear is unusual and irrational but feel

powerless to control it. o clients develop anticipatory anxiety when thinking about the possibility of

encountering the phobic object

o Types of phobia:

Specific phobia is irrational fear of an object or situation, such as fear of a natural phenomenon (for instance, storms, heights), fear of seeing blood or receiving an injection, fear of specific situations (for instance, being in an elevator), or fear of animals

Social phobia involves severe anxiety, even panic, when confronted with situations involving people, such as making a speech, having dinner with others, or meeting new people; or fear of eating in public, using public bathrooms, or being the center of attention

Specific phobias occur more often in women; social phobias occur in men and women equally; peak onset is childhood and mid-20s.

Etiology Biologic (phobias run in families, hormonal functions, or neurotransmitter activity) Psychodynamic (faulty thinking, belief one doesn’t control the environment, or

learned by modeling from parents)

Treatment and Prognosis Psychopharmacology:

o anxiolyticso SSRI antidepressantso beta blockers to slow heart rate and lower blood pressure

Psychotherapy: There are useful approaches, although some people do not seek treatment, especially for specific phobias that do not interfere with daily life.

Behavioral therapies include systematic desensitization and flooding.

OBSESSIVE-COMPULSIVE DISORDEROCD involves:

Obsessionso recurrent, persistent, intrusive, and unwanted thoughts, images, or

impulses that cause marked anxiety and interfere with interpersonal, social, or occupational functioning.

Compulsionso ritualistic or repetitive behaviors or mental acts that a person carries out

continuously in an attempt to neutralize anxietyo Examples:

o repeated checking or counting ritualso excessive handwashingo repeating wordso touching ritualso symmetry ritualso cleanliness

o The person knows the rituals are unreasonable but feels forced to continue them in an attempt to relieve anxiety caused by obsessions.

Treatment and Prognosiso behavior therapy

o exposure - confronting anxiety-provoking stimulio response prevention - delaying or avoiding ritual performance

o medication o SSRI antidepressantso fluvoxamine [Luvox]o clomipramine [Anafranil]o buspirone [BuSpar]o clonazepam [Klonopin])

Application of the Nursing Process for OCDAssessment

Client assessment focuses on what behaviors or rituals are performed, when and how often, client’s response, and so forth, to discover the pattern of behavior.

Data Analysis Anxiety Ineffective Coping Fatigue Situational Low Self-Esteem Impaired Skin Integrity (if scrubbing or washing rituals)

Outcome IdentificationThe client will:

Complete daily routine within realistic time frame Demonstrate effective use of relaxation techniques Discuss feelings with others Demonstrate effective use of behavior therapy techniques Spend less time performing rituals

Intervention Using therapeutic communication Teaching relaxation and behavioral techniques Completing a daily routine Providing client and family education

Evaluation Based on established goals Integrating loss into life

GENERALIZED ANXIETY DISORDER Excessive worry and anxiety that is unwarranted more days than not Seen most often by family physicians Treated with SSRI antidepressants and buspirone

SELF-AWARENESS ISSUES Stress and anxiety are common experiences for all people.

Persons with anxiety disorders often “look well enough” to control their behavior. Avoid trying to “fix” client’s problems.

ANTIANXIETY DRUGSIndications:

anxiety disordersinsomniaobsessive-compulsive disorderdepressionposttraumatic stress disorderalcohol withdrawal

Benzodiazepines are the antianxiety agents used most frequently (buspirone [BuSpar] is the only common nonbenzodiazepine in wide use). They moderate the actions of GABA. A wide variety of benzodiazepines are used. They vary in half-life, how they are

metabolized, and effectiveness. Some are used primarily for insomnia, due to sedation side effects.

Common side effects are drowsiness, sedation, poor coordination, memory impairment, clouded sensorium, and hangover effect in the morning. The biggest problem is psychological dependence: Long-term use can result in overuse or abuse.

Client teaching for anxiolytics: Avoid alcohol, and be aware of sedating side effects when driving.

Mood Disorders

Everyone has episodes of feeling sad, low, and tired, accompanied by anergia (lack of energy), exhaustion, agitation, noise intolerance, and slowed thinking processes.

Work, family, and social responsibilities drive most people to go through their daily routines, knowing that this mood and the feelings will pass. Mood disorders are diagnosed when these alterations in emotions are pervasive and interfere with the person’s ability to live life.

CATEGORIES Major depressive disorder: 2 or more weeks of sad mood, lack of interest in life

activities, and other symptoms Bipolar disorder (formerly called “manic-depressive illness”): mood cycles of mania

and/or depression and normalcy

RELATED DISORDERS Dysthymic disorder: sadness and low energy, but not severe enough to be

diagnosed as major depressive disorder Cyclothymic disorder: mood swings not severe enough to be diagnosed as bipolar

disorder Seasonal affective disorder (SAD) Depressive personality disorder Postpartum or “maternity” blues Postpartum depression Postpartum psychosis

ETIOLOGY Biologic theories include genetics (mood disorders run in families) and

neurochemical theories (dysregulation of serotonin and norepinephrine, and neuroendocrine or hormonal fluctuations).

Psychodynamic theories tend to “blame” clients and families for illness and have little use today. The exception is Beck, who viewed depression as resulting from specific cognitive distortions in susceptible people—cognitive therapy is used in the treatment of depression.

CULTURAL CONSIDERATIONS Depression, often masked by other symptoms Somatic complaints may accompany depression.

MAJOR DEPRESSIVE DISORDER Twice as common in women and more common in single or divorced people Involves 2 or more weeks of sad mood, lack of interest in life activities, and at least

four other symptoms, such as anhedonia and changes in weight, sleep, energy, concentration, decision making, self-esteem, and goal setting

Untreated, can last 6 to 24 months; recurs in 60% of people Symptoms range from mild to moderate to severe.

Treatment and PrognosisAntidepressants

Classification Indication Drugs Side EffectsSelective serotonin reuptake inhibitors (SSRIs)

mild and moderate depression

fluoxetine (Prozac)sertraline (Zoloft)paroxetine (Paxil)citalopram (Celexa)

insomnia weight gain sedationconstipation

nausea

Tricyclic antidepressants (TCAs)

moderate and severe depression

*effectiveness doesn’t begin for 4-6 weeks

amitriptyline (Elavil) imipramine (Tofranil)desipramine (Norpramin)nortriptyline (Pamelor)doxepin (Sinequan)

Atypical antidepressants

venlafaxine (Effexor)bupropion (Wellbutrin)nefazodone (Serzone) (trazodone used for insomnia due to sedation).

HeadacheDizzinessDrowsinessNauseavomiting

Monoamine oxidase inhibitors (MAOIs)

*Maximum effectiveness takes 6 weeks

isocarboxazid (Marplan)tranylcypromine (Parnate)phenelzine (Nardil)

interaction with tyramine causes hypertensive crisis

interact unfavorably with a variety of prescription and over-the-counter drugs

lethal in overdose

dry mouthblurred near vision constipationurinary retention sedationweight gainorthostatic hypotensionnausea

Electroconvulsive Therapy (ECT) used when medications are ineffective or side effects are intolerable After anesthesia and muscle relaxants, a shock is administered via electrodes to

produce seizure activity in the brain administered in a series (for instance, three times a week for 6 weeks) Care of client before and after ECT is similar to that for any minor surgical

procedure After ECT, there is short-term memory loss, confusion, headache, and

drowsiness.

Psychotherapy Psychotherapy in conjunction with medication is considered the most effective

treatment Useful therapies include behavioral, cognitive, interpersonal, and family therapy,

depending on client needs.

Application of the Nursing Process: Major Depressive DisorderAssessment Must include determination of suicidal ideas, lethality, and client’s perception of the

problem Psychomotor retardation or agitation;

feelings of helplessness anxiety sadness guilt frustration negativism pessimism lack of pleasure social withdrawal reduced concentration and decision making fatigue and exhaustion low self-esteem and rumination about past bad deeds or failures loss of ability to function in life roles sleep disturbances overeating or undereating lack of attention to hygiene and grooming

Depression and rating scales may be used.

Data Analysis Nursing diagnoses may include:

Risk for Suicide Imbalanced Nutrition Anxiety Ineffective Coping Hopelessness Ineffective Role Performance Chronic Low Self-Esteem Disturbed Sleep Pattern Impaired Social Interaction

OutcomesThe client will:

Not injure self or others Carry out activities of daily living independently Establish a balance of rest, sleep, and activity Establish a balance of adequate nutrition, hydration, and elimination Evaluate self-attributes realistically Socialize with staff, peers, and family/friends

Return to occupation or school activities Comply with medication regimen Verbalize symptoms of recurrence

Intervention Providing for the client’s safety and the safety of others Promoting a therapeutic relationship Promoting activities of daily living and physical care Using therapeutic communication Managing medications Providing client and family teaching

BIPOLAR DISORDER Bipolar disorder involves mood swings of depression (same symptoms of major

depressive disorder) and mania Major symptoms of mania:

o grandiose moodo Agitationo exaggerated self-esteemo sleeplessnesso pressured speecho flight of ideaso being easily distractibleo intrusive behavior with lack of personal boundarieso high-risk activities with potentially severe consequences, and poor

judgment.

Treatment and Prognosis Treatment may involve medication with lithium regular monitoring of serum lithium levels is needed Side effects of lithium therapy:

o mild nausea or diarrheao anorexiao fine hand tremoro fatigueo metallic taste in the moutho polydipsiao polyuria

Signs of lithium toxicity:o severe nauseao vomiting and diarrheao severe mental confusion

Anticonvulsant drugs are used for their mood-stabilizing effects: Tegretol Depakote Lamictal Topamax Trileptal

Neurontin Klonopin (a benzodiazepine)

Side effects: Drowsiness Sedation dry mouth blurred near vision weight gain

Application of the Nursing Process: Bipolar DisorderAssessment General appearance and motor behavior:

Assessing a client in the manic phase may be difficult and based more on observations of the client than on the client’s responses to structured questions

Client jumps from one subject to another cannot sit still may wear flamboyant clothing or makeup.

Mood and affect: psychomotor agitation racing thoughts pressured speech ignoring of directions or requests from others unusual speech patterns

Thought processes and content: starts many grandiose projects but finishes none careless spending sprees

Sensorium and intellectual processes: loud voice may be hypersexual

Judgment and insight: poor Self-concept:

false, grandiose sense of well-being that covers low self-esteem Roles and relationships:

may be charming and playful, then sarcastic and angry cannot take “no” for an answer

Physiologic and self-care considerations: inattention to hygiene and groominghunger, or fatigue

Data Analysis Nursing diagnoses may include:

Risk for Other-Directed Violence Risk for Injury Imbalanced Nutrition Ineffective Coping Noncompliance Ineffective Role Performance Chronic Low Self-Esteem Disturbed Sleep Pattern Fatigue Self-Care Deficits

OutcomesThe client will:

Not injure self or others Establish a balance of rest, sleep, and activity Establish adequate nutrition, hydration, and elimination Participate in self-care activities Evaluate personal qualities realistically Engage in socially appropriate, reality-based interaction Verbalize knowledge of illness and treatment

Intervention Providing for safety of client and others Meeting physiologic needs Providing therapeutic communication Promoting appropriate behaviors Managing medications Client and family teaching

Evaluation Based on client’s mood at “normal” level Medication compliance is essential.

SUICIDEFamilies need support when a member has committed suicide or is making attempts to do so. They may feel guilty, angry, and ashamed, and they are at increased risk for suicide themselves.

Assessment Populations at risk Warnings of suicidal intent Risky behaviors Lethality assessment

OutcomesThe client will:

Be safe from harming self or others Engage in a therapeutic relationship Establish a no-suicide contract Create a list of positive attributes Generate, test, and evaluate realistic plans to address underlying issues

Intervention Using an authoritative role Providing a safe environment Initiating a no-suicide contract Creating a support system list Supervision

SELF-AWARENESS ISSUES Nurses and other staff members need to deal with their own feelings about suicide. Depressed or manic clients can be frustrating and require a lot of energy to care

for. Keeping a journal may help deal with feelings; also, talking to colleagues is often

helpful.