Week 4 Discussion

PSYCHOSOCIAL NURSING

FOR GENERAL PATIENT CARE 3rd Edition

Linda M. Gorman, APRN, BC, MN, CHPN, OCN Palliative Care Clinical Nurse Specialist Cedars-Sinai Medical Center Los Angeles, California

Assistant Professor University of California, Los Angeles Los Angeles, California

Donna F. Sultan, RN, MS Mental Health Counselor, RN West Valley Mental Health Center Los Angeles County Department of Mental Health Los Angeles, California

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F. A. Davis Company 1915 Arch Street Philadelphia, PA 19103 www.fadavis.com

Copyright © 2008 by F. A. Davis Company

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Library of Congress Cataloging-in-Publication Data Gorman, Linda M. Psychosocial nursing for general patient care / Linda M. Gorman, Donna F. Sultan. —

3rd ed. p. ; cm.

Includes bibliographical references and index. ISBN-13: 978-0-8036-1784-1 ISBN-10: 0-8036-1784-4

1. Psychiatric nursing—Handbooks, manuals, etc. 2. Nursing—Social aspects— Handbooks, manuals, etc. I. Sultan, Donna. II. Title. [DNLM: 1. Nursing Care—psychology—Handbooks. 2. Nurse-Patient Relations—

Handbooks. 3. Nursing Assessment—Handbooks. WY 49 G671p 2008] RC440.G659 2008 616.89′0231—dc22 2007040704

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Preface

Having worked in a variety of specialty areas over the years as staff nurses, clin- ical nurse specialists, educators, therapists, and managers, we realize that nurses aspire to become highly proficient in their area of practice. But psychosocial skills are often more difficult to perfect. Very often nurses feel inadequately prepared to deal with complex behaviors and psychiatric problems on top of the demands of providing physical care for the patient and family. Even nurses who practice in the psychiatric setting find themselves dealing with unique situations that chal- lenge their level of expertise. And yet, a large percentage of a nurse’s time is spent dealing with these issues.

Psychosocial Nursing for General Patient Care bridges the gap between the information contained in the large, comprehensive psychiatric texts and the infor- mation needed to function effectively in a variety of healthcare settings. The cli- nician can refer to this book to find the information to effectively handle specific patient problems. The nursing student can use this book as a supplement to other texts and will be useful throughout nursing school curriculum.

The concise, quick reference format used throughout this book allows the nurse to easily find information on a specific psychosocial problem commonly seen in practice. In addition to common psychosocial problems, psychiatric dis- orders are explained and discussed. Each chapter is organized to provide easy access to information on etiology, assessment, age-specific implications, nursing diagnosis and interventions, patient/family education, interdisciplinary manage- ment including pharmacology, and community based care. The fast-paced health- care environment we are all experiencing demands quick assessment and treatment plans that are realistic, cost-effective, and outcome driving. The infor- mation contained in this book is readily applicable to all patient care settings.

Each psychosocial problem includes a section on common nurses’ reactions to the patient behaviors that may result from the problem. Nurses often think they should only have acceptable and “proper” emotional reactions to their patients. Nurses may deny certain feelings and have unrealistic expectations of themselves. These factors impact how the nurse then responds to the patient’s problems. The more aware the nurse becomes of how one reacts to the patient’s behaviors, the easier it will be to accept one’s own feelings and understand how these feelings affect the patient and influence interventions.

In this third edition we have added two new chapters that reflect concerns faced by many nurses. The Homeless Patient with Chronic Illness reflects the increasingly frequent encounters that nurses in all areas of the country are facing. Disaster Planning and Response–Psychosocial Impact provides the nurse with tools to prepare for the emotional impact of a natural or man-made disaster. Throughout this third edition we have updated information on patient safety, pharmacologic interventions, and psychiatric diagnoses and treatment. We con-

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tinue to include information that will apply to the inpatient hospital setting, long- term care, and outpatient care.

We wish to thank our contributors Yoshi Arai and Margaret Mitchell who revised their chapters from the second edition. We also thank our new contribu- tors Bill Whetstone and Carl Magnum. Particular thanks go to our editors Annette Ferrans and Joanne DaCunha of FA Davis. This was our third collabo- ration with Joanne and she remains a dynamic force that keeps us on track.

For those of you familiar with our earlier two editions, you will notice the name of author Marcia L. Raines, RN, PhD is missing. Marcia died in 2006 after a long illness. Marcia was the consummate nurse who strove for excellence throughout her career. She started as a psychiatric nurse, became a clinical nurse specialist, was an educator and administrator, and faculty member and chair of a university school of nursing. She inspired countless nurses over the years with her wise and gentle approach. She strove for excellence in all aspects of her career. Working with her on the previous two editions was always a joy because of her genuine love of the work and her enthusiasm to produce an outstanding book. Marcia wrote many of the original chapters from the first and second edition including chapters on anxiety, sexual dysfunction, confusion, pain, and sleep. We have strived to carry on in her memory but know the nursing world has lost a great one. This edition is dedicated to Marcia.

Linda M. Gorman Donna F. Sultan

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Contributors

Yoshinao Arai, RN, MN, CNS Senior Mental Health Counselor, RN Los Angeles County Department of Mental Health Los Angeles, California

Carl Magnum, RN, MSN, PhD(c), CHS, FF Assistant Professor of Nursing Emergency Preparedness Coordinator The University of Mississippi Medical Center Jackson, Mississippi

Margaret L. Mitchell, RN, MN, MDIV, MA, CNS Senior Mental Health Counselor, RN Los Angeles County Department of Mental Health Los Angeles, California

William R. Whetstone, RN, CNS, PhD Professor, Nursing Clinical Nurse Specialist, Adult Psychiatric Mental Health Nursing California State University, Dominguez Hills Carson, California

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Reviewers

Michael Beach, MSN, APRN, BC, ACNP, PNP Instructor University of Pittsburgh Pittsburgh, Pennsylvania

Dorie V. Beres, PhD, MSN, ANP-C Associate Professor and Coordinator Vitterbo University La Crosse, Wisconsin

Earl Goldberg, EdD, APRN, BC Assistant Professor LaSalle University Philadelphia, Pennsylvania

Barbara A. Jones, RN, MSN, DNSc Professor Gwynedd-Mercy College Gwynedd Valley, Pennsylvania

Nancy L. Kostin, MSN, RN Associate Professor Madonna University Livonia, Michigan

Karen P. Petersen, RN, CCRN, MSN Nursing Instructor Chemeketa Community College Salem, Oregon

Glenda Shockley, RN, MS Director of Nursing Connors State College Warner, Oklahoma

Ellen F. Wirtz, RN, MN Faculty Chemeketa Community College Salem, Oregon

Margaret A, Wetsel, PhD, MSN Associate Professor Clemson University Clemson, South Carolina

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Contents

SECTION I— Aspects of Psychosocial Nursing

1 Introduction to Psychosocial Nursing for General Patient Care ...................................................................1

2 Psychosocial Response to Illness............................................7 3 Psychosocial Skills .....................................................................15 4 Nurses’ Responses to Difficult Patient Behaviors............33 5 Crisis Intervention......................................................................43 6 Cultural Considerations: Implications for

Psychosocial Nursing Care......................................................49

SECTION II— Commonly Encountered Problems

7 Problems with Anxiety .............................................................57 The Anxious Patient ............................................................................57

8 Problems with Anger ................................................................73 The Angry Patient.................................................................................73

The Aggressive and Potentially Violent Patient.........................83

9 Problems with Affect and Mood...........................................99 The Depressed Patient ......................................................................99

The Suicidal Patient ..........................................................................113

The Grieving Patient .........................................................................129

The Hyperactive or Manic Patient...............................................142

10 Problems with Confusion.......................................................157 The Confused Patient ......................................................................157

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11 Problems with Psychotic Thought Processes...................177 The Psychotic Patient.......................................................................177

12 Problems Relating to Others .................................................191 The Manipulative Patient ................................................................191

The Noncompliant Patient.............................................................204

The Demanding, Dependent Patient.........................................219

13 Problems with Substance Abuse.........................................231 The Patient Abusing Alcohol .........................................................231

The Patient Abusing Other Substances ....................................250

14 Problems with Sexual Dysfunction .....................................273 The Patient with Sexual Dysfunction .........................................273

15 Problems with Pain ..................................................................291 The Patient in Pain............................................................................291

16 Problems with Nutrition .........................................................315 The Patient with Anorexia Nervosa or Bulimia.......................315

The Morbidly Obese Patient .........................................................330

17 Problems Within the Family...................................................341 Family Dysfunction............................................................................341

Family Violence ..................................................................................351

18 Problems with Spiritual Distress..........................................369 The Patient with Spiritual Distress ..............................................369

Margaret L. Mitchell, RN, MN, MDIV, MA, CNS

SECTION III— Special Topics

19 Nursing Management of Special Populations ................387 The Patient with Sleep Disturbances.........................................387

The Chronically Ill Patient...............................................................400

The Homeless Patient with Chronic Illness.............................410

William R. Whetstone, RN, CNS, PhD

The Dying Patient..............................................................................421

x Contents

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20 Disaster Planning and Response–Psychosocial Impact .........................................................................................435 The Disaster Victim/Patient

The Disaster Responder/Nurse ...................................................435

Carl Magnum, RN, MSN, PhD(c), CHS, FF

21 Psychopharmacology: Database for Patient and Family Education on Psychiatric Medications........451 Yoshinao Arai, RN, MN, CNS

References.........................................................................................487

Index....................................................................................................513

Contents xi

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1

SECTION I Aspects of Psychosocial Nursing

1Introduction to Psychosocial Nursing for General Patient Care

Learning Objectives • Define psychosocial nursing care. • Describe the impact of patient behavior problems in a managed-

care setting. • Describe the role of patient education in psychosocial care. • Name the resources the nurse can use when planning for patients across

care settings.

Every day, nurses are confronted with patient problems and crises that fall in the realm of the psychosocial, and they must find a way to deal with them.

The Agency for Healthcare Research and Quality found in 2004 that one in four stays in U.S. hospitals for patients 18 and over involved depressive, bipolar, schiz- ophrenia, and other mental disorders or substance abuse. Nurses often must care for patients with:

• Intense emotional responses to illness • Personality styles that make care difficult • Psychiatric disorders • Stresses and family problems that affect patients’ reactions to illness or hos-

pitalization

Nurses can be proficient in managing patients’ physical health problems and yet be less prepared to manage emotional problems. The ability to recognize

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behaviors that suggest psychosocial problems and to develop skills to manage them effectively not only improves the patients’ chances of healing but can also reduce frustration for nurses.

Psychosocial care emphasizes interventions to assist individuals who are having difficulty coping with the emotional aspects of illness, with life crises that affect health and health care, or with psychiatric disorders. For example, problems with depression, anger, substance abuse, or grief can influence a patient’s response to illness or to the interventions of the health-care system. In psychosocial care, the nurse focuses on the effects of stress in psychological or physiological illness and on the intrapsychic and social functioning of individuals responding to stress.

The nurse has a responsibility to facilitate each patient’s adaptations to his or her unique stresses by helping and supporting the person in his or her environ- ment, level of wellness, and adjustment to the illness or condition. Identifying the patient’s coping responses, maximizing strengths, and maintaining integrity will help the nurse meet this responsibility.

NURSES’ POSSIBLE REACTIONS

A factor whose importance cannot be overlooked in psychosocial care is aware- ness of one’s own reactions to patient behaviors. These reactions will influence the nurse-patient relationship, assessment findings, and selection of potential interventions. They can help or hinder the relationship. Recognizing the influence of these reactions can help the nurse to:

• Increase awareness of the reactions that influence objectivity • Identify reactions frequently experienced by other nurses to ease feelings of

guilt and resentment • Increase understanding of colleagues’ reactions to enhance the work envi-

ronment • Facilitate self-support by reducing self-criticism and reinforcing skills • Select better assessment tools to identify patients’ dilemmas and responses • Recognize how personal reactions to patients can influence assessment,

planning, and effective interventions

In coming chapters, “Possible Nurses’ Reactions” will be presented as boxed text, so that you can easily find and refer to it.

THE ROLE OF PSYCHOSOCIAL NURSING IN MANAGED-CARE SETTINGS

Patients with psychosocial and psychiatric problems often require many more resources than patients without such problems. A patient’s emotional reactions can increase his or her length of stay in the hospital or under a nurse’s care, can con- tribute to the patient’s not complying with care, and can drain physical and emo-

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tional resources. Once these patient problems are identified, the nurse needs to use skills to meet the patient’s needs while making judicious use of available resources.

In the managed-care system, controls are exerted over access, use, quality, and effectiveness of health services. Managed care is now the dominant form of health care in the United States (Shoemaker & Varcarolis, 2006). It has led to shortened hospital stays and limitations in available resources. Outpatient programs and home health care are now being used more to address problems in place of inpa- tient care. To work within this system, the nurse must quickly identify the patient’s needs, establish a realistic plan of care, implement interventions, and evaluate out- comes, all within a predetermined length of time. Psychosocial and psychiatric patient problems complicate the demands made on the nurse in an already stretched health-care environment and can negatively affect patient outcomes. When the nurse has skills readily at hand to identify problems and intervene effec- tively, patient outcomes can be improved and nurse satisfaction will be enhanced.

Managed care has also intensified the focus on outcome-based interventions to address key problems within a shorter timeframe. Clinical pathways or clini- cal practice guidelines are often used to drive this process. These pathways are evidence-based approaches to plans of care, and their focus is on outcomes. Psy- chosocial and psychiatric problems often have to be addressed to keep on target with the pathway.

PATIENT SAFETY

The incorporation of methods to improve patient safety is an important consid- eration for all levels of patient care today. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has spearheaded a national movement, which includes avoiding the use of abbreviations that can be confused with one another, using universal protocol to prevent surgical error involving “wrong site, wrong procedure, and wrong person,” and the development of National Patient Safety Goals (JCAHO, 2007). Psychosocial care incorporates these patient safety measures as a routine part of practice by maintaining open communication with the patient and health-care team.

LIFE SPAN ISSUES

Although each individual is unique, we all share certain patterns and common links throughout the life cycle. Psychosocial development proceeds through a series of stages and crises. Each phase of the life span presents new challenges, experiences, and problems. Many psychosocial problems have their origins in developmental crises that remain unresolved or that are resolved with negative outcomes. Problems such as depression and grief affect individuals differently in each stage of life. Childhood, adolescence, and old age are times of particular vulnerability to psychosocial dysfunction. Look for this heading in the coming chapters indicating discussions of life span issues.

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Interventions in this book are geared to adults, but many of them can be adapted to the care of children. To adapt an intervention to a pediatric population, the nurse must consider children’s developmental and cognitive levels, and incor- porate them in the care plan as well as consult specialists in pediatrics, if necessary.

COLLABORATIVE MANAGEMENT

Our complex health-care system relies on a variety of health-care professionals to meet patients’ needs. Obviously, the nurse does not work in a vacuum but must participate in the interdisciplinary team and be aware of other disciplines as resources for psychosocial intervention. The nurse also needs to know when work needs to be shared or delegated through referrals. For example, social workers may be helpful because they are often familiar with psychotherapists and community support groups for emotional problems. The nurse should be aware of agency policies regarding referrals to psychotherapists. Some may require a doctor’s order.

Other resources include physicians, advanced practice nurses, pharmacists, clergy, dietitians, and others, depending on the specialty and setting. Knowing when and how to access them and work effectively with them will improve patient outcomes and enhance the working environment. Collaborative manage- ment is addressed throughout the book in terms specific to the topic discussed in each chapter.

WHEN AND WHO TO CALL FOR HELP

Many difficult, challenging situations require a number of complex skills. While continuing to gain knowledge in identifying psychosocial issues and intervening in cases in which patients require psychosocial care, nurses also need to recognize their own limitations and be able to recognize patient behaviors that may precede or currently signal a dangerous or emergency situation. Knowing when to seek out resources and who to call for help are essential factors in providing quality, cost-effective care.

When and who to call for help will also be set inside a box in coming chap- ters so that you can easily reference it.

PATIENT EDUCATION

Patient education is an important component of psychosocial care. Nurses are required to incorporate appropriate patient education in their practice. To provide adequate education, the nurse needs to be aware of how psychosocial issues influ- ence learning. For example, assessing the patient’s anxiety level or disturbed thoughts will influence the timing of teaching as well as the type of information the nurse tries to convey. Patient education can enhance the patient’s independence and control, involvement of the patient and his or her family in the treatment plan,

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and help prepare the patient for possible emotional changes, coping skills needed, and responses to medications. Patient education can be influential in reducing length of stay and helping patients to take more responsibility for their own care.

Many factors can affect effective patient education, including patients’ cultural beliefs and language, as well as knowledge of and access to computer technology.

CHARTING TIPS

Changes in patients’ emotional responses and behaviors, and their responses to interventions and education are significant and must be noted in the medical record. The increased use of computerized documentation can present new challenges to nurses who are trying to identify and record behavioral problems succinctly.

Charting tips are given in each chapter for specific situations and are identified with a chapter heading.

COMMUNITY-BASED CARE

Many patients require care that crosses settings, for instance from hospital-based care to home nursing care. In most cases, acute hospital care is now a small part of the treatment plan and eventually ends. To ensure continuity of care, planning for the next level of care should begin as early as possible. While the patient is in the acute setting, this planning needs to begin on admission. Long-term care, out- patient rehabilitation, other outpatient programs, and home health care are now used for many patients. Nurses in all these settings must also consider planning for the next level of care.

Home health agencies may have nurses with psychiatric backgrounds on staff. Box 1–1 lists possible interventions by psychiatric home care nurses. These nurses can be helpful in evaluating patients’ responses to psychotropic medications, confusion, psychotic behavior, and suicide risk. Patients may need referrals to other types of care, such as psychiatric hospitalization or convalescent care, and

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BOX 1–1 Interventions by Psychiatric Home Care Nurses • Crisis intervention • Suicide risk assessment • Management of psychiatric medications and blood level monitoring • Administration of long-acting injectable psychiatric medications • Counseling and education • Assessment of patient and family coping • Safety assessment

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assistance with financial support. Other professionals such as social workers, case managers, and counselors can help ensure safe and effective home care. Other resources including support groups, hotlines, and even telemedicine increase access to care. For a patient to be eligible for psychiatric home care, usu- ally the patient has to be homebound, have a psychiatric diagnosis, and have a need for the skills of a psychiatric nurse (Shoemaker & Varcarolis, 2006).

PATIENT PRIVACY AND RIGHT TO CONFIDENTIALITY

Patient rights are becoming increasingly emphasized in all health-care settings. These rights generally include autonomy, informed consent, treatment with dig- nity and respect, and confidentiality. The Health Insurance Portability and Accountability Act (HIPAA) enacted in 2003 established a number of mechanisms to maintain privacy, including the requirement that health-care professional obtain permission from the patient to share information with persons who are not directly involved in the patient’s care, and that medical records be viewed only by people directly involved in patient’s treatment. The American Nurses’ Association Code of Ethics also requires a nurse to protect confidential information.

DSM-IV-TR

The American Psychiatric Association (APA) has developed a classification sys- tem for mental disorders. It is the most widely accepted system in the United States today and is published and revised periodically as the Diagnostic and Sta- tistical Manual. The fourth edition was published in 1994 and is referred to as DSM-IV. In 2000, the APA published a revised version called DSM-IV-TR, mean- ing text revision that is also referenced in this book. These references provide cli- nicians with guidelines, specific criteria, and accepted terminology. Throughout this book, you will see references to the criteria published in DSM-IV and DSM- IV-TR. These criteria are used to prevent negative labeling or incorrect catego- rization of patient behaviors as psychiatric disorders.

OVERVIEW OF THE BOOK

Chapters 2 through 6 cover basic skills and emphasize aspects of Psychosocial Nursing including assessment and culturally sensitive care. Chapters 7 through 18 address Commonly Encountered Problems. Nursing interventions are provided for major nursing diagnoses. Chapters 19 through 21 cover Special Topics, includ- ing care of patients who belong to special populations, care in the face of disaster, and medications that the nurse may be using to manage behavioral symptoms.

Many of the topics addressed in this opening chapter appear in the coming chapters, so readers should quickly be able to discern the pattern of approach and will be able to use this book not only as a textbook but also as a reference in their future care of patients with psychosocial problems.

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2

7

Psychosocial Response to Illness

Learning Objectives • Describe the role of self-esteem, body image, powerlessness, and guilt

in the patient’s emotional response to illness. • Describe the role of Maslow’s Hierarchy of Needs in explaining a

patient’s response to illness. • Define defense mechanisms and give examples of each. • Describe commonly used coping mechanisms.

Psychological impact is present in any illness. Illness threatens the individual and evokes a wide array of emotions, such as fear, sadness, anger, depression,

despair, and loss of control. Each individual who faces an illness responds differ- ently according to personality, previous life experiences, and coping style. Extreme denial, noncompliance, aggression, and threats of suicide are some of the more maladaptive responses that the nurse may face in caring for ill individuals. Most often these responses are temporary and subside with time. However, they can also be chronic maladaptive behavioral responses that the patient uses when- ever he or she experiences a stressful situation. There is often no way of knowing on first meeting a patient whether his or her response is temporary or habitual.

All behavior is an attempt to communicate needs. To determine a person’s underlying motivation, identifying the need can be a first step to understanding. Maslow’s Hierarchy of Needs (1954) provides a framework within which to begin examining the motivation a person may have for a behavior (Fig. 2–1). Maslow identified five levels of needs. Each type of need, starting at the most basic physiological level, must be met before one can move on to the next level.

Professional nursing uses a holistic framework by which it views the individ- ual and his or her environment in its entirety. The influence of the mind as well as the body is recognized in the development of and response to illness. It is known that the response to stress involves the immune and neuroendocrine sys- tems. Emotional response to stress suppresses the immune system, stimulates the cardiovascular system, and alters secretions of hormones that influence the body’s response to the illness.

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Stress cannot be avoided. It is a normal part of living. It does not matter if a stressor is pleasant, such as an upcoming holiday, or unpleasant, such as illness, disability, or hospitalization. What is critical is the individual’s perception of the intensity of the stressor requiring readjustment and his or her capacity to adjust to it.

KEY ISSUES IN RESPONSE TO ILLNESS

Altered Self-Esteem Self-esteem is the individual’s personal judgment of his or her own worth. The roots of self-esteem are in early parental and social relationships as well as in the person’s perception of goal attainment and his or her own ideal. Maslow places self-esteem at a very high level, indicating that this need can be accomplished only when the more basic needs are fulfilled. Self-esteem increases as the individual achieves personal goals. High self-esteem indicates that the individual has accepted his or her good and bad points and knows that he or she is loved and respected by others. High self-esteem also implies a sense of control over personal destiny. Feeling good about one’s self influences many aspects of life, including dealing with others, managing conflict, standing up for one’s own beliefs, taking risks, and believing in one’s ability to handle adversity.

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FIGURE 2–1. Maslow’s Hierarchy of Needs.

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Throughout life, both internal and external factors influence self-esteem. For instance, falling in love or graduating from school promotes positive self-esteem, whereas illness can represent a threat to self-esteem. Illness and disability often require a person to alter or even abandon personal goals and may strongly influ- ence the person’s view of himself or herself. Some people are able to adjust readily and create new, more realistic goals with little impact on self-esteem. Others may struggle with the changes and be unable to regain the previous level of self-esteem. Serious illnesses such as prostate or breast cancer, heart disease, or stroke not only require adaptation of personal goals but often distort the deeper sense of self. This is a major contributor to depression. But the desire to maintain a strong sense of self is a powerful drive, and over time many people adapt to changes in health.

Altered Body Image Body image is the mental picture a person has of his or her own body. It signifi- cantly influences the way a person thinks and feels about his or her body as a whole, about its functions, and about the internal and external sensations asso- ciated with it. It also includes perceptions of the way others see the person’s body and is central to self-concept and self-esteem. Often a person’s belief about his or her body mirrors self-concept. This is evident when an individual seeks out cos- metic surgery to alter his or her appearance. However, when the self-concept is poor, even cosmetic surgery may not change the person’s body image. This per- son may continue to struggle with low self-esteem even though the physical “imperfections” are changed.

A person’s body image changes constantly. Illness, surgery, and weight loss or gain can have a major influence on the view of self. Amputation, colostomy, and dependence on equipment such as dialysis are examples of obvious external changes that influence body image. Some conditions such as a myocardial infarc- tion may not cause obvious external body changes, but the individual may now view his or her body as weak or damaged. Altered body image can contribute to lowered self-esteem and, possibly, depression.

Powerlessness Powerlessness is a perceived lack of personal control over certain events and over one’s self. Individuals need to maintain a sense of power and control over their destiny and environment. Loss of this sense of control can negatively affect an individual’s view of his or her effectiveness. Illness consistently forces the indi- vidual to face his or her powerlessness over a situation.

Entry into the health-care system adds to this sense of powerlessness. Now, in addition to facing the feeling of helplessness over the illness, the person is being subjected to following the orders of strangers, complying with others’ schedules, and losing privacy. When an individual is hospitalized and gives up his/her clothes and puts on a hospital gown, a sense of powerlessness within this new role can occur quite quickly. Resisting a doctor’s orders and even refusing pain medication suggest that the patient is attempting to maintain some sense of control and fight off feelings of powerlessness. Helping these patients to maintain

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some sense of power and control is an important nursing intervention. Individu- als who chronically view themselves as helpless may be more prone to depression and vulnerable to victimization by others who try to control them.

Loss Actual or potential loss is any situation in which something a person values is rendered or threatened to be rendered inaccessible. Loss occurs throughout life as we experience changes in relationships, inability to reach an expected goal, and disappointment in others. Any time we have an emotional investment in someone or something, we are vulnerable to losing it. This includes loss of a body part or body function. All losses in life can contribute to loss of hopes, dreams, and goals and require some period of grieving as the individual adapts to the new situation. The degree of response to the loss depends on the amount of value the individual places on whatever is lost. Eventually the individual will go on to develop new attachments and goals. Maladaptive responses to loss can include anger, guilt, depression, and, possibly, suicidal thoughts.

Hopelessness Hope is fundamental to life. No matter how bad the situation may be, the abil- ity to hope for improvement will help an individual get through it. Hopelessness is the sustained subjective state in which an individual sees no alternatives or per- sonal choices available to solve problems or to achieve desired goals. Lack of hope can develop from an overwhelming loss of control and is related to a sense of despair, helplessness, apathy, and depression.

The person without hope is unable to mobilize enough energy to even estab- lish personal goals and may be unable to recognize or accept help or new ideas. Serious illness alone usually does not cause hopelessness. Usually deep personal feelings of loss, depleted emotional reserves, and an overwhelming sense of pow- erlessness also contribute. To regain a sense of hope, the individual needs to view the situation differently, alter negative goals and expectations, and, possibly, cre- ate new ones. For example, a terminally ill patient, rather than hoping to cure the illness, may need to refocus on achieving a pain-free state or making contact with family members. For some individuals, hopelessness can lead to discovery of alternatives that will add meaning and purpose to life. Spiritual crises may be related to hopelessness as well.

Guilt Guilt is self-blame and regret for some real or perceived action. It is a painful emotion that can negatively influence feelings, behaviors, and relationships with others. Conflicts within relationships can occur when an individual feels guilty about resentment that his or her needs are not being met.

Nurses frequently observe behavior in patients or their families that seems to be motivated by guilt. Family members may display guilt behaviors when they suddenly become very involved in the care of an ill patient they have not seen in

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years. Examples of this may include hovering over this patient or making numer- ous demands on the staff. Self-blame is another frequent behavior motivated by guilt. For example, a wife may blame herself for not taking her husband to the doctor sooner or a patient may blame himself for the stress his illness is causing his wife. Survivor guilt is often seen in people who survive traumatic events in which others are killed or injured.

Anxiety Anxiety is a universal, primitive, unpleasant feeling of tension and apprehension. It may be an early warning signal of possible danger. Anxiety is an important motivator of behavior that makes people act or change to reduce the uncomfort- able feelings of tension. Low to moderate levels of anxiety can enhance learning and action. More severe anxiety may be reduced by using defense or coping mechanisms as the unconscious self tries to protect us from this discomfort.

DEFENSE MECHANISMS

Defense mechanisms protect the individual from threats, feelings of inadequacy, and unacceptable feelings or thoughts. They are unconscious mental processes used to reduce anxiety and conflict by modifying, distorting, and rejecting reality (Table 2–1). Because they are unconscious, the individual is not aware of how these mechanisms affect thoughts, feelings, and behavior. In some ways, they are used to alter reality to make the situation more acceptable. Without these mech- anisms, the threatening feelings might overwhelm and paralyze the individual and interfere with daily living. Essential, adaptive defense mechanisms help to lower anxiety so that goals can be achieved. We could not survive without them. How- ever, when they are used too extensively, they can contribute to highly distorted perceptions and interfere with normal functioning and interpersonal relation- ships. Excessively distorted defense mechanisms can be characterized as psychi- atric disorders.

An individual’s repertoire of defense mechanisms is learned through childhood experiences. Each time a defense mechanism reduces uncomfortable anxiety feel- ings, it provides positive reinforcement.

COPING MECHANISMS

Coping mechanisms are usually conscious methods that the individual uses to overcome a problem or stressor. They are learned adaptive or maladaptive responses to anxiety based on problem-solving, and they may lead to changed behavior. They involve higher levels of emotional and ego development than defense mechanisms. However, overuse of coping mechanisms such as overeating or smoking can create problems. In addition, unconscious mechanisms can also play a role in using or selecting a specific coping mechanism. Inappropriate

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TABLE 2–1 Common Defense Mechanisms

Defense Mechanism Definition Example

Denial

Displacement

Identification

Intellectualization

Isolation

Attempt to remove an experience or a feeling from consciousness

The belief that one would be in great danger if true feelings about someone were known to that per- son, which causes the individual to discharge or displace feelings onto a third person or object

Accepting the other per- son’s circumstances as though they were one’s own

Separating emotion from an idea or thought because emotionally it is too painful

Blocking out feelings asso- ciated with an unpleas- ant or threatening situation or thought

After a diagnosis of termi- nal condition, the patient does not exhibit any expected emotional reac- tion and states that diag- nosis is not true.

A family member is angry at the patient for not tak- ing better care of himself and feels too guilty to express this to the ill per- son. Instead, he expresses anger at the nursing staff for giving inadequate care.

A man’s wife died a very painful death from can- cer. When he is diagnosed with cancer, he experi- ences extreme anxiety because he has accepted his wife’s experiences as if he had lived them.

A patient discusses the physiology of his leukemia at length without any emotional reaction.

A nurse caring for a criti- cally ill patient who is the same age provides care without experiencing the emotions related to tragedy of the patient’s situation.

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Defense Mechanism Definition Example

Projection

Rationalization

Reaction formation

Regression

Repression

Sublimation

Transferring or blaming others for one’s own unac- ceptable ideas, impulses, wishes, or feelings

Substituting acceptable rea- sons for the true reasons for personal behavior because admitting true reasons is too threatening

Actions that are opposite of the true, unacceptable feel- ings that the person is experiencing

Reverting to earlier patterns of development as a way to reduce anxiety and demands on one’s self

Forcibly dismissing unac- ceptable thoughts, feelings, impulses, or memories from consciousness

Expressing repressed urges or desires in socially acceptable ways

After a myocardial infarc- tion, a patient relates that his wife is coping poorly with his condition. This patient’s anxiety may be too great and threatening to face, so he places his own fears onto his wife.

Smoker continues to smoke despite physician’s warn- ing because he knows many people who smoke and have no ill effects.

A woman has negative feel- ings about her pregnancy but then lavishes constant attention on her newborn.

During serious illness, a patient exhibits behavior more appropriate for a younger developmental age, such as excessive dependency.

A person is unable to recall feelings of hostility toward a sibling or specific memo- ries from childhood.

An angry person writes a poem about his reactions to his feelings.

coping mechanisms can be readily changed because the patient is usually aware of using them.

Some common coping mechanisms include:

• Talking problems out with others and gaining new insights by other people’s view or approach to the problem

• Expressing intense emotion by crying, yelling, or laughing

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• Seeking comfort from friends, favorite foods, cigarettes, treasured objects, or consciousness-altering substances

• Using humor to discharge tension in a way that avoids fully acknowledging a difficult situation

• Exercising or performing manual labor to relieve tension • Problem-solving using a series of strategies and step-by-step approaches to

the resolution of a problem • Sleeping to avoid problems or escape • Avoiding upsetting situations, for example, by feigning illness, to avoid a

confrontation

CONCLUSION

Nurses will encounter in their patients a wide range of psychosocial responses to illness.

Understanding these types of responses and knowing what to expect can help the nurses to better care for their patients.

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3

15

Psychosocial Skills

Learning Objectives • Describe the key components of a psychosocial assessment. • Describe how and when to use a mental status examination. • List the forms of therapeutic communication. • Describe the impact of the psychosocial skills of role modeling, role

playing, and acceptance.

Providing psychosocial care requires a combination of astute psychosocial assessment skills, experience in performing mental status examinations, and

using therapeutic communication.

PSYCHOSOCIAL NURSING ASSESSMENT

To develop a thorough nursing diagnosis as well as goals and interventions, psy- chosocial information must be part of every patient assessment. The presence of psychosocial problems in a patient has an influence on the diagnosis arrived at and on the course of treatment chosen. With a thorough assessment, the nurse can determine the patient’s needs, problems, and potential problems, and identify patients who are at a higher risk for developing more serious problems. Infor- mation to be gathered in a psychosocial assessment includes the patient’s socio- cultural background, emotional and biologic aspects of current problems, history, spiritual and philosophical beliefs, and family issues.

To perform a thorough psychosocial assessment, the nurse uses many skills. The first is the ability to establish a rapport with the patient. Showing an inter- est in what the patient is saying, asking appropriate questions, and making obser- vations help to put the patient at ease and enable him or her to divulge personal information. Box 3–1 offers suggestions for creating an appropriate interview environment.

The psychosocial assessment focuses on the effect of the illness on the patient and family rather than on physical symptoms. This assessment begins the process of identifying key nursing diagnoses. In addition, it provides important infor- mation for the patient’s treatment plan. The assessment should include the following:

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Lifestyle information: Determine whom the patient lives with as well as the patient’s significant relationships, available support people, marital status, occupation, religion, and other important components of the patient’s lifestyle.

Normal coping patterns: Identify which coping mechanisms the patient uses when under stress and which he or she used during past illnesses or hospi- talizations. Questions that can be asked include the following: What hap- pened the last time the patient was under severe stress? How is the patient currently coping? What helps in stressful situations?

Understanding of current illness: Ask the patient about his or her understand- ing of the diagnosis or reason for seeking medical attention. Determine how the patient views the illness affecting his or her life.

Personality style: After interacting with the patient, identify any important personality traits that may affect his or her care or compliance, such as a tendency to be dependent, hostile, dramatic, or critical.

History of psychiatric disorder: If the patient is currently taking medications for psychiatric problems, be sure to ask why he or she is taking them. Consider asking if the patient has experienced any psychiatric symptoms, such as depression. If his or her behavior indicates a psychiatric disorder,

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BOX 3–1 Creating an Appropriate Interview Environment • Create a quiet, private space. • Minimize interruptions if possible. • Maintain appropriate eye contact. • Sit at eye level with the patient. • Ask open-ended questions to encourage the patient to talk. • Avoid writing a lot of notes during the interview. • Demonstrate an interest in the patient’s concerns. • Ask the patient’s permission to be interviewed. • Indicate acceptance of the patient by avoiding criticism, frowning, or

demonstrating shock. • Avoid asking more personal questions than are actually needed. • Determine whether the family can provide information if the patient is

unable to communicate. • Maintain confidentiality. • Be aware of your own biases and discomforts that could influence the

assessment. • Keep the focus on the patient.

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explore this further. Have a list of screening questions for alcohol use if needed (see Box 13–1).

Recent life changes or stressors: Determine if there have been any major changes or traumatic events recently (especially in the last year). Keep in mind that these changes may be both positive and negative, such as moving to a new house or area, a death in the family, a job or role change, or recent birth of a child.

Spirituality: Determine the role of spirituality and religion. Use of the HOPE assessment includes questions as follows: H–sources of hope, strength, com- fort; O–Role of organized religion for patient’s P–personal spirituality prac- tices; and E–effects on medical care and end of life decisions (Anandarajah & Hight, 2001).

Major issues raised by current illness: Determine how this illness has affected the patient’s lifestyle or sense of self, including areas such as self-esteem, body image, loss of intimacy, role changes, and change in family dynamics.

Mental status examination: Perform the mental status examination to help identify dysfunction in emotional, cognitive, or behavioral spheres.

THE MENTAL STATUS EXAMINATION

The mental status examination is used to determine whether or not there are abnormalities in the patient’s thinking and reasoning ability, feelings, or behav- ior. It is fundamental in all areas of medicine (Varcarolis, 2006). Nurses often perform quick mental status examinations every time they see their patients with- out realizing they are doing it. Changes in a patient’s appearance, memory, emo- tions, or thinking can be observed while the nurse is making quick rounds or having a social conversation with the patient. A more formal mental status exam- ination can be part of a psychosocial assessment in a new patient, or it may be done when changes in the patient’s condition are seen.

The mental status examination includes observations and questions in the fol- lowing categories: appearance, behavior, and speech; thoughts; mood and affect; ability to perform abstract reasoning; memory; intelligence; concentration; ori- entation; judgment; and insight (Table 3–1 and Fig. 3–1).

To gather a comprehensive evaluation, review all the categories of the exami- nation. Congruence or discrepancies between sections may reveal important information. Note inappropriate responses as well as the absence of the usual anticipated responses. For example, a patient may relate that the physician says her cancer has metastasized too much to consider surgery (thought). This clear and coherent thought, expressed in a droning, monotonous voice (speech) with- out any apparent intensity, distress, or expression of emotion (mood) may sug- gest that the patient is denying her illness. A patient who is experiencing an extreme stress response to his or her illness may be unable to verbalize any expected concerns (thoughts) but may become increasingly anxious or depressed (mood and/or emotions) with increasing restlessness (behavior). Choosing an

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TABLE 3–1 Mental Status Examination and Related Definitions

Category Description Related Definitions

Appearance

Behavior

Speech

Describe what patient looks like including dress, posture, grooming.

Describe behavior, motor activity, mannerisms.

Describe how patient speaks; list barriers to communication.

Catatonic: Remaining totally immobile

Posturing: Assuming inap- propriate or bizarre posi- tions

Compulsions: Insistent, repetitive unwanted actions

Perseveration: Mechanical repetition or words, thoughts

Pressured: Highly acceler- ated rapid speech

Loose associations: Absence of logical connections between thoughts

Flight of ideas: Rapidly jumping from one thought to another with minimal links

Tangential: Talking around main point

Word salad: Unconnected words and phrases without meaning or logic

Thought blocking: Stopping suddenly in the middle of verbalizing a thought and staring into space

Neologism: Making up new words only speaker under- stands

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Chapter 3 ■ Psychosocial Skills 19

Category Description Related Definitions

Mood/affect

Thoughts

Continued

Describe the emotions that are apparent from facial expressions, motor behav- ior, words used.

What are themes in conver- sation? Does patient make sense? Is patient preoccu- pied with certain thoughts?

Labile: Emotions that change quickly and unpredictably

Flat affect: No demonstra- tion of any feeling

Blunted affect: Constricted display of emotions

Anhedonia: Absence of any pleasure

Inappropriate affect: Emo- tions displayed not fitting with topic discussed

Ambivalence: Contradictory feelings experienced simul- taneously

Hallucinations: Sensory per- ceptions (auditory, visual, gustatory, olfactory, tactile) without external stimuli, e.g., hearing nonexistent voices.

Illusions: Misinterpretations of real external sensory stimuli, e.g., seeing a ghost in a shadow

Delusions: False, fixed beliefs not alterable by logical explanations

Obsessions: Unwanted, dis- tressing recurring thoughts

Phobia: Irrational fear of a specific situation, accompa- nied by avoidance of the phenomenon feared

Depersonalization: Sense of not being real; sense of being detached from one’s body or self

Magical thinking: Believing that thinking about some- thing happening is the same as doing it

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TABLE 3–1 Mental Status Examination and Related Definitions—cont’d

Category Description Related Definitions

Ability to abstract

Memory

Intelligence

Concentration

Describe the patient’s ability to define simi- larities between objects or explain a proverb.

Describe patient’s ability to repeat the names of 3 objects immediately after being told and again in 5 minutes.

Describe patient’s level of knowledge, lan- guage, understanding of instructions.

Describe patient’s ability to focus on a single thought without becoming distracted.

Grandiosity: Exaggerated beliefs in own worth and/or abilities

Paranoia: Unwarranted belief that others have harmful intentions to person

Concrete description: See objects in very definite simple ways, e.g., sees an apple and an orange as “round” rather than the overall category “fruit”

Abstract ability: Can gen- eralize the meaning of a concept and find meaning in symbols, e.g., “still water runs deep” means that quiet people have depth rather than lakes are deep bodies of water

Serial 7s: Test to determine the patient’s ability to concentrate by having him or her continually subtract from 100 by 7 (93, 86, etc.)

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Chapter 3 ■ Psychosocial Skills 21

Category Description Related Definitions

Orientation

Judgment

Insight

Describe patient’s aware- ness of person and sur- roundings. A person is fully oriented when he or she is aware of per- son, place, time and situation.

Describe patient’s ability to use common sense to make reasonable decisions.

Determine patient’s understanding of fac- tors contributing to his or her condition.

Orientation to person: Knows his or her name

Orientation to place: Knows where he or she is (Ask for specific location.)

Orientation to time: Knows the date, day of week, year; most serious impairment is if the patient cannot identify year

Orientation to situation: Knows what is wrong with him or her, why he or she is receiving care, the circum- stances of current situation

appropriate nursing diagnosis will depend on integrating all these observations along with knowledge of the patient’s usual responses to stress.

Changes in mental status are often caused by alterations in the psychological or physical state. For example, behavioral changes such as confusion, depression, delirium, or even psychosis may be signs of drug toxicity, electrolyte imbalance, or intracranial bleeding (Table 3–2).

THERAPEUTIC COMMUNICATION

Therapeutic communication, the essence of the helping relationship, occurs when the nurse communicates with the patient in a manner that facilitates acquiring information about and understanding of the patient’s concerns and problems. It is the art of reaching a person by means of verbal and nonverbal messages. Acceptance, respect, honesty, trust, concern, protection, and support must all be present for communication to be therapeutic. Therapeutic communication allows the patient to share feelings, feel accepted, and look at problems from a new per- spective. It should not be confused with counseling, which focuses on interpreta-

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22 Chapter 3 ■ Psychosocial Skills

Mental Status Examination Answer Sheet

Circle the correct words or fill in the blanks.

Appearance Neat clean disheveled poor grooming erect posture good eye contact inappropriate makeup

Behavior Calm appropriate restless agitated compulsions unusual actions

Speech Appropriate pressured loose association loud soft mute

Mood Appropriate labile flat depressed worried anxious angry hopeless

Thoughts Appropriate low self-esteem suicidal ideations hallucinations delusions phobias

Ability to abstract Impaired Yes No

Memory Impaired recent memory Yes No Impaired past memory Yes No Number of objects able to remember after 5 minutes

Estmated intelligence Below average average above average

Concentration Able to focus easily distractible Able to subtract backwards by 7’s from 100 correctly until the number

Orientation Person Time Place Situation

Judgment Realistic decision-making Yes No

Insight Good fair poor

Summary of Impressions:

FIGURE 3–1. Mental Status Examination Answer Sheet.

tion and the process of communication rather than the content. The patient should also be able to expect that confidentiality will be maintained (Tables 3–3 and 3–4).

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Chapter 3 ■ Psychosocial Skills 23

TABLE 3–2 Mental Status Changes Caused By Electrolyte Imbalance

Electrolyte Imbalance Possible Cause Mental Status Changes

Calcium (Blood Level: 8.5–10.5 mg/dL)

Hypercalcemia

Hypocalcemia

Sodium (Blood Level: 135–145 mEq/L)

Hypernatremia

Hyponatremia

Continued

Hyperparathyroidism Bone metastasis (breast, lung cancer)

Hypoparathyroidism due to calcium defi- ciency, lack of dietary vitamin D, or iatrogenic causes

Dehydration caused by excessive water loss (diarrhea, vom- iting, diuresis)

Restricted fluid intake

Diabetes insipidus

Severe dietary sodium restriction

Addison’s disease Excessive water intake

SIADH (syndrome inappropriate anti- diuretic hormone)

Loss of energy Depression Confusion Lethargy

Reduced concentra- tion and intellectual function

Emotional lability Depression Psychosis (if surgical excision of a parathy- roid gland)

Irritability Seizures

Irritability Hallucinations Hyperactive intellectual function

Stupor

Depression Lethargy Withdrawal Anorexia

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TABLE 3–2 Mental Status Changes Caused By Electrolyte Imbalance—cont’d

Electrolyte Imbalance Possible Cause Mental Status Changes

Phosphorus (Blood Level: 2.6–4.5 mg/dL)

Hypophosphatemia

Potassium (Blood Level: 3.5–5 mEq/L)

Hyperkalemia

Hypokalemia

Base Bicarbonate (Blood Level: 24 mEq/L, pH 7.38)

Alkalosis

Source: Adapted from Barry, P. (1989). Psychosocial nursing assessment and intervention (3rd ed). Philadelphia: Lippincott-Raven; Mulvey, M. A. (2004). Fluid and electrolytes: balance and distribution. In S. C. Smeltzer & B. G. Bare (Eds.), Brunner & Suddarth’s textbook of medical-surgical nursing (10th ed) (pp. 249–294). Philadelphia: Lippincott Williams & Wilkins.

Gram-negative septicemia Alcohol withdrawal Intravenous hyperalimentation Low dietary intake

Renal disease Potassium-sparing diuretics Increased IV intake

Renal disease Cushing’s syndrome Potassium-wasting diuretics Vomiting Diarrhea

Prolonged vomiting Status asthmaticus Renal failure Diabetes mellitus with ketosis

Apprehension Irritability Numbness Stupor

Weakness Dysphagia

Mood and personal- ity change

Tearfulness Hopeless Helplessness Fatigue

Decreased intellectual function

Drowsiness Confusion Delirium

Because nonverbal language is such a major part of any communication, the nurse needs to be aware of how his or her body language may enhance or inhibit therapeutic communication. Studies consistently support the concept that the way in which we communicate is much more powerful than the content of our words. Nonverbal communication includes eye contact, body movements, facial expressions, gestures, and posture. Facial expressions are probably one of the most important sources of communication. Posture can communicate interest, tension, or boredom. A person’s walk can convey anxiety or confidence. Eye con- tact can be comforting and supportive or invasive and threatening. Gestures such

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Chapter 3 ■ Psychosocial Skills 25

TABLE 3–3 Therapeutic Communication Techniques

Technique Definition Example

Empathy

Open-ended questions

Closed-ended questions

Active listening

Clarification

Silence

Reflection

Continued

The helper becomes keenly attuned to the patient’s feelings to understand them fully while main- taining a sense of one’s own separateness

Questions structured to encourage the patient to share information and feelings

Information-gathering questions that require only a one-word or very brief answer

Accepting what the speaker has said, analyzing it, and reflecting back your understanding of what was heard

Increasing the understand- ing of what the patient is trying to communicate

Allowing time for the patient to gather thoughts and ponder a topic with- out interruption (This can communicate acceptance and concern.)

Verbally giving back the feeling part of the patient’s communication to help focus on the feel- ing tone

In response to a patient’s recounting the recent loss of a baby, the nurse says, “You must have felt very disappointed.”

“How did you feel when the doctor told you of your diagnosis?”

“Where does it hurt?”

“From what I under- stand, you are plan- ning to stop coming to counseling.”

“I’m not sure I under- stand what happened next. Could you go over it again?”

“You sound very wor- ried about the test results.”

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TABLE 3–3 Therapeutic Communication Techniques—cont’d

Technique Definition Example

Nonverbal communication

Congruent communication

Overt behavior that indi- cates listening and atten- tion

Body language, facial expression, and verbal content all expressing the same thing

Maintaining eye con- tact, leaning forward, keeping facial expres- sions appropriate for the emotions being expressed, keeping a comfortable distance.

Nurse’s physical appearance, voice, and emotional reaction all communicate that she or he is listening, accepting, concerned, and understanding.

as placing a hand on the patient’s arm during intense emotions can be very sup- portive, especially in contrast to standing away from the patient with your arms crossed in a judgmental way.

OTHER PSYCHOSOCIAL SKILLS

In addition to therapeutic communication, nurses use a variety of other skills to help patients find new ways of coping with illness and the problems it causes. Many of these skills are used without the nurse’s even being aware of using them. Perfecting the following techniques can greatly enhance your ability to meet the psychosocial needs of your patients.

Acceptance: Demonstrating an interest in a patient’s behavior and feelings communicates to the patient that he or she is valued. You can demonstrate acceptance of the patient by listening to him or her even if you disagree with the ideas being communicated. It is important not to criticize or judge the patient. Acceptance reinforces self-esteem.

Reassurance: Providing support by giving your attention to matters that are important to the patient reinforces emotional security and helps reduce the patient’s anxiety. With less anxiety to deal with, the patient can spend more time on effective problem solving and healing. However, nurses should

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Chapter 3 ■ Psychosocial Skills 27

TABLE 3–4 Barriers to Therapeutic Communication

Technique Possible Result Example

Giving advice

False reassurances

Judgmental

Leading statements

Multiple questions

Why question

Parroting

Inhibits communication and sharing feelings. Patient may think you are not listening.

May communicate that you do not fully understand the patient’s feelings.

Patient will sense your disapproval.

Inhibits communication by possibly imposing feelings on the patient that he or she may not have.

Patient may not know what to answer first.

May inhibit communi- cation by threatening the patient. Often we may not know why we do the things we do or feel the way we do.

Continually repeating what the patient says may appear to be too mechanical and frus- trate the patient.

“You should go back to school.”

“I’m sure you’ll do just fine.”

“How can you still smoke when your husband has lung cancer?”

“I’m sure you must have felt depressed after the divorce.”

“Whom do you live with? Is that the way you want to live?”

“Why do you feel that way?”

Patient: “I’m worried about the test results.”

Nurse: “You’re wor- ried about the test results?”

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avoid giving false reassurance. If something unexpected occurs after the nurse has reassured the patient, for instance, that everything will be all right, it can reinforce a sense of distrust in the nurse.

Enhancing self-esteem: Increased self-esteem gives the patient a sense of con- trol and hope. This will help reduce anxiety and give the patient more time for problem solving and healing. Techniques to reinforce positive self- esteem include focusing on patient’s positive traits and accomplishments, providing opportunities for the patient to demonstrate skills and abilities successfully, and providing emotional support and reassurance.

Expression of feelings: Providing an environment in which a patient can feel safe and comfortable to express emotions, including sorrow or anger, and to verbalize disagreement, fear, and disappointment is essential for both enhancing a therapeutic relationship and allowing the patient to solve problems.

Role modeling: The nurse can exhibit more socially acceptable ways of per- forming a certain role or demonstrating a certain behavior. When the patient sees how effective these behaviors are, he or she can more easily understand how to use them and emulate the behaviors. For example, the nurse can communicate assertively with a family member who may be intimidating the patient. When the patient sees how that family member responds to assertive behavior, he or she may adopt that method of inter- action. The nurse also provides a role model for adopting a healthy lifestyle by eating healthy foods, exercising, and not smoking.

Role playing: Role playing is acting out other methods of response to a situa- tion. It can be done to increase one’s own or another’s understanding of the other’s point of view or to practice appropriate responses, such as assertive- ness. This is done with a supportive person playing the part of someone you want to communicate with in a new way.

Stress management: Accepting stress as a fact of life and managing it using spe- cific, tested techniques can reduce feelings of anxiety. The techniques are meant to promote a feeling of calm and a sense of control over the situa- tion. Common stress management techniques include physical interventions such as taking deep breaths, exercising, and avoiding caffeine and psycho- logical interventions such as counting to 10, avoiding additional stressors, maintaining a positive attitude, and seeking out emotional support.

Assertiveness: Assertiveness is the use of behavioral techniques that allow the individual to stand up for his or her rights without infringing on the rights of others. To gain expertise in using assertive behavior, role-playing, and practicing with others is useful. You may try role-playing assertive responses to common situations in a supportive environment, such as asking for a refund or telling a colleague that you are not satisfied with the quality of work performed.

Limit setting: Limit setting is a form of behavior modification rather than a punishment and is used for times when acceptance of the patient’s behavior

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Chapter 3 ■ Psychosocial Skills 29

is no longer appropriate. To set limits on behavior, you need to clearly define the desired behaviors and the consequences of not conforming to them. Then you must be prepared to follow through with the stated conse- quences. If appropriate limits are not set to control the patient’s inappro- priate behavior, it can escalate and possibly lead to injury and resentment from those who feel manipulated by the patient. Setting limits may be required to ensure patient safety (Manos & Braun, 2006).

De-escalation: De-escalation techniques are also used to reduce anxiety and slow down the emotional response to it, such as aggressive behavior. Useful techniques include removing the patient from volatile situations and using appropriate medication and physical restraints.

Confrontation: At times it is necessary to make direct statements that chal- lenge the patient’s behavior or beliefs. Confrontation is a verbal message designed to help the other person recognize inconsistencies or inappropri- ate behavior. It can assist the patient in gaining insight. However, it can also be so threatening that it could precipitate a crisis situation, so be sure to consult with specialists before using this method.

Empathy: Communicating an understanding of how the client feels indicates that the nurse shares the feelings. Empathy differs from sympathy in that empathy does not indicate sharing of personal feelings.

Silence: Sometimes saying nothing for a few moments can communicate more than words. This can convey support, acceptance, and concern and give the patient time to compose himself or herself.

Relaxation techniques: The nurse can use a variety of techniques, including deep breathing, imagery, and muscle relaxation. See Box 3–2 for more details.

ASSESSING USE OF COMPLEMENTARY AND ALTERNATIVE THERAPIES

Americans are using complementary and alternative therapies in increasing numbers. The National Center for Complementary and Alternative Medicine (NCCAM) reports that more than one third of U.S. adults uses complementary and alternative medicine (2004). The federal government established NCCAM (nccam.nih.gov) as a clearinghouse for information on products so consumers and health-care professionals can easily access the latest scientific and medical lit- erature on the various substances. The American Hospital Association (2005) reports that to meet this growing need, the number of hospitals with comple- mentary and alternative medicine programs doubled between 1999 and 2005. Complementary approaches are defined as those used in addition to conventional treatment. Alternative ones are used in place of conventional therapies. See Box 3–3 for a listing of commonly used approaches. Many of these are used to treat emotional problems such as anxiety and depression.

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BOX 3–2 Relaxation Techniques Relaxation techniques can include any of the following: • Deep Breathing: Take in several slow deep breaths by inhaling through your

nose and exhaling slowly through your mouth. As you exhale, focus on relaxing your shoulders. Each time you take a deep breath, repeat a calm- ing word to yourself such as “peace” or “one.”

• Muscle Relaxation: After taking two slow deep breaths, raise your shoul- ders for 2 to 3 seconds and then let go. Do this two to three times. Then make a fist, hold it for 2 to 3 seconds, and then let go. Each time you let go, think of another part of your body becoming more relaxed. Imagine your- self going limp like a rag doll. You can continue to tense and relax other muscle groups in your body.

• Imagery: After taking several slow deep breaths and relaxing your muscles, create a pleasant image in your mind that you associate with relaxation. It can be a comforting memory or an image such as a garden or floating on a raft in the sunshine. Let your mind wander to whatever you find relaxing. Tips on enhancing relaxation:

• Create a quiet environment. • Sit in a comfortable chair. • Give yourself permission to take this time for yourself. • Devote enough time for practice. • Every time your mind wanders to distracting thoughts, focus on your

breathing. • Practice regularly (relaxation is not always easy and often must become a

learned skill). • Consider the use of audio or video tapes or downloadable sources of relax-

ation information

BOX 3–3 Complementary and Alternative Approaches Acupressure—Using massage on traditional acupuncture points. Acupuncture—Using thin needles at designated points along meridians to bal-

ance the flow of energy. Used to treat uncomfortable symptoms and some conditions.

Alternative nutrition—Use of food to heal and maintain optimal health (e.g., macrobiotic diet).

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Chapter 3 ■ Psychosocial Skills 31

Aromatherapy—Therapeutic use of odors from plant oils to treat illness and promote relaxation.

Biofeedback—Using electrical devices to record changes in body function to achieve relaxation and/or muscle control.

Chelation therapy—Investigational therapy using the man-made amino acid, EDTA, to treat some conditions like heart disease

Chiropractic—Form of healthcare that focuses on the relationship between body structure–primarily the spine–and function

Energy medicine—Use of energy fields such as magnetic fields or biofields (energy fields that some believe surround and penetrate the human body).

Folk remedies—Alternative health practices and therapies based on health beliefs and practices within cultural groups.

Guided imagery—Using the conscious mind to create images to evoke physi- ological changes and promote healing and relaxation.

Healing touch—Healing method based on concept of human energy fields. Herbal medicine—Use of plants for healing purposes. Homeopathy—Therapy based on concept of “like cures like.” Uses minute

amounts of drug that normally would produce the same symptoms as the illness being treated.

Hypnotherapy—Creating a state of heightened awareness in which sugges- tions to improve health are made and are likely to be followed.

Light therapy—Use of alternative light (e.g., colored light, ultraviolet light) to treat various disorders.

Magnet therapy—Using electromagnetic frequencies emitting from the body to treat illness.

Massage—Manipulation of tissues and muscles to promote relaxation and healing.

Megavitamin therapy—Using higher doses of vitamins than usually recom- mended to prevent or cure illness.

Meditation—Ancient art of focusing one’s attention on a single sound or image to promote relaxation and health.

Naturopathy—A system of healing that views disease as a manifestation of alternation in processes that interfere with the body’s healing

Reiki—A form of energy medicine where practitioner through his/her hands transmits life force energy (Ki) for healing

Yoga—A philosophy and exercise system that combines movement and posi- tions to promote health.

Source: National Center for Complementary and Alternative Medicine. Available at nccam.nih.gov

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Health-care professionals need to incorporate assessment of complementary and alternative therapies in their care. Eisenberg (1998) found that fewer than 40 percent of patients tell their health-care provider about products they are using. Patients often do not tell their provider that they are using herbs or megavitamins because they believe the products are harmless or think their health-care provider will discourage the use of such products.

The Food and Drug Administration now tracks the adverse drug reactions of herbal products, and the public needs to be aware of possible drug interactions or negative effects. Impurities, lack of regulation in dosing, and lack of knowl- edge about interactions with other prescribed medications can create complica- tions. For example, St. John’s wort, which is often used for depression, interacts with some HIV protease inhibitors, making them less effective.

The increased use of these herbal products reflects the public’s wish for more control, incorporation of cultural values, and hope in their care. Nurses, as patient advocates, need to be sensitive to these approaches and incorporate them in the plan of care when possible. Routine questions about use of herbs and sup- plements should be part of the routine nursing assessment.

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4

33

Nurses’ Responses to Difficult Patient Behaviors

Learning Objectives • List qualities expected in a “good” patient. • Describe how the concept of a “difficult patient” reflects both the

patient’s behavior and the nurse’s interpretation of that behavior. • Identify the process of evaluating what patients may be communicating

by difficult behavior. • List types of nurses’ responses that may impair awareness of the dynam-

ics of problematic patient behavior. • List resources available in most health-care agencies for psychosocial

support.

Nurses often see patients behaving at their worst. Fear, stress, pain, and other discomforts all contribute to patients not being at their best, and the nurse

is frequently dealing with these responses. The nurse-patient relationships may change as the patient’s health-care needs change, requiring different types of involvement. Optimally, each nurse should respond positively to each patient, but human nature makes that all but impossible. The next best strategy, then, is to learn the most effective ways to deal with patients who are “difficult,” usually defined by the amount of trouble and distress that the staff experiences in man- aging them.

Manos and Braun (2006) define the difficult patient as one whose behavior is an obstacle to the provision of good nursing care. These patients often exhibit problem behaviors such as anger, regression, and out-of-control or manipulative behaviors (Fincannon, 1995). Nursing interventions may make the problem worse if staff members are unable to differentiate their responses to the behavior from their response to the person. If you think of these patients as having “difficult-to- care-for behaviors” rather than as being “difficult patients,” you may find that your frustration and also the staff’s frustration decreases and more effective care strategies can be identified. Sometimes the patient uses objectionable behaviors, with or without being aware of it, to regain personal equilibrium and to reduce anxiety and fears and maintain control. Thus, although these behaviors may cause

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stress for the staff, they work “just fine” for the patient. In addition, some patients are totally unaware that they are affecting the staff negatively. Nurses who learn effective skills to deal with these problem behaviors may experience a sense of enhanced competence, and improved patient outcomes will follow.

NURSE-PATIENT INTERACTIONS

The nurse-patient interaction is based on the continuous flow of communication between the nurse and patient with input from both. The nurse’s therapeutic use of self is the basic tool that enhances the interaction. Communication skills, an awareness of how personal responses can influence the patient, and a good knowledge base combine to enhance a positive nurse-patient interaction.

Difficult patient behaviors can negatively influence the nurse-patient interac- tion and, possibly, the quality of nursing care. Whenever a relationship is dis- rupted, the nurse needs to identify the source of the problem. Does it originate in the patient, in the nurse, or in both? For example, a demanding patient who con- stantly rings the call bell may be communicating the fear that she will not recover and is seeking reassurance that someone will respond if she needs it. If the nurse interprets this behavior to mean that the patient feels that the nurse is doing his or her job poorly, he or she may become resentful and angry. The nurse needs to assess the situation objectively to determine if the patient is truly looking for reas- surance or if the nurse is just not as tolerant as usual because of the workload. Responding without assessing the situation could inhibit favorable nurse-patient interactions and negatively affect the patient’s outcome. To be effective, the nurse must treat the behaviors as symptoms and assess their cause. The nurse needs to explore his or her own attitudes and reactions, which may be unwittingly initiat- ing or perpetuating the undesired behavior. Better understanding can lead to a greater acceptance of both the patient’s and the nurse’s feelings to create a more positive cycle of nurse-patient interactions. Table 4–1 compares the ways in which assessment and appropriate interventions can significantly alter patient outcomes.

Sometimes the only effective way to change a patient’s behavior is for the nurse to change his or her response. If there is still no resolution of the situation, the nurse should seek the advice or interventions of other available resources to help understand the patient’s behavior and the nurse’s response to it, and then select more effective interventions. If the patient continues to manifest difficult behaviors despite all efforts, the nurse should focus on self-awareness to remain objective.

ROLE EXPECTATIONS

Clarifying the nurse’s intertwining role expectations of the patient in the sick role and himself or herself as the helper can provide a useful perspective. Keep in mind that nurses have chosen their roles as helpers but most patients have not deliber- ately chosen to become patients. A nurse may have chosen this profession for the personal satisfaction and self-esteem resulting from attaining a high level of

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expertise. The patient, on the other hand, may feel that his or her self-esteem is threatened by entering the health-care system. The patient is expected to adapt to the routines and expectations of others. Some patients cannot accept this new role and may revert to using dysfunctional behaviors.

Optimally, “good” patients are consistently cooperative, comply with the nurse’s instructions and agency rules, are pleasant, polite, and respectful, show improvement, and appreciate the nurse’s help. These patients ensure that the nurse meets his or her own role expectations; that is, the nurse feels helpful, effective, and accepted and valued by both patients and colleagues. “Difficult” patients pro- duce the opposite effect. The nurse can experience frustration, anxiety, feelings of incompetence, lowered self-esteem, and a sense of being out of control.

Nurses must objectively evaluate some common myths about these role expec- tations. A prevalent one is that nurses can control their patients’ behavior to con- form to expectations. They cannot. They can encourage, suggest, negotiate, and set limits. Only in very rare situations such as when a patient poses a threat of imminent danger to himself or herself or to the staff can the nurse force a patient into expected behaviors. A nurse who believes that he or she can control a patient’s behavior is creating a setup for failure.

Chapter 4 ■ Nurses’ Responses to Difficult Patient Behaviors 35

TABLE 4–1 The Nursing Process with Difficult Patient Behaviors

Assessment Step Positive Cycle Negative Cycle

Assessment

Intervention

Patient outcome

Nurse assesses patient’s and his or her own understand- ing of what is happening.

Nurse evaluates if he or she is stereotyping or reacting personally.

Nurse gets assistance and support.

Nurse responds accurately and with empathy to patient.

Patient feels heard, accepted, and understood, resulting in less anxiety.

Difficult behavior decreases. Patient can participate more fully in health care.

Patient does not explore issues.

Patient responds only to surface level of communication.

Patient reacts personally. Nurse complains to staff about patient.

Nurse avoids or rejects patient.

Nurse is unable to con- trol patient’s behavior.

Patient feels alienated with escalation of undesirable behaviors.

Potential exists for nega- tive health outcome.

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Many nurses believe that only certain feelings toward patients are acceptable. Because nurses are human, they respond with a whole range of human emotions, including empathy, sympathy, disgust, love, hate, and, possibly, sexual feelings. Experiencing all feelings is acceptable. Displaying these feelings to patients may not be. The nurse must use professional judgment in determining which feelings are helpful to display to the patient and which are not. Responding genuinely to the patient with realistic concern is usually appropriate. If the nurse determines that it would not be appropriate to display other feelings, he or she may want to find suitable ways to express them. Often, just acknowledging the feelings to a trusted colleague can be beneficial.

Once the nurse has learned to accept and tolerate a broader range of human responses within himself or herself, he or she will develop more tolerance for for- merly forbidden feelings displayed by patients. The nurse will be less likely to blame or avoid patients who stir up disturbing feelings. Often, before engaging with patients to work on problems, the nurse needs to work with ways to accept and assimilate personal experiences. Throughout this book, common nurses’ reactions are listed as a way to help the reader identify them.

The following recommendations are listed to assist nurses in maintaining pro- fessional distance while remaining available to patients:

• Listen to what the patient is really asking. People have a need to be heard. When a patient tells a nurse about his or her concerns and problems, he or she may simply need someone to listen and understand his or her feelings and suffering and to feel less alone. The nurse may erroneously believe that he or she has to do something or give advice.

• Assess the patient’s ability to use comments or receive information about more negative emotions like anger before sharing them and risking alienat- ing the patient. Occasionally, however, it may be therapeutic to share even very negative feelings if this is done in a calm, matter-of-fact tone, without accusation. For example, when working with a very provocative patient, point out that this behavior elicits angry responses and pushes others away. The patient may not be aware of the cause and effect. Bringing it to his or her attention may lead to a fruitful discussion of the true fears underlying the behavior and ways of developing a realization of why others often react negatively.

• If a nurse determines that, even with the advice of specialists, he or she would not be able to work with the patient without bias, then alternate arrangements for patient care need to be made.

PATIENT ISSUES

Covert Communication Consciously or unconsciously, patients often communicate their real needs and wishes indirectly, possibly because they are not aware of their fears. If the nurse

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does not analyze the patient’s communication, the nurse may select ineffective interventions because he or she is dealing only with what the patient said, not what the patient really meant. Once the real concerns are identified, more effec- tive interventions can be used. For example, the noncompliant patient may be indirectly expressing fear or a need for more reassurance or help. If fear is the underlying issue, interventions directed toward reassuring the patient will be the most successful.

Transference This is a common issue with difficult-to-care-for patients. Sometimes even with- out being aware of it, the patient transfers early childhood perceptions, feelings, and experiences onto people with whom he or she is currently interacting. The patient may take positive or negative experiences with parents, teachers, siblings, or other significant people in his or her life and connect them to the nurse if there are similarities between them, either superficial or substantial. This usually occurs on an unconscious level, but the patient then feels, expects, and responds as if the nurse were that other person. For example, if the patient sees the nurse as his lov- ing but somewhat controlling mother, he may respond with dependence tinged with resentment along with magical expectations of the nurse’s effectiveness, reflecting earlier responses to his mother. If the nurse is viewed as a hostile, attack- ing parent, the patient may become hostile and defensive for self-protection.

Other examples of patient behaviors suggesting transference include a preoc- cupation with a particular nurse, a desire to be the nurse’s only patient, jealousy if the nurse spends time with other patients, and recurrent attempts to provoke a specific emotion from the nurse. A common warning sign of transference is when a patient displays a strong attachment to a single staff member.

If you suspect that the patient is using transference, use the following guidelines:

• Find out if the patient is responding in similar ways to other staff members. • Determine, if possible, whether the patient acts in similar ways toward other

individuals in his or her personal life. • Ask other staff members to provide support for the patient and a more

balanced viewpoint. • Avoid increasing the patient’s dependency on you. • Consult with a supervisor or specialist to determine the appropriateness of

gently confronting the patient with these issues. • Set limits on the patient’s behavior. Do not allow the patient to obtain spe-

cial privileges. • Do not personalize any hostility.

NURSING ISSUES

Usually, not all nurses have the same amount of difficulty dealing with a patient who displays problematic behaviors. Each nurse responds to the behavior based

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on individual expectations of correct and proper patient behavior, previous expe- rience working with a particular type of patient behavior, and the degree of suc- cess he or she has had in dealing with a similar situation. Personal value systems, coping mechanisms, styles of communication, conflicts, and “pet peeves” also play a role. A caring approach while maintaining professional boundaries is gen- erally the goal for the nurse/patient relationship (Manos & Braun, 2006). The following issues may contribute to a deteriorating nurse-patient relationship.

Identification The nurse may identify with a patient because of similarities such as age, gender, and social interests, and then superimpose his or her own conflicts, values, and expectations onto the patient. So when the nurse seems to be responding to the patient, he or she is actually responding to himself or herself. A classic example of identification is a young female nurse who is caring for a critically ill woman her own age. The nurse sees herself in the patient and begins feeling intense sad- ness for all the things she (the nurse) has not yet accomplished in life. The nurse may do things for the patient that she would want done for herself, regardless of their significance for this patient.

Countertransference Countertransference is a conscious or unconscious emotional response to the patient based on the nurse’s own inner needs rather than the patient’s. It occurs when the nurse transfers significant positive or negative early childhood figures and conflicts onto the patient. This may present problems if the nurse does not recognize what is happening and therefore chooses interventions based on faulty assessment findings. For example, a nurse whose father physically abused her may find herself reacting with fear or rage toward a particular male patient and initially may not understand why. If she does not recognize what is triggering her response, she may conclude that the problem is with the patient’s behavior rather than her response to the patient.

For both countertransference and identification, the nurse must recognize both personal feelings and the patient’s behavior, speech, or attitudes that contribute to the discomfort, and then determine whether the difficulty lies with the patient’s behavior or stems from the nurse’s own distorted or exaggerated response to it. It is always important for nurses to compare their own reactions to their usual way of responding and question other nurses to determine whether they have a similar reaction to the patient. If other staff members have not had the same reac- tion to the patient, the nurse may want to examine his or her personal feelings more closely. Box 4–1 lists guidelines to identify countertransference.

Judgmental Attitude Judging another’s behavior by personal values can significantly influence the nurse-patient relationship. Patients can usually sense these attitudes and may

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withhold important information for fear of being judged. The nurse may be unable or even unwilling to refrain from judging immediately but needs to be aware of these attitudes to diminish their impact on the patient.

Rescue Feelings The nurse may believe that he or she is the only person who really understands the patient and will be the one to save or cure a patient. This usually involves some internal needs of the nurse that are often reinforced by the patient. Secrets and secret alliances may result. Nurses should keep in mind, however, that becoming a rescuer undermines the patient’s responsibility for his or her own health care.

Losing Credibility Stating facts such as “85% of patients have no complications with this type of surgery” is very different from telling a patient that he or she will not have any problems with upcoming surgery. In this example, if problems do occur after the nurse has stated that they would not, the nurse will lose credibility, and the patient may stop sharing further concerns because the patient no longer feels

Chapter 4 ■ Nurses’ Responses to Difficult Patient Behaviors 39

BOX 4–1 Identifying Countertransference • Repeatedly experiences affectionate feeling toward certain patients • Experiences depressed or uneasy feelings during or after interactions with

certain patients • Permits or even encourages resistance in the form of acting out • Persistently attempts to impress a patient • Cultivates a patient’s continued dependence on nurse • Is sadistic or unnecessarily sharp with a particular patient • Experiences a strong need to care for patient • Experiences conscious satisfaction from patient’s praise, appreciation, and

evidence of affection • Constantly argues with the patient • Rigid about the structure of the nurse/patient relationship • Has an intense reaction to the patient • Instantly likes or dislikes patient • Does not trust anyone else to care for patient • Feels intimidated by or is angry with the patient

Source: Adapted from Lewis, A. & Levy, J. (1992). Psychiatric liasion nursing. Reston, VA: Reston Publishing; Leach McMahon, A. (1997). The nurse-client relationship. In J. Haber, B. Miller, A. Leach McMahon, & P. Price-Hoskins (Eds.), Comprehensive psychiatric nursing (5th ed) (pp. 143-161). St. Louis: Mosby.

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confident in the nurse’s opinions or information. Reassurance should be based on proper information and facts. Being evasive or dishonest also destroys credibility.

Labeling Labeling, or referring to the patient by his or her diagnosis, problem (“he’s just a junkie”), or even room number, diminishes the value of the person. Almost with- out realizing it, once a label is used, nurses will begin to focus on the label and place less value on the patient’s underlying needs and feelings. Optimal patient care requires that those needs and feelings be recognized and honored.

STRATEGIES FOR SURVIVAL

Some overall recommendations can help nurses to cope better with difficult patient behaviors. Table 4–2 offers some general guidelines for selecting effective interventions. Personal survival strategies also need to include strategies to main- tain objectivity and prevent burnout. These can include using relaxation and stress management techniques and assertiveness training, as well as developing a pro- fessional support group to share concerns and help with problem-solving. Devel- oping a sense of team cooperation also lessens the chances of a single nurse being called upon to meet everyone’s needs. Attending classes and reading about man- aging commonly seen difficult patient behaviors gives the nurse more effective tools as well. Maintaining a satisfying personal life is also very important. Nurses tend to give of themselves as much in their personal life as they do at work. To prevent becoming burned out, you need to create a balance in life. Developing supportive relationships and participating in enjoyable activities can decrease the pressure to have patients behave in ways that meet your own personal needs. Ade- quate rest and exercise and good nutrition are also extremely important.

IDENTIFYING PSYCHOSOCIAL RESOURCE PERSONNEL

Many times, outside assistance is needed in addition to the nurse’s own personal strategies. A first step is to identify the sources of help that are available in your agency. Depending on the institution, any or all of the following may be available:

• Social workers • Advanced Practice Nurses • Nurse Educators or managers • Psychiatric liaison staff • Psychiatrists or psychologists, including those specializing in chemical

dependency, rehabilitation, or pain • Chaplains • Psychotherapists or staff members from other agencies who are familiar

with the patient and his or her problem and previous treatment

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MENTAL HEALTH CONSULTATION

Sometimes agencies request outside consultation from mental health profession- als for staff support and education, management of a crisis such as patient sui- cide, problem-solving for difficult patient behaviors, or improving workplace communications. The consultant may be a mental health clinical nurse specialist, psychologist, psychiatrist, or social worker with consultation experience. This specialist needs to have experience and skill in providing consultation, as well as some understanding of the type of problems the staff is encountering. The

Chapter 4 ■ Nurses’ Responses to Difficult Patient Behaviors 41

TABLE 4–2 Staff Responses to Difficult-to-Care-for Patients

Staff Responses Intervention

Feeling inadequate to respond effectively to patient’s symptoms

Feeling angry when patient gets angry

Fear of the patient who exhibits bizarre or unpredictable behavior or who is con- fused, psychotic, or exhibits other psychiatric symptoms

Identifying with patients who are the same age or race or who share similar life experience

Frustrated because there is not enough time or energy to work with patient

Concern over being manipulated by patient’s demands

Labeling patients rather than their behavior in an attempt to achieve an emotional distance

Uncomfortable with certain personal topics related to family dynamics or personal history

Source: Reproduced with permission of Fincannon, J. L. (1995). Analysis of psychiatric referrals and interven- tions in an oncology population. Oncology Nursing Forum 22(1), 87.

Lower emotional reactivity.

Maintain objectivity.

Provide staff education on identifying and handling patients.

Use empathy rather than sympathy to protect self and yet not harm patient.

Share workload evenly.

Schedule consistent staffing.

Foster staff value system that precludes patients labeling.

Support staff through discus- sion and education.

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consultant may be from within or outside the agency. Staff attitudes can signifi- cantly influence whether this option can be used. Facilitative attitudes encourage use of these resources. These include:

• Feeling comfortable identifying problem areas and learning needs • Recognizing that requesting assistance for areas outside personal knowledge

or expertise is a sign of strength, not of weakness, and is necessary for pro- fessional development

• Approaching the consultant as a resource and role model • Anticipating the opportunity to gain insight

Hindering attitudes discourage or prevent use of resources. These include:

• Fearing exposure of inadequacies or embarrassment about not having all the answers

• Underestimating the specialized skill or knowledge needed to work with patients’ problems

• Viewing patients’ difficult-to-manage behaviors as deliberate or willful • Calling the consultant too late and then challenging him or her to “fix”

everything • Harboring a prejudice against or fear of psychiatry • Not maintaining confidentiality of group process

If the staff is meeting with the consultant as a group, the group leader will usu- ally establish the ground rules for staff participation at the first meeting. If mul- tiple sessions are planned, it will be necessary for all involved staff members to make a commitment to attend all of the sessions. The administration needs to ensure adequate resources for coverage to ensure patient safety and reduce the level of staff discomfort about leaving their patients to attend the meetings. All members need to be aware of the objectives of these meetings. Hidden agendas, such as finding out who the troublemaker is, must be avoided.

Even though today’s health-care environment is facing tremendous economic pressures, mental health consultation has been recognized as providing a cost- effective way to enhance problem solving, reduce workplace stress, and, poten- tially, increase productivity. For example, anger in staff members that has been expressed by chronic lateness or increased sick time can be explored through con- sultation. This resource should, therefore, not be overlooked.

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5

43

Crisis Intervention

Learning Objectives • Identify variables that influence the response to a crisis. • List interventions the nurse can use to reduce the impact of a crisis for a

patient. • Describe key questions to ask a patient experiencing a crisis.

All people experience crises. Crisis is a state of disequilibrium resulting from a stressful event or perceived threat to one’s self when usual coping mecha-

nisms are ineffective and lead to the individual’s experiencing increased anxiety. Nurses see patients and families in a crisis state as part of their daily routine.

It is impossible to predict what events will trigger a crisis in an individual. A breakup of a relationship or a minor car accident may cause a crisis situation for one person but not another. Certain events, such as the death of a spouse, trigger a crisis in everyone. A diagnosis of serious illness, recurrence or metastasis of can- cer, and terminal illness all present the likelihood of a crisis (Van Fleet, 2006).

Many factors influence how an individual responds to a specific situation and whether a crisis will ensue. Unresolved losses, coping with other stressful events at the same time, or being excessively tired or in pain, which may reduce one’s ability to cope, increase the risk of a person’s viewing the situation as a crisis. Per- sonal issues, such as low self-esteem, difficulty with anger, or need to control, may also cause an event to become a crisis in a vulnerable individual. With or without intervention, a crisis usually resolves in 4 to 6 weeks because it is much too difficult for the individual to maintain the high level of tension and distress. The person develops some type of coping mechanism to get through the situation, changes the goal, or redefines the problem.

A crisis represents both danger and opportunity. A person is at risk for emo- tional breakdown, but the period of vulnerability can also stimulate personal growth and strength. Crisis intervention is short-term active support that focuses on immediate problem solving and re-establishing emotional equilibrium to facil- itate a positive and adaptive resolution. See Table 5–1 for the most common types of crises.

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NURSES’ REACTIONS TO PATIENT CRISIS

The ways in which a nurse responds to a patient in crisis are as varied as the ways in which the patient will respond because nurse and patient are influenced by the same factors. Some common responses may be:

• Feeling anxious or unsure about how to proceed • Becoming overinvolved and attempting to take over for the patient, possi-

bly causing the patient to become dependent on the nurse • Viewing the patient’s crisis as insignificant • Taking on some of the patient’s anxiety • Setting unrealistic expectations or goals

Because health-care personnel can be exposed to traumatic events, critical inci- dent debriefing may be needed (Everly, Lating, & Mitchell, 2000). This gives the staff a safe and controlled environment to debrief after a difficult situation. Examples might include suicide of client or staff members or another type of traumatic event including violence against an employee.

ASSESSMENT

Aguilera (1998) identified three factors to determine the development of a crisis. They include:

Perception of the event: Successful resolution is more likely if the stressor is seen in a realistic rather than in a distorted way. For example, two students may get a C grade on an examination. One student may see this as an indi- cation of the need to study harder and may realize that it is only a part of the final picture for the school year. The other student may view the grade as a personal failure, reflecting his low self-esteem and feelings of worthlessness.

44 Chapter 5 ■ Crisis Intervention

TABLE 5–1 Types of Crises

Types of Crises Examples

Maturational—Crisis in response to facing a new developmental phase

Situational—An unanticipated, external event triggers a strong response

Adventitious—Crisis of disaster

Young adult leaving home for the first time, birth of a child

Loss of a job, death of a loved one

Natural disaster, terrorism

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Situational support: Lack of available resources or personal support systems, in addition to the specific situation, could be the factor that changes the sit- uation into a crisis. In contrast, having someone to whom to turn to vent grief or frustration can increase one’s ability to cope.

Adequate coping mechanisms: Having proven mechanisms to deal with anxi- ety can prevent the situation from escalating into a crisis. If the individual has never used effective coping mechanisms or the mechanisms are not cur- rently available, the situation could escalate into a crisis. For example, an individual who uses smoking or running as a mechanism to reduce stress may have a crisis response to being hospitalized in an intensive care unit because he will not be able to smoke or run.

To effectively assess the patient’s response, follow these guidelines for con- ducting a crisis interview:

• Identify the precipitating event and determine its meaning.

• What has happened in the past few days or hours? • If the patient describes an ongoing problem, what is different about the

problem today from yesterday? Be specific. • What does the event mean to the patient? • What is the patient most worried about in relation to the event? • What are some of the consequences of the event? • Does the patient see this event as influencing his or her future?

• Evaluate the patient’s support system.

• With whom does the patient have a close relationship? • To whom does the patient talk when he or she has a problem? • Are these people available now? • Have these resources helped in the past? • Whom does the patient trust? • Are any other resources available in the patient’s life such as a clergy

member or a counselor?

• Evaluate previously used effective coping mechanisms.

• What does the patient normally do to cope with stress? • What is he or she doing now to cope with this situation? • If this has not helped, does the patient have any idea why not? • What has helped in the past in similar situations?

INTERVENTIONS

Crisis intervention is short-term problem-oriented support that ideally allows the individual to advance to a higher level of functioning as he or she develops new insights, strengths, and coping mechanisms. At the minimum, the individual will

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return to the precrisis level of functioning. The crisis is considered unresolved if the person functions at a lower level after the crisis, for example, by abusing sub- stances, communicating ineffectively with family or loved ones, or exhibiting signs of depression or psychosis.

When facing a crisis, consider the following interventions:

• Make an accurate assessment of the precipitating event, the patient’s per- ception of the event, and the available support systems and coping mecha- nisms. Also assess the patient’s safety.

• Provide only small amounts of information at a time, and be prepared to repeat the information several times. Focus on concrete actions rather than vague ones.

• Communicate in a supportive, nonjudgmental way. Use gentle physical con- tact, as appropriate. Use calming hand gestures, a calm voice, and an unhur- ried manner.

• Help the patient to confront the reality of the event. This should be done slowly at first, such as gently bringing the patient back to a discussion of a car accident. More concrete, specific wording may be needed. This process may need to be repeated.

• Help the patient focus on one “here-and-now” problem at a time rather than jumping from one possible problem to another. For example, a man who is frantic about his continuing pain may begin thinking about what will happen if the pain never stops. This will only escalate his anxiety. Rather, help him stay focused on dealing with the pain he is having now.

• In some situations, you may need to direct the person as to what to do next. His or her ability to make even the smallest decision may be compromised due to the overwhelming anxiety the crisis is producing.

• Encourage the patient to express his or her emotions in a socially acceptable manner.

• Assist with problem solving. This may include brainstorming all possible options and helping the patient narrow these down to the ones that can be used now. Focus on one or two possible options to give the patient a sense of control without overwhelming him or her with multiple options.

• Encourage the people in the patient’s support system to become involved. Be sure to obtain the patient’s permission before notifying family and friends to ensure that the patient maintains control of the situation. Be creative in identifying sources of support.

• Reinforce the patient’s self-esteem by acknowledging how difficult the situ- ation is and saying that you understand he or she is doing all that is possi- ble to cope with it. Provide positive feedback.

• Reinforce effective coping mechanisms such as deep breathing, exercising, or making prioritized lists.

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• Identify other resources in the agency that could provide assistance. Avoid being the only staff member assisting this patient.

• Assess the need for medications to reduce anxiety.

Occasionally, a patient’s response to a crisis requires more intense interven- tion, including psychiatric treatment or hospitalization. The nurse needs to rec- ognize signs of patient decompensation that go beyond the usual symptoms of a crisis. For example, suicidal behavior, evidence of psychotic thoughts, or violent behavior that could endanger others must be identified and resources for inter- vention obtained. If these signs occur, be sure to obtain a consultation for spe- cialized assistance.

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6

49

Cultural Considerations: Implications for Psychosocial Nursing Care

Learning Objectives • Explain the concept of culturally sensitive psychosocial nursing care. • Discuss factors to consider when assessing culture and ethnicity in

patients and their families. • Consider treatment approaches to patients in various cultural and ethnic

groups. • Describe guidelines for using interpreters and what to do when an inter-

preter is not available.

Culture is a system of beliefs, behaviors, and symbols that are learned, shared, and passed on through generations of a social group. Culture influences what

people perceive, it guides their interactions, and it can change over time. Culture describes a particular society’s entire way of living. Ethnicity is a somewhat nar- rower term: it relates to people who identify with each other because of a shared heritage.

CULTURALLY COMPETENT NURSING CARE

The need to incorporate culturally competent care is more important than ever as the U.S. population continues to be increasingly diverse. More than 11% of the population is foreign born, and the primary language of about 20% is one other than English (U.S. Census Bureau, 2005).

Culturally competent nursing care is defined as being sensitive to issues related to culture, race, religion, gender, sexual orientation, and social or economic class. Cultural competence implies not only awareness of cultural differences but also the ability to assess and intervene appropriately and effectively. Cultural compe- tence in nursing care requires more than simply acquiring knowledge about other

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ethnic or cultural groups. It is a complex combination of attitudes and skills as well as knowledge (Campinha-Bacote, 1994).

Cultural information by itself can interfere with care if nurses use it in a “cook- book” manner. Inappropriate use of cultural information can lead to stereotyping patients by making assumptions based on limited information. Because stereotyp- ing comes from jumping to conclusions based on insufficient data or experience with a cultural group, it is important to suspend judgment as long as possible (Lip- son & Steiger, 1996). Cross-cultural misunderstandings surrounding end of life care are increasing as differences in attitudes exist toward truth telling, life-pro- longing technology, and decision-making styles between patients, families, and health-care providers (Kagawa-Singer & Blackhall, 2001).

Cultures can be compared using six phenomena that vary with application and use, yet are seen across all cultural groups (Giger & Davidhizar, 1995; 2004). These phenomena are:

1. Communication: This refers to all verbal and nonverbal behavior in the presence of another. Communication has its roots in culture. Cultural mores, norms, ideas, and customs are all expressed through communica- tion. The nurse who cares for diverse patients must have an understanding of the client’s needs and expectations as expressed through their communi- cation and culture.

2. Space: This element of culture refers to territoriality, density, and distance. It relates to how space is controlled, used, and defended. Three interper- sonal dimensions of space in Western culture have been identified: the inti- mate zone (0–18 inches), the personal zone (18–36 inches), and the social zone (3–6 feet).

3. Social organization: Cultural behaviors are acquired through social inter- actions in groups such as families, religious groups, and ethnic groups. This process of learning cultural values is called acculturation.

4. Time: Awareness of time is learned gradually. Some cultures place great importance on punctuality and efficiency, whereas others ignore the clock. Time orientation, meaning present-, future-, or past-oriented perceptions, influences many aspects of a culture.

5. Environmental control: This element has to do with the degree to which individuals perceive they have control over their environment. Persons from various cultures have different beliefs about how much they can influ- ence events in their lives, some being more fatalistic and others more active. To provide culturally appropriate care, nurses should respect the individ- ual’s unique beliefs while understanding how these beliefs can be used to promote health in the patient’s environment.

6. Biological variations: This element refers to biological differences in people from various racial and ethnic groups, such as body size and shape, skin and hair color, physiologic responses to medications, susceptibility to dis- ease, and nutritional preferences. A new field called ethnopharmacology is addressing different responses to medications.

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Acknowledging that people from different cultures and ethnic groups perceive these phenomena in different ways can help the nurse understand variations in patients’ behavior, values, and expectations.

A cultural assessment helps the nurse gather and use other information related to culture that is vital in providing culturally sensitive care. The nurse must be aware that beliefs about health and the causes of illness, appropriate care, and who should provide that care, can differ among cultures. It is important for the nurse to listen to what the patient believes, what has been done in the past, and even to consult with the patient’s cultural healers (perhaps a spiritualist, curan- dero, shaman, or medicine man).

The nurse must realize that mental illness is unacceptable in some cultures. People who believe that expressing emotions is unacceptable present unique problems in a psychiatric setting. Nurses need to work slowly to establish trust and rapport with patients from other cultures. In some cases, it may be nec- essary to follow the health-care practices that the client views as essential, as long as they do not harm the patient. For example, letting family members bring in special foods, inviting a folk healer to the hospital, or making time for a spir- itual reading serve as an important acknowledgment of the patient’s traditions (Townsend, 2006).

CULTURAL ASSESSMENT

A thorough cultural assessment may take several hours. The list of questions in Box 6–1 can provide a brief but helpful focus for a relevant cultural assessment. Answers to these questions do not guarantee culturally competent care, but nev- ertheless good care cannot be provided without specific cultural and ethnic infor- mation (Lipson, Dibble & Minarik, 1996). When patient and health-care professionals are from different cultures, questions must be asked that respect- fully acknowledge differences and build trust.

CULTURAL INFLUENCE ON MENTAL HEALTH BELIEFS

Culture can significantly influence communication, particularly when the cultures of the nurse and patient are vastly different and not understood by each other. Culture is defined as a configuration of learned behaviors and beliefs that are shared and transmitted in a society and by a particular group of people. The val- ues, beliefs, traditions, attitudes, and prejudices that each of us brings from our culture and past experiences influence all interactions with others. Ethnocentrism is defined as the belief that one’s own cultural beliefs and health-care practices are superior to those of other cultures. To provide quality care to all individuals, nurses must be sensitive to patients’ cultural differences and as aware as possible of their own cultural beliefs and behaviors.

Rather than stereotyping individuals into specific cultural classes, nurses should approach each patient as an individual who holds very personal attitudes,

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beliefs, and values that are influenced by his or her culture and environment. (See Box 6–2 for ways of enhancing cultural sensitivity.)

Culture often influences what a patient believes about his or her illness, its causes, and when and from whom to seek care. Although you may not be able to be aware of the specific beliefs of every culture, having some general information about the culture and ethnicity of patients for whom you frequently care for is important. Incorporating some questions in the assessment on culture and observing for influences can help you become more familiar with these cultures (Purnell & Paulanka, 1998).

52 Chapter 6 ■ Cultural Considerations

BOX 6–1 Cultural Assessment—Questions to Ask • Where was the patient born? If an immigrant, how long in this country? • What is the patient’s ethnic affiliation, how strong is the ethnic identity? • Who are the patient’s major support people? Does patient live in an ethnic

community? • Who in the family takes responsibility for health concerns and decisions? • Any activities in which the client may decline to participate because of cul-

ture, religious taboos? • Any special food preferences, food refusals because of culture, religion? • What are the primary and secondary languages, speaking and reading

abilities? • What is patient’s religion, its importance in daily life, current practices? • What is the patient’s economic situation, is income adequate for needs? • What are the patient’s health beliefs and practices? • What are patient’s perceptions of health problem and expectations of health

care?

BOX 6–2 Enhancing Cultural Sensitivity • Know your own attitudes, values, and beliefs. • Be aware of your own ethnocentrism. • Be aware of your own prejudices that may influence your assessment. • Maintain an open mind and seek out more information about your patient’s

culture, beliefs, and values. • Communicate your interest about the patient’s beliefs and values. • Approach each patient as an individual. Avoid assuming people from one

cultural background all hold the same beliefs.

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Questions to be included in the assessment may include, “What do you believe caused your illness?” and “What other treatments for the illness have you pur- sued?” Recognize the impact of these beliefs on the patient’s ability to accept the illness and his or her response to it. For example, in cultures that view men as always being strong, even a mild illness could contribute to depression (Spector, 1996).

Be sensitive to each individual’s beliefs about his or her illness and its causes, and design your care to incorporate these ideas. For example, in a culture in which the oldest woman plays a pivotal role in the family, the grandmother may be the one the patient consults on decisions about surgery, discharge planning, and follow-up care. She would need to be incorporated into the treatment planning in order for this patient to receive the best follow-up care. If a patient believes in folk healers or cures, don’t ridicule or judge his or her beliefs. Rather, acknowledge the beliefs, and incorporate them into the treatment plan if possible. For example, if a Chinese patient is taking herbs to cure his diabetes, it is more beneficial to dis- cuss the possible impact of these herbs on blood sugar than to ignore their use or forbid the patient to use them (Lipson, Dibble & Minarik, 1996).

Respect the role of the family in the patient’s treatment. In some cultures, the family is responsible for protecting the patient, especially when the patient is the parent. In their role, family members may want to protect the patient from bad news. This may be contrary to your own belief in patient autonomy and, there- fore, may lead to conflicts between the health-care providers and the family. Of course, the patient must be in agreement with involving the family. Also be aware that in psychiatric settings, different approaches may be used to preserve patient autonomy and confidentiality.

Psychiatric professionals have recognized that some symptoms commonly seen in mental illness, such as delusions or hallucinations, could represent a culturally appropriate behavior. For example, being possessed by an evil spirit could be a delusion or a culturally sanctioned experience of an altered state of conscious- ness. Be careful not to judge individual cultural variations as psychopathology. It is helpful to discuss these issues with other health-care providers from diverse cul- tural or ethnic groups who can increase your understanding of behaviors and beliefs outside your own experiences (Townsend, 2006). The Diagnostic and Sta- tistical Manual of Mental Disorder, fourth edition, revised (DSM-IV-TR, 2000) identifies behaviors (culture-bound syndromes) associated with various cultures that may be mistaken for psychiatric symptoms. This can be a useful reference.

CULTURAL AND ETHNIC INFLUENCE ON COMMUNICATION

Verbal and nonverbal communication patterns are closely tied to cultural beliefs and practices. Eye contact, hand gestures, facial expressions, and personal space, as well as how words or slang are used and what can be discussed, are defined by our culture and environment. For many people, eye contact indicates honesty,

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openness, and alertness. However, people in some cultures do not value eye con- tact and, in fact, even avoid it. For example, in some Asian cultures, eye contact is viewed as impolite and an invasion of privacy. It is especially inappropriate with authority figures, such as doctors and nurses. Judging a patient’s response based on eye contact without understanding this difference can lead to an invalid assessment finding (Luckmann, 1999).

Some nonverbal behaviors such as facial expressions, hand gestures, and social distance vary among cultures. For example, it may be important to know that lack of facial expression in some Asian groups is not an indication of lack of feel- ing or that an Arab family member who stands very close is not threatening but rather standing at the distance considered appropriate in their culture. Address- ing a patient, especially an elderly one, by his or her first name may suggest a lack of respect, or even seduction, in many Asian and Latin cultures. Also, some patients may be extremely uncomfortable when asked intimate, very personal questions, no matter how accepting and professional the nurse may be. If this information is vital to patient care, efforts need to be made to explain how the information will be used (Schuster, 2000).

COMMUNICATING THROUGH AN INTERPRETER

Language differences pose a barrier to even the most basic communication and cultural assessment. Caring for a patient who does not speak the same language as you can cause anxiety, frustration, fear, and a sense of helplessness on your part as well as the patient’s. It may cause resentment because of the extra time and work that are needed. Some nurses try to compensate for their perceived deficiency by concentrating on performing tasks rather than on the patient’s con- cerns. Although it is not usually possible to learn the language of every potential patient, it would be beneficial to learn the language spoken by a majority of the patients you care for. If you cannot speak the language, use an interpreter as much as possible.

There may be a family member who can translate, and you may need to pro- vide accommodations if this person needs to stay with the patient. When using a family member to translate, keep in mind that, because of the emotional ties or role conflicts and lack of medical vocabulary, the person may base messages to both patient and provider on his or her own perception of the situation and may withhold vital information because it may embarrass or overwhelm the patient. For example, if the family member does not want the patient to know about the seriousness of his or her condition, he or she may not relay all the information to the patient. In addition, patients may feel too embarrassed to disclose key infor- mation in the presence of their relatives, especially if it is of a sensitive nature. Using family members as interpreters is probably best when basic communication is needed rather than when critical conversations are needed for diagnosis, treat- ment, and psychosocial assessments (Luckmann, 1999).

Check with your institution to see if an interpreter is available. The Civil Rights Act of 1964, the 1973 Rehabilitation Act, and the more recent Americans

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with Disabilities Act (ADA) have established the federal standards that ensure that communication does not interfere with equal access to health care for all people. Therefore, all health-care institutions must establish systems for identify- ing available language interpreters, as well as interpreters trained in sign lan- guage, telecommunication device for the deaf (TDDs), closed-caption decoders for television, and amplifiers on the phones. Many institutions have access to tele- phone interpretation services, such as the AT&T Language Line. This nation- wide, 24-hour service provides interpreters for about 170 languages. Although this service cannot take the place of a trained interpreter at the bedside, it does allow patients to communicate their history and symptoms to health-care providers, especially in emergencies.

Interpreters can be professional interpreters or employees of the institution who have other duties. If you are using employees who are not trained inter- preters, evaluate their ability to understand the information you wish to have translated and how much time they have to provide the service. If the interpreter has limited medical knowledge or knowledge of the patient, it may be difficult to ensure effective communication.

In the home, family members and neighbors are usually the only resource unless nurses who speak the language are available. In addition to being aware of agency resources for interpreters, the nurse should become familiar with key words that can be useful in assessing patients who speak another language. A language board containing key words in the languages most frequently used in your agency can be a very effective, time-saving tool.

When using an interpreter, keep the following points in mind:

• Address the patient directly rather than speaking to the interpreter. Main- tain eye contact with the patient to ensure the patient’s involvement.

• Do not interrupt the patient and interpreter. At times, their interaction may take longer because of the need to clarify, and descriptions may require more time because of dialect differences or the interpreter’s aware- ness that the patient needs more preparation before being asked a particu- lar question.

• Ask the interpreter to give you verbatim translations so that you can assess what the patient is thinking and understanding.

• Avoid using medical jargon that the interpreter or patient may not under- stand.

• Avoid talking or commenting to the interpreter at length; the patient may feel left out and distrustful.

• Be aware that asking intimate or emotionally laden questions may be diffi- cult for both the patient and the interpreter. Lead up to these questions slowly. Always ask permission to discuss these topics first, and prepare the interpreter for the content of the interview.

• When possible, allow the patient and interpreter to meet each other ahead of time to establish some rapport. If possible, try to use the same interpreter for succeeding interviews with the patient.

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56 Chapter 6 ■ Cultural Considerations

• If possible, request an interpreter of the same gender as the patient and of similar age. To make good use of the interpreter’s time, decide beforehand which questions you will ask. Meet with the interpreter briefly before going to see the patient so that you can let the interpreter know what you are plan- ning to ask. During the session, face the patient and direct your questions to the patient, not the interpreter. After the session, review the questions and answers with the interpreter to check any remaining concerns (Luckmann, 1999).

• Anticipate when emotional, difficult topics will be addressed and prepare the interpreter ahead of time for this, for example, a discussion of code sta- tus. If not well prepared or well trained, an interpreter can identify with a patient and this could influence the interpretations as well as contribute to the interpreter’s discomfort (Norris et al, 2005).

GUIDELINES FOR WORKING WITHOUT AN INTERPRETER

If an interpreter is not available, using picture charts or flash cards can help the patient communicate some basic questions such as degree of pain or needs like water and elimination. Some patients with limited English may tend to appear agreeable and nod yes even though they do not understand. Be sure to determine that the patient understands by asking questions that require more than a “yes” or “no” answer.

If the patient understands a little English, you may be able to gather useful information without an interpreter by following these suggestions:

• Greet the patient respectfully. Be polite and formal, especially with older patients.

• Identify the patient’s primary language. If you can pronounce any words in the language, use them to show you are trying to communicate. A simple “buenos dias” or “bonjour” may help to reduce the patient’s anxiety.

• Speak slowly, clearly, and quietly in English if this is your only option. Do not shout. Make an effort not to appear frustrated, irritated, or hurried.

• Ask one question; talk about one symptom at a time. Use simple sentences. • Try to avoid medical terminology. For example use “bleeding, pus, or liq-

uid” rather than “discharge.” • Use picture cards or a phrase chart if they are available to verify patient

information. • Be aware that some patients may act as if they have understood all your

questions to avoid looking ignorant or rude (Luckmann, 1999).

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57

SECTION II Commonly Encountered Problems

7Problems with Anxiety

The Anxious Patient

Learning Objectives • Differentiate among the cognitive, affective, behavioral, and physical

symptoms of anxiety. • Use the different manifestations of anxiety to assess the anxious patient. • Select the most appropriate interventions for dealing with the patient

with anxiety. • Identify possible nurses’ reactions to an anxious patient.

Glossary Acute stress disorder – A disorder characterized by a high level of anxiety

immediately after a traumatic event. Agoraphobia – Fear, anxiety, or avoidance of places or situations from which

escape may be difficult or where help may not be available. Anxiety – An unpleasant feeling of tension, apprehension, and uneasiness or

a diffuse feeling of dread or unexplained discomfort; accompanied by phys- iological, psychological, and behavioral symptoms; may serve as an early warning that alerts the individual to impending real or symbolic threat to self, significant others, or way of life; motivates the individual to take cor- rective action to relieve the unpleasant feelings. The source of the anxiety is often nonspecific or unknown to the individual.

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Anxiety disorder due to a General Medical Condition – Anxiety characterized by prominent symptoms directly related to the physiological consequences of a general medical condition (e.g., hyperthyroidism or hypothyroidism, hypoglycemia, chronic obstructive pulmonary disease).

Fear – A reaction to a specific danger. Generalized anxiety disorder – A disorder characterized by at least 6 months

of persistent and excessive anxiety and worry. Obsessive-compulsive disorder (OCD) – Recurrent thoughts or ideas (obses-

sions) that an individual is unable to put out of his or her mind and actions that an individual is unable to refrain from performing (compulsions).

Panic attack – A discrete, sudden, unpredictable, intense episode of severe anxiety characterized by personality disorganization; a fear of losing one’s mind, going crazy, being unable to control one’s behavior; a sense of impending doom, helplessness, and being trapped.

Post-traumatic stress disorder (PTSD) – Anxiety and stress symptoms that occur after a massive traumatic event; often includes the feeling that the event is reoccurring, lasting for weeks, months, or years.

Post-traumatic stress response – A persistent, disorganizing, and distressing reaction to a catastrophic event that affects a person’s emotional, cognitive, and behavioral dimensions and relationships and extends beyond the time of the immediate crisis.

Social anxiety disorder – Intense, persistent fear of social situations. Specific phobias – Irrational fears characterized by clinically significant anxi-

ety provoked by exposure to a specific feared object or situation, often lead- ing to avoidance behavior.

Substance-induced anxiety disorder – A disorder characterized by prominent anxiety symptoms directly related to physiological consequences of drug abuse, medication use, or toxin exposure.

Anxiety is the primary emotion from which many other emotions or responses, such as anger, guilt, shame, and grief, are generated. The term anxiety brings

up images of someone pacing and wringing his or her hands with pounding heart and rapid breathing, perhaps before taking an important test in school or while waiting to hear from the doctor about results of a biopsy. Words such as worry, concern, fear, and uncertainty are often associated with the term anxiety.

Anxiety can also have a positive meaning, implying eagerness and readiness to face a challenge or perform some skill. Being mildly anxious can enhance experi- ences such as performing in a piano recital or completing a term paper. Anxiety is a healthy response to novel and unique experiences. In fact, being mildly anx- ious helps us to perform our best because perceptual, emotional, and physiolog- ical arousal can enhance learning, problem-solving, satisfaction, and pleasure during and after an event. Just as pain serves as a cue and a response to potential or actual physical danger, anxiety can serve as a cue and response to emotional, social, or spiritual danger.

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Anxiety is a universal emotion; everyone has experienced some level of anxi- ety associated with life events. Anxiety disorders are the most common psychi- atric disorder in America (Merikangus, 2006; Hollander & Simeon, 2003). Anxiety disorders affect 25% of the U.S. population (Merikangus, 2006). Social anxiety disorders are the most frequent form of anxiety disorders. It is triggered by certain types of performance situations (Bernardo, 2007). People vary signifi- cantly in their ability to manage feelings of anxiety and in their styles and pat- terns of coping with anxiety-producing situations. Knowing the meaning of the subjective experience to a particular individual is essential in understanding how to intervene with that individual. Fears are more specific, but the body reacts sim- ilarly to both fear and anxiety.

The DSM-IV-TR (2000) divides anxiety into these diagnostic categories: Panic Disorder with or without Agoraphobia, Social Phobia (also called social anxiety disorder), Specific Phobias, Obsessive-Compulsive Disorder, Post-Traumatic Stress Disorder, Acute Stress Disorder, Anxiety Disorder due to a General Med- ical Condition, Generalized Anxiety Disorder, and Substance-Induced Anxiety Disorder. Panic attacks and Agoraphobia may occur alone or in the context of several of these disorders. For treatment purposes, anxiety is often categorized into four levels: mild, moderate, severe, and panic (Table 7–1).

Chapter 7 ■ Problems with Anxiety 59

TABLE 7–1 Characteristics of Anxiety Levels

Level Characteristics

Mild

Moderate

Continued

• Enhanced ability to deal with stressors • Heightened awareness, problem-solving abilities; increased

attention to details • Curiosity increased, asks questions • Alert, confident • Logical thinking intact

• Hesitation and procrastination, blocking loss of train of thought

• Narrowing of perceptual field • Change in voice pitch; speech rate accelerates • Selective inattention • Frequent change in topics • Repetitive questioning, joking • Increased respiratory rate, heart rate, muscle tension • Dry mouth • Palpitations • Changing body positions frequently, restlessness • Purposeless activity (wringing hands, pacing)

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60 Chapter 7 ■ Problems with Anxiety

TABLE 7–1 Characteristics of Anxiety Levels—cont’d

Level Characteristics

Severe

Panic

• Highly distorted perceptual and cognitive function • Focus on small or scattered detail, inability to see connec-

tions between events • Selective inattention, inability to concentrate • Fear of losing control • Purposeless activity (pacing, wringing hands) • Difficult and inappropriate verbalizations, inability to

learn • Sense of impending doom • Sweating • Hyperventilation, tachycardia, frequency and urgency • Nausea, headache, dizziness • Gross motor tremors, trembling, shaking • Numbness or tingling sensations • Dilated pupils

• Dyspnea, choking feeling, chest pain • Extreme discomfort, emotional pain • Unrealistic, distorted perception of situation • Disruption of visual field, distortion and enlargement of

detail • Inability to speak, unintelligible communication, inco-

herent speech • Vomiting, incontinence • Feeling of personality disintegration • Fear of losing mind, fear of dying

Mild or moderate anxiety usually speeds up physiological operations, whereas severe anxiety may slow them down. Prolonged panic can cause complete paral- ysis of functioning and occasionally result in death. Anxiety can also be classified as normal or abnormal. The same feelings and behaviors (uncertainties, helpless- ness, and an intense sense of personal discomfort) characterize both, and the level of anxiety may be equally intense.

Normal anxiety results from a realistic perception of the danger and prepares the person for defense or change in face of the threat. Normal anxiety can be motivating and useful (e.g., to motivate a student to study harder and therefore to do better on a test). Abnormal anxiety arises when the perception of danger is distorted, unrealistic, and out of proportion, resulting in maladaptive, defensive coping and inappropriate behavior.

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ETIOLOGY

Theoretical approaches to anxiety are wide ranging. In the biological perspective, anxiety is the uneasy feeling aroused by a threat or danger and is accompanied by a physiological response. This response prepares the person for “fight or flight.” The fight response (sympathetic stimulation) causes changes primarily in the cardiovascular and neuroendocrine systems. During the flight response (parasympathetic stimulation), which occurs in acute fear states, an effort is made to conserve body resources. Other evidence suggests a biological basis for anxiety. Research on the metabolism of monoamines and the function of the lim- bic system are central to the expression of emotions such as anxiety; the discov- ery of the benefits of benzodiazepines for chronic anxiety; and studies on sodium lactate in persons with panic attacks.

In psychoanalytical theory, anxiety represents a person’s struggle with the demands and prohibitions in his or her environment, including the internal struggle among the person’s instinctual drives (id), the realistic assessment of the possibility for need fulfillment (ego), and the conscience (superego). Anxiety is a signal from the ego that an unacceptable drive is pressing for con- scious discharge. A conflict results between the drive, usually of a sexual or aggressive nature, and fear of punishment or disapproval. Phobias are fears that are disproportionate to the situation and cannot be explained or reasoned away. The significance and meaning of anxiety depend on the nature of the underlying conflict.

Interpersonal theorists believe that anxiety arises from experiences in rela- tionships with significant others (SOs) throughout a person’s development. If a child is treated malevolently, the foundation is laid for the child to become inse- cure and feel inferior and anxious in future situations. The child is forced to use coping strategies to allay anxiety; these become part of the personality when the child becomes an adult.

Learning and behavioral theorists explain anxiety as the result of a condition- ing process in which a neutral stimulus has come to represent punishment, pain, or fear. The individual learns to reduce anxiety by avoiding a negative stimulus or by approaching a positive reinforcer. Extinction of behavior is a process of reducing response strength by nonreinforcement.

An eclectic understanding of anxiety, incorporating components of all these theories, is most helpful. Anxiety can be understood as experienced at con- scious, unconscious, or preconscious levels. Sources of anxiety fall into two major categories:

1. Threats to biologic integrity: Actual or impending interference with basic human needs such as food, drink, shelter, warmth, safety and health

2. Threats to self-security or self-esteem which can include:

• Unmet expectations important to self-integrity • Unmet needs for status and prestige

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• Anticipated disapproval by SOs • Inability to gain or reinforce self-respect or to gain recognition from

others

• A severe, sudden, unexpected threat to sense of security, self-esteem, or well-being

• Guilt or discrepancies between self-perception and actual behavior

Experiences with anxiety in early life lead to the development of coping behav- iors, personality traits, and defense mechanisms intended to reduce anxiety and increase a sense of security. Over time, the individual develops characteristic pat- terns of relief behaviors intended to provide comfort and protection in the face of anxiety. When these behaviors, traits, or mechanisms fail to relieve anxiety, the patient experiences intense emotional or physical discomfort.

Behavioral responses to anxiety can be constructive (problem-solving, task- oriented) or destructive (defensive, aggressive, violent). When anxiety levels exceed a person’s adaptive coping abilities, maladaptive behaviors may develop. Disturbed coping mechanisms are characterized by the inability to make choices, conflict, repetition and rigidity, and alienation. Frustration and anxiety can lead to anger, hostility, and violence.

Anxiety often increases when a person expects one thing and is suddenly con- fronted with something very different. The same stressor may not always lead to anxiety or the same level of anxiety in everyone or even in the same person at dif- ferent times. Generally, the patient experiences anxiety as very painful and unbearable if it continues for any length of time. Behavior patterns used to cope with anxiety include the following:

Acting out: Converting anxiety into anger, which is either overtly or covertly expressed

Paralysis or retreating: Withdrawing or being immobilized by anxiety

Somatizing: Converting anxiety into physical symptoms such as stomachache or headache

Avoidance: Evasive behaviors performed unconsciously to ward off or relieve anxiety before it is directly experienced (alcohol, sleeping, keep- ing busy)

Constructive action: Using anxiety to learn and problem solve (goal setting, learning new skills, seeking information)

Syndromes of abnormal anxiety frequently observed in patients include the following:

Panic attacks: Acute, intense attacks of anxiety associated with extreme changes in physical and emotional behavior that can last from minutes to hours, are severely debilitating, and are characterized by sudden, intense, and discrete periods of anxiety and fear that may occur without warning in

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previously calm and untroubled individuals. Recent research points to physical or organic causes for some patients.

Post-traumatic stress disorder (PTSD): Re-experience of the trauma of a pre- vious traumatic event (e.g., rape, assault, military combat, flood, earth- quake, major car accident, airplane crash, bombing, torture). The symptoms are usually more severe and last longer when the cause is a man- made rather than a natural disaster. Three subtypes of PTSD are recognized:

• Acute: Symptoms begin within 6 months of the event and do not last longer than 6 months.

• Chronic: Symptoms last for 6 months or more. • Delayed: Symptoms begin after a latency period of 6 months or more.

Re-experiencing the trauma in PTSD may include recurrent and intrusive rec- ollections of the event, recurrent dreams or nightmares of the event, or sud- den acting or feeling as if the event were recurring because of an association with an environmental or mental stimulus. Other behaviors and affect asso- ciated with the syndrome include decreased interest in usually significant activities, feelings of detachment or estrangement from others, and con- stricted affect. Symptoms not present before the trauma include hyperalert- ness or exaggerated startle response, sleep disturbance, guilt about surviving while others died or about behavior required for survival, mem- ory impairment, difficulty concentrating, avoidance of activities that arouse recollection of the event, or intensification of symptoms by exposure to events that symbolize or resemble the traumatic event.

Phobia: An intense, irrational fear response to a specific external object or sit- uation. Unlike an anxiety reaction, in which the anxiety is free floating and the person cannot easily identify the cause or source, a phobia is a persist- ent fear of specific places, things, or situations. The major dynamic mecha- nism of phobic behavior is the displacement of the original anxiety from its real source and the symbolization of the stressor in the phobia (e.g., fear of sex becomes a fear of snakes).

The hallmark of phobias is that they are irrational and persist even though the person recognizes that they are irrational. The unconscious operations involved in the phobia help the person to control anxiety by providing a specific object to attach it to. The phobic person can then control the inten- sity of the anxiety by avoiding the object or situation to which the anxiety has become attached. Some of the more common phobias include claustro- phobia (fear of closed places), agoraphobia (fear of leaving home and of open spaces), acrophobia (fear of heights), xenophobia (fear of strangers), and zoophobia (fear of animals).

Obsessive-compulsive disorder (OCD): A paralyzing anxiety disorder associated with repetitive, compulsive thoughts (obsessions) and behaviors (compulsions). These patterns of thoughts and behaviors are senseless

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and distressing but help achieve the goal of avoiding anxiety. This disorder has been treated very effectively with some of the newer antide- pressants, leading some investigators to think this disorder is related to sero- tonin reuptake.

RELATED CLINICAL CONCERNS

Anxiety is the most common complaint in medical practice (Epstein & Hicks, 2005). It presents in many ways and with great variation in intensity and duration; therefore, treatment must be individualized and monitored very closely. Anxiety may be caused by many other medical and psychiatric problems such as cardiac and vascular disorders, sleep disorders, hyperthyroidism, anemia, depression with agitation, dementia, delirium, hypochondriasis, schizo- phrenia, mania, and personality disorders. Some medications, caffeine intoxica- tion, and withdrawal from alcohol or sedatives may cause anxiety. Anxiety can also contribute to medical illness such as arrhythmias and labile hypertension (Epstein & Hicks, 2005). Physical illness or underlying major psychiatric syn- dromes must be considered and ruled out before treatment for anxiety is under- taken. Because many patients with anxiety disorders do not present to mental health providers, general medical practitioners may be the first to identify anxi- ety disorders.

LIFE SPAN ISSUES

Children The anxiety most frequently experienced by children is separation anxiety. When a child is separated from those to whom he or she is attached, excessive anxiety to the point of panic may occur. Onset may be as early as preschool age. The child may refuse to go to sleep or go to school. Complaints of physical symp- toms, such as headache, stomachache, and nausea and vomiting are also com- mon. The most common sign of anxiety in children is increased motor activity (Wong, 2003).

Older Adults Anxiety in elderly people has not been systematically investigated. It is the con- sensus of clinical gerontologists that anxiety is a common response to the stresses of late life, including fear of dependency, illness, dying, and multiple losses of friends, home, or lifestyle. A long-standing tendency toward excessive anxiety can persist into late life and usually is not dysfunctional in the patient who has adapted to it. Anxiety in elderly persons may be the presenting symptom of a new illness, especially depression with agitation; of early dementia; or of low-grade or chronic toxic states caused by drugs or alcohol.

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ASSESSMENT

Behavior and Appearance See Table 7–1 for Characteristics of Anxiety Levels.

Mood and Emotions • Dread, fear, apprehension

• Lack of control or self-confidence

• Guilt

• Anger

• Grief

• Sense of imminent catastrophe

Thoughts, Beliefs, and Perceptions • Narrowed focus of attention • Perceptual focus scattered or fixed • Inability to focus on reality

Chapter 7 ■ Problems with Anxiety 65

POSSIBLE NURSES’ REACTIONS • May be apprehensive and even fearful about caring for patients experienc-

ing severe anxiety or a panic attack. Intense anxiety can be very contagious, not only to staff members but also to other patients.

• May try to determine the cause of patient’s anxiety and do what is possible to reassure and assist patient to decrease it, then become frustrated when patient’s anxiety continues.

• May find it too strenuous to work with patient for more than a day at a time if patient’s anxiety does not subside as the nurse thinks it should.

• May interpret the anxiety as a weakness in the patient, who is seen as unable or unwilling to control it or may judge the anxiety as part of a more serious psychological problem and feel very uncomfortable caring for these patients.

• May prefer to keep patient sedated. • May feel resentment and even hostility toward anxious patients who require

more attention and time than their physical conditions alone warrant. • May want to avoid family members or SOs who are also quite anxious and

make unreasonable requests in a demanding or complaining manner. Most of these behaviors may be caused by the families’ own frustration or appre- hension in dealing with the patient’s anxiety, and they are often unaware that their behavior is affecting the staff.

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• Inability to learn or remember, forgetfulness • Inability to reason or problem solve • Difficulty concentrating, lack of awareness of environment • Distorted perceptions

Relationships and Interactions • Withdrawal and isolation, avoidance behaviors • Demanding, complaining, quarreling, attention-seeking behavior • Defensive, uses denial • Tense, strained relationships; others frustrated over dealing with patient’s

anxiety and maladaptive coping

Physical Responses See Table 7–1 for physical responses to various anxiety levels.

Pertinent History • Medical conditions that present with anxiety as a symptom

• Thyroid, pituitary, and adrenocortical disorders • Low hemoglobin • Hypoglycemia • Impending heart attack

• Use if stimulants including crystal meth, cocaine, amphetamines • Synergistic or idiosyncratic drug reactions • Alcohol or sedative withdrawal • Cerebrovascular disorders • Sequelae to head injury • Chronic anxiety • Recent loss of loved one, significant object, work, finances, or self-esteem • Phobic behavior • Recent re-exposure to anxiety-causing situation • Traumatic experience

COLLABORATIVE MANAGEMENT

Anxiety disorders are usually treated with some form of counseling or psy- chotherapy or pharmacotherapy, either alone or in combination. The milder forms may be effectively treated with cognitive or behavior therapy alone, but more severe and persistent symptoms may require pharmacotherapy.

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Pharmacological The medications typically used to treat patients with anxiety are benzodiazepines and antidepressants. Benzodiazepines, such as diazepam, lorazepam, clon- azepam, and alprazolam, are the medications commonly prescribed for treating most types of anxiety, including short-term (situational) anxiety and long-term (generalized) anxiety. Unfortunately, because they are so efficacious and safe, these medications are often prescribed without full appreciation of the potential problem of physical dependency. OCD and PTSD are more effectively treated by antidepressants. Several drugs in the selective serotonin reuptake inhibitors (SSRIs) class of antidepressants including fluoxetine, sertraline, paroxetine, and fluvoxamine have emerged as the preferred type of antidepressant for treatment of OCD. Clonidine and beta blockers such as propranolol and atenolol are also used. Herbal products include kava kava and valerian. Another nonbenzodi- azepine used for more long-term treatment is buspirone.

Psychological During the past decade, there has been increasing enthusiasm and demand for focused, time-limited therapies that address ways of coping with anxiety symp- toms directly rather than exploring unconscious conflicts or other personal vul- nerabilities. These therapies emphasize cognitive and behavioral assessments and interventions, such as relaxation training, biofeedback, systematic desensitiza- tion, reframing, thought stopping, aversion therapy, and social skills training.

The hallmarks of cognitive-behavioral therapies are evaluating cause-and- effect relationships among thoughts, feelings, and behaviors, as well as using straightforward strategies to lessen symptoms and reduce avoidant behaviors. Therapeutic modalities such as guided imagery and muscle relaxation, exercise and rest programs, aromatherapy, and music and art therapy may be used as adjuncts to medication or alone. All mental health disciplines, including psychi- atric mental health nurses, psychiatric social workers, psychologists, and psychi- atrists, may use these anxiety reduction approaches in their collaborative treatment of clients with anxiety.

NURSING MANAGEMENT

ANXIETY manifested by tension, distress, uncertainty related to threat to health, self-concept and lifestyle.

Patient Outcomes • Demonstrates decreased level of anxiety • Will report feeling less anxious after using coping strategies • Will use coping strategies effectively when anxiety is recognized • Demonstrates increased ability to prevent episodes of anxiety by problem-

solving

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Interventions • Speak in a calm, quiet voice; convey a sense of confidence and control

and a tolerant, understanding attitude. • Place patient in quiet environment; reduce distracting stimuli (e.g., noise,

activity, light). • Use discretion in conversations with patient and near patient’s room. • Recognize factors that may stimulate more anxiety. • Reduce demands placed on patient until anxiety is reduced. Provide rest

periods between tests, activities, and visitors. • Provide diversional activity and exercise. Monitor changes in level of

activity. • Allow supportive others (clergy, social workers, volunteers) to visit

patient. Explain tests and equipment to them so they can in turn be more relaxed around patient.

• Provide realistic feedback about patient’s situation; do not give false reas- surances. Help patient understand the anxiety by having him or her name the feeling.

• Encourage patient to express feelings (some crying and anger are appro- priate).

• Have patient identify what happened just before the anxiety started and try to identify the causative event. Discuss the possible connection between the precipitating event and the meaning it has for the patient.

• Determine patient’s usual coping mechanism in similar situations. • Encourage patient to recall and think through similar instances of anxi-

ety, what alternative behaviors could be used to cope more adaptively. • Attempt to discuss what patient understands as cause of anxiety or panic

once the anxiety level is reduced. • Stay with patient but do not require explanations for the distress; indi-

viduals with severe or panic-level anxiety may become more agitated by attempts to communicate with them.

• Provide measures to relieve anxiety (e.g., warm bath, back rub, walk). Discuss other techniques for reducing anxiety (relaxation exercises, stress-reduction techniques) when patient is calmer and more rested. Encourage slow, deep breathing if patient is hyperventilating; breathing with patient to set pattern may be helpful.

• Assist patient in learning and problem solving when anxiety is dimin- ished enough to allow concentration.

• Evaluate need for antianxiety medications; anxiolytics can be very effec- tive in relieving panic; if none have been ordered, consult with physician for pharmacologic therapy.

• Assess for potential injury or violence to self or others.

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• Give feedback about patient’s current coping ability; reinforce any attempts to cope adaptively.

• Refer patients with recurrent anxiety and maladaptive coping mecha- nisms for further psychiatric/psychological evaluation and treatment.

• For patients with panic-level anxiety:

• Take patient to a quiet area with minimal stimuli. • Administer anxiolytics as needed (ask what medications patient has

used in past) • Remain with patient through the attack. • Give patient clear, honest feedback (“You are having a panic attack; I

will stay with you”).

INEFFECTIVE COPING. Individual evidenced by anxiety/fear/avoidance of objects or events, as well as irrational thoughts related to phobias, extreme guilt.

Patient Outcomes • Demonstrate increased ability to think rationally and without undue guilt • Identify thoughts and situations that evoke anxiety • Show decreased anxiety related to improved thought processes and prob-

lem solving • Demonstrate appropriate coping strategy for reducing anxiety related to

phobia

Interventions • Realize that phobic reactions are irrational and are not changed by

rational, logical explanations; work around phobias (e.g., do not require a claustrophobic patient to use an elevator).

• Promote communication that reinforces rational thinking and decreases guilt.

• Verify your interpretation of what patient is experiencing (e.g., “I under- stand that you are afraid to go to the radiology department.”)

• Use words familiar to patient when describing new events or expectations. • Help patient to clarify thoughts and avoid misinterpretation; ask mean-

ing of anything that you do not understand. • Do not talk around or whisper near patient; include patient in conversa-

tion and check that he or she heard what you actually said by asking him or her to repeat it.

• Set limits on discussing irrational material; focus on topics based in real- ity that you can verify.

• Avoid belittling or derogating when patient misinterprets stimuli or is irrational; do not laugh or make fun of the individual.

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• Assist patient to set limits on own behavior; suggest alternative ways to cope with anxiety (e.g., take a walk instead of crying).

• Be aware of potential for violence; observe for changes in behavior indi- cating increased anxiety, irrational thoughts, or any destructive behavior that requires attention.

• Anticipate difficulties in adjusting to return or transfer to home or other facility; discuss concerns with family or SO.

• Let patient have some control in anxiety-provoking situation; do not force patient to do anything that seems to be extremely frightening.

• Provide time to discuss anxiety or fear while continuing supportive ver- bal and behavioral interventions.

• Refer patients with phobias for more specific treatment (e.g., desensitiza- tion, behavioral modification) to a psychiatrist, psychologist, advanced practice nurse, or social worker if anxiety is not managed by previous interventions.

ALTERNATE NURSING DIAGNOSES

Comfort, Impaired Fear Gas Exchange, Impaired Perception, Disturbed

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WHEN TO CALL FOR HELP

• Increased anxiety leading to refusal of treatment or noncompliance • Onset of paranoid, psychotic thinking • Onset of panic attack • Staff conflict over management of patient behavior • Increased staff anxiety over caring for patient.

WHO TO CALL FOR HELP

• Psychiatric Team • Social Worker • Chaplain • Colleagues who know patient • Patient’s family/friends • Coworkers

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Chapter 7 ■ Problems with Anxiety 71

Post-Trauma Syndrome Sleep Deprivation Spiritual Distress Thought Processes, Disturbed Violence, Risk for

PATIENT AND FAMILY EDUCATION

• Teach patient and family or SO anxiety-reducing exercises such as muscle relaxation, guided imagery, music, or other activities for distraction.

• Discuss with patient and family or SO the causes and treatment of patient’s anxiety.

• Review possible negative short-term and long-term effects of anxiety on physical and mental health.

• If patient is using antianxiety medications, review the need to monitor their use and potential problems when overused or discontinued without weaning.

• Educate on the use of appropriate medications to treat paralyzing symptoms such as OCD.

CHARTING TIPS

• Use objective assessment and nonjudgmental terms to describe behavior. • Use patient’s own words to describe amount and type of anxiety experienced. • Note which interventions are most helpful in decreasing patient’s anxiety and

specific treatments that patient successfully learned to control own anxiety. • Document family or SO responses to education about anxiety reduction

methods. • Document use of antianxiety medications and patient’s response to them.

COMMUNITY-BASED CARE

• Discharge can be a particularly anxiety-provoking time for many patients. Begin discharge planning early and include all caretakers in planning for future care needs.

• Allow enough time to discuss alternatives and provide as much emotional support as possible during the transition time.

• Discuss available community resources: their functions, services, capabili- ties, and limitations.

• If transferring patient to another facility or agency for follow-up care, pro- vide information about patient’s progress in and successful interventions for dealing with anxiety.

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• Refer to a psychiatrist or internist specializing in psychotropics if patient has frequent panic attacks or chronic, moderate to severe anxiety.

• Refer family for counseling early in patient’s hospitalization so that thera- peutic behaviors that will minimize patient’s anxious behavior can be learned before patient returns home.

• To ensure consistency, record and communicate to family or others respon- sible for patient after discharge, those interventions that worked well.

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8

73

Problems with Anger

The Angry Patient

Learning Objectives • Identify three positive functions of anger. • Identify possible nurses’ reactions to an angry patient. • Differentiate among assertive, passive, and hostile expressions of anger. • Select the most appropriate interventions for dealing with an angry

patient.

Glossary Anger – A state of emotional excitement and tension induced by intense dis-

pleasure, frustration, and/or anxiety in response to a perceived threat. Assertiveness – Behavior directed toward claiming one’s rights without deny-

ing the rights of others. Assertiveness training – Learning behavioral techniques that allow an indi-

vidual to stand up for his or her own rights without infringing on the rights of others.

Frustration – Feelings generated from the inability to meet a goal. Hostility – Feelings of anger and resentment that are destructive. Passive-aggressive behavior – Behavior characterized by angry, hostile feel-

ings that are expressed indirectly, leading to impaired communication and inappropriate expression. This behavior masks anger in such a way as to obstruct honesty in relationships. It may also be associated with obsessive- compulsive personality, borderline personality, and depression.

Rational anger – Anger expressed in a direct, socially acceptable manner.

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Anger is a normal human emotion. It can result from frustration, fear, or rejec- tion. When handled appropriately, anger can help people resolve conflicts

and make decisions. It can energize us into action. It can also contribute to physical and emotional distress if handled in a destructive manner. Expressing anger directly can be uncomfortable. However, denying it, suppressing it, or expressing it inappropriately tends to lead to more negative outcomes. The inap- propriate expression of anger may be threatening to oneself and others (Harper- Jaques & Reimer, 2005). Learning to deal with anger is an ongoing process, and when we learn how to deal with our anger and others’ anger appropriately, we can gain a positive feeling of control, a sense of power and energy, and increased self-esteem. Some people fear anger because they think it could get out of con- trol. Generally, though, anger tends to be of short duration and low intensity for most people. It does not necessarily lead to violence and aggression. Thomas (2001) asserts that expression of anger may prevent aggression and help resolve a situation.

Anger can be viewed along a continuum. At one extreme is passive-aggressive behavior, in which a person avoids direct, open expression of anger but finds hid- den ways to express it. At the other extreme is aggressive expression, in which a person inflicts pain on others when he or she expresses anger. Rational anger falls in the middle. When anger is rational, feelings are expressed in a direct, socially acceptable manner that allows the person to gain some control over the threat without causing harm to others.

ETIOLOGY

No single theory can explain the complex emotion of anger. Most likely, an inter- twining of biological, psychological, and sociocultural factors create each indi- vidual’s unique response. Box 8–1 lists positive and negative functions of anger.

Biological theories of anger focus mainly on neurotransmitters, such as dopamine, norepinephrine, and serotonin. The balance of these and other brain chemicals seem to influence or even aggravate response to anger and stress. Actual physical changes in the brain have been noted in aggressive behavior (Wat- son, 2006).

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BOX 8–1 Positive and Negative Functions of Anger Positive Functions Energizes body for self-defense Can promote conflict resolution Can increase self-esteem and sense

of control

Negative Functions Can lead to impulsive behavior Can lead to hostility and rage Can hurt others emotionally or

physically

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Psychological theories look at the various dynamics and learned responses that cause anger. Anger occurs as a result of a buildup of frustration. Pacquette (1998) points out that frustration and feelings of powerlessness precede expression of anger. Children often use inappropriate anger responses, such as temper tantrums, to deal with frustration and feelings of powerlessness. Positive reinforcement for this behavior can cause inappropriate anger responses to continue into adulthood. When the child’s caregivers are demanding, hypercriti- cal, and punitive, the child may develop coping mechanisms aimed at avoiding expressing anger directly for fear of displeasing the caregiver and risking emotional abandonment or retaliation. These coping mechanisms often lead to a passive-aggressive anger response and resentment, which eventually erupt into inappropriate or destructive behavior. Anger can sometimes be a normal response to fear and help the person gain control of a perceived threat, or it can be part of the adaptive process in adjusting to a loss. In addition, suppressed anger can contribute to depression and low self-esteem (Townsend, 2006). Anger can also be a motivating factor to stimulate action that in turn can raise self- esteem.

Sociocultural factors also play an important role in the way an individual expresses anger. Social groups, including families, often display common patterns in the degree of acceptance of expressed anger. For example, in some families yelling and aggressive confrontation are acceptable means of dealing with anger and conflict, whereas in others, any overt display of anger is not tolerated. Although both of these styles may work within individual families, they may not be the healthiest ways of dealing with anger. Expressions of anger are also seen in major depression, especially when the depressed person feels trapped (Fava & Rosenbaum, 1999).

Women are often socialized to deal with anger differently from men. They may tend to displace or suppress angry feelings and attempt to give in and compro- mise rather than deal with the conflict directly (Hollinworth, Clark, Harland, Johnson, & Partington, 2005). This behavior can lead to passive-aggressive responses or resentment that may eventually become destructive. Such repres- sion can also be detrimental and lead to misunderstanding when dealing with male colleagues.

CLINICAL CONCERNS

Medical conditions, such as chronic illness or loss of body function, may strain one’s coping abilities and lead to an uncharacteristic display of anger. Adjusting to the loss of body function includes anger as part of the grieving process. Illness often means facing feelings of powerlessness and frustration in meeting one’s goals and contributes to angry responses such as irritability. Some conditions, including some brain tumors and different forms of dementia, may also directly contribute to inappropriate expressions of anger because of their influence on

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brain function. Emerson-Rose (2005) has found evidence that negative emotional states contribute to cardiovascular disease.

Abuse of mind-altering substances may reduce inhibitions and contribute to inappropriate expression of anger.

LIFE SPAN ISSUES

Children Children normally respond with anger when faced with frustration. If they are raised in an environment where intense anger and violence are accepted, they can develop overly aggressive anger responses, including cruelty to others, animal abuse, and intolerance for frustration. Conversely, children who are taught that anger is unacceptable may tend to suppress or deny angry feelings and can develop extreme distress and guilt when faced with conflict. Children who learn appropriate ways to relieve tensions are more able to express anger rationally. Because children are vulnerable, they may be at increased risk of injury caused by inappropriate expressions of anger by caregivers.

Adolescents Anger in adolescents is often seen as part of their developmental process of sep- aration from parents and asserting their individuality. Hostility can also come from overstimulation from all they are dealing with. They may also have fears of being unable to control their impulses, leading to anxiety about anger.

Adults Adults who must deal with difficult life experiences, such as a chronic illness or the onset of an acute illness compounding stressful life events, can become very angry. This anger can further complicate the disease by depleting coping skills and interfering with the recommended medical treatment.

Older Adults Uncharacteristic displays of anger in elderly people may be the result of frustra- tion caused by a variety of physical, mental, and lifestyle changes such as demen- tia, altered sensory function (particularly hearing loss), altered mobility, changes in sleep-rest patterns, effects of medications, depression, loss of loved ones, and fear of dying. Inappropriate behavior may cause elderly persons to be alienated, further increasing their sense of fear, frustration, and possible confusion. Addi- tionally, vulnerable elderly people are at risk of being victims of someone else’s anger.

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ASSESSMENT

Behavior and Appearance • Loud voice, change in pitch, or very soft voice, forcing other to strain to

hear (Table 8–1) • Intense eye contact or avoidance of eye contact • Rapid, pacing movement • Ruminating about an issue • Passive-aggressive behavior, possibly including sarcastic humor; chronic

complaining; socially annoying habits; pseudocompliance (agreeing to do something but not doing it)

• Possible physical violence

Chapter 8 ■ Problems with Anger 77

POSSIBLE NURSES’ REACTIONS • May take patient’s anger personally, causing an unhealthy emotional

response. • May respond defensively by using an aggressive response or avoidance. This

can accelerate the anger cycle. • May attribute the patient’s anger to a specific event, such as the quality of

care provided, and respond by feeling unappreciated and resentful. • May feel uncomfortable or fearful and respond by suppressing or denying

the anger. • May avoid the patient for fear of emotional or physical retaliation.

TABLE 8–1 Comparing Behavioral Responses to Anger

Traits Passive Assertive Aggressive

Speech content

Voice

Posture Eye contact Gestures

Negative: “Can I”, “Should I”, Puts self down

Whispers Whiny, weak

Drooping Looks down Fidgets

Positive: “I can”, “I will”, “I” messages

Firm, clear

Erect, relaxed Appropriate Appropriate

Hostile: “You never …”, “You always …”, Derogatory

Loud

Tense Invasive Threatening

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Mood and Emotions • Annoyance, discomfort, frustration, continuous state of tension • May be quick to anger, then let it go or take time to “stew” before express-

ing anger • Guilt • Powerlessness • Vulnerability, easily offended • Defensive response to criticism • Passive-aggressive emotional response, possibly including being sullen, yet

denying any concerns, or inappropriate cheerfulness for the situation

Thoughts, Beliefs, and Perceptions • May believe that anger is normal and can be expressed without hurting

others • May take responsibility appropriately without blaming others • May be angry at others but still care for them • May lack ability to express true feelings • May fear loss of love if anger is expressed directly • May fear emotional or physical abandonment if anger is expressed • May feel a sense of power when angry

Relationships and Interactions • May communicate concerns clearly to avoid additional misunderstanding • May avoid other hostile or angry persons • May be catered to by others who fear patient’s anger

Physical Responses • Fight-or-flight response during confrontations, possibly including rapid

pulse, increased blood pressure, rapid breathing, muscle tension, sweating, or intense feelings of wanting to attack or run

• Episodes of headaches, depression, sleep alterations, pain, or gastrointesti- nal symptoms associated with repressed anger

COLLABORATIVE MANAGEMENT

Pharmacological Antianxiety medications, including benzodiazepines, are sometimes used for short-term relief of feelings of tension and anger. However, they should not be used as a substitute for acknowledging and dealing with anger, and they should not interfere with pharmacological actions of medications being taken for the

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underlying medical condition. In addition, antidepressants may be effective in controlling impulsive and aggressive behavior associated with mood swings. Beta blockers have also been used occasionally to control aggressive behaviors.

Common herbal products used for tension include St. John’s wort, kava kava, and valerian.

NURSING MANAGEMENT

ANXIETY evidenced by tension, distress, uncertainty, restlessness, or displeas- ure related to threat to self-concept, frustration, or unconscious conflict.

Patient Outcomes • Verbalizes concerns and frustrations directly at an appropriate time • Demonstrates reduced tension including lowered voice and more appro-

priate anger response • Demonstrates problem-solving skills when faced with frustration • Demonstrates behaviors to calm self when faced with frustration

Interventions • Use therapeutic communication techniques including open-ended ques-

tions, appropriate eye contact, and supportive gestures to encourage patient to vent feelings and concerns. Avoid providing solutions before the patient has a chance to relieve tension.

• Listen with concern without being patronizing or condescending. Phrases such as “Tell me what happened next” or “That really sounds frustrat- ing” allow the patient to feel accepted and understood. Avoid phrases that escalate feelings of powerlessness, such as “Calm down” or “It can’t be that bad.”

• If needed, direct the patient to a more private setting to express his or her feelings. Having others view the demonstration of anger can make it more difficult to back down and contribute to escalation of hostility or aggression.

• When the tension of the situation is reduced, focus on identifying the source of anger and validating the problem. Explore options on how to deal with the problem more constructively. Ask the patient which meth- ods he or she has used successfully in the past when dealing with frus- tration. Teach problem-solving skills. Assist the patient to identify and use more effective coping mechanisms.

• Teach tension-reducing techniques, such as deep breathing, counting to 10, walking away, and talking to self about remaining in control.

• Encourage the patient to express angry feelings toward the appropriate person. Role-playing before the confrontation may help the patient choose effective strategies.

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• Recognize that an angry outburst may result from an accumulation of multiple stressors that causes the patient to overreact.

• If the patient is justifiably angry because of something you have done or not done, accept appropriate responsibility. Work with the patient or colleagues to resolve the problem. Accepting and validating the patient’s feelings sends the message that you value his or her viewpoint.

• Encourage children to vent frustration by redirecting their activity, such as hitting a pillow or engaging in exercise.

INEFFECTIVE COPING evidenced by inappropriate expression of anger, dis- tress, destructive behavior to self or others, and related to threat to self-esteem or unconscious conflict.

Patient Outcomes • Able to identify personal strength that may help to reduce stress • Accepts personal limits in dealing with inappropriate demands • Demonstrates effective skills for dealing with frustration

Interventions • Identify ways to increase the person’s self-esteem as part of expressing

anger by treating him or her respectfully and acknowledging his or her skills or attributes. For example, when dealing with an angry daughter’s confrontation about her parent’s care, state, “Your father is lucky to have you as his advocate.” Avoid a defensive response or ignoring complaints.

• Focus on the patient’s strengths to deal with frustration. Help him or her identify which coping skills have been successful in the past.

• Teach the patient that anger is a normal response to loss. Some individ- uals are unable to accept this anger as normal and experience unneeded guilt.

• Encourage the patient to state the cause of the problem clearly to avoid erroneous assumptions.

• If the patient rejects or finds fault with all of your suggestions, place the responsibility for choosing the appropriate response on the patient. You might say, “We’ve discussed many options. Now it is up to you to con- sider which one is best for you.”

• Set clear limits on the patient’s expressions of anger toward the staff. Refuse to listen to extensive complaining if the patient is not willing to participate in determining an acceptable solution.

• Be assertive when explaining which types of behavior are not appropriate. • Be consistent with the demands the patient can set on the staff. • Promote effective problem-solving.

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• Encourage self-evaluation of behavior to give patient sense of control (e.g., what did you learn from that?)

• Be a role model for expressing negative emotions in a positive manner. Use “I messages,” such as “I feel angry” rather than accusing the other person, which can lead to a defensive response. Speak firmly without yelling and avoid threatening gestures when confronting issues.

DEFENSIVE COPING evidenced by blaming others for his/her problems; hypersentive to criticism and related to feeling powerless.

Patient Outcomes • Demonstrates reduced defensive behaviors • Able to verbalize realistic causes for distress

Interventions • Avoid challenging or criticizing the patients’ responses • Listen to his/her concerns • Help patient identify ways to evaluate progress in changing behavior. • Provide consistent staff so patient can establish a relationship to reduce

the threat of different to his/her behavior. This will help develop trust. • Avoid getting into power struggles with patient. Work to identify posi-

tives outcomes.

ALTERNATE NURSING DIAGNOSES

Noncompliance Powerlessness Self-Concept, Disturbed Social Interaction, Impaired Violence, Risk for

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WHEN TO CALL FOR HELP

• Increased aggressiveness; violent behavior, including damaging prop- erty; increasing use of abusive language, threats made to patients or staff

• Onset of paranoid thinking or psychotic behavior • Onset of extreme obsessive-compulsive behavior • Increased staff conflict over management of patient behavior • Increased staff anxiety over caring for patient

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PATIENT AND FAMILY EDUCATION

• Teach assertiveness skills by role-modeling appropriate responses and help- ing the patient practice these skills.

• Review with the patient frequently encountered frustrations, and explain that giving up control of the outcome may be the most effective strategy for dealing with them.

• Review potential negative health effects of inappropriate anger expression. • If the patient is using antianxiety medications, review the need to monitor

their use and avoid using them in place of trying to resolve the cause of anger. • Review with patient/family what has helped in the past.

CHARTING TIPS

• Use objective, nonjudgmental terms to describe behavior. • Document patient’s response to frustration. • Document the limits set on care plan or treatment plan for consistency. • Document use of medications (including herbal products) and patient’s

response to them.

COMMUNITY-BASED CARE

• Communicate plan of care to all involved in discharge planning. • Inform any appropriate agencies of patient behaviors to avoid miscommu-

nication. • Refer patient to counseling services or assertiveness training, if needed. • Encourage patient’s active participation in treatment plan. • Encourage family/caregivers to take the time to understand some of the

dynamics of the patient’s behavior • Inform caregivers/family of effective coping mechanisms to reduce the risk

of anger escalating to violence.

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WHO TO CALL FOR HELP

• Psychiatric Team • Social Worker • Security if concern for potential violence • Manager to address any conflict between staff members • Work colleagues if you need assistance

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The Aggressive and Potentially Violent Patient

Learning Objectives • Identify factors that precipitate aggressive behavior. • Describe effective techniques for verbal de-escalation of aggressive

behavior. • List possible nursing staff reactions to violent behavior in patients. • List interventions a nurse could use in working with a violent patient.

Glossary Aggression – Any verbal or nonverbal, actual or attempted, forceful abuse of

the self or another person or object. Assaultive behavior – An intentional act that is designed to make another

person fearful and produces harm. Chemical Restraints – Use of medication as a restriction to manage the

patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition

Hostility – Anger that is destructive in nature and purpose as opposed to rational anger that is appropriate to the situation and is not destructive in intent.

Intimidation – The use of threats to frighten and control. Physical restraint – Any physical method of restricting an individual’s free-

dom of movement, activity, or normal access to his or her body and cannot be easily removed.

Rage – Engulfing emotional experience of extreme anger. Seclusion – Involuntary confinement of the patient alone in a room or an

area where the patient is prevented from leaving as a means of controlling impulses that might lead to the immediate harm of the patient, staff, or others

Workplace violence – Violent acts including physical assaults and threats of assaults directed toward any persons at work or on duty. Four cate- gories include violence by strangers, clients, coworkers, and personal relations.

Violent behavior – Exertion of extreme force or destructive acts with intent to hurt another and that can cause injury.

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The presence of violence in our society has unfortunately become increasingly common. This increased violence is also reflected in the health-care setting (Win- stanley & Whittington, 2004). U.S. Labor Department statistics report that hos- pital-related violence is higher than in other private service businesses. Health-care and social service workers have the highest rate of nonfatal assault injuries in the workplace with nurses being 3 times more likely to experience vio- lence than other professionals. Psychiatric and emergency room nurses are at highest risk (Catlette, 2005; Emergency Nurses Association, 2006). The Ameri- can Nurses Association (2002) also reports that more than 80% of assaults on nurses go unreported. NIOSH (National Institute for Occupation Safety and Health) has identified times when violent behavior may be more likely in patient care settings. These include visiting hours, meal times, when service is denied, when limits are set, and involuntary admissions.

Historically, nurses working with psychiatric patients have been taught to be alert to and manage violent, assaultive behavior; however, now all health-care workers need to be alert to this problem. Health-care facilities must institute secu- rity measures and policies to ensure the safety of staff and patients, and to reduce the fear of impending violence among staff and visitors. Consistently being con- fronted with aggressive and potentially violent patients, families, and visitors can cause excessive fear, stress, job dissatisfaction, lost work time, poor morale, turnover, increased errors and possible injury (Anderson, 2002; Gates, 2004). The Occupational Health and Safety Administration (OSHA) has developed voluntary guidelines for employers to address this problem. They created “Universal Pre- cautions for Violence,” which acknowledges that violence should be expected but can be avoided or mitigated by proper training, policies, and security measures.

Past history of violence is the greatest predictor of this behavior (Blair & New, 1991). In addition, a history of psychiatric illness, particularly schizophrenia, paranoia, borderline personality disorder, other personality disorders, post- traumatic stress disorder, and dementia is frequently associated with predict- ing an aggressive outburst. Other major risk factors include drug and alcohol use but predicting when or if a patient will become violent remains difficult (Domrose, 2007).

The causes of the increased violence in our society and, consequently, in health care are varied and complex. Some of these causes include the following:

• Attitudinal changes in society with increased acceptance of violent response to authority figures

• Increased prevalence of handguns among patients, families, and visitors • Increased use of mind-altering drugs and alcohol • Court decisions that give psychiatric patients the right to refuse treatment

and medication • Health care staff members who are inadequately prepared to respond to

aggression or who deny the risk of violence and fail to report it • Increasing frustrations in health-care settings, including inadequate staffing

and long waits

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• Health-care workers in isolated environments (e.g., examining rooms, in patient’s home) with no backup, communication devices, or alarms

• Impersonal care, which may stress already frustrated patients

• Legal and ethical concerns about using chemical and physical restraints • Media coverage of violence, which triggers additional crimes

Using restraints to manage potentially violent patients can create ethical dilem- mas for the nurse concerning patient autonomy, human dignity, and informed consent. In 1993, the Joint Commission on Accreditation of Health Care Orga- nizations (JCAHO) created standards for physical restraints, requiring each agency to provide clear policies and education on appropriate restraint use. They have continued to refine these because of ongoing problems (JCAHO, 2005, 2006, 2007). The aim is to reduce the incidence of injuries that can result from restraint use, such as loss of mobility, skin breakdown, and, possibly, death from strangulation. The least restrictive to maintain patient safety should be used when other alternatives to this restraint have been ineffective. In 1999, Medicare and Medicaid developed new federal standards for the use of restraints that included the following: the emphasis must be on prevention; health-care institu- tions must continually work to reduce the use of restrictive measures of restraints and seclusion; restraints can be applied only with a physician’s order for each occurrence; continuous assessment of the patient while he or she is being restrained must be done; and alternatives to restraints must be tried. In 2006, The Centers for Medicare and Medicaid revised restraint and seclusion standards to include that health-care providers who use physical restraints and seclusions when treating violent or self-destructive patients must undergo rigorous training on the use of these approaches. In the medical setting, new alternatives to tradi- tional physical restraints called freedom splints have been developed. They allow more movement but reduce the risk of interference with medical procedures like pulling out IVs or nasogastric tubes (Markwell, 2005).

ETIOLOGY

Aggressive, violent behavior has many causes. Most studies of the causes of aggression have been done on subjects with mental illness or prison populations, which may skew the results.

Biological theories include genetics, which links chromosomal abnormalities to aggressive behavior, hormone imbalances, and neurotransmitter irregularities, specifically the abnormal secretions of dopamine and serotonin.

Psychological theories on aggression are related to a person’s view of the world as a source of anxiety. Individuals prone to violence often have low self- esteem and need to maintain control to enhance their own feelings of power and self-worth. Fear and anxiety can distort an individual’s perception of the stimu- lus. The presence of alcohol or other drugs can further distort these perceptions and reduce inhibitions. Aggressive behavior temporarily reduces the anxiety and

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creates a temporary sense of power. In addition, individuals with poor impulse control or a personality disorder may use violence to intimidate others. Aggres- sive individuals may have limited ability to tolerate frustration and demand to have their needs met immediately. Individuals who have experienced emotional deprivation in childhood may be particularly vulnerable and respond with vio- lent outbursts when they sense an attack on their self-esteem.

Social learning theory views aggression as a learned behavior. Individuals with a tendency toward aggressive, violent behavior may be more likely to respond to stressors such as illness, school or work pressures, or relationship problems with anger and hostility because they have learned that such behavior temporarily reduces their anxiety.

Sociocultural theories look at an aggressive individual’s poor interpersonal skills. Exposure to aggression and violence as part of family life may also be a significantly influential factor. Children who are treated with violence may view violence as a normal way to deal with others. The cycle of family violence con- tinues when children learn to use violence as their only coping mechanism instead of more socially acceptable ones. Poverty, deprivation, and hopelessness can also increase the risk of violent behavior.

RELATED CLINICAL CONCERNS

A wide variety of organic disorders may be associated with aggressive and vio- lent behavior. These include the following:

Intracranial Disorders Brain tumors Head injury Seizure disorders Cerebrovascular accident Dementia Systemic Disorders Endocrine disorders such as thyroid storm or Cushing’s syndrome Electrolyte imbalance Oxygen deficiency Septicemia Hepatic encephalopathy Exposure to Substances Alcohol use or withdrawal Use of mind-altering substances such as phencyclidine and amphetamines and

crystal methamphetamine Withdrawal from barbiturates and sedatives Use of aromatic hydrocarbons (glue, paint)

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Use of medications such as steroids, central nervous system stimulants, and antiparkinsonian agents

Exposure to toxic chemicals, pesticides, lead

LIFE SPAN ISSUES

Children Constant exposure to violence in childhood is a major factor contributing to the cycle of child abuse and family violence. Children who learn to use violent behav- ior to cope with frustrations and problems are likely to carry these behaviors into adulthood and may need to learn effective coping skills. Early signs of problems may include cruelty to animals and other children, as well as difficulty control- ling responses to frustration. The alarming presence of violence in schools and neighborhoods and in the media has increased the number of children who are exposed to seeing aggressive behavior and weapons used to resolve frustration in what may appear to them to be socially acceptable, normal behavior. Autism, mental retardation, learning disabilities, and attention deficit/hyperactivity disor- ders (ADHD) may also cause aggressive and violent behavior in children. The American Academy of Pediatrics Clinical Practice Guidelines (2000) recommend that children 6 to 12 years who present with hyperactivity, impulsivity, or behav- ior problems be evaluated for ADHD.

Adolescents Adolescents may act out aggressive feelings by participating in self-destructive behavior such as drug or alcohol use, smoking, or crime. Using mind-altering substances increases the risk of violent behavior. Homicide is the leading cause of death in the 15- to 24-year-old age group (Dowd, 1998).

Adults Aggressive behavior in adults often reflects lifelong learned patterns. For instance, persons who abuse their spouses have often witnessed abuse in their parents’ relationship or been abused themselves as children.

Older Adults Like anger, violent behavior can be a lifelong pattern or be caused by physical ill- ness or adverse reactions to medications. Aggressive behavior may also be a self- protective response related to confusion, fear, or sensory loss (particularly hearing loss). Most frequently, aggressive behavior in elderly persons is associ- ated with Alzheimer’s disease, senile dementia, cerebrovascular accidents, meta- bolic disorders, and hypoxia. Management of aggressive and violent behavior in nursing homes may be impacted by policies and federal requirements to reduce use of physical and chemical restraints.

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ASSESSMENT

Behavior and Appearance • Pacing, restlessness • Tense facial expression and body language • Unpredictable behavior • Loud voice, shouting, use of obscenities, argumentative • Overreacting to stimuli such as noise • Exhibiting poor impulse control evidenced by acting quickly before consid-

ering consequences of actions • Grasping potential weapons and attempting to use them

Mood and Emotions • Anger, resentment, rage, hostility • Anxiety; fear of loss of control leading to panic • Inappropriate affect for situation, labile emotions

Thoughts, Beliefs, and Perceptions • Low self-esteem • Low frustration tolerance

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POSSIBLE NURSES’ REACTIONS • May fear being hurt by the violent or aggressive patient or one who uses

intimidation with the threat of violence. This fear can cause the nurse to use poor judgment or totally deny feeling fearful. Other common fear responses include avoiding the patient or bending the rules in an attempt to appease the patient. All of these responses can affect continuity of patient care.

• May feel abused and unappreciated, leading to defensive responses such as attempting to punish the patient. Defensive responses and treating patient with less respect can escalate anger.

• May feel guilty for not being able to control the behavior or feel uncom- fortable for participating in applying restraints.

• May feel offended or frustrated because the patient does not respond to care positively.

• A nurse who has been assaulted in the past may experience self-blame and question his or her competence, depression, anxiety, and hyperalertness to any situation that could lead to aggressiveness.

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• Thoughts or plans to harm someone

• Inability to trust others to follow through without strong intimidation and suspiciousness

• Hallucinations, paranoid delusions

• Views others as out to hurt him or her

• Sense of being out of control

Relationships and Interactions • Difficulty with close relationships; lack of trust, which causes person to fear

closeness

• Others fearful of and avoid aggressive person, believing that they might be hurt or manipulated

• Family and friends have learned to meet person’s demands to avoid aggres- sive response or exhibiting passive-aggressive behaviors in response to the person’s demands

Physical Responses • Increased muscle tension

• Increased heart rate and blood pressure

• Altered level of consciousness, confusion, lethargy

• Possible abnormal laboratory values including blood sugar, blood alcohol, drug screening

• Increased use of medications

Pertinent History • History of violent behavior, particularly assault

• Psychiatric diagnosis

• Substance and/or alcohol abuse

• Physical, emotional, or sexual abuse in childhood or by intimate partner

COLLABORATIVE MANAGEMENT

Pharmacological It is important to use appropriate medications in adequate doses as an alternative or adjunct to physical restraints to manage aggressive behavior. Just as physical

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restraints and seclusion must be closely regulated, so is the use of psychotropic medication when it functions as a chemical restraint.

Pharmacological management of acute aggressive or violent behavior may require rapid tranquilization, which involves regular, frequent administration of antipsychotic medications such as haloperidol (Videbeck, 2004). Parenteral administration may be required if oral route is not feasible. If the patient is in physical restraints, parenteral administration reduces the risk of aspiration. For example, haloperidol, 5 mg, may be administered every 30 to 60 minutes until symptoms are under control. Dosage should be reduced in elderly people. When using this drug, monitor the patient closely for hypotension and signs of extrapyramidal symptoms including akathisias and dystonia (see Chapter 21).

Antianxiety medications and sedatives may also be useful. Anticonvulsants, such as carbamazepine (Tegretol), have been used with some success. Lithium and beta blockers, such as propranolol, are other alternatives. Antidepressants have also been used to treat impulsive, aggressive behavior. When using these drugs, evaluate how they may interfere with the medications ordered to treat the patient’s underlying medical condition.

Convincing an aggressive, agitated patient to accept medication can be diffi- cult and may lead the nurse to face an ethical dilemma of giving medication against a patient’s will. Be aware of hospital or agency policies and state laws regarding patient rights (Box 8–2).

Herbal products, such as valerian, have been shown to be helpful in some cases to calm the person.

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BOX 8–2 Encouraging an Uncooperative Patient to Take Medication • Have the nurse who has the best relationship with patient offer the med-

ication. Avoid power struggles and confrontations, which would most likely escalate the situation.

• Have the medication in hand so that it can be given quickly when the patient gives consent. The patient may change his or her mind suddenly.

• Be prepared for the patient to spit out the medication. This is especially common in elderly, aggressive patients.

• Use liquid oral medication if available. It is absorbed more quickly and is less likely to be “cheeked.” If medication needs to be given by injection, work quickly. Have adequate staff available in case violence erupts.

• Review with the patient the benefits of medication and that it will help him or her gain control of his or her feelings.

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NURSING MANAGEMENT

RISK FOR VIOLENCE, DIRECTED TO OTHERS evidenced by overt hos- tility and/or aggression to others, threatening others, possession of potential weapon, assaulting others related to impaired judgment, feelings of power- lessness, impulsive behavior, inability to evaluate reality secondary to neuro- logic problems, psychotic thoughts, and/or drug/alcohol use.

Patient Outcomes • Demonstrates increased self-control while in nurse’s care • Does not harm others or self while in nurse’s care • Demonstrates alternative coping mechanisms to reduce tension while in

nurse’s care • Behavior does not escalate while in nurse’s care

Interventions • Help patient to verbalize angry feelings by reflecting and by clarifying

your understanding of these feelings. Communicate your interest by appropriate eye contact, restating what patient has said, and asking ques- tions. Help patient identify source of anger. Recognize that response to illness may make the person feel helpless with the need to strike out to gain a sense of control.

• Early recognition of problem behavior is essential so that staff members can develop a plan.

• If needed, allow patient to release tension physically on inanimate objects such as pillows or in prescribed exercise, as appropriate.

• Do not take patient’s behavior personally. For example, if a patient calls you derogatory names, refrain from reacting emotionally. Rather, remind yourself that you represent an authority figure to the patient, and that he or she is reacting to you as such. Remember that patient may use deroga- tory remarks as a way to bolster his or her own self-esteem and seem to zero in on your sensitive, vulnerable points, such as weight or speech pat- terns. Avoid responding with sarcasm or ridicule.

• Do not ignore aggressive behavior in the hope that it will go away. It needs to be addressed. Minimization of behavior and ineffective limit set- ting are the most frequent factors contributing to escalation to violence.

• Set clear, consistent limits in a timely manner on what will and will not be tolerated. Clarify any specific consequences of patient behavior. For example, “If you attempt to hurt anyone, we will be compelled to con- trol your behavior, which may mean using restraints” (Box 8–3).

• Identify one or two staff members who are comfortable with the patient to handle most of the care if possible to help provide consistent inter- ventions. Evaluate whether a male or female staff member has a more

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calming influence. Sometimes a man’s presence is too threatening and powerful. Other times, it is reassuring to the patient that a male staff member is available. A male patient may be less likely to hurt a woman and may see her as nurturing and supportive. Conversely, male patients may view the female staff as less able to provide control or have other conflicted feelings toward women.

• Free patient’s environment of extra stimulation, such as noise or an agi- tated roommate. Extra stimulation may reduce impulse control. Remove objects around patients that could be used as potential weapons such as portable IV poles or food trays and utensils. Consider providing plastic food dishes and utensils. Avoid startling the patient. Call patient by name before walking into room. Avoid sudden movements that the patient may interpret as threatening.

• Remain calm and communicate that you are in control and can handle the situation. Use a moderate, firm voice and calming hand gestures. Avoid touching patient. Table 8–2 lists a summary of staff interventions.

• Place yourself between the door and the patient. Always have a quick exit available. Never turn your back on this type of patient. Keep door of room open. Let other staff members know you are going in patient’s room. Protect other patients who may get in the way of the violent indi- vidual.

• Never force an agitated patient to have a test or treatment. Power strug- gles will escalate aggression. Rather, prioritize care that must be given and focus only on that. Explain all procedures and ask patient’s permis- sion before beginning. Give patient choices as often as possible.

• If the patient is psychotic, he or she may be hearing voices. If so, ask what the voices are telling him or her to do. This gives you more information on

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BOX 8–3 Setting Limits 1. Explain exactly which behavior is inappropriate. Don’t assume the indi-

vidual knows which behavior is inappropriate. 2. Explain why the behavior is inappropriate. Don’t assume the individual

knows why the behavior is inappropriate. 3. Give the individual reasonable choices or consequences. Present them as

choices, and always present the positive first. 4. Allow time—if you don’t allow time to comply, it may be perceived as an

ultimatum. 5. Enforce consequences—limits don’t work unless you follow through with

the consequences.

Source: Reprinted from the Art of Setting Limits Participant Manual, p. 8, with permission of the National Crisis Prevention Institute, Inc., © 1991.

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what to expect. Hallucinations that command the patient to initiate aggression can be an extremely powerful force for the patient to overcome.

• A nurse who has been assaulted in the past and is now faced with a poten- tially violent patient may bring fears from this past experience, which could inhibit his or her response. Sharing these fears with colleagues may provide much needed support. Use agency resources for support includ- ing employee assistance or critical incident debriefing to help colleagues.

• If a patient makes threats to harm specific people, the nurse needs to notify his or her supervisor and follow protocol for notifying potential victims.

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TABLE 8–2 Summary of Staff Interventions to Avoid Escalation to Aggression

Patient Staff

Anxiety

Threatening

Acting out aggression

Tension reduction

Source: Adapted from Haven, E. & Piscitello, V. (1989). The patient with violent behavior. In S. Lewis, R.D. Grainger, W.A. McDowell, R.J. Gregory, & R.L. Messner (Eds.), Manual of psychosocial nursing inter- ventions (pp. 187–204). Philadelphia: WB Saunders; Lewis, S. (1993). Verbal intervention. In P.E. Blumenre- ich, & S. Lewis (Eds.), Managing the violent patient (pp. 41–52). New York: Brunner/Mazel.

Verbal intervention: • Assess. • Use verbal calming techniques. • Attempt to calm patient. • Do not invade patient’s personal space; avoid

antagonizing.

Set limits: • Continue verbal calming techniques. • Set clear and definite limits. • Be directive and matter of fact. • Be prepared to enforce limits.

Physical management: • Recognize mounting tension. • Have a plan. • Designate team leader. • Use only after other measures fail.

Emotional support: • Allow patient to express feelings. • Listen nonjudgmentally. • Show concern for patient, not anger. • Discuss events with colleagues. • Avoid blaming.

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• A visitor who becomes aggressive or violent needs to be reported to the agency security staff immediately and removed from the patient care area.

• Ensure that measures and policies are in place to prevent workplace vio- lence. For areas more prone to violence such as emergency department, work with other departments like security and other support resources to have an action plan in place if behavior escalates (Box 8–4).

• In the patient’s home setting, be aware of exits in case a problem devel- ops. Never stay alone in a home with a patient or family who is threat- ening violence, drinking, or displaying firearms. Consider making home visits with a colleague when there is a known risk of violence. Leave the home immediately if there is any sign of out-of-control behavior. Have access to a cellular phone in case of emergency.

RISK FOR INJURY evidenced by falls, pain, trauma, skin breakdown related to restraining patient to control violent behavior.

Patient Outcomes • Remains free of injury and complications during restraint application • Demonstrates control of behavior once restraints are removed

Interventions • The decision to use restraints should be made only after other efforts to

reduce tension have been tried and proven ineffective. A physician’s order must be obtained each time restraints are to be used. Standing orders are not acceptable.

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BOX 8–4 Preventing Workplace Violence • Be particularly vigilant during change of shifts and on night shift. Events

often occur between 8:30 p.m. and 10:30 a.m. • Minimize stress factors such as long waits, crowded, confined spaces, and

inflexible policies for patients where possible. • Avoid wearing jewelry or neckties that can be grabbed or tugged. • Recognize and report any signs of inappropriate angry responses in co-

workers, patients and families • Encourage coworkers to report incidents • Immediately report all assaults to your supervisor and security. • Be aware that many agency security staffs have minimal training. • Receive education on local gangs and gang violence. • Participate in agency safety committees to ensure that adequate security

measures are in place.

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• Once the decision is made to restrain patient, act quickly and decisively. Determine what appropriate type of restraint is to be applied before approaching patient. Restraints include cloth chest and limb restraints or leather (hard) locked restraints. (Note: When using hard restraints, make sure you have the key, and double-check that they are locked after apply- ing them to patient.) Have equipment ready before approaching patient.

• Never attempt to restrain a patient by yourself. Have adequate staff members available (usually three to five persons) and a plan of action before attempting to physically control a patient. Recruit reliable help from all possible sources, such as security. Assess their experience in managing a violent patient and review the plan. Decide in advance who will grab which arm or leg if patient must be restrained. The presence of a number of staff members (show of force) alone may subdue a patient. Identify a leader before taking any action.

• Designate one person to talk with the patient and another to direct the other staff. Only one staff member should talk with patient, preferably someone who knows him or her. It is important to communicate in a firm manner, speaking slowly. Lack of leadership can cause confusing and contradictory messages and result in someone being hurt or the patient escaping. Remove other patients from the area.

• Maintain a firm base of support for balance if you are suddenly pushed. Remove name badge, eyeglasses, jewelry, and so on to avoid injury.

• If patient is resisting, he or she may need to be distracted. Each staff member should grab one of the patient’s limbs when given the command by the coordinating person and take the patient down to the floor or bed quickly. Attempt to cradle patient’s head to prevent injury.

• Once restraints are applied to bed frame, take the time to talk with the patient in a calm, concerned manner to try to humanize situation. Call patient by his or her name.

• Make sure patient has no potential weapons within reach. Patient needs to be searched for sharp objects, matches, and so on.

• Administer medications as ordered. • Be aware of agency policy regarding application of restraints. Require-

ments for monitoring patients while in restraints, reasons for restraints, doctor’s orders, and the length of time each order remains valid should be clearly spelled out in agency policies. If you are not sure about using restraints on someone, discuss with your supervisor to weigh your obli- gations to protect the patient versus going against the patient’s wishes.

• Monitor the patient closely and document findings according to agency policy including vital signs, circulation extremities, and intake/output.

• Remove restraints and observe patient closely when the situation is under control. Consider removing restraints from one limb at a time so that the patient has time to adjust. For the high-risk patient, keep one arm and one leg in restraints at all times until it is clear that patient can be

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released. Inform other staff members that patient has been released. Establish clear criteria for reapplying restraints with patient and staff. Prepare family for patient’s condition, as appropriate.

• Once the patient has regained control, discuss with him or her why that intervention was used, and allow opportunity to express feelings. This increases his or her sense of control and decreases dehumanization.

• If the patient has a gun or other weapon, never attempt to disarm him or her. Contact security and/or law enforcement agency as soon as possible. Focus on getting assistance and protecting patients and staff. Patients and staff should remain in a safe area until help arrives.

• Consider taking a specialized class on use of defensive techniques such as management of assaultive behavior. Proper training is essential to prevent injury to patients and staff. Staff members can practice with each other to demonstrate how they would handle a violent patient.

• Identify jobs at higher risk of exposure to violence and ensure that employees in these jobs have adequate training. Agency management should be providing adequate support and possibly critical incident debriefing to assist staff recovery after a violent event.

ALTERNATE NURSING DIAGNOSIS

Anxiety Coping, Ineffective Self-Esteem, Disturbed Thought Processes, Disturbed

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WHEN TO CALL FOR HELP

• Escalation of behavior from aggressive to violent • Patient in possession of a weapon • Inadequate staff members available to control behavior • Increased staff anxiety over caring for the patient • Staff members at risk for violence without adequate training/security • Staff potential for injury or emotional trauma

WHO TO CALL FOR HELP

• Other colleagues in area of incident • Security/law enforcement • Psychiatric Team

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PATIENT AND FAMILY EDUCATION

• Review early warning signs of escalation of aggressive behavior with patient and his or her family.

• Instruct patient on role of alcohol and drugs in contributing to aggressive behavior.

• Instruct on use of prescribed medications to control tension. Instruct on when to ask for PRN medications.

• If patient is in restraints, review with him or her criteria for removal and reinstatement.

CHARTING TIPS

• Document all actions taken to prevent violent behavior. • Document application of restraints including type, length of time in

restraints, reasons for application, patient response, release of limbs, and care given while in restraints. Document vital sign monitoring.

• Document need for and response to medication given. • Document any threats made by patient • Document alternatives tried to avoid restraints • Document all interventions and responses to them.

COMMUNITY-BASED CARE

• Provide information to patient’s family and/or caregivers about emergency psychiatric services, if needed. Discuss potential for violence with family to share possible strategies from nursing care plan.

• Provide information on shelters and/or domestic violence services, if appro- priate.

• If patient is being transferred to another facility, share concerns about patient’s behavior and interventions and share any history of violent behavior.

• Provide information to family and caregivers on what to do if behavior is out of control. Encourage them to call for help immediately.

• Provide information and referrals on drug treatment if appropriate. • Provide family/caregivers with information on resources for support, how

to get emergency assistance

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9

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Problems with Affect and Mood

The Depressed Patient

Learning Objectives • Differentiate feeling depressed from a depressive disorder. • Describe common physical symptoms seen in depressive disorders. • Describe interventions for the patient with low self-esteem. • Describe possible nurses’ reactions to the depressed patient

Glossary Anhedonia – Loss of pleasure in activities or interests that were previously

enjoyed. Dysthymic disorder – Mild to moderate chronic depression lasting at least

2 years. Major Depressive Disorder – Primary psychiatric illness manifested by char-

acteristic symptom clusters such as depressed mood, lowered self-esteem, pessimistic thoughts, and loss of pleasure or interest in former activities.

Masked depression – Concealed depression in which patient is not aware of depressed mood or does not display obvious sadness. The depression is expressed through other means, such as physical complaints or diverse psy- chiatric symptoms such as phobias or compulsions.

Psychomotor agitation – Classic symptom cluster of depression including restlessness with rapid, agitated, purposeless movements like pacing or wringing hands .

Psychomotor retardation – Classic symptom cluster of depression including slow movements and speech.

Seasonal affective disorder (SAD) – Depression associated with shortened daylight in winter and fall. It disappears during spring and summer.

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Feeling down, discouraged, and depressed is something all people experience at different times in their lives. Periods of emotional highs and lows are normal.

Depressive illness, also known as major depressive disorder, however, is very dif- ferent from simply feeling depressed. Major depressive disorder is a psychiatric illness characterized by a cluster of symptoms including prolonged depressed mood, lowered self-esteem, pessimistic thoughts, and loss of pleasure or interest in former activities for at least 2 weeks. It is a painful, debilitating illness. It needs to be differentiated from short-term depressed moods or grief reactions, which are normal. Although grief displays many of the signs and symptoms of depres- sion, it is a time-limited condition in response to an obvious loss and does not cause lowered self-esteem. The Diagnostic and Statistical Manual of Mental Dis- orders, 4th edition text revision, 2000, also known as DSM-IV-TR, describes dys- thymic disorder as a chronic depressed mood most of the day for more days than not during a period of 2 years. Seasonal affective disorder is another form of depression. Adjustment disorders with depressed mood can also occur in response to situations like illness and loss. This disorder is of shorter duration but may progress to major depressive disorder in some cases.

Depression is the most common reason for seeking out mental health professionals. A major source of diagnosis is primary care providers who diagnose one-third to one-half of people identified as having depression (Agency for Healthcare Quality and Research, 2000). It is the leading cause of disability in the United States (Montano, 2003). About 5% to 8% of the population suf- fers from some form of depression at any one time (NAMI, 2007). There is a 16.6% chance of developing a major depressive disorder in one’s lifetime (Kessler et al., 2005). Because the symptoms of depression can be hidden and vague, and may present as physical symptoms instead of a mood disturbance, primary care physicians may be the first to see the patient. However, the symp- toms of depression can often go unrecognized and are often misdiagnosed. Undiagnosed and untreated depression is considered a major national health con- cern, contributing to poor work performance, family disruption, substance abuse, and premature death as a result of suicide or lack of self-care. Family history, stressful life events, and a previous history of depression are major pre- dictors. Women are twice as likely to suffer from depression as men. Although men have a greater tendency to suffer a masked depression that can be concealed with drug use, alcohol abuse, and long work hours. Without treatment, these episodes can increase over time. It crosses all ethnic lines. In addition, depression can be part of a bipolar disorder psychosis, eating disorders, or dementia. Depression can also be secondary to a primary problem such as substance abuse or schizophrenia.

Once a person experiences a depressive episode, there is a high risk for recur- rence. After one depressive episode, an individual has a 50% chance of another; after two episodes, there is a 70% to 80% risk of another; and after three episodes, the individual is at very high risk for chronic disability from depression (DSM-IV-TR, 2000).

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ETIOLOGY

No single theory of depression is accepted by all theorists and clinicians. Differ- ent theories may apply to the divergent pathways that patients travel to arrive at the various types of depression.

Biological theories have focused on an insufficiency of neurotransmitters, especially norepinephrine and serotonin. These insufficiencies may be the result of inherited or environmental factors. The effectiveness of antidepressants may result from enhanced levels of these neurotransmitters. The most severe depres- sions are predominantly biologically determined. Hormonal factors, including abnormal melatonin metabolism, are associated with seasonal affective disorder (also called major depression with seasonal pattern).

Genetics may be a factor in more severe depressions. Relatives of people with depression have a higher incidence of this illness than those in the general population.

Psychological theories about a predisposition to depression have focused on a personal history of deprivation, trauma, or significant loss during childhood. These patients may be more susceptible to depression because current losses revive memories of former losses. They are more likely to experience low self- esteem and powerlessness.

Depression can be viewed as forbidden anger that has been turned inward. Classic psychoanalytic theory identified depression as the reaction to the loss of a significant person who has been both hated and loved. The patient handles this ambivalence by turning the hatred inward, resulting in depression and low self-esteem, whereas the memory of the departed person remains beloved and idealized.

Certain predominant issues of low self-esteem and helplessness are major con- tributors. For instance, low self-esteem may be based on the faulty development of an adequate, competent sense of self during childhood. As a child, the patient may have received attention and approval only when meeting parental needs and expectations. In adulthood, the absence of external support and praise and espe- cially the loss of a supportive person may make the patient vulnerable to loss of self-esteem, which triggers depression.

Learned helplessness is displayed by a lack of adequate effort based on the belief that a person cannot be effective in getting needs met or making an impact. This person grew up in an environment that did not respond to any actions or initiative that he or she took (Seligman, 1975).

Distorted thinking can generate depression. Typically, the patient has negative expectations about himself or herself, the world, and the future. If he or she con- sistently overgeneralizes any mistake into the conclusion “I can’t do anything right” and judges himself or herself as deficient, these negative beliefs can build toward depression. Negative expectations of the world, such as receiving no help from others or expecting only criticism, reinforce helplessness and lead to hope- lessness (Beck, 1979).

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RELATED CLINICAL CONCERNS

Clinically significant depressive symptoms are detectable in about 12% to 36% of the medically ill population (DHHS, 1993). The risk for depression greatly increases among people with a medical disorder (Varcarolis, 2006). Valente and Saunders (1997) reported that 20% to 25% of people with cancer experience depression that often goes untreated. Untreated depression in the medically ill can contribute to longer hospital stays, poor compliance, poorer quality of life, and increased doctor visits. It may also impact morbidity and mortality (Rouchell, Pounds, & Tierney, 2002). Major depressive disorder associated with a myocardial infarction has been shown to contribute to a higher mortality rate. This may be caused by changes in the endocrine and immune systems as well as reduced motivation and compliance (Rouchell et al., 2002). Stewart, Janicki, Muldoon, Slatton-Tyrell, & Kamarck (2007) reported that physical symptoms of depression may play an important role in the earlier stages of the development of cardiovascular disease. The patient’s response to a medical illness could cause depression, and in some cases might precede it as can been seen in hypo- or hyperthyroidism, Addison’s disease, and Huntington’s disease. Symptoms of some illnesses such as fatigue or changes in appetite or bowel habits, can also mask depressive symptoms, making it diffi- cult to diagnose. See Box 9–1 for a list of medical disorders associated with depression.

In addition, some medications can trigger depression (Box 9–2).

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BOX 9–1 Medical Conditions Associated with Depression • Stroke (especially frontal lesions)

• Myocardial infarction

• Adrenal disorders

• Dementia

• Diabetes

• Cancer

• Hypothyroidism

• Brain tumors

• Parkinson’s disease

• Multiple sclerosis

• Chronic pain

• End stage renal disease

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LIFE SPAN ISSUES

Children Experts do not agree on the prevalence of depression in children; however, there is consensus that it does occur, even in young children. Children as young as 3 years of age have been diagnosed with depression (Varcarolis, 2006). Depression could be the aftermath of emotional deprivation, abuse, or separation. Children who were abused or neglected are known to be at a higher risk for major depres- sive disorder in childhood and adulthood (Widom, Dumong, & Czaja, 2007).

Because the child may be unable to express feelings or worries, other signs need to be analyzed, including acting-out behaviors, conduct disorders, inappro- priate aggression, refusal to go to school, negativity, irritability, not meeting

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BOX 9–2 Drugs That Cause Depression • Antihypertensive agents

• Reserpine • Beta blockers • Methyldopa • Oral contraceptives

• Steroids • Benzodiazepines • Anabolic steroids • Amphotericin-B • Cancer chemotherapeutic agents

• Vincristine • Vinblastine • Interferon • Procarbazine • L-asparaginase

• Psychoactive agents • Alcohol • Amphetamine or cocaine withdrawal • Opioids

Source: Rouchell, A. M., Pounds R., & Tierney, J. G. (2002). Depression. In J. R. Rundell & M. G. Wise (Eds.), Textbook of consultation-liaison psychiatry (pp. 307–338). Washington DC: Ameri- can Psychiatric Press; Dubovsky, S. L., Davies, R., & Doboxsky, A. N. (2003). Mood disorders. In R. E. Hales & S. C. Yodofsky (Eds.), Textbook of clinical psychiatry (4th ed) (pp. 439–542). Washington, DC: American Psychiatric Press.

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developmental tasks, sleep disorders, inability to experience joy (anhedonia), and self-destructive behaviors. There is a higher risk of depression in children when one or both parents suffer from major depression. Depression can also be a sec- ondary reaction to other problems such as learning disorders and substance abuse. Children have been treated successfully with antidepressants in conjunc- tion with psychotherapeutic interventions. However, precautions must be taken because of the potential increased suicide risk for children and adolescents. The Food and Drug Administration label on anti-depressants recommends close mon- itoring for increased suicide risk (Fochtmann & Gelenberg, 2005) leading to a dramatic reduction in prescriptions for SSRIs for young people (Leckman & King, 2007). Maternal depression while a child is young puts him or her at par- ticularly high risk. Because the recurrence rate of depression is so high in children and adolescents, treatment is essential to prevent a lifetime of disability from it (NIMH, 2007a).

Adolescents National Institute of Mental Health (NIMH) (2007b) estimates that 5% of ado- lescents suffer from major depressive disorder. Adolescents often do not express feelings of depression verbally because they may fear exhibiting feelings of vul- nerability and dependency. Rather, their feelings of depression are often expressed in self-destructive or antisocial behaviors including sexual promiscuity, school truancy, threats, or petty crime. Some experts believe that substance abuse, antisocial behavior, and eating disorders in adolescence may be masking or related to depression. A depression-prone adolescent with low self-esteem will have greater difficulty achieving a positive sense of self as an adult. Adolescent victims of abuse and a history of parental depression contribute to a particular vulnerability to depression.

Postpartum Debate continues as to whether the cause of postpartum depression is solely hor- monal or represents an intermingling of psychological and physiological stres- sors. Although postpartum “blues” (a few days of labile mood after the birth of a baby) are extremely common, more severe reactions are relatively rare. Post- partum depression can include psychotic symptoms including delusions that often concern the newborn infant. Bonding with the infant is disrupted. Women with a history of prenatal depression and bipolar disorder are at higher risk. Once a woman experiences a major postpartum depression with psychotic fea- tures, the risk of recurrence in subsequent deliveries is between 30% and 50% (DSM-IV-TR, 2000).

Older Adults Depression is the most common emotional disorder of later life. Elderly people are at higher risk because they experience multiple losses and more medical

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illnesses than the rest of the population. However, in geriatric patients, depres- sion is more likely to be masked rather than exhibited by typical depression symptoms such as sadness, so it is often not diagnosed. Using the Geriatric Depression Scale is a useful way to capture this diagnosis. Even though these individuals may see a doctor more frequently than younger adults, it remains undertreated (Varcarolis, 2006). Symptoms are often more physical or expressed as personality changes, including irritability. Depression can also be superim- posed on dementia or confused with pseudodementia because common depres- sive symptoms in elderly persons include confusion, distractibility, and memory loss. In addition, some of the physical symptoms of depression such as fatigue, anorexia, constipation, and psychomotor retardation can be confused with phys- ical illness, medication interactions, substance abuse, or “signs of old age.” Treat- ment with antidepressants must be very closely supervised because of the possibility of severe side effects, but it can be very helpful. Electroshock treat- ments may also be tried in an elderly patient who is unresponsive to antidepres- sants. Risk factors for depression in older adults include alcohol and substance abuse, dementia, cancer, stroke, myocardial infarction, functional disability, being widowed or a caregiver, and social isolation (Kurlowicz, 2003).

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POSSIBLE NURSES’ REACTIONS • May feel depressed when working with these patients. A patient’s despair

and unhappiness can be very painful to be around and could lead to the nurse’s avoidance of the patient.

• May reject the patient because of own perception of the patient’s depend- ency. Or may become over-involved because of patient’s needs and inadver- tently create more dependency.

• May resent patient because of the longer time it takes to provide care.

• May feel angry or frustrated with depressed patient who isn’t “helping him- self or herself” or can’t just “snap out of it.”

• May feel inadequate when unable to make a quick impact on a patient’s depression. Nurse may create unrealistic expectations of patient’s recovery.

• Staff members may have inaccurate beliefs about the cause of depression, which may lead to their minimizing the degree of the patient’s suffering.

• Because of the high prevalence of depression in our society, the nurse may have personally experienced it or may have witnessed a family member’s struggle with depression. This can cause the nurse to identify with the depressed patient and reexperience these feelings.

• Reaction may depend on whether the nurse believes that the expression of sadness is an acceptable behavior; for example, the nurse may believe sad- ness is acceptable in women but not in men.

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ASSESSMENT

Behavior and Appearance • Persistently sad, anguished, or apathetic facial expression • Dejected appearance: Head down, poor eye contact, posture slumped as if

bearing a heavy weight • Psychomotor agitation and/or retardation • Decreased interest in grooming and self-care • Decreased sexual interest • Makes statements like “I don’t care any more” • May have difficulty with even simple tasks • Anhedonia

Mood and Emotions • Dysphoric mood: Verbalizes feelings of sadness and depression • Inability to enjoy activities that were enjoyed previously • Low self-esteem with feelings of worthlessness and inadequacy • Feeling ineffective, powerless, and helpless • Pessimistic: May appear brooding and express feelings of futility and despair • Feelings of great heaviness • Mild to high levels of anxiety, possibly including panic attacks and irritability • Unexpressed anger, turned inward against self • May express generalized anger • Ambivalence: may feel two opposing ways at the same time

Thoughts, Beliefs, and Perceptions • Thoughts slowed • Poor concentration with possible temporary impairment of recent memory • Self-doubt with relentless rumination and obsessions • Lack of self-worth: Believes self undeserving of good experiences • Indecisiveness • Preoccupation with body changes • Loss of perspective: May reject positive comments from others; gives self no

credit for achievements • Excessive guilt: condemns self; feels deserving of punishment • Narrowing of interest to self • Possible suicidal thoughts • Confusion

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• In severe depression: delusions; hallucinations that express feelings of worthlessness; guilt

• Believes life has no meaning and that there is no future

Relationships and Interactions • Withdrawal from social interactions • Deterioration of relationships because of preoccupation with self, anger,

and anxiety • Increasing dependence on others because of inability to make decisions or

care for self

Physical Responses • Slowed physiologic functioning evidenced by:

• Lethargy and fatigue, especially in the morning • Constipation • Decreased appetite with weight loss or increased appetite with weight

gain • Sleep problems including early morning awakening, frequent awaken-

ings, waking up feeling tired, sleeping all the time • Body aches; pains such as headaches; indigestion; dizziness

• Thyroid function tests may be ordered to rule out hypothyroidism

Pertinent History • Past history of depression, bipolar disorder, panic attacks, suicide attempts • Family history of depression • History of substance abuse • History of stroke or myocardial infarction (particularly high rate of

depression)

See Box 9–3 for List of Commonly Used Depression Scales.

COLLABORATIVE MANAGEMENT

Pharmacological The advent of so many new antidepressants has provided many more opportuni- ties for successful treatment. The American Psychiatric Association Practice Guidelines for Major Depressive Disorders (Karasu, Gelengerg, Merriam, & Wang, 2000; Fochtman & Gelenberg, 2005) recommend antidepressants be pre- scribed for moderate to severe depression and can be used with mild depressive symptoms if the patient wishes. Components of firstline treatment today are the Selective Serotonin Reuptake Inhibitors (SSRIs) and newer atypical antidepres-

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sants. Because there are so many on the market that have the same effectiveness but side effects differ (AHRQ, 2007). Other variables are patient profile, history of previous response, type of depression, rate of onset, concurrent medical or psy- chiatric illnesses, and other medications the patient is taking. See Chapter 21 for a detailed discussion of antidepressants, their side effects, and nursing implica- tions. Most antidepressants require at least 3 to 4 weeks of use before full bene- fits are obtained. Often, relief of other symptoms occurs before a change in the patient’s subjective sense of feeling better. Side effects must be monitored closely. The patient may need to remain on a maintenance dose of antidepressant for many years.

Monoamine oxidase inhibitors (MAOIs) are used less today but may be a second- or third-line treatment for depressions that do not respond to the more commonly used antidepressants. If the patient is experiencing anxiety, panic attacks, hallucinations, or delusions, other medications may need to be added. A trial of stimulants such as methylphenidate hydrochloride (Ritalin) or modafinil (Provigil) may be tried in adults with severe psychomotor retardation.

Herbal products that are used for depression include stimulants such as ma huang, which contains ephedra, Gingko biloba, and SAM-e. The most common herbal product for this use is St. John’s wort. As with most herbal products, there are potential side effects and drug interactions. St. John’s wort is known to inter- act with some HIV medications and can inhibit effectiveness. However, con- trolled trials on St. John’s wort have been inconclusive (Fochtmann & Gelenberg, 2005). An alternative, nonpharmacological approach is light therapy, particularly useful in seasonal affective disorders. Exposure to natural light is shown to reduce depression and improve alertness (Nelson, 2006).

Psychotherapy Psychotherapy and other psychosocial treatments continue to be an important component of depression treatment. A combination of psychotherapy and phar- macotherapy is more effective than pharmacotherapy alone. Combination ther- apy is particularly helpful in improving treatment adherence (Fochtmann & Gelenberg, 2005). One short-term psychotherapy approach is cognitive therapy. This method is brief, structured, directive treatment designed to alter the negative thoughts so common in depression. Group therapy can also be helpful to enhance the patient’s socialization.

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BOX 9–3 Commonly used Depression Assessment Scales • Beck Depression Inventory • Zung Self-rating Depression Scale • Geriatric Depression Scale • Hamilton Depression Scale

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Electroconvulsive Therapy Electroconvulsive therapy (ECT) is a first-line treatment option only for patients with more severe or psychotic forms of depression. It may also be used for those who have failed to respond to other therapies or those with medical conditions that preclude the use of antidepressants.

NURSING MANAGEMENT

SELF-CARE DEFICIT evidenced by decreased ability to manage own hygiene, grooming, feeding, and daily activities related to loss of energy, inhibition of motivation, anxiety, and/or dependency.

Patient Outcomes • Increased participation in self-care, daily activities • Improved grooming and hygiene

Interventions • Determine patient’s level of self-care before onset of depressive symptoms

to set realistic goals. • Assess whether the patient is expressing certain psychological needs such

as dependency or rebellion by not performing self-care. Observe whether patient acts more independently when unaware of being watched.

• Encourage as much independence as possible. Take the time to allow patient to do things for himself or herself. Assign care to staff member who may have more time or is especially patient. Make sure all staff members reinforce patient’s participation. Encourage patient’s participa- tion in decisions about timing, sequence, and approaches to self-care.

• Create a positive attitude that patient can learn and progress with prac- tice. Avoid taking over for the patient if he or she has trouble.

• If patient is not eating, encourage small meals that are high in protein and nutrition dense.

• Break down tasks into small steps so patient can experience some suc- cess. For instance, have the patient focus on washing his or her face rather than completing the whole bath. Recognize that patient’s thinking processes are slowed.

• Create an environment to ease patient’s participation, such as having proper utensils available at mealtime or having the walker available in room if patient is ambulating to bathroom.

• Provide reassurance and encouragement. Avoid minimizing patient’s problems or infantilizing him or her.

• At times, a nurse may need to make all decisions for a very depressed patient such as when to eat. Then, as the patient begins to improve,

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limited options can be presented. With further improvement, the patient should take on increasing decision making.

SELF-ESTEEM DISTURBANCE evidenced by statements of low self-esteem, misinterpreting positive or pleasurable experiences, expressions of shame and guilt related to feelings, thoughts of worthlessness, failures, and negative rein- forcement.

Patient Outcomes • Identifies positive aspects of self • Modifies unrealistic expectations for self • Demonstrates reduced symptoms of depression

Interventions • Provide emotional nurturing through empathetic listening and support-

ive encouragement. Treating the patient as a valued individual will enhance his or her self-esteem.

• Avoid blanket reassurances like “things will get better soon.” These tend to alienate the patient, who may feel that you don’t understand his or her pain.

• Encourage patient to share feelings, especially negative ones. If this is too difficult, consider alternative means of expression such as writing about feelings or drawing pictures.

• Point out any specific improvement, no matter how small. Depressed people often do not see improvement because they are so focused on the negative. Consider keeping a progress chart at the bedside to record con- crete accomplishments such as the number of times the patient ambulates or the percentage of food he or she eats.

• Encourage patient to speak up if he or she disagrees or feels his or her rights are being violated. Reinforce assertive response.

• Recognize and point out manifestations of self-destructive or self- undermining thinking or behavior:

• Requiring self to be perfect or setting unattainable goals • Assuming responsibility for and feeling guilt about failures and events

that are outside the patient’s control • Basing entire feeling of self-worth on one achievement or attribute, a

single relationship, or obtaining approval from others • Projecting own feelings of self-hate onto family, staff, or friends, such

as “All the nurses hate me.” “My family blames me for my illness.” • Expressing self-hate directly through suicidal thoughts and behavior • Expressing self-hate indirectly with repeated accidents, noncompli-

ance, provoking or being antagonistic to others, thereby unwittingly creating rejection

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• Covering poor self-esteem with anger, blaming, or other maneuvers that displace responsibility onto others

• Suggest that the patient identify a few achievements from the past. • Discuss and practice with patient alternative ways to respond to stress

and to ask for what he or she wants.

POWERLESSNESS evidenced by lack of initiative, nonachievement of realis- tic goals, passivity; nonparticipation in decision making related to decreased motivation, decreased energy, hopelessness, perfectionistic expectations or sadness.

Patient Outcomes • Identifies factors that he or she can control • Participates in decisions about his or her care

Interventions • Encourage the patient to describe feelings or the experience of power-

lessness. Let the patient know that you are interested and that you under- stand his or her pain. For instance, you may state, “You believe there is no hope for you to ever feel better.”

• Once the patient indicates that he or she feels understood, suggest alter- native viewpoints. Work with patient to identify times in life when he or she felt better or felt more in control.

• Work with the patient to identify realistic goals to work toward. Encour- age having patience and accepting current limitations. Break down goals into small steps and recognize progress as each is achieved.

• Allow the patient to maintain reasonable control over some of the daily routine if able.

• Have the patient list specific situations in which he or she felt powerless. Correct distorted assumptions, discuss alternative ways to handle situa- tions, and identify helpful resources.

• Direct the patient to other topics if he or she obsesses on unrealistic goals or things that cannot be changed.

ALTERNATE NURSING DIAGNOSES

Anxiety Coping, Ineffective Grieving, Dysfunctional Hopelessness Injury, Risk for Nutrition, Altered Sleep Pattern, Disturbed

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Social Interaction, Impaired Thought Processes, Disturbed

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WHEN TO CALL FOR HELP

• Extreme self-care deficit to point of not being able to care for basic needs

• Suicidal thoughts, threats, or attempts • Hallucinations or delusions • Severe side effects from antidepressants, including severe urinary

retention, dramatic fluctuations in blood pressure, cardiac complica- tions, seizures

WHO TO CALL FOR HELP

• Psychiatric Team • Social Worker • Attending Physician

PATIENT AND FAMILY EDUCATION

• Teach the patient that depression can generate feelings of helplessness, pow- erlessness, and pessimism. Encourage the patient to delay major decisions and actions based on those feelings, and reinforce the idea that the severe symptoms will abate with treatment and time.

• Reinforce the idea that depression is a treatable illness. Even though the patient may feel hopeless, the illness is not.

• For patients on antidepressants, review potential side effects and impor- tance of taking the medication even when they start feeling better. Patient should know which side effects to report to physician. Reinforce that these medications should not be stopped abruptly.

• Inform the patient that other medications are available if the side effects from the current one are too uncomfortable.

• Encourage the patient to maintain a schedule of activity. • Explain to the family the symptoms of depression, medication management,

and interventions and what the family can do to assist and encourage the patient.

• Teach the patient and family to report signs of increasing depression or sui- cidal thoughts.

• Teach the patient that long-term, enduring self-esteem comes from beliefs about self as a valuable human being and is expressed through achieve- ments, relationships, and healthful living.

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• Inform the patient that the negative assumptions about himself or herself are not necessarily true.

• Direct patient to American Psychiatric Association Website for “Patient and Family Guide to Major Depressive Disorders” (healthyminds.org) and National Mental Health Association website for a confidential screening test on depression (depression-screening.org).

CHARTING TIPS

• Document patient activity, intake, sleep patterns, and bowel patterns. • Document any expressed suicide thoughts, plans, or attempts. • Document side effects of medication. • Document patient response to encouragement or support.

COMMUNITY-BASED CARE

• Strongly encourage patient to seek counseling. Give appropriate referrals. If patient is too depressed to have the energy to follow through, involve fam- ily or friends in seeking help.

• If patient is unable to care for himself or herself or is potentially suicidal, work with other members of the team as well as family to determine dis- charge options. Patient may need psychiatric hospitalization or temporary placement in a board and care or convalescent facility.

• Refer patient for psychiatric home health care for follow-up on medication compliance and self-care activities.

• Encourage patient to maintain follow-up with physician and compliance with treatment plan.

The Suicidal Patient

Learning Objectives • Identify risk factors for suicide. • Differentiate between a suicide attempt and a suicide gesture. • Describe effective interventions to protect the high risk patient in the

hospital. • Describe common nurses’ reactions to the suicidal patient.

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Glossary Completed suicide – Suicide attempt resulting in death. Deliberate self-harm – Willful self-inflicting of painful, injurious acts without

intent to die. Lethality – The level of risk in suicide method chosen to cause death. The

more lethal methods include guns, jumping, and hanging. Lower lethality methods include superficially slashing wrists, inhaling house gas, and ingesting pills because death is not immediate and there is more of a chance of being found and treated.

Psychological autopsy – Retrospective review of deceased person’s life to establish likely diagnosis at time of death.

Suicidal ideation – Thoughts about harming one’s self. Suicide – Self-inflicted death with evidence that person intended to die. Suicide attempt – Any act intended to end in suicide. Suicide gesture – Any action that appears to be a suicide attempt but that is

actually contrived or manipulative and that results in only minimal harm, such as superficial cuts on the wrist or a small overdose of sleeping pills.

Suicide threat – Verbal threat to commit suicide.

Some nurses mistakenly believe suicidal patients are found only in psychiatric settings. However, patients with suicidal tendencies are not always easily iden-

tified, and they can be the same patients you care for in an intensive care unit, medical unit, nursing home, or in their own homes.

Many people have experienced momentary self-destructive thoughts. But obsessive preoccupation with these thoughts and acting on them is another mat- ter. Thinking about suicide does not mean that the individual will act on those thoughts; however, anyone who talks about, threatens, or attempts suicide must be taken seriously. There are individuals who may perform deliberate self-harm when they inflict injury on themselves without intent of death. These individuals often are not suicidal, but a psychiatric evaluation would need to be done to determine this. In approximately 70% of suicides, the individual has one or more active or chronic medical illnesses at the time of death (DHHS, 1993). See Table 9–1 for key risk factors. 90% of suicide victims suffer from at least one psychi- atric disorder. Major depressive disorder is most common. Others include bipo- lar disorder, schizophrenia, substance abuse, panic disorder, borderline and antisocial personality.

There are approximately seven suicide attempts for every completed suicide. All cultural groups are vulnerable although American Indians have a higher rate. Women make more attempts than men, but men are more likely to complete the suicide because they tend to use more lethal methods, particularly firearms (CDC/National Center for Health Statistics, 2004). Firearms are the leading form of suicide followed by suffocation and poisoning (CDC, 2004). Three factors that need to be present for a completed suicide include:

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• Specific plan, • Lethality, and • Access to lethal method.

Suicide is the 11th leading cause of death in the United States and there are about 89 suicides per day (American Association of Suicidology, 2004). However, it may be higher because hidden suicides such as “accidental” overdoses, auto accidents, noncompliance with medical regimens, or not seeking medical care for symptoms are not reported as suicides. Most suicide attempts are expressions of extreme distress, not bids for attention (Captain, 2006).

Because suicide is basically not accepted by our culture, it generates anxiety that has led to a number of myths (Box 9–4).

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BOX 9–4 Clearing up the Myths About Suicide Myth Asking people about their suicidal thoughts will make them more likely to act on them. All people who attempt sui- cide have a psychiatric dis- order. A person who talks about suicide won’t do it.

A person who attempts sui- cide won’t try again.

People who attempt suicide are always determined to die. People who attempt suicide just want attention. As the person becomes less depressed, the risk of suicide decreases.

Truth Most patients are not afraid to talk about their thoughts of committing suicide and are usually grateful that someone is available and cares. Talking can reduce the sense of isolation. People can become overwhelmed with life circumstances without having a psychiatric disorder. Approximately 80% of individuals who attempt or complete suicide give some definite verbal or indirect clues. As many as 50% have seen their physician within the previous month, often with vague somatic complaints. Almost 75% of those individuals who com- plete suicide have attempted it at least once before. Many individuals are ambivalent and are using the suicide as a cry for help. Even if the suicide attempt is manipulative, the individual may go on to complete the suicide. As the depression lifts, the individual’s energy level can increase before feelings of hopeless- ness are relieved. Once the individual makes the decision that suicide is an effective solu- tion to the problems, his or her mood may even elevate.

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It is estimated that each person who commits suicide leaves behind at least six survivors who suffer many emotional complications. The American Association of Suicidology (2007) notes that survivors have a higher risk of suicide them- selves. Surviving family and friends of the suicide victim often experience com- plicated grief reactions that may affect them for the rest of their lives. They are faced with the stigma of this form of death as well as many unresolved feelings of anger and guilt. Unfortunately, they may receive less support from others because of the discomfort surrounding the cause of death. In addition, many life insurance policies do not cover self-inflicted death, so the surviving family may be economically devastated.

ETIOLOGY

Suicide is not a disease in itself but a symptom of some underlying problem. Bio- logical and genetic theories are closely tied to those causing depression. It is believed that low levels of the neurotransmitters, serotonin and norepinephrine, are a factor in the decision to commit suicide. There is also a strong link to alco- hol and substance abuse. Suicidal behavior also runs in families. This may be related to genetics or to psychological factors in which suicide is viewed as an acceptable way to cope. The risk of suicide in family members of individuals who have committed suicide is 15 times greater than in the general population. Cap- tain (2006) reports that psychological autopsies reveal that in 90% of completed suicides, the person had one or more mental disorders with the most common being major depression and substance abuse.

Psychological theory focuses on a number of motivating forces. Suicide can be a way to escape deep psychological pain or atone for past sins. Intense feelings of hopelessness and helplessness are key factors. It can be related to unacceptable feelings of aggression, which the individual turns inward. The individual could believe that he or she is reuniting with a loved one. The wish to instill guilt in a significant person who is perceived as abandoning or rejecting could motivate the suicidal person. Individuals with limited coping reserves who become over- whelmed with stress may seek self-destructive acts as a way to escape these feel- ings. Because the suicidal person may be severely depressed, the theories on etiology of depression and substance abuse may also relate to suicide.

Suicidal behavior can also be a symptom of psychosis as the person acts out hallucinations or delusions. Command hallucinations, in which voices tell the patient to kill himself or herself, create a very high risk. Severe anxiety and dis- tress regarding psychotic symptoms as well as lack of judgment or reality testing may lead to suicide as a way to escape overwhelming anxiety or disturbed thoughts.

Suicidal gestures with nonlethal self-mutilation may occur in individuals who have poor impulse control or a high need for the attention or control of others. An individual with a history of multiple threats and gestures may have a border- line or other personality disorder.

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Sociological views look at a person who may feel alienated from others. A sus- ceptible individual who no longer feels part of his or her culture or social group could be at an increased risk, especially if cultural or religious taboos against sui- cide are not very strong. For some, suicide is a way of expressing political beliefs. Economic losses or unemployment could also play a role as a person feels trapped and powerless to change. Suicide is an increasing problem in minority and eco- nomically deprived groups. It can also be associated with substance abuse. A psy- chological autopsy can be used by the psychiatry team and survivors after a completed suicide to try to understand the etiology. See Box 9–5 for Risk Factors and Protective Factors that may help to estimate suicide risk.

RELATED CLINICAL CONCERNS

Physical illness is a frequent contributor to suicidal behavior. Illnesses associated with suffering and dependency, such as advanced cancer and AIDS, are more apt to be associated with higher suicide rates. Uncontrolled pain and delirium are the key variables with these illnesses. The terminally ill patient’s “right” to commit suicide has been debated for many years. Right-to-die groups have supported

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BOX 9–5 Risk and Protective Factors Risk Factors for Increased

Risk of Suicide Psychiatric diagnosis Physical illness Psychosocial factors including recent lack of social support, unem- ployment, recent stressful event Childhood traumas such as sexual abuse Family history of suicide, mental illness Psychological characteristics includ- ing hopelessness, anxiety, impul- siveness, aggression Demographics including male, widowed/divorced/single, elderly

Factors Associated with Protective Effects for Suicide

Children at home Sense of responsibility to family Pregnancy

Religiosity

Life Satisfaction

Positive coping skills

Positive social support

Positive problem solving skills

Source: Jacobs, D. G., Baldessarini, R. J., Conwell, Y., Fawcett, J. A., Horton, L., Meltzer, H., et al. (2003). Practice guideline for the assessment and treatment of patients with suicidal behaviors. Washington, DC: American Psychiatric Association.

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initiatives in several states seeking physician-assisted suicide for terminal patients. The patient’s ability to remain in control until death is a key motivation for this action. Other illnesses, such as multiple sclerosis and Huntington’s disease, that may not be terminal but are chronic and debilitating may also be associated with increased suicide risk. Suicidal patients with physical illnesses should be carefully evaluated and treated for depression. In addition, every effort to identify and con- trol any uncomfortable symptoms will enhance quality of life.

Medications that contribute to depressive or psychotic symptoms could also precipitate a suicide attempt. See Box 9–2 and Box 11–4 for lists of medications that contribute to these symptoms. Patients with suicidal tendencies who are tak- ing prescribed analgesics, tranquilizers, or sleeping pills may be at risk for saving up medications to use later for a possible suicide attempt.

LIFE SPAN ISSUES

Children Although the rate of suicide in children is low, it is rising and is cause for great concern and analysis. Young children have tried to kill themselves by jumping out of windows, hanging themselves, or running in front of moving cars. Firearms and suffocation are also common methods in the 10- to 14-year-old age group. These actions are generally impulsive and in response to intense emotion. A suicidal act may be an attempt to gain power, punish a parent, or escape stressful situations. It could also be a response to parental neglect, rejection, or abuse. A young child who does not understand the finality of death may not understand the consequences of his or her action. Children could also be imitat- ing parental behaviors. Suicidal behavior can also be related to substance abuse and school problems. Suicide is the 3rd leading cause of death in 10- to 19-year- olds (CDC, 2004).

Adolescents Suicidal behavior in adolescents is considered a serious health problem. It is the second leading cause of death in teens, accidents being the first. And some acci- dents could be concealed suicide attempts. Teens who are depressed, socially iso- lated, or using drugs and alcohol are at highest risk. Low self-esteem, history of abuse, not fitting in with peers, and school pressures may be other risk factors. As with adults, girls make more attempts but boys are more likely to use more lethal methods such as firearms. The availability of firearms in our society is believed to contribute to the increase in teenage suicides. Carbon monoxide poi- soning and ingestion of pills are other common methods used by adolescents. High-risk behaviors like drug use, drag racing, and gang activity could be mask- ing suicidal thoughts. Substance abuse, psychiatric disorders, and conduct disor- ders are risk factors in this age group. Suicide assessment should be performed on any high-risk teen.

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“Cluster” or copycat suicides, in which adolescents copy an episode of suicide of an acquaintance or celebrity, is a recent and alarming trend. To some teens the suicide of an idol can be romanticized.

Older Adults Elderly people commit suicide more often than any other age group in the United States (Jacobs et al., 2003). Elderly white men older than 80 years of age are at highest risk (Moscicki, 1999). Guns remain the most frequent method. Suicide statistics in elderly persons are probably even higher because of the prevalence of passive suicides. Elderly people are more likely to use noncompliance with medical regimens or refusal to eat as a way to hasten their death. Risk factors include living alone, widowhood, lack of financial resources, poor health, and social isolation. In addition, misuse of alcohol and antianxiety medications may contribute.

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ASSESSMENT

See Boxes 9–6 and 9–7 for suicide assessment of lethality and assessing a suicide attempt.

POSSIBLE NURSES’ REACTIONS • May see a suicidal patient as weak or bad because of personal religious or

moral beliefs. • May experience feelings of anxiety with these patients, which prevent

recognition of warning signs. • May avoid dealing with suicidal patients for fear of saying the wrong thing

or contributing to their suicide because of lack of adequate training. May believe talking to patient about suicide would increase risk.

• May believe he or she is rescuing patient and then experience intense guilt if patient does attempt or complete suicide. May take patient’s behavior as a personal rejection.

• May feel angry with patient for creating chaos, especially if the nurse per- ceives that the patient has much to live for, such as children and a good job. The nurse’s anger may conflict with his or her mission of promoting health and saving lives.

• May deny or minimize suicidal behavior as a defense against anxiety and helplessness.

• Patient’s behavior could stir up personal feelings of depression. Nurses have six times the suicide rate of the general population and much higher lethal- ity because of their knowledge and access to drugs.

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BOX 9–6 Assessing Current Suicide Lethality 1. Do you think about hurting or killing yourself? If yes: 2. Do you have a plan? How have you considered doing it? If yes: 3. Do you think you may or will do something to act on your thoughts?

If yes, where and when? Do you feel you have control over your own behavior?

4. Do you have the means available (such as rope, rolled-up sheet, gun, saved- up pills [note lethality of plan])?

5. Have you ever tried to harm yourself in the past? If yes, how? Did you expect to survive?

6. Are you willing to contract or notify staff whenever you feel you may act on these thoughts? Our side of the contract is to be available and actively help you during these times.

If patient denies having a suicide plan, ask about other plans for the future and support systems.

1. What do you see yourself doing in a week, in a month, and in a year from now?

2. Do you feel optimistic or pessimistic about the future? 3. Do you have family members or friends with whom you can freely discuss

your problems?

BOX 9–7 Assessing the Suicide Attempt 1. Did the patient expect to die? (yes, no, uncertain). Did the patient think his

or her chance of dying was high, medium, or low? Did he or she underes- timate?

2. How does the patient feel about surviving? If the patient regrets surviving, question him or her about any current plan to attempt suicide.

3. If the patient’s objective in suicide attempt or gesture was to manipulate a significant other to behave differently, have the sought-after changes occurred? Does the patient have alternative, more adaptive methods for coping?

4. Is the support system present (helpful, unhelpful)? 5. Does the patient have any hope for the future? How optimistic or pes-

simistic is he or she? 6. Is the patient willing to make a no-suicide contract?

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Behavior and Appearance • Direct verbal statements (e.g., “I wish I were dead”) • Indirect verbal statements (e.g., “You won’t see me when you come back to

work” or asking about specific suicide methods) • Giving away possessions • Agitation • Sudden changes in eating, sleeping, or usual activities • Neglecting appearance or hygiene • Drawing up a will • Refusing medications

Mood and Emotions • Depression or despair • Sudden lifting of depression, sudden elevation in mood • Apathy • Hopelessness • Helplessness • Anxiety • Bitter anger

Thoughts, Beliefs, and Perceptions • Disorganized, chaotic, irrational thinking • Tunnel vision—unable to see options other than death • Poor judgment • Persecutory delusions and hallucinations, especially commands • Excessive guilt or self-blame • Low self-esteem

Relationships and Interactions • Social isolation; withdrawn; feels alone and abandoned • Recent loss of significant person through death or separation • Recent tumultuous termination or interruption of psychiatric treatment

Physical Responses • Chronic debilitating illness • Unrelieved pain • Terminal illness • Recent, catastrophic loss of physical abilities

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Pertinent History • History of suicide attempts • Self-destructive behavior, such as drug abuse, reckless acts, or self-mutilation • Family history of suicide attempts or depression • Psychiatric illness • Recent significant loss

COLLABORATIVE MANAGEMENT

Pharmacological Suicidal patients may benefit from taking antianxiety medication, such as lorazepam, to reduce feelings of intense anxiety or distress. In addition, antipsy- chotic and antimanic medication may be prescribed as needed. If antidepressants are being started, it is important to remember that it will take a number of weeks to lift depression, so other interventions must be used in the interim to prevent suicide. Antidepressants could actually increase suicide risk if the patient gets a sudden burst of energy to act out the plan before the depression lifts. Overdos- ing on antidepressants is an increasingly frequent method of suicide. However, untreated depression puts the patient at greater risk so antidepressants are seen as protection against suicidality (APA, 2006).

Adequate symptom management for pain and other distressing symptoms must be provided to the patient with a serious or terminal illness. A patient’s belief that his or her symptoms cannot be controlled could be a contributing fac- tor in hopelessness and suicide.

Patients at high risk for suicide may need to have medications administered in liquid or parenteral form to avoid “cheeking” and hoarding pills. Outpatients should be given only a few days’ supply of any medication that could potentially be used in a suicide attempt.

NURSING MANAGEMENT

RISK FOR VIOLENCE TO SELF evidenced by suicide attempts. self-mutila- tion, suicide plan related to suicide ideation, poor impulse control, depression.

Patient Outcomes • Remains free from injury • Verbalizes intent not to harm self • Expresses more optimistic view of future in specific terms

Interventions • Determine if patient has a plan and how potentially lethal and available

that plan is (see Box 9–3). A patient in the hospital who talks about using

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a gun to kill himself or herself would be at lower risk (until discharge) as long as he or she does not have a gun available. A patient who has a stash of medication would be at higher risk. Seek input from other profession- als to participate in this assessment. If your agency has mental health pro- fessionals on staff, it is essential to involve them in the assessment. See high risk interventions in subsequent text.

• Make a thorough assessment of patient’s risk of suicide (see Table 9–1). Note: research is being conducted to develop assessment rating scales to better predict suicide potential.

Chapter 9 ■ Problems with Affect and Mood 123

TABLE 9–1 Suicide: Intensity of Risk

Intensity of Risk

Behaviors or Symptoms Low Moderate High

Anxiety

Depression

Isolation or withdrawal

Daily functioning

Resources

Coping strategies being used

Significant others

Previous psy- chiatric help

Life-style

Alcohol or drug use

Mild

Mild

Some feelings of isolation; no withdrawal

Fairly good in most activities

Several

Generally con- structive

Several available

None, or positive attitude toward

Stable

Infrequently to excess

Moderate

Moderate

Some feelings of helplessness, hopelessness, or withdrawal

Moderately good in some activities

Some

Some are construc- tive

Few or only one available

Yes, and moder- ately satisfied with the help

Moderately stable

Frequently to excess

High or panic state

Severe

Hopeless, helpless, with- drawn, self- deprecating

Not good in any activities

Few or none

Predominantly destructive

Only one or none available

Negative view of help received

Unstable

Continual use

Continued

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• Talk openly with patient about your concern that he or she is suicidal. Let the patient know you are concerned and available to help and that confidentiality is shared among the entire health-care team for optimum care. Encouraging the patient to talk about this does not increase risk for suicide. Do not promise to keep secrets from the team. Notify all mem- bers of the health-care team of the patient’s risk of suicide. Staff members must be supportive, empathetic, and familiar with treatment plan.

• If the patient has attempted suicide, see Box 9–7. • Talk to patient about making a no-suicide contract with you. Ask him or

her to wait or postpone action so that you and other professionals have time to help. Point out that depression is not permanent (with time, med- ication, and therapy there is hope for a change) but that death is perma- nent and cuts off other options. Renew the contract each shift and as needed between patient and main caregiver.

• Never attempt to work with a suicidal patient by yourself. Involve all members of the team. Seek additional resources such as social workers; notify supervisory staff.

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TABLE 9–1 Suicide: Intensity of Risk—cont’d

Intensity of Risk

Behaviors or Symptoms Low Moderate High

Previous suicide attempts

Disorientation or disorganization

Depression

Hostility

Suicide plan

Source: Adapted with permission from Hatton C. & Valente S. (1984). Suicide: assessment and interventions. Norwalk, CT: Appleton-Century-Crofts.

None or low lethality

None

Some feelings

Little or none

Vague fleeting thoughts but no plan

One or more; mod- erate lethality

Some

Some feelings

Some

Frequent thoughts; occasional ideas about a plan

Multiple attempts; high lethality

Marked

Negative view of self

Marked

Frequent or constant thought with a specific plan

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For patients assessed to be at high risk for suicide: • Follow agency policy for need for continuous supervision. Discourage

use of family for this purpose. • If patient is in the hospital, arrange for a room close to the nurses’ sta-

tion or in an ICU for closer monitoring. • Avoid checking on patient at predictable intervals; check more frequently

during danger times (changes of shift) when patient may think staff will be preoccupied.

• Remove objects with self-harm potential (such as glasses, razors, belts, or lighters) from the room. Be aware of agency policy regarding need to search personal belongings or do a body search.

• Make sure windows cannot be opened. • If all other interventions have been ineffective, use physical restraints for

brief periods to prevent patient self-harm. • Make sure family and friends are not bringing in potentially dangerous

items such as medications, alcohol, or razors. • When patient is sleeping, ensure both hands in view. • Meal trays should have no glass or metal silverware • Obtain Recommendations from American Association of Suicidology for

Inpatient and Residential Patients Known to be at Elevated Risk for Sui- cide for inpatient settings.

• Arrange (per physician) to transfer the suicidal patient to a psychiatric unit as soon as medically stable.

• If patient is not hospitalized, make sure family and friends are aware of the possible suicide risk. The patient probably should not be left alone. Give him or her a list of resources such as hotlines, therapists’ phone numbers, or support people he or she can call. Call MD/Psychiatric Assessment Team if you believe the patient is still at risk of suicide.

HOPELESSNESS evidenced by expectations that there will be no improve- ment in situation related to depression: overwhelmed by life circumstances.

Patient Outcomes • Verbalizes more optimistic expectations for the future • Initiates realistic plans for the immediate future • Demonstrates initiative in decision making

Interventions • Recognize that extreme hopelessness is a strong indicator of suicide;

assess thoroughly. • Listen to patient’s concerns and issues. Convey empathy to promote ver-

balizing about doubts and fears. Reflect back patient’s despair without

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agreeing with it. For instance, you might say “You describe a world that seems empty to you.”

• Encourage patient to discuss recent events or stresses that have con- tributed to the hopeless view. Offer alternative analysis viewing the event without arguing or minimizing patient’s concerns. Minimizing or joking about the patient’s feelings will increase the patient’s sense of isolation and lack of trust.

• Emphasize the patient’s strengths and problem-solving abilities. Describe a recent situation in which you observed the patient being successful. Have him or her describe a past success. Point out obstacles or negative thinking that get in the way of effective problem solving.

• Provide a balanced point of view to counteract patient’s tendency to judge himself or herself harshly. Point out unrealistic, perfectionistic thinking. Offer more constructive interpretations to open real options for the future.

• Acknowledge that you understand that the patient feels that everything is useless and nothing will help, but also that you believe something help- ful can be done.

INEFFECTIVE COPING evidenced by repeated suicide threats/gestures, related to stunted areas of personality development with intermittent self- destructive impulses.

Patient Outcomes • Decrease in self-destructive behaviors • Demonstrates more adaptive means of communicating thoughts, feelings,

and needs

Interventions • Determine if self-destructive behavior is a pattern. • Remain calm and neutral; treat patient’s suicide threats and gestures in

matter-of-fact manner. Treat any physical injury without excessive emo- tion. Avoid creating a sense of alarm about the patient’s behavior. Cau- tion: Do not dismiss any threat or gesture as manipulative or not serious. Any self-destructive threat or gesture should be taken seriously and not ignored.

• Ask the patient to identify any disturbing thoughts or feelings that occurred just before the threat or action. Encourage him or her to put thoughts and feelings into words rather than acting them out impulsively and destructively. Teach that anger can hide more painful feelings such as sadness and rejection.

• Teach alternate coping: talking, relaxation, distraction, exercise, music, and so forth.

• Confront the patient who wants to commit suicide for revenge and retal- iation. These patients may state, “They’ll be sorry when I’m dead.”

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Remind patient this is not a solution because he or she won’t be there to see the results.

• Encourage the patient to alert staff members if feeling out of control or when having thoughts of self-harm. Consider discussing a no-suicide con- tract and including guidelines for behavior.

• Establish limits with patient on amount of time staff will spend listening to patient’s concerns. Set limits on the patient’s use of verbal abuse and demands.

• Review with the patient possible causes for self-destructive behavior that could include an attempt to get others to assume responsibility for patient’s life. The patient needs to be encouraged to take more self- responsibility. See Chapter 12, The Manipulative Patient, for additional interventions.

ALTERNATE NURSING DIAGNOSES

Anxiety Grieving, Dysfunctional Self-Concept, Disturbed Self-Mutilation, Risk for Spiritual Distress (Distress of the Human Spirit) Thought Processes, Disturbed

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WHEN TO CALL FOR HELP

• Self-mutilation • Suicide threats or attempts • Access to highly lethal methods such as firearms, car in an enclosed

space, or sleeping pills in a high-risk patient • Hallucinations or delusions • Lack of staff members available to manage suicidal patient • Increasing staff anxiety and fear over patient’s behavior

WHO TO CALL FOR HELP

• Security • Psychiatric Team • Law Enforcement • Manager • Critical Incident Team

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PATIENT AND FAMILY EDUCATION

• Teach patient that his or her view of the options available becomes nar- rowed when he or she is depressed or suicidal. Review alternative ways of viewing problems. Incorporate family into this education.

• Encourage patient and family to obtain educational material including Understanding and Helping Suicidal Persons and Surviving after Suicide (suicidology.org).

• Review with the patient the idea that he or she needs to reach out to others for support and assistance. Teach the patient to reach out immediately when feeling the urge for self-harm.

• Encourage the patient to report and seek out adequate treatment for uncom- fortable symptoms of physical illness, possibly including analgesics, to reduce suffering.

• Teach alternative outlets for anger rather than self-destructive ones. (See Coping Interventions.)

• Make sure that patient and family understand the purpose of close obser- vation by staff members if patient is actively suicidal.

• Make sure that the family knows signs of increasing suicide risk and inter- ventions.

• If a patient does commit suicide, prepare the family for the complex grief reaction that may follow (Box 9–8).

CHARTING TIPS

• Document all behaviors that could be considered a suicide thought, threat, or action, and who was notified about them.

• Note patient’s response to suicide assessment. • Document all measures in place to prevent suicide.

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BOX 9–8 Information for Survivors of Suicide • Recognize that their grief may have an added burden of guilt, shame, and

anger. • Sharing their grief with others about the cause of death will put the tragedy

out in the open and provide added support. • Recognize that factors contributing to the suicide may be out of the family’s

control. • Provide information on dynamics of suicide. • Encourage attendance at bereavement support groups specific for survivors

of suicide.

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• Document patient’s response to a no-suicide contract and teaching. • Document any information from others on availability of potential methods

for suicide available to the patient and interventions to protect patient.

COMMUNITY-BASED CARE

• Make sure that patient and family have information on referrals for follow- up counseling. They should also have emergency numbers such as suicide hotlines. Provide written information and education.

• Determine if psychiatric evaluation needs to be made before the patient leaves the agency/institution.

• Determine the appropriate quantities of prescribed medications to send home with the patient.

• Refer for home health follow-up and make sure that the agency is aware of the patient’s suicide risk. Refer for psychiatric home care if available.

• If patient is a high suicide risk, transfer to a psychiatric hospital as soon as possible.

The Grieving Patient

Learning Objectives • Describe the variables that contribute to the intensity of the grief

response. • Describe some common behavioral responses to grief in children. • Identify dysfunctional grief reactions. • Describe effective nursing interventions to assist the grieving family. • Describe common nursing staff reactions to the grieving patient.

Glossary Absent grief – In an effort to avoid aspects of the loss and avoid relinquish-

ing the lost object, no grief is experienced. Anticipatory grief – Grief response before and in preparation for a significant

actual or potential loss. Bereavement – State of having suffered a loss. Delayed grief – The absence of grief behavior when it would be normally

expected.

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Disenfranchised grief – Loss that cannot be acknowledged or publicly shared.

Distorted grief – Abnormal extension or overelaboration of grief behavior. Dysfunctional or complicated grief – Grief reaction that does not follow the

usual pattern and may include delayed and/or distorted grief. Grief – Subjective, emotional response to a loss. Loss – Situation, real or potential, in which a valued object is rendered inac-

cessible or is altered in such a way that it no longer has the valued qualities. Mourning – The process by which grief is resolved. Prolonged grief – Continued grief behavior lasting much longer than would

be expected.

Experiencing loss is a normal part of life. Friends moving away, loss of a job, loss of functional abilities or physical health, or the death of a loved one are

something we all experience. Grief is the normal human response that usually follows these experiences. As

things change in our lives, we must adapt. This process of adaptation is called grieving. The purpose of grief is to begin to face the loss, work through the emo- tions, and eventually let go or adapt with renewed energy to focus on new rela- tionships and goals. Because all individuals respond to loss differently, the process of adapting varies widely and can take days, months, or years depending on many variables. Grief does not decline in a linear, predictable fashion over time. Rather, it can fluctuate over time and be affected by many factors. Variables that can influence the sense of loss include:

• The meaning of the lost object to the person (Generally, the more important the loss is to the person, the more intense the reaction.)

• The degree of preparation and past unresolved losses • Physical health • The degree of conflict or dependency in the relationship • Support system • Concurrent stressors

Culture also influences the way an individual responds to loss. Most cultures have specific rituals and traditions that provide support and reassurance during the grieving process. Grief caused by a death can be influenced by the cause of death. Unexpected deaths, deaths viewed as preventable, and the death of a child all create additional distress. Death resulting from a cause with a social stigma, such as suicide or AIDS, can be particularly difficult. With suicide, death is unex- pected, violent, and possibly preventable. Survivors may experience intense anger, guilt, and self-blame. Those who lose a loved one from AIDS may have had time to prepare for the death, but many complicated feelings may still need to be resolved before grieving can be accomplished. Society’s reactions to deaths caused by problems such as these may affect the type of support the mourners receive.

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ETIOLOGY

There is no one comprehensive theory that explains normal grief. Research has shown that grief occurs in a sequence of phases or stages with predictable symp- toms that change over time, and that these stages do not necessarily progress in an orderly, set fashion.

Acute grief symptoms were first described in Lindemann’s classic study of 1944 after the Coconut Grove Night Club fire in Boston. Symptoms include sighing, sobbing, hyperventilating, and a sense of unreality or shock as the first reactions to facing a major loss. Elisabeth Kübler-Ross (1969) and Theresa Rando (1993) both describe stages through which individuals advance in their progression toward resolution (Table 9–2). These stages give us guides for expected behaviors, but each individual goes through the process in his or her own way and time.

During the initial period of shock, the mourner may experience denial or avoid- ance as a protective mechanism from the overwhelming stress to block out the pain. As denial and shock fade, the mourner begins to face the sadness of the loss. In addition to depression, there may be periods of anger and guilt. Anger can be directed at the lost person for leaving or the person responsible for the situation (if applicable), or it can be displaced onto others. Guilt feelings, possibly evidenced by self-reproach for real or imagined acts of negligence or omissions, can be espe- cially painful. All of these behaviors force the individual to confront the pain over and over again. However, not all reactions cause the individual to feel discomfort. Some can provide comfort, such as a sense of being watched over by the lost per- son. Maciejewski, Zhang, Block, & Prigerson’s (2007) research has validated the model of stages of grief and noted that depression peaked at six months post loss.

The ability to tolerate intense emotions, increasing periods of stability, taking on new roles and relationships, having the energy to invest oneself in new endeav- ors and ability to bring meaning to one’s life (Niemeyer, 1997) are signs that the individual is recovering. Remembering both the positives and negatives of the lost person or object can also indicate successful completion of grieving. However, brief periods of intense feelings may still occur at significant times, such as anniver- saries and holidays. Because each individual is unique, the extent of a grief reac- tion may vary. People may grieve as deeply over the loss of a pet or a longed-for goal as over the death of a family member. Disenfranchised grief can prevent out- ward expression of grief. This may be seen after an abortion or when the depth of relationship of deceased person is not known publicly. In addition, the length of time to resolution is individual, not necessarily fitting the 1-year tradition. How long grief should go on is less related to the calendar and more to the depth of the loss and the individual’s reaction. Also, grief may be delayed because of extreme situations, such as multiple losses, and the mourner must deal with many respon- sibilities before taking time to experience the loss. Grief can take a more compli- cated or maladaptive form that interferes with the adaptation to the loss. Examples of these include absent, delayed and distorted grief. These forms of complicated grief often require professional intervention (Ott, 2003). These complicated forms of grief may be related to the circumstances that do not allow the person to

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TABLE 9–2 Adapting to Loss

Stage Purpose Behavior

Rando’s Stages of Adapting to Loss

Avoidance phase

Confirmation phase

Accommodation phase

Kübler-Ross’s Stages: Adapting to a Loss of Self

Denial

Anger

Bargaining

• Recognize the loss

• React to separation

• Recollect and re- experience the deceased

• Relinquish old attach- ments to deceased and old assumptive world

• Readjust to move adap- tively into new world without forgetting old

• Reinvest

• Unconscious avoidance to protect self from painful reality

• Attempt to take control when feeling out of con- trol by attacking, blaming other

• Attempting to change real- ity by making agreement, bargains for more time

• Indicates beginning acceptance

• Acknowledge loss (intel- lectually first, then emo- tionally)

• Experience pain of loss—it will impact all areas of functioning

• Make changes in one’s life to adapt to life without person

• Change old habits, find new support systems

• New relationship with deceased

• Form new identity • Emotional energy into

new things

• “No, not me.”

• Lack of expected reac- tion; using unproved treatment methods; doc- tor shopping to avoid confronting diagnosis

• “Why me?”

• Irrational demands; crit- icizing staff; hostile behavior

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complete the grieving process for some reason. With a long illness, anticipatory (or preventative) grief may prepare the person for the future loss (Rando, 2000).

RELATED CLINICAL CONCERNS

The physical stress of grief can place the mourner at risk for health problems (Stroehe & Schut, 2001). Lack of sleep, poor eating, and changes in routine can predispose the individual to illness. Loss of a spouse in elderly people is associ- ated with higher morbidity and mortality rates. Two months after a death, bereaved elderly persons report more illness, greater use of medications, and poor health ratings. Major depressive disorder associated with complicated grief can contribute to higher mortality rate, poor wound healing and immune system dys- function (Duffy, 2005).

LIFE SPAN ISSUES

Children Often adults try to protect children by not including them in the crisis or expres- sions of grief for other family members. However, they need to be included in the process, based on their level of development, so that they do not feel abandoned

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Stage Purpose Behavior

Depression

Acceptance

Source: Adapted from Rando T. (1993). Treatment of complicated mourning. Champaign, IL: Research Press; and Kübler-Ross, E. (1969). On death and dying. New York: MacMillan.

• Work of grief as realiza- tion hits

• Involves despair, the pain of experiencing loss

• Resolution of feelings about death

• Neither happy nor sad • Acceptance of reality, sense

of peace and letting go

• “It’s me, but …”

• “I want to live til my son’s wedding, then I’ll accept death.”

• Making bargains with God to change if can have more time, change reality

• “It’s me.” • Sad, tearful, life review

• Comforting others to accept impending death; remembering the past with fondness but without fighting to hang on to life

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and left to face their fear and loss alone. Children generally display grief differ- ently from adults, and it is important not to misinterpret their behaviors to mean that they are not grieving or that they are unaware of what is happening. Chil- dren often use symbolic or nonverbal language to communicate their awareness of loss and may even feel ashamed of their loss because they feel differently from their peers. Because they may also need more time to really assimilate what has happened, grief reactions may be delayed (Table 9–3).

Children’s initial reaction to death is often shock and sadness but can quickly return to seemingly inappropriate laughter or activity. But their suffering may continue under a different guise (Brown-Saltzman, 2006).

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TABLE 9–3 Children’s Understanding of Death

Common Behaviors in Age Understanding of Death Response to Death

Infant to toddler

3–5 years

School age

Adolescence

• Unable to comprehend death • Fears separation and aban-

donment

• Views illness as punishment for real or imagined wrong- doings

• May view death as sleep; cannot comprehend death

• Magical thinking; may think they caused the event by their thoughts or actions

• Associates death with pun- ishment multilation, violence

• May feel responsible for event

• By age 9, understands that death is final

• Understands own mortality

• May seem to have adult view of death but not emo- tional view

• Frightened, difficulty sep- arating

• Sadness • Clinging to parent

• Nightmares, sleep disrup- tion

• Regression in toilet habits • Complaints of stom-

achache and headaches • Temper tantrums

• School phobia, dimin- ished school performance

• Aggressive behavior

• Preoccupation with par- ent’s health

• Loss of appetite • Change in relationship

with friends

• Acting out; substance abuse

• Increased time with peers • Withdrawal from family • Depression

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Adolescents As they struggle with dependency issues, the adolescent may feel vulnerable to express feelings of grief. They may appear to deny or avoid the dying patient, act out their frustration in such ways as school truancy, substance abuse. This may be very distressing to other family members who may view the teen as uncaring.

Older Adults Elderly people face multiple changes, often including the loss of a spouse, friends, job, financial status, health, and mobility. In spite of the extent of these losses, most elderly persons seem able to adapt, probably because of their past experi- ence. However, the death of a spouse or partner still remains one of the major losses in life. This loss requires multiple life changes that become more difficult with increasing age. Grief can be masked by symptoms of dementia, depression, suicidal ideation, and substance abuse. Brown-Saltzman (2006) notes that the older adults may suffer disenfranchised grief as they experience multiple losses which others may consider normal for this age.

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POSSIBLE NURSES’ REACTIONS • May feel helpless and uncomfortable, not knowing what to say. This could

lead to avoidance or inappropriate hopefulness. • May fear saying the wrong thing that will cause the patient or family to feel

more pain. • May fear losing control of emotions, crying. • May make judgments regarding the degree of intensity of grief behavior,

such as thinking that a family is “not upset enough” or too upset for a dying 95-year-old parent.

• May feel guilty for “causing” client to cry when discussing the loss. • May become detached from the situation and attempt to minimize the loss

to the patient with phrases like “This was for the best” or “At least you can have more children.”

• May expect all people to experience the stages of grief in the same way. • May relive past and unresolved personal losses, causing intense emotions.

ASSESSMENT

Behavior and Appearance

• Crying, agitation • Extreme change from usual behavior patterns • Unable to concentrate, distractible • Taking on behavior traits of lost person • No apparent reaction when one would be expected • Unkempt, not caring for self

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Mood and Emotions • Shock, numbness • Depression (Table 9–4) • Anxiety, panic

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TABLE 9–4 Differentiating Grief From Depression

Uncomplicated Grief Major Depression

Reaction

Behavior

Sleep patterns

Anger

Sadness

Cognition

History

Responsiveness

Loss

Source: Adapted from Ferszt, G. G. (2006). How to distinguish between grief and depression? Nursing, 36, 60–61; Brown-Saltzman, K. (2006). Transforming the grief experience. In R. M. Carroll-Johnson, L. M. Gor- man, N. J. Bush (Eds.), Psychosocial nursing care along the cancer continuum (2nd ed) (pp. 293–314). Pitts- burgh, PA: Oncology Nursing Press.

• Labile • Heightened when thinking

of loss

• Variable, shifts from shar- ing pain to being alone

• Variable restriction of pleasure

• Periodic episodes of inability to sleep

• Often expressed

• Varying periods

• Preoccupied with loss • Self-esteem not as affected

• Generally no history of depression

• Responds to warmth and support

• Recognizable, current

• Mood consistently low • Prolonged, severe symp-

toms lasting more than 2 months

• Completely withdrawn or fear of being alone

• Persistent restriction of pleasure

• Wakes early morning

• Turned inward

• Consistently sad

• Focused on self • Feels worthless; has

negative self-image

• History of depression or other psychiatric illness

• Hopelessness • Limited response to

support • Avoids socializing

• Often not related to an identified loss

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• Mood swings • No obvious emotional reaction or one that is inappropriate to situation • Anger • Guilt, remorse • Relief that ordeal is over

Thoughts, Beliefs, and Perceptions • Self-blame • Idealizing lost person • Remembering only positive aspects of lost person • Ruminating over events leading to the loss • Obsession with lost person • Illusory phenomena in which mourner thinks lost person is present • Preoccupied with thoughts that can bring only pain • Imagining that lost person is watching over mourner • Difficulty making decisions

Relationships and Interactions • Seeking support from others, may become more dependent • Fear of being alone • Unable to participate in conversation because of preoccupation with loss • Feeling that others do not understand the pain (“How can they have a good

time when I hurt so much?”) • Projection of anger onto others

Physical Responses • Initial symptoms that may include hyperventilating, sighing, sobbing, mus-

cle tension, chest pain, fainting • Gastrointestinal distress • Loss of appetite • Change in bowel habits • Insomnia, constant fatigue • Dehydration

Pertinent History • Unresolved or multiple past losses • Ambivalent relationship with lost person • History of psychiatric disorder or substance abuse • Tendency to isolate self

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COLLABORATIVE MANAGEMENT

Pharmacological Sedatives and tranquilizers are often used in the early stages of grief to reduce the impact of the intense emotions and promote rest and sleep. However, these med- ications suppress the intense emotions and interfere with the purpose of the grief process. Antidepressants may be useful, along with psychotherapy, when depres- sive symptoms are prolonged.

Spiritual As people face loss and grief, they may be more likely to reach out for spiritual support. They may question their beliefs, talk about an afterlife, and face past wrongdoing. Allow the patient to express feelings and, as needed, seek out clergy available within the agency or ask the patient’s or family’s own clergy to assist. Churches and temples may also offer special support programs. If the patient requests, provide information on important religious rituals such as the Sacra- ment of the Sick and prayer, and provide religious articles such as Bibles, prayer books, medals, rosaries, candles, and special clothing. Clergy may also provide important support for staff members who may be struggling with helping patient or family with spiritual issues.

NURSING MANAGEMENT

GRIEVING evidenced by denial, anger, depression, sorrow related to signifi- cant personal loss (actual or potential) including change in relationship, unex- pected outcome, illness, death.

Patient Outcomes • Acknowledges loss • Expresses concerns, feelings of grief • Verbalizes feeling of being supported in the grieving process • Identifies potential coping mechanisms, support systems

Interventions • Accept all grieving behavior. Recognize that responses to grief are highly

individual. • Provide private environment for person to acknowledge loss and express

grief. • Recognize your role as listener. Providing an accepting, supportive envi-

ronment to share feelings is extremely important. Recognize that words are often less important than just being present at these times.

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• Support grief rituals used by individual from his or her culture. These can provide reassurance and comfort to the bereaved.

• Accept feelings, tolerate mourner’s expressions of extreme emotions such as sobbing, wailing.

• Provide privacy for the mourner.

• Recognize that it is not only acceptable but preferable to talk about the loss and express feelings. Not talking or not expressing feelings is a greater concern.

• If you are helping someone who just heard about the death or other loss, provide needed information such as mortuary, support groups in small amounts. Information may need to be repeated several times. Focus assis- tant on helping to get other family members or friends to assist so that mourner will not be alone. Assist with making phone calls. Provide con- crete written information whenever possible.

• Seek assistance from colleagues if possible. Dealing with acute grief can be very draining.

• Use touch; holding the mourner can be very supportive. Recognize that waves of emotions will come and go. Be prepared for more intensity as the person relives events leading to the death or other loss.

GRIEVING, DYSFUNCTIONAL evidenced by inhibition, suppression, absence, prolongation, or distorted grief reactions related to significant loss, multiple losses, unresolved guilt, lack of support system, difficulty expressing feelings.

Patient Outcomes • Acknowledges the loss • Demonstrates absence of abnormal, prolonged, excessive reactions to

loss • Resumes or develops social relationship. • Expresses feelings expected with the loss

Interventions • Recognize that the individual needs to confront the loss slowly and

accept it into his or her reality at the individual’s own pace. Part of this process will include talking about the loss, reliving memories, talking about events leading to the loss, and expressing feelings.

• Use supportive phrases such as “It must be hard for you now” or “I’m so sorry to hear of your loss.” These phrases acknowledge the loss and encourage the person to tell his or her story. Avoid phrases such as “At least you had him for 20 years.” These statements diminish the loss to the mourner and can lead to feeling isolated and misunderstood.

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• Monitor for signs of dysfunctional grieving, including prolonged denial, lack of emotional response, living in the past, or self-destructive behav- ior. If the mourner exhibits these behaviors, monitor closely and talk with him or her about your concerns. Point out feelings or reactions that the individual might be experiencing, for example, “You might be feeling like you’re in a dream right now” to encourage expressing feelings.

• Encourage involvement in new activities and meeting new people. Help the person to set small goals to begin these activities very slowly, and identify realistic expectations.

• Assist the mourner to redefine the relationship with the lost person or object. This includes remembering the positives and negatives and acknowledging possible angry feelings.

• If the mourner does not acknowledge the loss, bring up the subject. You might say “I notice you never mention your deceased husband. How has it been for you?”

• Provide spiritual support as requested. Encourage involvement of clergy. • Recognize that patients with histories of psychiatric disorders or sub-

stance abuse may need additional support to maintain their past improve- ments during these times.

ALTERNATE NURSING DIAGNOSES

Anxiety Coping, Family: Compromised Coping, Ineffective Knowledge, Deficient Powerlessness Self-Esteem, Disturbed Sleep Pattern, Disturbed Social Isolation Spiritual Distress (Distress of the Human Spirit)

PATIENT AND FAMILY EDUCATION

• Prepare patient and family for the normal stages of grieving. • Inform them that anticipatory grief does not necessarily reduce the emo-

tional impact of the loss. Mourners still may expect an intense reaction. • Tell the family the signs of dysfunctional grief and encourage them to seek

help if they begin to experience them. • Tell the patient that feelings of anger and guilt may be normal. Encourage

seeking professional help if he or she is having difficulty resolving these feelings.

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• Encourage mourner to be very patient through this process. Time is needed to slowly face the grief. Discourage making major decisions early on in grieving.

• Discourage use of tranquilizers as a way to avoid intense emotions. • Let the mourner know that his or her feelings may be intensified at key times

such as holidays and anniversaries and that they may last for a few days. • Encourage good nutrition and good health habits, especially for elderly peo-

ple. Encourage seeking medical attention, as needed, during the bereave- ment period because the mourner is at an increased risk of illness.

• Prepare mourner and family for delayed grief reaction when intense feelings may occur in response to future loss.

• Provide written information on grief for family members.

CHARTING TIPS

• Document grieving behaviors. • Document use of medications such as tranquilizers and analgesics.

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WHEN TO CALL FOR HELP

• Disturbing behavior including hallucinating, delusions, obsessions • Evidence of intense prolonged preoccupation with the loss • Recurrence of psychiatric symptoms, substance abuse • Dwelling on detailed events leading to loss or death long after the event • Long periods of depression, possibly including suicidal thoughts or

gestures • Living in the past many months or years after loss occurred • No emotional reaction to loss for a prolonged period of time • Or if the staff exhibits: Intense emotional reaction to death of patient;

Difficulty in dealing with personal grief to the extent that it impacts on patient care

WHO TO CALL FOR HELP

• Social Worker • Chaplain • Psychiatric Support • Bereavement Counselor • Critical Incident Team/Employee Assistance

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• Avoid documenting judgments about patient behavior. • Document available resources identified to support grieving individual.

COMMUNITY-BASED CARE

• Provide information on bereavement counseling and support groups. Pro- vide the information in writing because mourners may be unable to con- centrate.

• Inform referring agencies and home health agencies about patients’ recent losses and grief reactions.

• Identify opportunities for socialization. Encourage involvement in activities when appropriate.

• Encourage involvement of family and friends to expand mourner’s support system.

• Provide follow-up phone calls to mourner to reinforce information given.

The Hyperactive or Manic Patient

Learning Objectives • List the outstanding characteristics of mania. • List possible contributing factors to manic episodes. • Describe effective nursing interventions for a manic episode. • Describe possible nurses’ reactions to manic behavior.

Glossary Cyclothymic disorder – A chronic mood disturbance lasting at least 2 years

that can be thought of as a muted version of bipolar disorder Bipolar Disorder – Psychiatric disorder marked by shifts in mood, energy and

ability to function. Alternating moods are characterized by mania, hypoma- nia, depression. There are two types: Bipolar I disorder: Characterized by the occurrence of one or more manic episodes or mixed episodes. Often, but not always, individuals with this disorder also have one or more major

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depressive episodes. Bipolar II disorder: Characterized by the occurrence of one or more major depressive episodes with the presence (or history) of at least one hypomanic episode.

Hypomania – A distinct period that is similar to a manic episode but with less severe symptoms. There is impairment of social or occupational function- ing, mood is clearly different from usual nondepressed mood, but psychotic features may not be present.

Mania – A distinct period during which there is an abnormally and persist- ently elated, expansive, or irritable mood possibly accompanied by inflated self-esteem or grandiosity, decreased need for sleep, pressured speech, flight of ideas, or subjective experience that thoughts are racing, dis- tractibility, increased involvement in goal-directed activities or psychomotor agitation, and excessive involvement in pleasurable activities with a high potential for painful consequences. Marked changes in social or occupa- tional functioning or need for hospitalization or psychotic features must be present.

Mixed episode – A period during which the criteria for both a manic and a major depressive episode are met nearly every day.

Rapid cycling – At least four episodes of a mood disturbance in the previous 12 months that meet criteria for a major depressive episode or a manic, mixed, or hypomanic episode.

Schizoaffective disorder – An uninterrupted period of illness during which, at some time, there is a major depressive, manic, or mixed episode concurrent with the characteristic symptoms of schizophrenia.

Bipolar disorder, formerly called “manic depression,” is best viewed as a recurrent, life-long illness. Episodes of mania or depression can last from

days, to weeks, to months. 1.2% to 1.6% of the population suffer from some form of bipolar disorder (DSM-TR-IV, 2000). There is a 3.9% lifetime risk of developing this disorder (Kessler et al., 2005). First episodes are more likely in a younger population especially if there is a family history. More than 90% of patients who experience a first manic episode go on to have future episodes. The majority of individuals with bipolar disorders eventually return to a fully functional level between episodes. Many patients with bipolar I disorder return to work when properly medicated. Manic and hypomanic episodes often precede or follow major depressive episodes in a characteristic pattern for a particular person. The frequency of manic episodes varies. Some have periodic episodes separated by years, and some have close repetition. Long- term, even life-long medication may be necessary. (Medication-free trials should be tried only under physician supervision.) Cyclothymic disorder may also require medication.

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In the early phase of a manic episode an individual can become engaging, outgoing, and charming, presenting as one who is achieving and successful with excessive energy and optimism. During the hypomanic episode, the person accelerates to an “abnormally and persistently elevated, expansive or irritable mood lasting at least 4 days.” (APA: DSM-IV-TR, 2000, p 365). Mania can continue to accelerate to a continuously frenzied, out-of-control pace, leading to seriously impaired decision making and potentially very hazardous activity. An increasing manic episode can be viewed as a series of stages during which the symptoms become more intense and severe. For example, an initial overestimation of abilities (“I can earn more money than any other salesman in the United States”) can balloon to grandiose delusions (“I am Jesus Christ”) and hallucinations. What begins as pressured, rapid, but still organized speaking can escalate to constant, loose, flitting verbalizations from topic to topic with little or no connections and, eventually, incoherence. Irritability, especially when demands are not met, can escalate into belligerent explosiveness and combativeness. Restlessness can peak into a state of continuous motion. A patient in an escalated manic phase frequently denies the seriousness or even the existence of illness, both medical and psychiatric. This individual could walk endless miles for days, expecting cars to clear a path for him or her, ignores the need for any food and sleep, and disregards any physical impairment. Without medication, a manic episode can last months. Individuals may be prone to abuse substances like tranquilizers to sleep or control some aspect of the manic episode.

Interestingly, descriptions of manic episodes reflect a mirror image of depres- sion. Depression is characterized by an insidious slowing down of movement, thought, self-esteem, and initiative, accompanied by dejected, constricting, pes- simistic, and even despairing mood. Internally focused guilt abounds, and anger is usually self-directed. In mania, everything seems to speed up, including thought, speech, decisions, activity, mood, self-esteem and a belief that all desires and dreams can be fulfilled. Externally focused anger and blame are directed out- ward: Guilt is noticeably absent. In the extreme forms of both depression and mania, there is a psychotic break with reality, including delusions and/or halluci- nations.

During the acute manic phase, the primary goal is maintaining patient safety and hospitalization may be required in severe cases. When the manic episode has resolved, the patient may need to deal with substance abuse issues and need help to reduce the risk of relapse. Long term the goal is to try to prevent or at least reduce the severity and duration of future episodes. People often emerge from a manic episode in a confused and startled state with minimal memory of what happened. They may be shocked to see what has happened to their lives—bills, destroyed relationships, legal problems (Varcarolis, 2006).

Depressive episodes in bipolar patients tend to have a greater impact for the patient but there is less research on this phase of the illness (Hirshfeld, 2005). Schizo-affective disorder may also be present in a patient with schizophrenia.

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ETIOLOGY

Bipolar disorder is a complex phenomenon in which a variety of factors converge.

Biological theory predominates. Studies indicate that this disorder is caused by an imbalance in neurotransmitters, particularly norepinephrine, dopamine, and serotonin. Increased levels are believed to be present in manic episodes and decreased in depressive ones. Impaired interrelationships of the hormonal and endocrine systems are currently being explored. Investigation of brain electrical activity is also being studied because valproate, carbamazepine, and other anticonvulsants have been successfully used with lithium-resistant manic episodes. Electroencephalographic changes have been linked to mood dis- turbances as well. Disruptions in circadian rhythms and exposure to light, as in light therapy for depression with seasonal pattern, can contribute to manic episodes.

A genetic link has also been demonstrated through family studies. Bipolar patients have a significantly greater percentage of relatives with bipolar and depressive disorders than the general population. Studies done on twins and adopted individuals provide strong evidence of a genetic influence for bipolar I disorder. When a family history is present, the first episode tends to be at a younger age.

Sociologically, there are no reports of differential incidence of bipolar I disor- der based on race, ethnicity, or sex. Mania is more often the initial episode in men and depression in women. Bipolar II disorder may be somewhat more common in women.

Psychological theory views mania as a defensive flight from an underlying extreme depression with its attendant painful feelings of hopelessness, worthless- ness, and emptiness. It is suggested that the individual uses denial as a defense mechanism. Hypotheses requiring further investigation are that the patient uses manic symptoms to covertly get dependency needs met; approval from others maintains self-esteem, whereas manic symptoms prevent others from setting lim- its and containing out-of-control behavior. Psychological factors may be a larger factor in precipitating relapse.

RELATED CLINICAL CONCERNS

Hyperactive symptoms caused by substance abuse, medication use, or a general medical condition are not considered to be a bipolar disease. Under these cir- cumstances, the diagnoses would be substance-induced mood disorder or mood disorder caused by a general medical condition but not be considered bipolar dis- order (Box 9–9).

Manic episodes can be induced in susceptible individuals by other somatic treatments for depression, such as ECT or light therapy for depression with sea-

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sonal pattern (exposure to increased amount of bright visible-spectrum light dur- ing seasons of the year with diminished daylight).

Sleep disturbance is both a symptom of manic episodes and an irritant that can exacerbate manic episodes and worsen the overall condition.

Patients with extreme manic episodes may be at risk for illness owing to phys- ical exhaustion and immune system compromise.

LIFE SPAN ISSUES

Children Studies indicate that frequently bipolar disorders have their onset before the age of 20. This disorder is now being diagnosed in younger people. Children may manifest bipolar disorder as an ongoing, continuous mood disturbance that includes both depression and mania rather than distinct phases (Child and Ado- lescent Bipolar Foundation-CABF, 2007). Children may be misdiagnosed as hav- ing a conduct disorder such as attention deficit hyperactivity disorder (ADHD). Before putting a child on a stimulant for ADHD, an evaluation for history of bipolar disorder should be done. A stimulant could precipitate a manic episode in an at-risk child. If one parent has bipolar disorder, a child has a 15% to 30% chance of having this disorder (CABF, 2007).

Adolescents Manic episodes in adolescents are more likely to include psychotic features and can be misdiagnosed as schizophrenia. As with younger children, behavioral

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BOX 9–9 Drugs and Physical Illnesses That can Cause Manic States Drug Related Infections Steroids Influenza Levodopa Q fever Amphetamines St. Louis encephalitis Tricyclic antidepressants Other Illnesses Monoamine oxidase inhibitors Hyperthyroidism Methylphenidate Multiple sclerosis Cocaine Systemic lupus erythematosus Thyroid hormone Brain tumors

Stroke

Source: Dubovsky S. L., Davies, R., & Doboxsky, A. N. (2003). Mood disorders. In R. E. Hales, S. C. Yodofsky (Eds.), Textbook of clinical psychiatry (4th ed.) (pp. 439–542). Washington, DC: American Psychiatric Press; McDaniels J. S., & Sharma S. M. (2002). Mania. In M. G. Wise & J. R. Rundell (Eds.), Textbook of consultation liaison psychiatry (2nd ed.) (pp. 339–359). Washing- ton, DC: American Psychiatric Press.

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problems can lead to the misdiagnosis of conduct disorder. Approximately 10% to 15% of adolescents with recurrent major depressive episodes will go on to develop bipolar I disorder (DSM-IV-TR, 2000). Assessments should include a family history of mood disorders.

In adolescents, manic and hypomanic episodes may be associated with school truancy, antisocial behavior, suicide attempts, school failure, or substance abuse. A significant minority of adolescents appear to have a history of long- standing behavior problems preceding a frank manic episode. It is unclear whether these problems represent a prolonged prodrome to bipolar disorder or an inde- pendent disorder. The Child and Adolescent Bipolar Foundation has developed consensus guidelines for diagnosis and treatment for this age group (Kowatch et al, 2005). Screening for substance abuse should be done with any teen with bipo- lar disorder.

Antimanic medications can be used in adjusted doses along with psychothera- peutic interventions in this age group.

Adults The majority of first manic episodes in bipolar disorder occur between 20 and 30 years of age with preponderance in the early 20s. If the onset of a first manic episode occurs in a patient 40 years of age or older who has no previous psychi- atric illness, medical conditions and drug-inducing manic symptoms should be ruled out.

In the adult years, uncontrolled symptoms can result in job losses, marital and other relationship breakups, grave financial problems, or serious legal repercus- sions from violating laws. During manic episodes parents may be unable to care for and provide safety for a child. Child abuse, spousal abuse, or other violent behaviors may occur during severe manic episodes or during those with psychotic features.

Postpartum “Postpartum onset” is applied to manic, depressive, or mixed episodes that occur within 4 weeks after delivery of a child. The symptoms remain the same. If delu- sions are present, they often concern the newborn child. If a manic episode devel- ops in the postpartum period, risk for recurrence in subsequent postpartum periods may be increased.

Older Adults The intervals between episodes tend to decrease in bipolar I disorder and to increase in bipolar II disorder as an individual ages. Medical conditions and drug reactions as causative factors in manic episodes need to be carefully evaluated particularly when initial episodes occur in elderly people. Managing patients with bipolar disorder in long-term care settings can create major challenges for staff members.

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ASSESSMENT

Behavior and Appearance • Excessive in all areas: bizarre, garish, flamboyant, eccentric • Pressured speech (profuse, rapid, as if generated by an engine) • Poor personal grooming and excessive and bizarre clothing or make-up

changes • Restlessness, hyperactivity with constant moving and pacing • Flitting attempts to participate in multiple activities, unable to complete

things, impulsive • Poor judgment in decision making; undertakes risky or dangerous endeav-

ors without awareness of consequences, including buying sprees, foolish business investments, reckless driving, hypersexuality

• Behavior inappropriate to situation • Complaints, hostile comments, and angry tirades; may be violent

Mood and Emotions • Elation; heightened sense of pleasure; unrealistic optimism • Lack of shame or guilt • Anger escalating to rage, especially when wishes are thwarted • Labile mood swings including depression, irritability, and anger

Thoughts, Beliefs, and Perceptions • Distracted; unable to concentrate on task at hand; overly attuned and

responsive to stimulation from people and events • Grandiose overestimation of own abilities, talents; exaggeration of past

achievements; inflated self-esteem; impaired judgment

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POSSIBLE NURSES’ REACTIONS • May be entertained or amused by the initial exuberance and acting out and

not set limits • May become irritable, anxious, or angry when patient is noncompliant with

healthcare regimen or routine • May be embarrassed or sense lowered self-esteem if the nurse believes that

a “good” nurse should be able to control patients or prevent them from behaving strangely

• May feel verbally abused and unrecognized by the patient • May feel manipulated, outsmarted, and defensive, needing to justify actions

and motives • May feel frightened if patient becomes violent

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• Complicated plans to acquire unlimited fame, fortune, and/or power • Poor insight; unaware of his or her distortion and negative effect on others • Makes puns, plays on words, and jokes • Flight of ideas (continuously jumps rapidly from one topic to another) • Suspicious; escalates to delusions or hallucinations of grandiosity or perse-

cution

Relationships and Interactions • Excessively gregarious; can be charming; lacks true concern for others • Forms superficial relationships quickly but becomes manipulative, demand-

ing, intrusive, taunting • Attempts to engage everyone into his or her plans and activities; constantly

demands attention • Manipulates self-esteem of others by flattery • Irresponsible; gives quick, deceptively plausible excuses for own actions;

puts responsibility on others • Intimidating

Physical Responses • Sometimes initial overeating; weight gain, even food hoarding • As mania escalates, inadequate nutritional intake leading to weight loss and

even dehydration • Physical exhaustion with insomnia, reduced need for sleep, changes in sleep

patterns • May exhibit side effects of drug abuse and symptoms of general medical

conditions that can cause mania • Patients on lithium must have blood levels monitored for therapeutic level

Pertinent History • Earlier episodes or family history of depressive and/or manic episodes • Dramatic changes in personality during manic phases • Psychiatric diagnosis and treatment of schizophrenia or schizoaffective dis-

order may occur; differential diagnosis is often confused because extremes of manic episodes have similar symptoms

• History of substance abuse

COLLABORATIVE MANAGEMENT

Pharmacological Patients may need to take antimanic (mood stabilizer) medications for the rest of their lives; therefore education and compliance are very important.

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Lithium carbonate remains first-line treatment for a severe manic episode (Hirschfeld et al, 2002). An antipsychotic medication may be added as well. Lower maintenance doses are often continued in the intervals between episodes. Blood levels and side effects need to be monitored because lithium can reach a toxic range, possibly causing seizures, coma, and even death. Therapeutic lithium levels are between 0.5 and 1.2 mEq/L for most patients. Blood lithium levels can be elevated when there is significant lowering of body fluids as in such conditions as limited fluid intake, dehydration, profuse sweating, or chronic diarrhea. It is essential to constantly monitor for adverse drug reactions because some individ- uals can become toxic at blood levels considered normal for most people. Onset of sedation, nausea, and vomiting are early warning signs of lithium toxicity. As toxicity increases, tremors and muscle twitching may occur as well as renal fail- ure when blood levels approach 2.0 mEq/L.

Lithium can take 7 to 10 days to reach the desired effect. If psychotic symp- toms are present, antipsychotics can be used on a regular or as-needed basis. The need should diminish as lithium or other antimanic medications reach therapeu- tic levels. The antipsychotic drug aripiprozole (Abilify) has been used to treat severe agitation in bipolar disorder.

Antimanic drugs are available only in oral forms. If the patient is unable to take oral medications, other medications may be used, such as antipsychotics or antianxiety drugs, which can be given parenterally.

Anticonvulsants, such as carbamazepine and divalproex, are also used. Carba- mazepine can cause agranulocytosis with lethal implications. The incidence of this adverse effect is low; however, it is important to monitor the patient continually for changes in white blood cell and granulocyte count and any signs of infection. Agranulocytosis subsides promptly when the drug is discontinued. Antidepres- sants that are normally used to treat depression unrelated to bipolar disorder may be used but they need to be combined with a mood stabilizer (Hirschfeld, 2005).

Herbal products such as valerian root and chamomile may be used to calm the person. During depressive periods, the individual may use stimulants to recreate some of the feelings of the hypomanic period.

Dietary A patient in an escalated manic phase may be too restless to sit down and eat. Patients may need “finger foods” that can be carried, such as sandwiches and milkshakes. A high-calorie diet should be provided if patient is in constant move- ment.

Psychotherapy Maintaining a psychotherapeutic relationship is an important part of the total treatment program to prevent or reduce the severity of relapses and promote compliance with the lifelong medication regimen. The patient has to take the time to work through the denial and, later, anger over having an incurable condition. Medications can control the frequency and intensity of manic episodes, but exac-

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erbations can still happen. The patient may need assistance in dealing with shame over behavior during manic episodes. He or she may also need to learn how to discriminate normal from abnormal moods and will probably need help in learn- ing to tolerate more dysphoric feelings and moods.

As life becomes flatter and less colorful without mania, the patient may need to grieve for the losses associated with giving up mania, such as fantasies, high or euphoric states, increased level of energy and sexuality, decreased need for sleep, and possibly decreased degree of productivity and creativity.

Developmental tasks may have been overshadowed by the illness. For exam- ple, the adolescent tasks of establishing a separate identity and learning about relationships may have been disrupted. Once the patient is stabilized, these issues will need to be addressed. If the patient has an alcohol or drug abuse dependency, this needs to be acknowledged as a problem, especially because the patient usu- ally denies the problem. Mood disorders can mask substance abuse just as sub- stance abuse often masks mood disorders. Effective substance abuse treatment should be used concurrently with approaches for bipolar disorder (Goodwin & Jamison, 1990). In extreme depressive phases when the patient exhibits suicidal ideation or psychosis, electroshock therapy may be needed.

NURSING MANAGEMENT

ANXIETY evidenced by hyperactivity, distractibility, disorganized and unre- alistic thoughts related to manic phase of bipolar disorder.

Patient Outcomes • Slower and more controlled speech and behavior • No evidence of delusions or hallucinations • Demonstrates an increased ability to concentrate • Demonstrates more realistic decision making • Complies with medication regimen

Interventions • Determine psychiatric care provider for treatment of mania. If none,

strongly encourage immediate referral and assessment. Make sure that physician and other staff members are aware of the patient’s history.

• Provide firm, clear limits. Describe exactly what is expected and what is not allowed. Be realistic. For instance, patient may need to have a desig- nated area in which to pace without being disruptive.

• Administer ordered antimanic medications; monitor blood levels, adverse effects, and signs of possible toxicity.

• Assess for psychotic symptoms; evaluate for need to administer PRN antipsychotic medications.

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• Do not reinforce patient’s delusional beliefs. Present reality without argu- ing with the patient.

• Be consistent even if the patient produces seemingly plausible reasons and excuses. Do not participate in verbal battles—just repeat the rules. Avoid power struggles. Keep directions simple and specific.

• Use a calm, relaxed approach. • Provide a focus to conversation if patient jumps from one topic to another.

Interrupt to slow him/her down. Refocus on the chosen topic. Phrase questions so that they require a brief answer. If the patient’s thoughts are speeding to the point of confusion, do not encourage continued speaking, and, if possible, arrange for someone to sit quietly with patient. Supervise other caregivers who are unfamiliar with manic patients.

• Explain to staff, patients, and visitors who complain about patient’s con- stant need for attention that the patient will feel better in a quiet atmos- phere. Encourage them to limit interactions with the patient without abandoning him or her.

• Remove patient from external stimulation. If possible, place patient in a room in a quiet area and use dim lighting. A private room is preferable. Calming music may help.

• Assess whether patient should be allowed to verbalize anger or fear. If patient becomes overly agitated, change or redirect the topic of conver- sation. As the mania decreases, the patient may be better able to tolerate more processing of emotion.

• Limit the patient’s choices. Attempt to limit the number of objects patient has in the room. Encourage family and/or friends to take home unneces- sary possessions.

• Remove hazardous objects from patient’s room.

• Provide brief activities because of short attention span. Tasks can be more complex as mania decreases.

• If the patient’s behavior is unacceptable, distract with more productive activities. Do not reinforce inappropriate behaviors by giving them a lot of attention.

• Assess for activities patient can do in his or her room, such as writing or drawing.

• Provide an outlet for excessive energy. Assess whether a stationary bike or other equipment can safely be placed in the patient’s room. Supervise any physical activity. Consider physical and/or occupational therapy evaluation.

• Support and encourage the patient’s ideas that are realistic and consistent with the healthcare regimen.

• Assess for any injuries, bruises, and signs of infection.

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• Assess for substance abuse. • Assist the family in dealing with any negative feelings they may have

toward the patient so that they can interact more constructively with him or her.

• Obtain support from peers and other resources if patient’s manipulations begin to erode the nurses’ abilities to maintain an effective approach.

SLEEP PATTERN, DISTURBED evidenced by inability to lie down at night, sleeping only brief periods, and erratic sleep patterns related to manic/uncon- trolled activity.

Patient Outcomes • Remains alert and awake during the day without daytime fatigue • Sleeps at least 5 hours per night • Does not require naps during the day

Interventions • Monitor sleep patterns and assess for signs of fatigue. • Use calming techniques just before bedtime: warm milk, soothing music,

or warm bath. Avoid stimulants such as caffeine. • Decrease stimulation at bedtime: lights out, curtains drawn, phone

unplugged. Avoid loud noises nearby and loud talking. Some patients may respond well to having someone sit quietly just outside the room until he or she is asleep. Encourage the patient to remain in bed long enough to fall asleep.

• Provide ordered sleep medication if patient is unable to sleep. • Encourage the patient to go to bed at the same time each night. • If naps are needed during the day, encourage taking them at the same

time each day.

ALTERNATE NURSING DIAGNOSES

Coping, Ineffective Fluid Volume, Deficient Injury, Risk for Noncompliance Nutrition, Imbalanced: Less Than or More Than Body Requirements Social Interaction, Impaired Therapeutic Regimen Management: Ineffective Thought Processes, Disturbed Violence, Risk for

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PATIENT AND FAMILY EDUCATION

• Avoid health teaching until patient displays significant reduction in psychi- atric symptoms and demonstrates good awareness of reality.

• Teach the family the symptoms of a manic episode so they can recognize what is occurring and not personalize the patient’s interactions with them.

• Teach the patient and family the importance of continuing psychiatric med- ications and treatment, monitoring signs of medication adverse effects and toxicity, and noting early signs and symptoms of recurrent episodes.

• Teach patients, especially those on lithium, to maintain normal diet, fluid, and salt intake.

• Teach patients on lithium to check with their physician about withholding drug if excessive diarrhea, vomiting, or diaphoresis occurs.

• Provide educational resources such as healthymind.org for Bipolar Disorder pamphlet.

• Teach the patient to make a contract with a family member or a trusted sig- nificant other to encourage and assist the patient to make contact with psy- chiatrist or counselor if there is a resurgence of symptoms. Often family members are the first to notice behavioral changes.

• Help the family to make plans for hospitalization so they will be able to act quickly if an emergency situation arises.

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WHEN TO CALL FOR HELP

• Out-of-control verbalizations and behavior • Psychotic symptoms • Patient refusing health care or refusing to take medications • Gross interference in other patients’ care • Symptoms of lithium toxicity • Laboratory values indicating agranulocytosis in patients taking carba-

mazepine

WHO TO CALL FOR HELP

• Attending Physician • Social Worker • Psychiatric Team • Security

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• Teach patient about the process of realistic decision-making and the effect of one’s decisions on others.

• Teach patient that life includes accepting periods of sadness, disappoint- ment, and uncomfortable feelings.

• Teach patient about his or her effect on others. • Explain to the patient and family that alcohol or drug abuse can undermine

bipolar treatment. • Encourage continuing in psychotherapy even when symptoms have stabi-

lized.

CHARTING TIPS

• Note the presence or absence of adverse effects of lithium. • Document the amount of PRN antipsychotics given and the results if used. • Document any factors that could lead to dehydration. • Document percentage of food eaten and weight changes. • Note changes in patient’s behavior and thoughts expressed. • Document patient’s compliance or lack of compliance with health-care

regimen.

COMMUNITY-BASED CARE

• Reinforce the idea that it is essential that the patient continue in medical and psychiatric treatment and take prescribed medications after discharge.

• Make sure that patient has appointments for required blood level tests and follow-up referrals.

• Social service referrals may be helpful for patients who may have alienated friends, family, or associates before hospitalization. Financial and legal issues may be pending because of unwise actions such as excessive spending sprees.

• Recommend assessing the need for transfer to psychiatric facility if patient’s behavior and thought processes are not sufficiently stabilized.

• Recommend that the patient attend community support groups for bipolar disorder such as the Manic Depressive and Depressive Association; refer for alcohol or drug problems if indicated.

• Recommend that the family attend support groups such as those sponsored by the National Alliance for the Mentally III (NAMI).

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10

157

Problems with Confusion

The Confused Patient

Learning Objectives • Differentiate between dementia and delirium. • List the most common types of dementia. • Describe common nurses’ reactions to the confused patient. • Describe effective nursing interventions for the confused patient with the

following: memory deficits, unable to verbalize his or her needs, and at risk for falling.

Glossary Agnosia – Loss of ability to recognize objects Apraxia – Inability to carry out motor activities despite intact motor function Agraphia – Difficulty writing and drawing Alzheimer’s disease – Progressive deterioration of memory, and intellectual

functioning, often leading to complete loss of functioning and personality. Autopsy reveals brain atrophy, senile plaques, and neurofibrillary tangles.

Delirium – Rapid fluctuations in mental status, memory deficits, disorienta- tion, and perceptual disturbances over a short period of time.

Dementia – Multiple cognitive deficits: aphasia, apraxia, agnosia, or distur- bance in executive function such as organizing or abstracting.

Mild cognitive impairment – Subtle but measurable memory disorder when memory problems are greater than what are normally expected with aging but no other dementia symptoms.

Mixed dementia – Vascular dementia and Alzheimer’s disease simultane- ously.

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Nocturnal delirium (sundowning syndrome) – Increased confusion and agi- tation at dusk.

Prompts – Staff actions used to help dementia patient initiate self-care or other desired behaviors after loss of verbal comprehension.

Pseudodementia – Depression in elderly people that appears similar to dementia.

Substance-induced persisting dementia – Dementia caused by intoxication or withdrawal from a substance such as alcohol or drugs.

Vascular dementia – Dementia caused by multiple strokes that have usually occurred at different times and involve the cortex and underlying white matter.

Confusion is not just a state of the mind seen in elderly people. It has many causes and can occur at any age. It significantly influences a patient’s dignity,

independence, personality, and support system, and can complicate the diagnosis and treatment of an illness. Confused patients are experiencing an alteration in higher level brain functioning such as comprehension or abstract thinking caused by delirium or dementia (Boxes 10–1 and 10–2). These patients have difficulty remembering, learning, following directions, and communicating needs and pains.

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BOX 10–1 Factors That Contribute to Misdiagnosis in Dementia and Delirium • The symptoms of dementia and delirium are similar. • Several causes may occur simultaneously to bring about dementia. • Delirium occurring in a patient with a dementia can exacerbate already

existing symptoms. • Health-care personnel may harbor unfounded beliefs that serious memory

deficits, confusion, and other progressive intellectual deficits are a normal part of the aging process.

• Health-care personnel may harbor unfounded beliefs that confusion always indicates Alzheimer’s disease in an older patient.

• Confusion and behavioral changes may be the first sign of medical illness in the elderly.

• Head injuries and other conditions causing brain tissue trauma may present with symptoms similar to those of dementia.

• Confusion is an adverse reaction to many medications.

Source: Gorman, L., Raines, M., & Sultan, D. (2002). Psychosocial nursing for general patient care (2nd ed). Philadelphia: FA Davis.

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Nursing care must be modified to help these patients to retain and regain the mental abilities that can be recovered and to compensate for those that cannot.

Delirium is a reaction to underlying physiologic (illness, drug reaction, or exposure to a toxin) or psychologic stress. Nurses in the intensive care unit often see delirium induced by the disorienting and confusing environment, sensory dep- rivation, or sensory overload. It may also occur postoperatively related to anes- thetic or electrolyte changes. It is also very common in advanced cancers and in the terminally ill (Kuebler, Heidrich, Vena, & English, 2006). Delirium is caused by a temporary malfunction of the brain. When the underlying causative condi- tion is resolved, the delirium generally resolves. It is a medical emergency. If left untreated, it could progress to dementia, coma, or death depending on the underlying cause. It is often under-recognized until the symptoms become more flagrant. Delirium can take 3 forms: hyperalert-hyperactive, hypoalert- hypoactive, and mixed (Irving, Fick, & Foreman, 2006). See Table 10-1 for Types of Delirium.

Dementia is generally a permanent condition caused by a variety of factors that lead to cellular brain changes or malformations. It is characterized by slow, insidious onset affecting memory (impaired ability to learn new information or to recall previously learned information), intellectual functioning, and the ability to problem solve. Types of dementia include Alzheimer’s disease, vascular demen- tia, substance-induced dementia, and dementia caused by other medical condi- tions including HIV, Parkinson’s disease, and Creutzfeldt-Jakob disease.

Alzheimer’s disease is the most frequently seen type of dementia, affecting between 4 to 5 million Americans (Alzheimer’s Association, 2006). The number

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BOX 10–2 Characteristics of Delirium and Dementia Delirium • Fluctuating levels of

awareness and symptoms • Sudden onset • Clouding of consciousness

• Perceptual disturbances (hallucinations, illusions)

• Memory disturbance, more often for recent events

• Highly distractible

• Reversibility possible with treatment

Dementia • Slow, insidious onset with less fluctua-

tion of symptoms • Deterioration of cognitive abilities • Impaired long-and short-term memory

(memory impairment always present)

• Personality changes

• May focus on one thing for a long time

• Often irreversible

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affected has doubled since the 1980s because people are living longer. The cur- rent rate of dementia is expected to triple by 2050 (Davis, 2003; Hebert, Scherr, Bienias, Bennett, & Evans, 2003). It strikes at least 50% of people older than 85 years because the risk to develop it increases with age. Initial changes occur so slowly that they may not be recognized. The person may be regarded as absent minded. Changes in communication, personality, and social skills occur gradu- ally. Because the decline is usually so slow, patients and families may deny its existence until a crisis occurs. The person with Alzheimer’s disease loses the abil- ity to relate to the environment and recognize loved ones. This contributes to

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TABLE 10–1 Types of Delirium

Hypoactive- Hyperactive- Assessments Hypoalert Hyperaltert Mixed

Level of alertness

Motor activity

Ability to follow commands

Thinking Ability

Source: Adapted from Forrest, J., Willis, L., Holm, K., Kwan, M. S., Anderson, M. A., & Foreman, M. D. (2007). Recognizing quiet delirium. American Journal of Nursing, 107(4), 35–39.

Lethargic, falls asleep between questions, diffi- cult to arouse

Decreased activ- ity

Follows a simple command, e.g., lift your foot

Is passively cooperative

Difficulty in focusing atten- tion, disorgan- ized

Alternates between hyper- alert and hypoalert states within hours or days

Alternates within one episode of delirium

Alternates between hypoactive and hyperactive states, may be unpredictable

Alternates between hypoactive and hyperactive states in an unpredictable manner

Overly atten- tive to cues

Moves quickly

May be com- bative, pulls at tubes, tries to climb out of bed

Easily dis- tracted, ram- bles

May mumble, swear, or yell

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families experiencing a prolonged grief process as they slowly lose who their loved one was. Because of the long trajectory, this disease has many financial impacts because the patient will require care for many years. In later stages, the individual may develop gait and motor disturbances and eventually become mute, bedridden, and incontinent. Death often occurs from severe debilitation, aspiration pneumonia, and recurrent infections. The average duration of the ill- ness from onset of symptoms to death is 8 to 20 years.

Vascular dementia, the second most common form, is caused by multiple strokes. Symptoms are variable depending on the extent, location, and timing of the strokes. Decline tends to occur in steps rather than a gradual decline. There is usually more fluctuation in functioning. Impairment is limited and distinct depending on the area of the brain affected. This contrasts with more global intellectual impairment in Alzheimer’s disease. Evidence of strokes, such as one-sided weakness, sudden onset of loss of speech, and focal neurological signs, such as hyperactive deep tendon reflexes, occur with vascular dementia. Treat- ment of underlying hypertension and vascular disease may prevent further progression.

In 2001, guidelines for Mild Cognitive Impairment were developed by the American Academy of Neurology. This condition may be a predictor of demen- tia in about 50% of patients (Gauthier et al, 2006).

ETIOLOGY

Delirium can have biological and psychological causes. Biological causes include a variety of medical conditions, exposure to toxins, and drugs. The onset of symptoms is related to exacerbation of a medical condition or introduction of a new medication for example, and contributes to the diagnosis. Psychological causes include sensory deprivation or overload, relocation or sudden changes, sleep deprivation, and immobilization.

Dementia can be caused by a variety of biological factors including the direct physiological effects of a medical condition, the persisting effects of a substance (drug of abuse, medication, or toxin), or multiple etiologies such as the combined effects of a stroke and Alzheimer’s disease. Alzheimer’s disease destroys brain cells and nerves leading to shrinkage as gaps develop in the temporal lobe and hippocampus where storing and retrieval of new information occurs. Diagnosis can now be made by magnetic resonance imaging (MRI) and positron emission tomography (PET) scan to document the brain atrophy.

The etiology of Alzheimer’s disease remains the focus of much research. Cur- rent theories under investigation include decrease in the activity of the neuro- transmitter acetylcholine and presence in the brain of the protein beta-amyloid. Thus far, theories of environmental toxins, poisons, or a slow-acting virus are unsupported. Genetic factors may also be present. There is a greater incidence of Alzheimer’s disease in the family members of patients who acquire the disease before the age of 60 (Schutte, 2006).

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RELATED CLINICAL CONCERNS

Delirium Medical conditions that can generate delirium include systemic infections, hypoxia, hypercapnia, hypoglycemia, fluid or electrolyte imbalances, hepatic or renal disease, thiamine deficiency, sequelae of head trauma, postictal states, post- operative states, and complications of cancer. Some of the risk factors for delir- ium include vision impairment, cognitive impairment, restraints, malnutrition, and addition of more than three new medications (Samuels & Neugraschl, 2005). Elderly patients and cancer patients with pain are particularly vulnerable (Kue- bler et al., 2006). Delirium is the most common cognitive disorder seen in pallia- tive care and in as many as 80% of patients with advanced cancer (Elsayem, Driver, & Bruera, 2003). The presence of delirium increases the risk of compli- cations associated with a medical illness and increases the risk of mortality.

Substance intoxication delirium can occur from ingestion of alcohol, amphet- amines, cannabis, cocaine, hallucinogens, phencyclidine (PCP), opioids, hyp- notics, and sedatives. Substance withdrawal delirium can occur from abruptly stopping significant abuse of alcohol (formerly called “delirium tremens”), hyp- notics, antianxiety medications, and corticosteroids.

Many prescribed medications can contribute to delirium, including analgesics, anesthetics, anticonvulsants, antihistamines, antiparkinson drugs, corticos- teroids, gastrointestinal medications, and psychotropic medications with anti- cholinergic side effects.

Dementia Medical conditions that contribute to development of dementia include stroke, Parkinson’s disease, Huntington’s disease, AIDS, Creutzfeldt-Jakob disease, hypothyroidism, multiple sclerosis, traumatic brain injury, brain tumors, anoxia, lupus, and hepatic failure. Substance-induced persisting dementia can also occur with a long history of alcohol or substance abuse.

The dementia patient is at risk for many complications including unrelieved pain due to inability to express it. In addition this patient is at risk for skin break- down, aspiration pneumonia, weight loss, and sepsis.

LIFE SPAN ISSUES

Children to Adolescents Children may be more susceptible to delirium than adults, particularly in the pres- ence of febrile episodes and in response to some medications such as anticholiner- gics. Assessment may be complicated by difficulty in eliciting the signs of problems in thinking, memory, and orientation. In fact, delirium can be mistaken for unco- operative behavior. One indication of delirium may be the inability of familiar fig- ures to soothe the child. Children and teens may be at risk for delirium when they abuse club drugs, PCP, inhalants, or combinations of several illicit drugs.

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Dementia is rare in children and adolescents but can occur as a result of med- ical conditions including AIDS, brain tumors, and head injury. As with delirium, dementia can be difficult to identify in young children. It may present as a dete- rioration in function, as in adults, or as a significant delay or deviation in normal development. Deterioration in school performance may be an early sign.

Older Adults Delirium is extremely common in medically ill elderly people. It is a complex process that is caused by many age-related physiologic changes in the brain and other organs (Bond, Neelon, & Belyea, 2006). Ten percent to fifteen percent of hospitalized elderly persons exhibit delirium on admission (DSM-IV-TR, 2000); 15% to 30% of hospitalized medically ill older people may develop it at some time while they are in the hospital. Multiple medications, multiple chronic ill- nesses, use of over-the-counter medications, and impaired kidney and liver func- tion contribute to the development of delirium. Specific conditions that put the elderly patient at greater risk include urinary tract infections, sepsis, stroke, bypass surgery, myocardial infarctions, and dehydration (Liptzen & Jacobson, 2006). A masked depression can appear as confusion (pseudodementia). Acutely confused elderly persons are often inappropriately labelled “demented,” when potentially reversible conditions go undiagnosed and untreated.

Dementia in general is most common after the age of 85 and is often seen in residents of nursing homes. It occurs with increasing frequency after the age of 65 but is not a normal or expected part of the aging process. Mixed dementias are also more common as people continue to live longer.

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POSSIBLE NURSES’ REACTIONS • May have a more positive attitude and take more active measures in care of

patients if they believe the confusion is reversible. • May feel very frustrated and helpless because of lack of improvement, con-

stant need to repeat instructions or break tasks down step by step, repeti- tion of the same question, and time requirements for care of patients with irreversible dementia.

• To avoid feeling hopeless and helpless, may become emotionally detached and give only impersonal care.

• May find themselves bored, unfocused, or confused if patients have consid- erable problems in communicating verbally.

• May be angry with patient’s pathology; may believe patient can control own behavior.

• May become impatient with negative, hostile, impulsive patients who are very slow to respond.

• May feel repulsed by poor hygiene, messy eating behaviors, incontinence, or inappropriate behaviors.

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ASSESSMENT

Behavior and Appearance • Disheveled, inappropriate clothing; poor grooming • Restless, agitated, impulsive, aggressive • Wandering

• Perseveration (involuntary repetitive movements, speech [most common] or activity)

• Apraxia • Agraphia • Loss of coordination; stiff awkward movements; impairment of learned

skilled movements • Unsteady, shuffling gait; stooped, leaning posture • Loss of ability to perform activities of daily living (ADLs)

• Types of aphasia including

• Echolalia (repetition of word, phrase, or syllable just said by someone else) • Repetitive questions • Palilalia (repeating sounds or words over and over) • Anomia (difficulty finding wanted words) leading to paraphasia (using

similar-sounding words) and circumlocution (using many words in place of the one word that is wanted)

• Slurred speech • In late stages, may remember only a few key words used inappropriately

in all situations (such as no) • May become mute • Hoarding • Regression

• Hypersexual behavior such as obsessive masturbation • Hyperoral symptoms including increased appetite • Inappropriate eating and toileting behavior • Sleep disturbance including nocturnal delirium (sundown syndrome) • Overreaction to neutral stimuli (catastrophic reactions) • Inability to tolerate stress and change

Mood and Emotions • Emotional lability • Depression

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• Suspicion, paranoia, hostility • Anxiety

Thoughts, Beliefs, and Perceptions • Loss of recent or remote memory or both • Disorientation, first to time, then place, then person • Impaired concentration • Loss of abstract thinking ability • Loss of ability to calculate • Inability to learn and use new information • Loss of ability to plan, initiate, sequence, monitor, and stop complex

behavior • Agnosia • Ability to read words without knowing what they mean • Loss of ability to read • Confabulation • Loss of awareness of spatial relationships; loss of awareness of own body

parts and how they are organized in relation to each other • Illusions • Delusions, hallucinations • Impaired insight and judgment

Relationships and Interactions • Personality changes: accentuation or alteration of premorbid traits that

affects previous relationships (e.g., caretaker role reversals); family unsure how to interact with patient

• Loss of social skills; social withdrawal • Clinging, demanding • Inability to sustain real relationships as memory gaps eliminate continuity;

in later phases, may not recognize family or friends • Negative, belligerent, briefly combative at times; hostility caused by brain

damage or by misinterpreting events; not necessarily by the behavior of others

Physical Responses • The patient may not verbalize or demonstrate common physical signs of

pain or other symptoms such as bladder distention, constipation, dehydra- tion, injuries, or urinary tract infections.

• Laboratory data, medication history, and possibly drug screening should be performed to evaluate patient at the onset of confusion.

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Pertinent History • Complex medical history • Chronic illness • Substance abuse • Head trauma

COLLABORATIVE MANAGEMENT

Pharmacological A great many medications cause confusion. Confused patients who are taking multiple medications may need to have the medications withdrawn one at a time to determine their impact on the symptoms and the underlying illness. Any med- ications used to treat confusion should be started at lower dosages. Drugs that commonly cause delirium include anticholinergics, benzodiazepines, steroids, antiemetics, and opioids.

Confused patients often become disruptive and may need to be controlled to protect the patient and environment. Haloperidol (Haldol) is frequently used to treat agitation and aggression. Atypical antipsychotics like resperidone are also useful. Side effects such as orthostatic hypotension must be closely monitored because the patient may not be able to verbalize how he or she is feeling. Other medications used with this population include short acting benzodiazepines like lorazepam and selective serotonin reuptake inhibitors (SSRIs).

Buspirone (Buspar) has been used successfully in patient’s with Alzheimer’s disease, although it may take several weeks to take effect fully. Hypnotics, anti- depressants (particularly SSRIs used for irritability), and anticonvulsants (used for rage) are also useful. However, using medications to control agitation should not replace other interventions. There can be a tendency to use medications to sedate the patient rather than pursue behavioral techniques.

Medications to slow down the decline of Alzheimer’s disease include cholinesterase inhibitors such as donepezil hydrochloride (Aricept), rivastignine (Exelon) and Galantamine (Rozadyne) have been used to temporarily improve cognitive function. Memantine (Namenda) is used to treat moderate to advanced Alzheimer’s disease. It is a NMDA antagonist that protects brain cells against the influx of calcium into the nerve cells. It does not stop the disease but may help increase independence in activities of daily living and slow the progression.

Rehabilitation A multidisciplinary approach for the patient with dementia is essential. Physical and occupational therapy, nutritional support, speech therapy, psychiatry, social work, nursing, and medicine all need to be part of the long-term management of this patient. It is important that families use all available resources to reduce their isolation and stress. A variety of nonpharmacological approaches have been

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helpful to reduce agitation. Some include pet therapy, massage, therapeutic touch, and aromatherapy.

NURSING MANAGEMENT

IMPAIRED VERBAL COMMUNICATION evidenced by inability to name objects or sensations such as pain; inability to comprehend verbal instructions; inability to communicate needs; inappropriate, dramatic reactions or accusa- tions, catastrophic reactions related to confusion, disorientation, memory loss.

Patient Outcomes • Demonstrates understanding of nurses and communication • Able to communicate thoughts and needs • Responds appropriately

Interventions • Look directly at patient when speaking. Call patient by name frequently.

Identify yourself by name before each conversation and refer to others by their names rather than “he” or “she.”

• Keep interactions simple. Use short words and simple sentences that express one thought or question at a time.

• Ask specific questions such as “Does your stomach hurt?” rather than general ones like “How are you?”

• Reinforce speech with nonverbal techniques. For example, point, touch, or demonstrate an action while talking about it. For instance, if the patient is trying to tell you about his or her body, point as well as ask “Is this where it hurts?”

• Note in the chart or on the care plan the phrases, key words, and tech- niques that the patient responds to so that others can use them as well.

• If patient keeps repeating a question, try distraction and give reassurance that he or she will be cared for. Repetitive questions may indicate anxi- ety, and you want to be reassuring.

• If patient is searching for a particular word or trying to communicate something, guess at what it is, and ask if your guess is correct. If you are unable to determine what he or she is trying to say, focus on the feelings possibly being communicated. Always ask patient to confirm whether your determination is correct.

• If patient is reacting inappropriately, remain calm and reassure him or her that you are there to help. Avoid arguing or trying to convince patient that he or she is overreacting. Clarify any information or instructions. Assist patient with the next step of a task that is the source of frustration. Try to distract patient by removing him or her from disturbing situation.

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• If patient makes inappropriate accusations, such as accusing the staff of stealing his or her glasses, help look for the missing item. Remember that the patient may accuse you of stealing because of memory loss. Also, rou- tinely check wastebaskets for missing items.

• Family/caregiver support to deal with difficult behaviors. Resources for support should be provided to avoid reactions to behavior with frustra- tion and aggression.

IMPAIRED MEMORY evidenced by confusion, decreased ability to perform activities of daily living (ADLs), or inability to follow therapeutic regimen; inappropriate emotional or behavioral responses related to delirium, demen- tia, or other cognitive deficits.

Patient Outcomes • Demonstrates improved orientation to person, place, and time • Demonstrates improved ability to perform ADLs • Displays less emotional or behavioral agitation

Interventions • Establish a baseline assessment of patient’s mental status and functioning:

• Observe ability to perform ADLs. • Use a standardized method of mental status assessment such as that

found in Table 3–1. • Ask the patient orientation questions. For example, ask patient per-

sonal questions such as names of his or her children or home address. Make sure that you can verify the answers from the chart or family.

• Assess if patient is willing to discuss memory lapses. Determine emo- tional responses to these lapses. Do not push the discussion if the patient becomes agitated or defensive.

• Be aware that patient may try to disguise memory loss by confabulation, avoiding responding, or by speaking in a rambling style to hide the fact that no thought or information is being expressed.

• Be aware that when social skills and personality are still intact, patient may mistakenly appear stubborn and resistant rather than unable to remember.

• Do not argue with patient about what he or she remembers. Rather, focus on immediate and specific tasks to be completed. Give patient step-by- step instructions on what needs to be done. Be directive without being domineering.

• Do not make demands that the patient cannot handle or focus on topics that clearly cause distress. Such demands will only add to the confusion and/or agitation.

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• Break down complex tasks into individual steps. The seemingly simple act of brushing one’s teeth can take over 10 steps. Be aware of the steps the patient can handle himself or herself and those requiring assistance. Use prompts to cue each step of the task.

• Establish a regular and predictable routine. Try to do things at the same time and in the same order each day, such as shave, bathe, and then eat breakfast. Communicate routines to the staff to coordinate patient’s care and ensure that the same techniques are used. Obtain input from the fam- ily on patient’s usual routine. Use prompts such as consistent cue words or signs to remind patient of the routine.

• Attempt to arrange for consistent staff to care for patient. • Keep surroundings simple. Reduce clutter. Do not leave equipment in the

patient’s room if possible. • Personalize the patient’s room. Have the family bring in photos and

favorite objects. Encourage the family to create a memory box with mean- ingful items from the patient’s past (wedding photos, special momentos).

• Place a large, visible clock and calendar in the patient’s room. Cross each day off the calendar daily. Place large signs on the wall noting where patient is and special events such as when the family is coming and the next upcoming holiday.

• Write lists of daily activities or tasks patient needs to do if still able to read and comprehend. Put labels on possessions and patient’s name on his or her door in large letters.

• Avoid an overstimulating environment. In the hospital, the patient’s room should be close enough to nurses’ station to monitor safety yet far enough away to avoid noise. Restrict the number of people visiting at one time.

• If the patient tends to wander, make sure all staff are aware of this prob- lem and can bring him or her back to the unit. Consider using alarms, if available, for a patient at high risk of leaving the area. Monitor all exits. Draw a large red octagon-shaped stop sign and hang it by the exit. At home, make sure exits are monitored. Have the family notify neighbors of the problem and elicit their assistance to monitor for wandering. Make sure the patient always has some form of identification stating that he or she is confused, such as an identification bracelet. Maintain photos of the patient to be shown if he or she is missing.

• Provide some form of night light. If the bathroom is connected to patient’s room, leave the bathroom light on. Otherwise, use reflective tape in the shape of arrows to direct the patient to the bathroom door. Encourage the use of a bedside commode.

RISK FOR INJURY evidenced by falls and bumping into objects. related to problems in gait, vision, hearing, lack of coordination, confusion, or lack of understanding of environmental hazards.

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Patient Outcomes

• Remains free of injury • Demonstrates appropriate actions to avoid injury • Reduce use of restraints

Interventions

• Be aware of factors that increase risk for falls (Box 10–3). • If patient is a fall risk, keep side rails up and bed in lowest position. At

home consider taking the mattress off the bed frame and putting it on the floor to avoid injuries from falls. In the inpatient setting, bed alarms and hip protectors can be used to prevent injury.

• Even with side rails up, be aware that patient may get out of bed. Keep area around bed free from clutter. Make sure that there is always a clear path to the bathroom because that is the place where the patient will most often attempt to go. Make sure that patient uses the bathroom before going to bed at night. Plan administration of medications such as laxatives and diuretics so that they are not given in the evening. Recog- nize that the patient with dementia may have sleep pattern disturbances and become more confused at night.

• Make rounds frequently for patients at high risk for falling. Keep the patient’s door open, and make sure all staff members know that this patient is at risk.

• Use restraints only after all other methods are ineffective. In some instances, restraints can increase confusion in elderly patients.

• If the patient has an unsteady gait, have him or her take your arm instead of the reverse while walking. Make sure the patient has access to any needed equipment such as walkers or wheelchairs. Provide instruction as appropriate within the patient’s ability to understand. Ensure that any furniture or objects the patient leans on for support are sturdy and well balanced. Railings in hallways and bathrooms are very help- ful. The patient may need prompts to perform simple actions, such as walking.

• Make sure the patient receives adequate exercise within the limitations of his or her abilities and condition.

• If the patient wears glasses or a hearing aid, make sure that these are in place before any activity. Be sure to check that the hearing aid battery is good.

• Ensure that the room is adequately lighted for any activity and that the call light is within reach when patient is in bed, in bathroom, or sitting in chair.

• Check the patient routinely for bruises, cuts, or burns.

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• Use colored waterproof tape along the area of the bathtub where patient is to stop filling with water. Decorative markers that stick to the bottom of the shower or tub can compensate for spatial disorientation.

• Use brightly colored materials in the room, if possible. • Be aware that the patient may try to pull out catheters or intravenous

tubing. Try to reduce risk of the patient’s pulling out the tubes by reduc- ing the discomfort associated with tubes. For instance, use the smallest-

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BOX 10–3 Causes of Increased Risk of Falls and Injury • Stiff, awkward movements caused by damage to areas of brain that control

muscle movement: • Difficulty getting out of bed • Stooped or leaning posture and shuffling gait as disease progresses • Apraxia, with inability to make or coordinate movements

• Overmedication: Changes in drowsiness, walking, posture, stiffness, agita- tion, falling, increased postural hypertension

• Visual problems: • Cataracts • Increased near- or farsightedness • Inability to distinguish between similar color intensities (may have diffi-

culty identifying railings that are same color as walls; may stumble into walls of color intensity similar to that of floor)

• Poor depth perception • Blurred vision (may be side effect of medication, anticholinergic action)

• Hearing problems: May not hear approaching machinery or people • Agnosia: May bump into furniture, not recognizing what it is • Diminished or absent pain perception:

• Inability to recognize or communicate injury (for example, patient may try to walk on broken leg)

• Only manifestation may be change in behavior • May burn self while smoking

• Sundowning syndrome (increased confusion at night) with night restless- ness, wandering

• Any factor, including concurrent delirium, that increases confusion and dis- orientation

Source: Gorman, L., Raines, M., & Sultan, D. (2002). Psychosocial nursing for general patient care (2nd ed). Philadelphia: FA Davis.

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size nasogastric tube or cover the IV site with a large bandage to avoid the patient’s pulling on the tubes. Wrist restraints, freedom splints, or monitoring by a family member may be required to avoid injury.

• Be aware of medication interactions that could add to confusion and the risk for falls.

NUTRITION, IMBALANCED: LESS THAN BODY REQUIREMENTS, AND FLUID VOLUME DEFICIT evidenced by weight loss, electrolyte imbal- ance, increased confusion, or other signs of dehydration, related to impaired recognition of hunger and thirst, memory loss, impaired movements.

Patient Outcomes • Receives adequate nutritional and fluid intake

• Displays ability to recognize signs of hunger and thirst

• Demonstrates ability to feed self

Interventions • Assess the patient’s ability to feed and care for self (Fig. 10–1).

• Provide assistance, as needed, for dressing, personal hygiene, and eating.

• Determine how much patient can safely do independently. Perhaps just opening containers or cutting meat is all that is needed to promote inde- pendence. Provide verbal cues to keep patient on track.

• Determine patient’s food preferences and provide these foods, if possible. Encourage the family to bring familiar foods from home if appropriate.

• Make sure that dentures are in place and that they fit correctly before serving a meal.

• Allow hot foods to cool to prevent burn injury.

• Simplify the meal routine. The patient may be able to cope with only one food or one utensil at a time. Provide finger foods if utensils are difficult to use.

• Reduce distraction during mealtimes. For instance, turn off the television or radio.

• Assess regularly for signs of dehydration and aspiration (coughing after eating/drinking). Use thickened liquids or pureed diet.

• Make sure that patient can see his or her food and hear your instructions.

• Consider liquid supplements if eating solid food is too difficult.

• Assess for constipation.

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Chapter 10 ■ Problems with Confusion 173

FIGURE 10–1. Self-care checklist.

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• For patient with end-stage dementia, family may face decision on whether to pursue aggressive nutrition intervention if patient refuses to eat or is unable to swallow. Provide support for the family in attempting to weigh these difficult options. Consider offering ethics consultation or palliative care/hospice assistance, if appropriate.

ALTERNATE NURSING DIAGNOSES

Confusion, Acute Confusion, Chronic Family Processes, Interrupted Sensory Perception, Disturbed Sleep Pattern, Disturbed Therapeutic Regimen Management: Ineffective Thought Processes, Disturbed

PATIENT AND FAMILY EDUCATION

• Provide simple instructions based on patient’s current ability to compre- hend.

• Teach the family techniques to control uncooperative and aggressive behavior.

• Give the family information about the disease so that they can better under- stand that the patient has no control over his or her behavior.

• Teach the family or caregivers about the need to avoid stress and fatigue for the patient because this can increase behavior problems.

• Encourage family to obtain material and newsletters from the Alzheimer’s Association (alzheimers.org). Also encourage them to obtain a copy of The 36-Hour Day by Mace and Rabins.

• Alert family to signs of caregiver abuse.

• Teach the family or caregivers to build support systems to maintain a bal- ance in their lives. Give information on obtaining caregivers.

• Encourage family to consider options for the future such as nursing homes, in-patient dementia programs.

• If the patient is in the early stages of dementia, encourage discussion of wishes for resuscitation and feeding tubes when the disease advances. Encourage completion of an advance directive.

• Review realistic expectations from Alzheimer’s drugs and symptom man- agement medications.

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• For patients with delirium, help the patient/family identify possible sources of the delirium so the risk can be minimized in the future.

• Teach the family about the emotional strain created by caring for the con- fused patient. Educate them that, with Alzheimer’s disease in particular, the family may go through a mourning process for the person who their loved one used to be. This process is complicated because the patient looks the same but no longer has the same personality. Adult children must be pre- pared to reverse roles and become caretakers.

CHARTING TIPS

• Document any changes in levels of confusion, memory, behavioral routines, or consciousness.

• Document which activities the patient cannot do.

• Document if patient is able to start an activity but requires a prompt to con- tinue. Document words or physical directions that work as a prompt.

• Document stimulus that causes the patient to have catastrophic reactions, such as too much noise or too many demands at the same time.

• Document the patient’s response to medications.

• Document any techniques that have been effective in calming patient.

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WHO TO CALL FOR HELP

• Social Worker

• Security

• Psychiatric Team

• Geriatrician

WHEN TO CALL FOR HELP

• Sudden onset of confusion

• Episodes of patient’s becoming physically combative

• Patient who becomes a danger to self or others because of poor judg- ment (driving, cooking, etc.)

• Severe agitation unresponsive to medication or other interventions

• Delirium that does not remit or gets worse

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COMMUNITY-BASED CARE

• Be sure that the family has the needed information on financial resources and legal information for power of attorney.

• Report all indications of caregiver abuse. • Assist the family or caregivers to set a plan to provide them with needed rest

and recreation. Encourage family and caregivers to seek out support of friends or clergy. Encourage attendance at local support groups.

• If the care demands become too great, families need to consider placing the patient in a nursing home, specialized Alzheimer’s program, or day care. Provide information on any specialized programs in the community and suggestions for what to look for in a facility. Provide families with support to make this difficult decision.

• Give specific information on this patient’s management to home health agencies and skilled nursing facilities.

• Give information from local Alzheimer’s Association chapters on treatment programs, research, and facilities.

• Patients with end-stage dementia may be appropriate for referral for pallia- tive care or hospice care when they are bedbound, experiencing repeated infections, and are having difficulty with eating and drinking.

• Refer to home health agency if patient to be discharged home with a feed- ing tube or needs further instructions on prevention of aspiration, skin breakdown.

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11

177

Problems with Psychotic Thought Processes

The Psychotic Patient

Learning Objectives • Differentiate between schizophrenia and other psychoses. • Describe effective interventions for the hallucinating and delusional

patient. • Describe possible nurses’ reactions to the psychotic patient. • Discuss specific interventions for the patient experiencing intensive care

unit psychosis.

Glossary Delusional disorder – Persistent suspicions, persecutory ideation, and delu-

sions or delusional jealousies with resentment, anger, and sometimes grandiosity without other signs of psychotic thoughts or mood disorders. Patients are usually able to maintain daily functioning. (Previously known as paranoid disorder).

Brief psychotic disorder – Sudden onset of psychosis precipitated by severe stress with patient returning to premorbid state within 30 days.

Delusions – False, fixed beliefs that cannot be corrected by feedback and are not accepted as true by others in the same culture.

Good reality testing – The ability to accurately identify and evaluate events. Absence of delusions, hallucinations, and other distorted perceptions.

Hallucinations – Sensory experiences that are very real to the patient but that do not exist in external reality, occurring while the patient is awake and when no one else has a similar experience.

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Poor reality testing – Defects in a person’s ability to accurately assess exter- nal events and interactions with others.

Psychosis – Severe distortion of and withdrawal from reality accompanied by severe disorganization of the personality.

Schizoaffective disorder – Symptoms of major depressive disorder or the manic phase of bipolar disorder as well as some of the symptoms of schiz- ophrenia.

Schizoid personality – Individual who is indifferent to social relationships and with a very limited range of emotional experiences and expressions

Schizophrenia – A severe thought disturbance characterized by impaired reality testing, hallucinations, delusions, limited socialization; diagnosis requires the symptoms to last at least 6 months.

Caring for a patient who is hearing voices, believes that the staff is trying to kill him or her, or exhibits other bizarre behavior can be confusing, disori-

enting, frightening, and disarming for the nurse. Although nurses in the psychi- atric setting may frequently see psychotic patients (more than 50% of psychiatric beds are occupied by patients with schizophrenia [Berkow, 1992]), nurses in other settings may be unprepared for managing the psychotic patient. These patients are often feared and shunned by healthcare workers.

Hallucinations and delusions can be frightening for both the patient to expe- rience and the nurse to observe. Even hallucinations that begin as fairly innocu- ous experiences can become frightening or accusatory to the patient (Box 11–1). Subjects of delusions vary. Common delusions are described in Box 11–2.

Hallucinations, delusions, or other psychotic thought disorders occur in patients with a primary psychiatric disorder such as schizophrenia, delusional disorder, brief psychotic disorder, or severe depressive disorder. Physiological

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BOX 11–1 Recognizing Hallucinations Affected Sense Example Visual

Auditory (most common) Tactile

Olfactory

Gustatory Kinesthetic (bodily or movement sense)

“I watch gypsies bring different babies to my apartment, each night.” “The voices are calling me a prostitute.” “When I touched my arm, I could tell my arm is made of stone.” “I don’t want to stay in that room. I can smell the odors of the people who died there.” “I taste milk in my mouth all the time.” “It feels as if the rats in my head are eating up my brain.”

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changes or drug and alcohol use or withdrawal can also cause these thought dis- orders. Whether or not the etiology of the symptoms is known, the basic inter- ventions are similar.

Psychotic thought disorders lead to severe distortion of and withdrawal from reality, accompanied by major personality disorganization. This disorganization leads to hallucinations, delusions, and bizarre behavior such as catatonia (assum- ing inappropriate postures or becoming completely immobile) or echolalia (repe- tition of words heard).

Schizophrenia, a psychiatric diagnosis characterized by changes in cognitive, perceptual, affective, motor, and social domains, is one of the most common forms of psychosis. Schizophrenics have psychotic episodes, but not all psychotic episodes are caused by schizophrenia. The word schizophrenia refers to splits between different components of the personality; for example, what the patient says does not match the emotion shown. The onset of schizophrenia occurs between the ages of 17 and 25 for 75% of cases (Moller and Murphy, 2001). Ear- lier onset is associated with poorer outcome. The lifetime prevalence of schizo- phrenia is 1% worldwide, with no differences related to race, social status, culture or environment (Mariani, 2004). All socioeconomic and cultural groups are affected, but schizophrenics tend to cluster in the lower socioeconomic levels because of their difficulty maintaining employment and functioning in society. Schizophrenia is a chronic, disabling condition, although symptoms can usually be controlled with appropriate medication. Schizophrenic patients can also have features of depression, manic behaviors, or both (schizoaffective disorder). Pre- dictors for schizophrenia include social maladjustment and schizoid personality. See Box 11-3 for the various forms of schizophrenia.

Other types of psychoses include delusional disorder, brief psychotic disorder and psychosis due to general medical condition.

Patients without a psychiatric illness who experience sensory deprivation or overstimulation can become psychotic. A common example is referred to as intensive care unit (ICU) psychosis. However, the patient does not need to be physically located in the intensive care unit to experience this problem. Psycho- logical stress, sleep deprivation, sensory overload, and immobilization all con-

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BOX 11–2 Common Delusions Delusion Example Grandeur (belief of exaggerated importance) Paranoia (belief of deliberate harassment and persecution) Reference (belief that the thoughts and behavior of others is directed toward self) Physical sensations (belief that parts of body are diseased, distorted, or missing)

“I am Napoleon Bonaparte.” “The FBI is following me and wants to kill me.” “Those people on the TV show are talking to me.” “I have no blood in me.”

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tribute to the critically ill person’s developing personality changes, hallucinations, and delusions. A delirium from a medical condition or drug reaction can also contribute to psychotic behavior. Physiological changes such as hypoxia, renal failure, and response to medications also contribute.

ETIOLOGY

No single cause of schizophrenia has been identified. Genetic theories recognize possible hereditary tendencies because there is a higher incidence in families with one schizophrenic parent or sibling. Biological theories have received increasing attention. Some causes may be brain dysfunction in the limbic system and pre- frontal cortex or biochemical disruption in neurotransmitters such as dopamine. Antipsychotic medications work by blocking dopamine activity. Psychological theory focuses on deficits caused by severely inadequate parenting throughout development, with special recognition of the devastating impact of deprivation during the first years of life. The more research validates the genetic and biologic theories, the less psychological theories appear to be causal. Clearly, though, per- sonality is affected by psychological development and in turn affects outcomes in patients with schizophrenia. Cognitive theories indicate that the patient with schizophrenia has problems with attention or information processing. The per- son is unable to filter stimuli, leading to disorganization of mental functioning. Family theory has examined communication patterns that present unrealistic and unworkable expectations for the susceptible individual.

Other types of psychotic disorders may develop in individuals with fragile egos who become flooded with anxiety under severe stress.

RELATED CLINICAL CONCERNS

Certain physical conditions and medications, drug and alcohol withdrawal, and sleep and sensory deprivation cause some type of brain dysfunction that may result in psychosis. Examples of physical conditions include brain tumors, head injuries, high fever, septicemia, AIDS, encephalitis, epilepsy, and hepatic encephalopathy. Box 11–4 lists the types of psychotic reactions caused by med-

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BOX 11–3 Types of Schizophrenia Type Characteristics Disorganized Catatonic Paranoid Schizophrenic Undifferentiated

Regressive and primitive behaviors Marked abnormalities in motor function Delusions of persecution or grandeur Does not meet criteria for other types

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ications. Withdrawal from alcohol as well as effects of drugs such as LSD, PCP, stimulants and cocaine can also produce psychosis.

Disorders, medications, and environmental factors can alter cerebral perfusion and chemistry to create biological states that mimic some psychiatric disorders, including exhibiting psychosis and thought disorders. The combination of med- ications, sensory and sleep deprivation, fear and anxiety, and illness put the patient in an intensive care unit at risk of experiencing psychotic episodes. If this occurs, a thorough assessment is essential to accurately determine the underlying cause.

A patient with a psychotic disorder may also misuse drugs or alcohol as a way to self-medicate for uncomfortable symptoms. These medications could intensify psychotic symptoms and confuse the diagnosis and treatment. Dual or co- occurring diagnosis is the term used to describe someone with a substance dependency and a major psychiatric disorder.

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BOX 11–4 Drugs Associated with Psychotic Reactions • Amphetamines • Antidepressants (particularly tricyclics) • Anticholinergics (e.g., atropine) • Anticonvulsants (e.g., carbamazepine, valproic acid) • Antihistimines (e.g., diphenhydramine) • Antiparkinsonians (e.g., L-dopa) • Antituberculosis (e.g., isoniazid) • Antivirals (e.g., acyclovir, amantadine) • Antiarrythmics (e.g., Lidocaine) • Alcohol • Beta blockers (e.g., propranalol) • Corticosteroids • H2-receptor blockers (e.g., cimetidine) • Cyclosporine • Digitalis • Dilsulfiram (antabase) • Anesthetics (e.g., ketamine) • Antibiotics (e.g., cephalosporins, ciprofloxacin, sulfonamides) • Opioids (e.g., morphine, hydromorphone)

Source: Adapted from Goff D.C., Freudenreich, O., & Henderson, D. C. (2004). Psychotic patients. In T. Stern, G. L. Friccione, N. H. Cassem, M. S. Jellinek, &. J. F. Rosenbaum (Eds.), Massachu- setts General Hospital handbook of general hospital psychiatry (5th ed.) (pp. 155–173). St Louis: Mosby.

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LIFE SPAN ISSUES

Children Although schizophrenia is rare in children, it has been identified. Symptoms include inappropriate affect, hallucinations, and mutism. It is often confused with autism, which is the most severe developmental disability of childhood, but it is not the same disorder. Children with psychotic disorders can be treated with antipsychotic medications, but side effects such as sedation and weight gain are a concern.

Children of parents with schizophrenia are at high risk for developing the dis- order. As children of the mentally ill, they are at risk for being victims of abuse because they may be inadequately protected as a result of parental illness. They are likely to take on more responsibility to care for the household and less likely to have developmentally appropriate social skills because of the poor skills of their parents. Because so many people with schizophrenia are homeless, their children may be living on the streets.

Adolescents The diagnosis of schizophrenia is more common in adolescence. Teens may be more likely to experiment with drugs in an effort to self-medicate to deal with distressing symptoms of anxiety and hallucinations. The move to college can trig- ger a psychotic episode in an at-risk teen or an exacerbation of long standing mental disorder. Being away from home, increased pressure to make independent decisions, and exposure to drugs and alcohol can all contribute to a psychiatric crisis in an adolescent at risk for psychosis.

Postpartum Postpartum psychosis is a relatively rare disorder. Psychotic behavior tends to be evident within 4 weeks of delivery. Women with a past history of this are at higher risk for recurrence with succeeding pregnancies. If the symptoms last longer than 4 weeks, other diagnoses need to be considered. For patients at risk for this con- dition, precautions need to be in place to prevent child abuse and/or neglect.

Older Adults Elderly schizophrenics often have fewer and less severe symptoms, especially hal- lucinations and delusions, although symptoms of emotional flattening and loss of motivation often continue. These patients often do not verbalize pain or discom- fort, which leads to under-treatment of medical conditions. The first signs of physical illness in these patients may be changes in ability to perform activities of daily living. They are also more prone to the nonreversible drug side effect of tar- dive dyskinesia (constant involuntary movements). See Chapter 21 for further discussion. With elderly persons living longer and mentally ill people less likely

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to be institutionalized, it is believed that there will be an increase in the number of these patients in nursing homes and retirement settings.

A new onset of psychotic behavior in elderly people must be closely assessed to rule out physical illness, delirium, or medication toxicity. Because elderly per- sons may already have some sensory deprivation, illness, and use a variety of medications, the simple fact of their being hospitalized can increase anxiety and can make them at risk for confusion and psychosis. Symptoms can easily be con- fused with those of dementia, which could lead to inappropriate treatment.

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POSSIBLE NURSES’ REACTIONS • May avoid psychotic patients because the nurse feels that he or she lacks

knowledge or experience with them. • May feel strangely uncomfortable or detached because of patient’s lack of

emotional connectedness. • May feel frustrated and angry and have unrealistic expectations regarding

the patient’s self-care. • May feel afraid because of patient’s bizarre behavior. May fear violence and

personal harm. • May feel confused when patient responds unpredictably. • May ignore patient’s complaints because “he’s crazy.” • May feel rejected if patient’s extreme mistrust or fear of others is not under-

stood. • May feel that he or she has to control patient’s bizarre behavior to be

effective. • May feel unable to intervene, leading to the nurse’s giving up on the patient.

ASSESSMENT

Behavior and Appearance • Strange or bizarre appearance, poor grooming, disheveled, eccentric clothing • Unusual gestures, mannerisms, facial grimaces, posturing • Neglect or difficulty performing activities of daily living • Incoherent, repetitive speech; mumbling; talking to self • May not answer questions or responds only partly; frequently asks that

questions be repeated. • May be watchful or withdrawn: head positioned, eyes moving, watching

something that is not there. • Socially unacceptable behavior and speech; may make up words • Marginal functioning, such as being unable to maintain employment

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Mood and Emotions • Displays emotions inappropriate to situation such as crying when others are

laughing • Displays contradictory emotions at same time; unpredictable mood changes • Flat affect • Highly anxious, panic • Difficulty controlling emotions: outbursts of rage, crying, laughing

Thoughts, Beliefs, and Perceptions • Poor concentration • Impaired ability for abstract and/or logical thinking • Loose associations (ideas shift rapidly from one unrelated subject to another) • Hallucinations; sensory distortions such as seeing objects or people change

in size and shape • Delusions • Extreme sense of worthlessness; overwhelming, inappropriate guilt • Decreased recognition of own body sensations, such as hunger, pain, and

urge to urinate • Depersonalization (sense of feeling separated from body) • Suspicious; paranoid • Extreme ambivalence; impaired decision-making ability; inability to prob-

lem solve • Altered sense of self; uncertain where own body stops and external objects

and people begin

Relationships and Interactions • Dependent on others for basic needs • Fear and distrust of others • Unable to maintain close relationships • Lack of social skills • Interactions seem cold and detached • Poor eye contact; withdrawn

Physical Responses • Complaints of unusual or bizarre symptoms • Blunting of pain

Pertinent History • Psychiatric hospitalizations • Ongoing or periodic outpatient psychotherapy • Substance abuse

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• Childhood behavior problems such as being isolated or described as “odd” • Minor infractions of law • History of suicide attempts

COLLABORATIVE MANAGEMENT

Pharmacological Although they are not cures, antipsychotic (or neuroleptic) medications can reduce and control many of the symptoms of psychosis. See Chapter 21 for a detailed dis- cussion of these medications. Antipsychotics are especially effective in managing agitation, combativeness, and belligerence. Newer antipsychotics, often called atypical, such as risperidone (Risperdal), quetiapine (Seroquel), and olanzapine (Zyprexa) are particularly effective in treating social withdrawal, flat affect, hal- lucinations, and delusions. These are now being used for patients with schizo- phrenia that is refractory to other antipsychotics. They have fewer extrapyramidal side effects than the older antipsychotics. One of the original atypical medications, clozapine, can cause agranulocytosis. Though more effective, these drugs are con- siderably more expensive than traditional antipsychotics. Patients with schizo- phrenia may need to remain on these medications for the rest of their lives, and symptoms can recur if they stop taking them. Approximately 25% of patients with schizophrenia do not respond adequately to traditional antipsychotics (Moller & Murphy, 2001). For patients with chronic psychotic processes, finding the right antipsychotic with minimal side effect profiles can take months or even years of trial and error. Traditional antipsychotic drugs like haloperidol are used less today due to the extrapyramidal side effects which impact functioning.

Antipsychotics can be given on an occasional basis to manage acute agitation, such as might be seen in ICU psychosis or drug reaction. They control the symp- toms until the problem resolves or the cause can be treated.

NURSING MANAGEMENT

RISK FOR VIOLENCE evidenced by agitation, aggressive behavior related to delusions and hallucinations.

Patient Outcomes • Able to maintain control of own behavior • Demonstrates less anxiety • Does not cause harm to self or others

Interventions • Reassure patient that he or she is safe and that the staff will provide pro-

tection. Be aware that the psychotic patient is more timid and frightened than dangerous.

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• Avoid putting patient on the defensive. Avoid ultimatums. • Maintain nonstimulating environment. Use a calm voice with relaxed,

nonthreatening body language. • Ask if patient is hearing voices and if he or she can tell you what they are

saying. • Ask the patient if he or she is hearing “command” hallucinations, such

as voices commanding him or her to act a certain way. If these commands are for dangerous behavior, monitor the patient closely.

• Reinforce the patient’s ability to remain in control of his or her behavior. • Be aware of signs that indicate tension level is increasing. • Monitor patient’s behavior closely. If having hallucinations or delusions

that are very frightening, patient could inadvertently harm self or others (e.g., the patient has to protect himself or herself from a monster in the room or voices saying to kill himself or herself). Observe closely if this occurs and seek out additional assistance.

• The patient may interpret even the most innocent behavior as threatening (turning up the thermostat could be interpreted as turning on poison gas).

• Administer ordered antipsychotic medications. Consider injectable ones for faster onset of action. Patient may need these medications admin- istered frequently (rapid tranquilization) until behavior is controlled. Monitor closely for side effects including postural hypotension and extra- pyramidal symptoms.

• Determine if use of touch calms patient or adds to his or her distress. Ask the patient’s permission to be touched.

• Set limits on destructive behavior. Let the patient know what behavior is and is not allowed. Reinforce to staff members that everyone must sup- port the same approach.

• If patient is out of control, use restraints only as last resort. See Chapter 8 on managing violent behavior and restraint application. For the psy- chotic patient, restraints can represent a relief from the tremendous anx- iety and loss of control being experienced, or they can significantly increase anxiety and persecution delusions. Have adequate, trained staff available to manage potential violence.

DISTURBED THOUGHT PROCESSES evidenced by inability to evaluate reality; hallucinations, delusions related to schizophrenia or other psychoses.

Patient Outcomes • Demonstrates clear communication to others • Maintains reality orientation (person, place, time, situation) and demon-

strates good reality testing • Demonstrates improved ability to participate in treatment plan

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Interventions • Determine if patient’s behavior is a chronic problem or if this is a new

onset. If chronic, determine baseline behavior, medications taken, psy- chiatric care received, and provider. If new, determine possible causes.

• Make short, frequent contacts to help build trust by helping the patient feel secure.

• Focus on the present reality rather than future or past. Speak simply. Focus on concrete subjects. Keep directions simple. Give only one step at a time. Avoid theoretic or philosophical topics.

• Provide a quiet, nonstimulating environment.

• Use one form of communication at a time; avoid using a lot of hand motions while speaking.

• Although psychotic speech is unclear, listen for unconsciously symbolic communication.

• Avoid giving choices to severely disorganized patients to avoid provoking anxiety.

• If possible, problem solve with the patient about ways to cope with anxiety.

• Provide frequent reality orientation: review location, date, and so on.

• Arrange for the same staff members to care for patient, if possible.

• Find ways to provide structure in patient’s day; provide a written sched- ule to follow.

• Make sure patient is taking and swallowing prescribed antipsychotic medications. Recognize that hallucinations and especially delusions may take weeks to months to diminish fully once the medication is started.

• Patient can easily misinterpret what you are saying or doing. Obtain fre- quent feedback from patient.

• Monitor patient’s decisions. Poor judgment may indicate an exacerbation.

• Ask the physician to arrange for a psychiatric consultation.

• For the patient who may be reacting psychotically to the stressful hospi- tal environment:

• Ensure that patient is able to get adequate rest and sleep.

• Make sure patient is oriented to the time of day.

• Explain equipment and noises and their significance to patient.

• Call patient by name and personalize his or her care.

• Encourage family to bring in personal belongings such as photographs.

• Vary stimuli around the patient; for example, turn on music or TV at times.

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• If the patient is hallucinating:

• Ask patient directly about his or her hallucinations. For instance, you may say, “Are you hearing voices? What are they saying to you?” “Are they telling you to do anything or not to tell?”

• Watch patient for cues that he or she is hallucinating: eyes darting to one side, muttering, or watching a vacant area of the room. Patient may deny hallucinations per imagined commands to do so.

• Avoid reacting to hallucinations as if they are real. Do not argue back to the “voices.”

• Do not negate patient’s experience, but offer your own perceptions. For instance, you may say, “I don’t see the devil standing over you, but I do understand how upsetting that must be for you to be seeing that.”

• Focus on reality-based diversions and topics such as conversations or simple projects. Tell patient, “Try to not listen to the voices right now. I have to talk with you.”

• Be alert to signs of anxiety in the patient, which may indicate that hal- lucinations are increasing.

• If the patient is having delusions:

• Be open, honest, and reliable in interactions to reduce suspiciousness. Respond to suspicions in a matter-of-fact and calm manner. Ask patient to describe the delusions: for example, “Who is trying to hurt you?”

• Avoid arguing about the content of the delusions, but interject doubt where appropriate: for example, “I don’t think it would be possible for that petite girl to hurt you.”

• Focus on the feelings that the delusions generate, such as “It must feel frightening to think there is a conspiracy against you.”

• Once patient describes delusion, do not dwell on it. Rather, focus con- versation on more reality-based topics. If patient obsesses on delusions, set firm limits on amount of time you will devote to talking about them.

• Observe for events that trigger delusions. If possible, discuss these with patient.

• Validate if part of the delusion is real, for instance, “Yes, there was a man at the nurse’s station, but I did not hear him talk about you.”

ALTERNATE NURSING DIAGNOSES

Coping, Ineffective Injury, Risk for Self-Mutilation Self-Care Deficit Sleep Pattern, Disturbed Social Isolation

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PATIENT AND FAMILY EDUCATION

• Teach patient signs of escalating symptoms. • Teach patient effective interventions to control anxiety and fears, such as

distraction, listening to music. • The patient needs to have strategies for coping with hallucinations. Some

suggestions include reading aloud, telling voices to go away, physical aciv- ity, calling someone for help.

• Review with patient ways to validate whether what is being experienced is real, such as asking others if they see or hear the same things.

• Make sure family or caregivers are aware of signs of escalating symptoms and provide suggestions for managing them. For chronic psychotic disorders, give the family written information on the diagnosis or suggest appropriate reading, such as Surviving Schizophrenia: A Family Manual by E. F. Torrey.

• Teach the importance of taking prescribed medications and ways to manage side effects.

• Teach the importance of informing the physician of new symptoms, delu- sions, physical symptoms, and pains.

CHARTING TIPS

• Document patient’s behavior and content of delusions and hallucinations. • Document the administration of medications, side effects, and patient’s

response to the medication.

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WHEN TO CALL FOR HELP

• Self-mutilation • Suicide threats or attempts • Aggressive behavior escalating to violence • Hallucinations or delusions with increasingly violent, bizarre content • Patient’s inability to care for self • Increasing staff anxiety and fear over patient’s behavior

WHO TO CALL FOR HELP

• Psychiatric Team • Security • Social Worker

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• Document efforts and effectiveness in controlling patient’s behavior. • If restraints are needed, document the type used and appropriate monitor-

ing provided. • Document the family response to patient and the education and discharge

plan.

COMMUNITY-BASED CARE

• Determine psychiatric care and provider. Reinforce the need to continue in treatment. Reinforce to the family or caregivers their responsibility for get- ting the patient to follow-up appointments. Give patient and family written referrals and specific appointments for psychiatric care.

• Emphasize to the family their need for emotional support. Refer to appro- priate programs or support groups, such as local chapters of the National Alliance for the Mentally Ill.

• If the patient has a chronic psychiatric disorder, determine patient’s func- tional ability. Referrals may be needed to programs to assist with employ- ment skills and living arrangements.

• If the patient has difficulty functioning in society, he or she may need to be transferred to a psychiatric hospital or more protected living arrangements, such as a halfway house, group living home, or day treatment program.

• Reinforce need to continue follow-up medical care. Give written specific appointments.

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12

191

Problems Relating to Others

The Manipulative Patient

Learning Objectives • Identify types of manipulative behaviors. • Identify some possible nurses’ reactions toward manipulative patients. • Describe “staff splitting” and characteristic manifestations. • Define confrontation and limit setting as therapeutic responses. • List effective nursing interventions to deal with manipulative patients.

Glossary Adaptive manipulation – Skillful management or use of one’s self to affect or

change a situation to one’s best advantage. It is goal oriented, used only when appropriate, considers others’ needs and welfare, and is only one of several coping mechanisms used.

Antisocial personality disorder – A psychiatric disorder in which there is a pervasive pattern of disregard for and violation of the rights of others. Indi- viduals with this disorder rarely feel motivated to change.

Borderline personality disorder – A psychiatric disorder in which there is a chro- nic state of instability with changes in relationships, self-image, and mood.

Cognitive behavior therapy – Form of psychotherapy that focuses on chal- lenging core beliefs that adversely affect self-perception

Dialectical behavior therapy – Form of cognitive behavioral therapy for the borderline client that focuses on gradual behavior change, teaching skills to regulate emotions, group social skills training, and psychotherapy.

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Maladaptive manipulation – Similar to an addiction and not goal directed, it is the predominant, continuous controlling of others whether or not it is appropriate, effective, or attains specific goals.

Personality disorder – A group of psychiatric disorders in which specific, per- vasive patterns of inflexible, enduring maladaptive thinking about one’s self and the environment cause difficulties in interpersonal relationships and the ability to do work.

Splitting – An unconscious defense mechanism found in certain manipula- tive people that causes them to experience others only in the extremes of love or hate, or good or bad.

Staff splitting – An unfortunate staff response to a patient that leaves the staff members arguing and not coordinating with each other. The staff members whom the patient treats well think highly of the patient and the others do not.

The word manipulation usually conjures up negative images of pushy, untrust- worthy individuals who are concerned only with getting what they want with

no regard for other people’s feelings, priorities, or needs. However, manipulation can be viewed more accurately as a tool that is not inherently bad and that can be used in either constructive or maladaptive ways. For instance, adaptive or constructive manipulation is an effective technique for a charge nurse making assignments to ensure the best use of nursing personnel to meet patients’ needs while considering the nurses’ preferences and learning needs. Some people use maladaptive manipulation strategies during periods of stress to avoid uncom- fortable, anxiety-arousing feelings and to gain a sense of security. The patient may use manipulation to compensate for feeling overwhelmed, out of control, and frightened by illness, hospitalization, or personal or occupational concerns.

People who consistently use maladaptive manipulation regardless of the cir- cumstances may have a personality disorder. Personality disorders are frequent in the general population and may coexist with other psychiatric diagnoses. Bor- derline personality is the most common personality disorder seen in the clinical setting (Oldham et al, 2001). People with this disorder make up about 1% to 2% of the population and 20% of psychiatric inpatients (Gunderson, 2001). These individuals operate using ingrained behavior patterns that have been effective for them, and they may not be aware of their manipulative behavior, the cause-and- effect relationship between their actions and resulting consequences, or the pos- sibility of alternative, effective approaches. This behavior can be very difficult to change because the person is repeatedly rewarded by achieving his or her goal when the manipulation is successful. People with borderline personality disorder manipulate to gain nurturance. They are so fearful of separation that they use manipulation to try to achieve a goal of maintaining closeness. They may exhibit both clinging and distancing behavior as they struggle with these issues (Townsend, 2006). The family of borderline patients may have a long history of

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frustration and exhaustion with having to deal with multiple impulsive acts. Another common disorder is antisocial personality disorder. Individuals with this disorder manipulate to gain power, possessions, or some other material gratifica- tion. Antisocial personality disorder is also associated with social irresponsibility and reckless or criminal behavior. Manipulative behavior stemming from per- sonality disorders can be either blatant or insidiously covert. The manipulative person may appear superficially pleasant. However, the person being manipu- lated often recognizes the impact or results even if he or she is unable to describe clearly how they occurred.

Manipulative behavior can also take the form of sexually inappropriate behav- ior such as provocative language or inappropriate touching or threats of violence as a way to maintain control over others (Manos & Braun, 2006).

The first sign of a patient’s use of maladaptive manipulative behavior may be the staff’s growing frustration and anger. Manipulative patients may uncon- sciously project their own thoughts and feelings onto staff members and see one or some of them as a mirror image of themselves. As a result, the patient per- ceives the staff members as manipulative, unreliable, and even verbally abusive. When the patient feels threatened, he or she tries to control the situation by manipulating, attacking, or avoiding the staff members.

Two effective techniques for working with manipulative patients are con- frontation and limit setting. Both of these techniques need to be used consistently with concern for the patient. Although the word confrontation is usually associ- ated with hostile, antagonistic battles, it is used effectively as an intervention to dispassionately point out to the patient a discrepancy among words, actions, or feelings. For instance, “You said you have not seen a doctor before coming to the ER, but you have a bottle of prescription drugs dated last week. Where did you get that?” Setting limits is teaching and maintaining boundaries of the nurses’ and the patient’s roles and acceptable behaviors. This may mean telling a patient what he or she may or may not do under certain conditions or in certain situa- tions (see Box 8–3).

Despite protests, manipulative patients feel more secure and less out of control when their behavior is contained. Using these techniques, nurses can alleviate much of the patient’s insecurity and help to create the appropriate boundaries of acceptable behavior. Before being successful at using these techniques, however, you need to feel comfortable being assertive and being in the role of an author- ity figure. The nurse’s past experiences with authority figures and individual per- sonalities influence his or her ability to master these techniques. It is important to realize that no one can completely control another person’s behavior.

Manipulative patients who unconsciously block painful feelings by splitting their perceptions of people into the extremes of all good or all bad can have a very disruptive, divisive effect on the staff. Staff splitting is a possible response to splitting when the patient idealizes certain staff members, treating them as all worthy and good while viewing others as all bad and criticizing and devaluing them. The staff may respond similarly, each one either intensely liking or dislik- ing the patient and eventually becoming alienated from each other (Box 12–1).

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ETIOLOGY

According to psychological theory, manipulative patients do not trust other peo- ple to like or accept them, to be responsive to them, or to be responsible toward them. Consciously or unconsciously, they rely on manipulative behavior to de- mand that others supply what they need and want.

Manipulative behavior in health-care settings may reflect the patient’s ongo- ing, habitual mode of interaction, or it may be an escalation of milder, more com- mon control mechanisms. In the hospital setting, the patient may regress and have unrealistic expectations that his or her every need will be instantly gratified. Disappointment results in fury and an increase in manipulative behavior.

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BOX 12–1 Warning Signs of Staff Splitting A manipulative patient can have a devastating effect on the staff and func- tioning of the unit. Staff group behavior that can indicate that staff splitting has occurred includes:

• The staff viewed as “all bad” by the patient demonstrates resentment toward the other staff members who are liked by the patient.

• Lunch hour and coffee breaks are dominated by discussion of the specific patient.

• The nucleus of an in-group believes that only they can help the patient.

• Loss of morale and confusion in the out-group.

• Criticizing each other for how they handle patient issues

• Blurring of staff-client role boundaries (for instance, patient and staff dis- cuss another staff member, staff share personal information with patient, give personal phone number to patient, spend off time worrying about the patient).

• Split in- and out-groups make accusations: “ins” accuse “outs” of being cold and insensitive; “outs” accuse “ins” of being too permissive and gullible and of spoiling patient.

• Splits between departments in a hospital agency structure.

• Staff keeping secrets about the patient.

• Staff members use poor judgment in decisions about this patient.

Source: Adapted from Lego, S. (1990). Borderline personality disorders. In E. Varcarolis (Ed.), Foun- dations in mental health nursing (pp. 408–420). Philadelphia: WB Saunders; Groves, J. E. (2004). Difficult patients. In T. A. Stern, G. I. Friccione, N. H. Cassem, M. S. Jellinek, & J. F. Rosenbaum (Eds.), Massachusetts General Hospital handbook of general hospital psychiatry (5th ed.) (pp. 293–312). St. Louis: Mosby; Manos, P. J., & Braun J. (2006). Care of the difficult patient. New York: Routledge.

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Chronic manipulative behavior may result from childhood dilemmas if parents undermined attempts toward independence and autonomy. Manipulative indi- viduals have come to suspect that any person or institution may try to control them, rendering them powerless and vulnerable to attack. Even being cooperative can be viewed as giving in or being weak, negatively affecting self-esteem. Authority figures are seen as being stronger and having too much control over the patient’s life. The patient may seek ways to equalize the power by controlling staff, not complying with medical regimen, and making excess demands. Suicidal gestures may be a frantic attempt to regain control or block painful feelings of helplessness or dependence. Fear of rejection and abandonment or expectation of increased responsibility are also triggers for self-destructive acts.

The learning theory of manipulative behavior focuses on the concept that the behavior may have been learned in childhood based on adult role models, peers, and even the media. The family theory suggests that manipulative behavior may have been developed, especially in younger years, as the only way to cope with a severely dysfunctional family.

Antisocial personality disorder frequently arises from a chaotic home environ- ment with early parental deprivation. There may be some genetic link. Borderline disorder is associated with separation issues concerning parental figures. Brain dysfunction causing poor impulse control and mood instability have also been implicated in the etiology of borderline personality (NIMH, 2001). Personality disorders are generally associated with depression.

RELATED CLINICAL CONCERNS

These patients may rely on sedatives, analgesics, or other substances to reduce feelings of anxiety. These substances may trigger reduced inhibitions and increased aggressive responses. These patients are high users of inpatient services because of multiple crises (Shoemaker & Varcarolis, 2006). Borderline patients may use the hospital for multiple medical problems and results of self-destructive behaviors.

LIFE SPAN ISSUES

Children and Adolescents Manipulative behavior begins in the earliest years, partly as a way to test the responses of parents and other caretakers. Toddlers have temper tantrums and quickly learn whether or not they can get their way. Children of all ages mimic the manipulative behavior of parents and siblings, such as making promises that are not kept. Or they may try getting permission from one parent after receiving a “no” from the other. They also learn from their peers. They may try to obtain privileges or possessions by saying that all their friends have these already.

Disturbed, maladaptive manipulative behaviors manifested in conduct disor- ders are seen in childhood and adolescence. Those who rely on deceitfulness can

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also display cruelty to animals or other children, destructiveness of property, and serious violations of rules. This can evolve into antisocial personality disorder in adulthood. These children may have experienced more severe deprivations such as multiple rejections, neglect, or abuse.

Adults People who have successfully used manipulative behavior as children tend to become more proficient at this behavior as they grow older. They tend to flour- ish in systems where they are able to manipulate. People who are extremely manipulative and exploitative may violate laws and end up in the criminal justice system. Those who exhibit strong manipulative tendencies but are able to stay within legal confines may become successful in using people, personally and pro- fessionally, for their own goals.

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POSSIBLE NURSES’ REACTIONS • May feel angry, frustrated, or resentful for being tricked; may have lowered

self-esteem if unable to stop the manipulation; or may feel embarrassed or humiliated.

• May feel helpless in relieving patient’s apparent distress or when attempting to get patient to conform to nurse’s expectations of reasonable conduct.

• May feel vulnerable and afraid of patient’s attacks.

• May take manipulations personally and react defensively, especially when challenged in authority or position.

• May reject patient because the experience of coping with personal reactions is too draining and demoralizing.

• May avoid patient, spend minimal time needed to provide physical nursing care, or assign a different nurse to the patient each day.

• May compensate by becoming overcontrolling or engage in power struggles with patient.

• May experience desire for revenge, retaliation; may become punitive, want to counterattack by insulting, hurting, or embarrassing patient. May secretly hope things go wrong for patient.

• May experience guilt about negative feelings toward patient.

• May become overinvolved or overattached and wish to rescue patient.

• May feel total responsibility for patient’s improvement or lack of improve- ment.

• May be punitive in setting limits or confronting the patient or may be inconsistent or hesitant in enforcing rules for fear of patient’s reaction.

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Older Adults As people age and become more dependent on others for assistance in activities or socialization, they may resort more frequently or aggressively to manipulative behaviors to get their needs met. If inducing guilt has been a personal trait, dec- larations such as “I don’t want to be a burden” may be intended to stir guilt and get attention.

ASSESSMENT

Behavior and Appearance • Frequent disregard of rules • Argumentative • Can be superficially charming and entertaining • Demanding; the more staff try to cater to demands, the more they escalate • Impulsive and unpredictable; lacks ability to tolerate frustration; can easily

become out of control • Uses threats to get demands met • May use intimidation to control or feel superior • Frustration causes more intense manipulative behavior • Destructive toward self, others, property without taking responsibility • Suicide threats and/or attempts • Lies, cheats, steals • Intense manipulation around medication; overuse of medication • Noncompliant with health-care treatment • Undermines treatment of other patients, such as encouraging them to ignore

doctor’s recommendations or suggesting alternate treatments

Mood and Emotions • Anger predominates. Behavior can be cutting, sarcastic, and vicious.

• Anxiety rises rapidly to panic, which precipitates impulsive actions. May not experience anxiety unless facing a threat to self-image or self-esteem.

• Views self as very vulnerable and frightened, even when being intimidating, or as totally invulnerable to harm or negative consequences, resulting in reckless behavior.

• Has labile moods and emotions. The more patient is in crisis, the more fre- quently moods and emotions may fluctuate over the course of a day. May appear resistant to depression or may have periodic depressive reactions.

• May have inflated or diminished self-esteem. If inflated, denies or distorts information that would lower self-esteem.

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Thoughts, Beliefs, and Perceptions • Thinking can contain gross distortions of some specific events or people and

yet maintain accurate perception and good reality of others. • Projects own thoughts and feelings onto others, resulting in feelings of fear

and manipulation by others.

Relationships and Interactions • May seek or avoid attention • Exploitative with little real concern for others; limited capacity for empathy;

demonstrates caring only to get own needs met • Quick to recognize vulnerable areas in others • Limited ability to see others for who they really are; distorted perceptions

of how others experience self • Needs to feel either in control or helpless and vulnerable (Life is seen as a

seesaw competition. If someone else is up, then patient feels down) • Does not feel a sense of obligation to reciprocate favors or helpful acts • Devalues others to feel good about self • Sees others as attacking or dangerous • Feels and acts as if he or she were entitled to having needs met without com-

parable effort or cost • Becomes a “special patient” to the staff • Blames others for mistakes and problems without taking personal responsi-

bility; confuses taking responsibility with being blamed, worthless, and vul- nerable to attack

• Belief of being superior; cannot admit lack of knowledge and has great dif- ficulty asking for assistance and information; obtains information by using indirect manipulation; unable to accept suggestions or criticism

Physical Responses • Physical complaints that cannot be substantiated with testing • Magnifies any subjective symptoms that cannot be measured • With documented disability, usually requires more frequent medication and

higher dosages; recovery takes longer than usual

Pertinent History • Erratic, impulsive behavior with marked instability; frequent changes in jobs,

relationships, and physicians • Drug or alcohol abuse • Long history of many physical complaints

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• Suicide threats and attempts • Psychiatric diagnoses including major depression, borderline or antisocial

personality disorder

COLLABORATIVE MANAGEMENT

Pharmacological If the patient is given tranquilizers to reduce anxiety, there is a risk for drug dependence and power struggles (e.g., patient may try to manipulate the nurse to get extra doses). Individuals with personality disorders may benefit from antide- pressants to address depression and reduce impulsive behaviors. Fluoxetine and olanzapine have been helpful in controlling rapid mood shifts. The anticonvul- sant carbamezepine has been used to improve mood stability. Avoiding PRN medications can reduce power struggles with the nurse. Regular dosing schedules of analgesics if needed can be useful. Herbal products may be used as a way to self-medicate uncomfortable symptoms.

Multidisciplinary Team Communication When staff members have extremely different experiences with the same patient, infighting among each other can occur when discussing care for the patient. These variations in experiences can occur between or among individuals in the nursing staff, different shifts, nurses and physicians, or all staff members and administrators. To overcome this staff splitting, the group needs to recognize the patient’s dynamics and cooperatively share their different perceptions to gain a more complete picture of the patient. They need to identify whom the patient sees as “all good” or “all bad” and how this affects interactions.

Once the team has identified the problem behaviors, it is essential to formu- late a united, consistent care plan. Each staff member should monitor the inten- sity of his or her individual reactions to the manipulative behavior. This will help to avoid becoming entrapped into feeling the need to be special or the only one who can help or avoid getting caught in power struggles. A supportive and coor- dinated multidisciplinary team approach helps neutralize the manipulative patient’s ability to identify vulnerability in team members and discord in the health-care organization.

Psychotherapy Psychotherapy represents the core treatment for borderline personality (Gunder- son, 2001; Oldman, 2005). Dialectal behavior therapy (DLT) has been shown to have the best results for borderline patient with substance abuse (Oldman, 2005). Dialectal behavior therapy uses a multimodal approach of individual and group therapy as well as education. Other useful therapeutic approaches include family therapy, cognitive behavior therapy, and traditional psychotherapy.

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NURSING MANAGEMENT

INEFFECTIVE COPING evidenced by noncompliance with rules and treat- ments related to impulsive, manipulative behavior.

Patient Outcomes • Decreased use of maladaptive, manipulative behaviors • Complies with treatment regimen and hospital rules • Demonstrates use of effective coping patterns • Demonstrates more adaptive methods of dealing with stress, such as

using problem-solving skills

Interventions • Carefully assess patient’s mode of interaction and frequency over time

before labeling behavior as “manipulative.” • Determine if the patient is using manipulation to indirectly express a

need, anxiety, or distressful emotion. Active listening and empathetic responses to underlying issues can help diminish the patient’s anxiety and need to control others.

• Approach patient in a calm and matter-of-fact manner, using a neutral tone of voice.

• Provide feedback to patient, who may not be aware that manipulative behaviors are being used. State specific observations about his or her style of interactions without arguing. If patient argues or denies, calmly repeat your observation without becoming defensive. Describe options and con- sequences. Follow through consistently with consequences.

• Don’t state consequences that you do not have the authority to exercise. • State which behaviors are not acceptable without personally rejecting the

patient. • Help patient identify when using manipulative behavior becomes an

attempt to control anxiety. Encourage patient to identify triggers for anger and frustration.

• Encourage patient to verbalize feelings instead of acting them out. Ask the patient to identify what he or she is experiencing and what feelings and thoughts preceded the behavior.

• Evaluate whether patient’s manipulative behavior increases or decreases when not reinforced by nurse’s attention. Be aware that even when ignor- ing provocation is effective over time, there may be an initial escalation to test responses.

• Avoid power struggles and attempts to outmanipulate the patient. Point out that the patient is undermining his or her own care. State explicitly that the patient will not be forced to accept treatment and that each indi- vidual is responsible for the outcome of the treatment.

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• Explain as early as possible rules and regulations and the reasons for them. If allowable limits are not stated, patient may push and test until they are clarified. If he or she attempts to break the rules, review firmly the stated expectations.

• Include the patient in decisions about limits and provide opportunities for personal decision making to enhance sense of control. When all rules are rigid, the patient may feel a greater need to rebel. Be careful not to allow patient to dictate nursing decisions.

• Written contracts defining both staff and patient expectations can be most effective. Specifically define any consequences of patient’s continued manipulation and lack of cooperation. Nurse and patient can sign con- tracts.

• Describe in detail on the care plan the limits set and the consequences of breaking them. In periodic staff meetings and multidisciplinary case con- ferences, give current information and promote agreement about the patient, which will enable staff members to work more consistently and cohesively.

• Make sure all staff members are aware of limits and consequences. Con- front colleagues who are observed not following the treatment plan.

• Consult with physician when patient seems to exaggerate complaints of pain or becomes preoccupied with timing of medications. The physician may decide to convert a PRN order to low doses of regularly adminis- tered medications to avoid power struggles.

• Assess for signs of substance abuse or withdrawal if patient has such a history or shows symptoms.

IMPAIRED SOCIAL INTERACTION evidenced by attempts to undermine, control and influence, and cause conflict related to splitting, distorted percep- tions of others, impulsivity, and anxiety.

Patient Outcomes • Uses acceptable methods to interact with others to communicate and

obtain needs • Positively responds to confrontation and limit setting • Demonstrates tolerance of frustration and waiting • Does not reject or denigrate the staff as “bad” when they are unable to

respond in desired manner • Demonstrates more trust in relationship with at least one staff member

by sharing personal thoughts and feelings

Interventions • Maintain assertive, centered, firm but fair, and even-toned stance when

patient tries to manipulate or undermine you.

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• Tell the patient that he or she may understand events and interactions dif- ferently than the staff does.

• Direct patient who complains about staff member to discuss the problem with implicated staff person. Do not allow yourself to be used as an inter- mediary; do not take sides.

• Use “I” statements indicating how patient made you feel. Avoid becom- ing defensive, which can escalate manipulative behavior.

• Confront the patient with your perception that he or she is trying to put you down. This can have an impact even if patient denies it.

• Take time to think about effective responses and to diminish the intensity of your reactions if patient is trying to manipulate. Use stress reduction techniques.

• Role play or discuss situation with other staff, if necessary. • Return to original topic if patient tries to divert topic to a personal attack. • Be aware of patient interactions that can increase staff divisiveness by

blaming, accusations, or comparisons. Monitor your own responses. • Provide praise and reinforcement when patient communicates directly

and openly about needs and concerns. • Use kind but firm approach. Clarify that setting limits is constructive and

caring rather than punitive. • Establish from the beginning that you take all of the limits very seriously.

More flexibility can be introduced later as the patient takes more respon- sibility.

• Find neutral actions and topics for conversation. This will help to pres- ent you as a person interested in the patient and not just a rule keeper.

• Be aware that patient may need to test limits repeatedly to see whether there are repercussions and to be reassured that the staff will follow through on the consequences.

• Let patient know immediately that threats or verbal abuse is unaccept- able, that you expect these will never be repeated, and state the conse- quences of repeated abuses.

• Confront patient when he or she attempts to undermine other patients’ treatment.

• Do not allow patient to manipulate, flatter, seduce, bargain, or intimidate staff into granting him or her special status. Do not accept gifts or favors or share personal information, especially about any current difficulties.

• Never agree to keep a secret with a patient. Remind patient that the entire health team needs to be aware of patient’s concerns in order to offer the best care.

• Assess interactions with family. If patient uses same approaches with them, family members may need information on changing their response.

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ALTERNATE NURSING DIAGNOSES

Anxiety Coping, Defensive Noncompliance Powerlessness Self-Esteem, Disturbed

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WHEN TO CALL FOR HELP

• Threats or actions of physical harm to others or self, including suici- dal threats or gestures

• Undermining own or other’s health care and unresponsive to nursing interventions

• Repeated violation of agency rules • Evidence of staff splitting • Noncompliance, which jeopardizes patient’s health status, such as

refusing to take medications

WHO TO CALL FOR HELP

• Psychiatric Team • Social Worker • Manager • Attending Physician • Advanced Practice Nurse • Critical Incident Team/Employee Assistance

PATIENT AND FAMILY EDUCATION

• Teach patient to ask directly for what he or she wants and needs in words, not actions. Teach problem-solving skills.

• Help patient recognize that his or her desires may not require immediate action and that he or she may not always get desired responses.

• Explain the consequences of manipulative behavior. • If a patient will not take responsibility for own actions, explain how his or

her behavior contributed to the unwanted response or consequences and that taking responsibility is not the same as being blamed.

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• Teach patient that understanding of one’s own behavior and developing improved interactions are the avenues for developing stable support net- works.

• Involve family in patient education. The same skills used in working with the patient may be helpful for the family.

• Provide information for family members of individuals with personality dis- orders. Several websites provide information including www.mental-health- matters.com/borderline.html and nimh.nih.gov for patient information on borderline personality

CHARTING TIPS

• Describe specific manipulative behaviors objectively rather than just label- ing the patient as manipulative.

• Develop a detailed treatment plan with interventions so that the team can respond consistently. Chart patient’s responses to interventions. Update team care plan as needed.

• Document usage of PRN medication, reason for use, and patient’s response.

COMMUNITY-BASED CARE

• Begin discharge planning as early as possible to decrease last-minute impul- sive and inappropriate decisions the patient might make without considera- tion for consequences. When last-minute disruptions to the plan occur, maintain a consistent, clear approach on the plan that has been developed.

• Inform the family and patient together of patient’s healthcare needs to reduce manipulative behavior with family.

• Inform referring agencies of patient’s behavior, team care plan, and short- term treatment planning goals.

• If appropriate, make referrals for individual and group psychotherapy as well as substance abuse treatment if needed.

The Noncompliant Patient

Learning Objectives • Identify factors that contribute to a patient’s noncompliance with treat-

ment plans. • List the principles of adult education that contribute to effective patient

education.

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• Identify nursing interventions to reduce noncompliance in the patient whose cultural beliefs impede compliance.

• List some nursing staff reactions to the noncompliant patient.

Glossary Compliance – Patient’s accurately following a prescribed regimen of treat-

ment. Sometimes referred to as adherence. Ineffective management of therapeutic regimen – A pattern of regulating

and integrating into daily living a program for treatment of illness and the sequelae of illness that is unsatisfactory for meeting specific health goals.

Noncompliance – State in which an individual desires to comply but factors are present that deter adherence to health-related advice given by health- care professionals. Sometimes referred to as nonadherence.

Compliance and noncompliance are terms that are used to describe patient behaviors in response to information they are given about their health care.

Compliance usually requires some form of motivation, perception of vulnerabil- ity, and the belief that the recommendation will control or prevent an illness (Carpenito-Moyet, 2006). What makes a patient follow, change, or ignore health teaching is complex and may not always be related to the amount and quality of information provided. Nurses need to be aware that noncompliance is a symp- tom of an underlying problem and not the actual problem, and that labeling behavior as “noncompliant” can have negative connotations, such as blaming or criticizing a patient who is not following instructions. Once you have identified that the patient is not following the medical regimen, you need to investigate what barriers prevented the patient from following the recommendations. Carpenito-Moyet (2006) describes noncompliance as occurring when the patient is prevented from compliance due to factors like overly complex instructions, lack of understanding of instructions, and lack of funds to follow through with recommendations. If the patient makes an autonomous, educated decision not to follow recommendations, that behavior is not noncompliance as long as the indi- vidual understands the risks and benefits of not following the recommendations. Some educators prefer the term adherence rather than compliance.

The cost of noncompliance is greater than can actually be documented. Besides factors such as the cost of medications purchased but not taken or taken incor- rectly, poor results of diagnostic tests caused by poor preparation, and more severe illness from not following recommended treatments, both patients and health-care providers can experience a great deal of frustration. Although not the only reason for noncompliance, inadequate or inappropriate patient education is among the most common.

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When teaching adults, the nurse needs to incorporate principles of adult learn- ing (Box 12–2). Adults have different learning needs than children do. Adults are goal oriented. The goals need to be clearly identified and attainable, and adult patients need to consistently be made aware of their progress toward their goal. Adults need to understand how the education will benefit them. Adults tend to learn better when they understand the rationale for what they are learning, apply what they learn immediately, and can compare what they are learning to knowl- edge from past experiences. Learning is inhibited when authoritarian teaching methods are used. Interpersonal relationships with teachers are important.

ETIOLOGY

Many factors can interfere with the patient not being receptive or not be able to receive or follow health information:

• Denial: This may be a conscious or unconscious method of believing that he or she is not sick. For example, by not checking blood sugars, the patient can block the diagnosis of diabetes from his or her mind.

• Power struggles: At times, the patient who feels a lack of control over his or her body uses noncompliance as a way to maintain some control over a sense of destiny or over health-care providers.

• Counterdependence: The patient could be concerned that following recom- mendations would increase dependency on others. Because dependency can enhance feelings of loss of identity, noncompliance becomes a statement of independence and individualism.

• Loss of coping mechanisms: Often, health teaching involves asking the patient to give up habits that are part of the person’s usual coping strategies.

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BOX 12–2 Adult Learning Principles • Adults need to participate in the learning process. Avoid directive approach.

Give them some control. • Adults need to understand the purpose behind any information they receive. • Adults learn more effectively if past experiences are integrated into the

teaching. • Put new information to immediate use. • Give specific feedback to learner of progress made in learning process. • Match medication format with learning style • Barriers to learning are addressed

Source: Knowles, M. A. (1970). The modern practice of adult education. Englewood Cliffs, NJ: Prentice-Hall; Russell, S. S. (2006). An overview of adult-learning processes. Urologic Nursing, 26(5), 349–352.

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For example, smoking, diet changes, or exercise may need to be altered or avoided. If the patient has not yet developed alternative coping mechanisms, the anxiety created by the loss of these habits may be overwhelming.

• Conflict with self-image: Noncompliance may be a method of self-protection against the threat of an altered body image, particularly in individuals whose health and activity are a source of pride. Taking medication or imposing lim- itations on activity may represent a threat to the individual’s self-image.

• Fatalistic viewpoint: A patient may believe there is no point to following instructions because of the belief that nothing will change the outcome.

• Hidden benefits of illness: Some people may consciously or unconsciously perceive benefits from the sick role, such as attention, avoidance of respon- sibility, controlling the destiny of another, or maintaining stability in a rocky relationship.

• Self-destructive behavior: A patient could be consciously or unconsciously participating in a wish to die or hurt himself or herself, possibly reflecting depression or suicidal tendencies. It could represent behaviors associated with a serious personality disorder.

• Psychiatric disorder: Psychiatric illness or altered thought processes may make consistent compliance with a health routine impossible.

• Family influence: Family members may discourage or undermine compli- ance because they are using denial, lack the understanding of the treatment, or unconsciously need to maintain the patient in the sick role.

• Lack of economic resources: If the patient has insufficient funds or no insur- ance, he or she may need to decide between eating or feeding the family and buying needed medications.

• Lack of social resources: Lack of funds, fear of being dependent on others, or lack of social contacts may cause the patient to miss appointments because there is no transportation.

• Unsatisfactory relationship with health-care team: If the patient perceives the doctors or nurses as cold, uncaring, not knowledgeable, or authoritar- ian, he or she may resent or ignore instructions. This may stir up in the patient such issues as resentment of authority and feeling unrecognized as an individual. This patient may minimize or distort information given because of his or her emotional response. Long waits and uncomfortable waiting areas may also contribute to the poor relationship.

• Lack of trust in information given: Patient may not believe health informa- tion given because it has not proved useful in the past. Also, with the increase in media reporting of conflicting reports of studies, patients may think the information is not trustworthy enough to warrant a change in life-style.

• Cultural beliefs: Cultural or religious beliefs may influence the way the patient views his or her illness and the treatments that are acceptable. For instance, women in some cultures may not allow a male health-care provider to examine their breasts or a Jehovah’s Witness may not accept a blood transfusion.

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• Inability to read or understand instructions: Some patients may be too embarrassed to acknowledge that they cannot read English. This may apply to those who speak another language or even to those who do speak Eng- lish. Literacy rates in the United States are dropping, so some patients who function well in society may not be able to read. Also, be aware that some patients will not admit that they do not understand language that is too technical or that contains too much jargon. To be understood by the major- ity, patient education materials should be written at the average reading level, which for most adults is the fifth to eighth grade level. Low health lit- eracy contributes to higher rates of hospitalization and use of emergency services (Contillo, 2007). The Joint Commission for Accreditation of Healthcare Organizations (JCAHO) has addressed the unsafe care that is provided because patients do not understand medical jargon. They have developed recommendations for health-care organizations to improve com- munication and supported an educational campaign called Speak Up to encourage patient engagement in their health care (JCAHO, 2007).

• Uncomfortable side effects: Patients may not follow instructions because of real or perceived side effects, especially with medications. The patient may be less likely to report them if they are embarrassing, such as impotence or incontinence. In addition, incorrect beliefs such as fear of becoming depend- ent on medications may cause some patients not to take medications. Non- compliance can become part of a negative cycle because the patient feels embarrassed or guilty for not following through and then begins cancelling appointments to avoid health-care providers.

RELATED CLINICAL CONCERNS

When patients are dealing with an acute crisis, most of their energy will be focused on just coping with the situation at hand. They will not be able to con- centrate on learning until the crisis has subsided or they have made adaptations to deal with the situation. During this time, instruction should involve only what is absolutely necessary. You will need to be prepared to repeat much of the infor- mation provided as the patient may not remember what he or she was told.

Any physical or mental problem that impairs cognition will also interfere with learning. Depression, hopelessness, social isolation, and cognitive difficulties may contribute to compliance when a serious health problem such as myocardial infarction is diagnosed (Rieckmann et al., 2006).

LIFE SPAN ISSUES

Children Following a particular treatment plan can be difficult for ill children and their families. Medications may affect behavior, alertness, or school performance.

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Incorporating a child’s medical care into family life can create many stressors, contributing to noncompliance because the child may not be able to be responsi- ble. It can be time consuming and difficult to administer. Working parents and single-parent families may not have the time to be able to supervise the child or take him or her for follow-up care. Because the child may not be able to com- municate his or her needs, medical care can be difficult to monitor.

The presence of attention deficit hyperactivity disorder (ADHD) can contribute to discipline problems that make following recommendations very difficult. DSM- IV-TR (2000) lists a diagnosis of Oppositional Defiant disorder in children and teens. This diagnosis is found in 2% to 16% of children and is characterized by a recurrent pattern of negative, defiant, disobedient behavior that can contribute to noncompliance with health-care instructions.

Parents who refuse to give a child needed medical attention can have legal and ethical ramifications that could be interpreted as negligence or even abuse. Parental autonomy to make decisions for their child may be overridden in the courts if it is determined the child is placed at some risk. In these extreme situa- tions, legal intervention would be required. Further assessment of parental moti- vation and religious and cultural beliefs that affect the care of the child needs to done before any further actions are taken.

Adolescents Adolescents are particularly vulnerable to problems with compliance. Their atti- tude is often related to struggles with maintaining independence and rebelling against adult authority. In addition, any medical regimen that affects body image puts additional demands on the teenager. Also, because the adolescent does not want to appear different from his or her peer group, complying with instructions may be particularly difficult. For example, a diabetic adolescent who is eating lunch with friends may be fearful of exposing his or her dietary restrictions.

Older Adults Noncompliance is an extremely important issue for elderly people, who experi- ence more chronic illness than the general population. Chronic illnesses often require multiple medications and are often combined with over-the-counter drugs as well as complementary and alternative therapies. Some elderly persons see more than one specialist and have a variety of prescriptions from the physicians they see or may be given contradictory treatment advice. They may become eas- ily confused. Decreased muscle mass and increased fat stores may make individ- uals more prone to drug side effects. The elderly patient may need more assistance and time to explain instructions. If living alone, the elderly patient may have limited support for encouragement or reminding. Hearing and vision deficits as well as limited manual dexterity caused by arthritis can present other problems. In addition, cognitive impairments including poor short-term memory may inhibit the patient’s compliance by causing him or her to forget instructions or how many pills have already been taken.

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ASSESSMENT

Behavior and Appearance • Does not follow rules or instructions, demonstrated by:

• Refusing to take or change medications • Continuing unhealthy habits • Missing medical appointments • Altering medical regimen • Challenging the necessity or helpfulness of treatments • Leaving facility against medical advice • Arguing without constructive resolution • Indicating understanding or agreement with treatment plan and then not

following through • Hiding inability to read or comprehend educational material

Mood and Emotions • Anger • Depression • Resentment • Irritability • Anxiety

Thoughts, Beliefs, and Perceptions • Religious or cultural beliefs in contradiction with compliance actions • Believes health care should be obtained only when symptoms are blatant or

impairing needed activity

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POSSIBLE NURSES’ REACTIONS • May become angry or frustrated because the time spent with patient seemed

fruitless. • May criticize or judge patient who does not follow instructions. • May feel that situation is hopeless and makes less effort to communicate

with patient. • May judge self as inadequate or incompetent when patient does not follow

instructions. • May feel responsible for patient’s noncompliance. Nurse may have diffi-

culty recognizing that ultimately the responsibility for health care belongs to the patient.

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• Suspicions concerning motivations of health-care professionals

• Lack of confidence in own abilities

• Denial of health-care needs

• Psychotic thought process or suicidal thoughts

• Belief that one cannot question health-care provider

• Low self-esteem and fear of acknowledging lack of understanding of instructions

Relationships and Interactions • May avoid sharing information with others about medical regimen

• Tendency to manipulate or control others

• Family not providing needed support

• Inconsistent relationship with health-care team; at times may be very criti- cal of them and other times more positive toward them

• Following instructions from only one particular nurse

Physical Responses • Deterioration of health because of lack of compliance

• Blood or urine tests showing drug levels inconsistent with reported medica- tion intake; discrepancies in other tests

Pertinent History • Poor outcomes from previous medical treatment

• Poor relationships with past health-care providers

• Noncompliance in earlier health-care treatments

• Inability to read or write

COLLABORATIVE MANAGEMENT

Pharmacological Noncompliance for medication regimen is a major health problem. Not follow- ing instructions for medications can contribute to safety problems including over- doses. Many side effects of drugs are caused by misunderstandings about how to take medication (Goldberg, 2006). Patients do not take medications for a variety of reasons including fear of side effects, lack of knowledge about the purpose of the drug, denial of the diagnosis, lack of money to pay for medications, and lack of support or reinforcement (Box 12–3).

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Multidisciplinary Team Communication To ensure the best chance for patient compliance, a team approach is essential. All health-care providers should be consulted to ensure a cohesive treatment plan and approach that the patient understands. This is a pivotal nursing responsibil- ity because nurses coordinate most of the care provided, both in the hospital and in the home. Discrepancies in instructions from physicians, physical or occupa-

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BOX 12–3 Factors that Influence Medication Compliance Factors that Increase Compliance: • Client’s perception that illness is severe and medication is needed • Client’s knowledge of illness and treatment • Moderate level of anxiety (useful worrying) • Continuity and length of relationship with caregiver • Return of unpleasant symptoms immediately on stopping medication • Caregiver optimism regarding use of medication • Written instructions tailored to patient’s reading level provided • Family support • Side effect management is addressed • Patient has easy access to obtaining medications (pharmacy close by) • Longer acting tablets used where possible to reduce frequency of taking pills • Client receives positive reinforcement for taking medicaitons • Self-monitoring tools/diaries are easy to maintain • Patient obtains health information over the Internet that reinforces need for

medication • Simpler way to take medication provided or fewer number of tablets pre-

scribed Factors that Decrease Compliance: • Numerous lifestyle changes required • Uncomfortable side effects • Lack of support for compliance • Fear of independence and recovery • Lack of immediate return of symptoms if medication is stopped • Fear of drug dependence • High-cost drugs or equipment required • Long period when symptoms are controlled

Source: Adapted from Carpenito-Moyet, L. (2006). Nursing diagnosis: Application to clinical prac- tice (11th ed). Philadelphia: Lippincott Williams & Wilkins; Falvo, D. R. (2004). Effective patient education (3rd ed.). Sudbury, MA: Jones and Bartlett.

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tional therapists, pharmacists, or other health-care providers need to be discussed so that the patient is not left to choose whose advice to follow. Understanding factors that may contribute to poor compliance must be communicated to all team members.

NURSING MANAGEMENT

NONCOMPLIANCE evidenced by failure to adhere to medical regimen, fail- ure to keep appointments related to health beliefs, cultural influences, lack of understanding instructions.

Patient Outcomes • Verbalizes beliefs that influence noncompliance • Demonstrates adherence to treatment plan • Expected therapeutic goals realized

Interventions • Develop a trusting relationship with patient. Communicate interest and

openness to patient’s needs and beliefs. • Assess the degree of noncompliance and the underlying reason for it. One

common area of noncompliance is in using medications. Many prescrip- tions are never filled, or they are filled and never used. When seeing a patient in the hospital or in the home, always review the medications the patient has, how they are being taken, and the patient’s understanding of why the drug is necessary. Check expiration dates, the name of the physi- cian who ordered the drugs, and the instructions on the labels. Analyze whether the patient is taking more than one drug for the same reason, especially if they were ordered by different physicians. If necessary, encourage patient to bring in pill bottles to doctor appointments so pills can actually be counted.

• Encourage the patient to share beliefs or traditions that affect health care. Demonstrate to patient your interest in learning about these. Do not crit- icize or belittle these beliefs; rather, communicate your respect for them.

• Ask the patient to share rationale for avoiding the prescribed treatment. Resolve any misunderstanding the patient may have about the treatment, its side effects, or its potential outcome. Avoid insisting that the patient give up his or her beliefs. Never argue with the patient about the value of the beliefs. Instead, explain any negative outcomes that these beliefs may cause with his or her condition.

• In critical situations, the patient may need to be confronted more direc- tly with life-threatening consequences of noncompliance (e.g., taking insulin).

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• Enlist assistance of family, friends, caregivers, or, if beliefs are based in a particular culture, others with whom the patient may relate to, to explain the consequences of these actions on the patient’s health status.

• Talk with family members about their beliefs about the patient’s illness to determine their role in noncompliance.

• Obtain feedback from the patient to ensure that he or she understands the instructions given. Use an interpreter if needed.

• If appropriate, negotiate the best compromise with the patient. Have him or her commit to one or two areas in which he or she will comply rather than expecting the patient to give up all his or her beliefs completely.

• Identify one staff member who has the best relationship with patient to provide information.

• Recognize that it may be impossible to alter the patient’s strong cultural or religious beliefs. Understand that in some cases, illness, or even death, may be more acceptable and a higher priority than giving up one’s beliefs.

• Encourage patient to share factors that contribute to noncompliance. Ask the patient to explain the rationale for actions taken or not taken.

• Avoid using medical jargon or abbreviations that may confuse or intimi- date. Encourage open communication so that the patient will tell you when he or she does not understand something.

• Have patient perform a return demonstration or verbalize his or her rou- tine to determine patient’s understanding and determine areas of non- compliance.

• Break down complex regimens into small steps. • Assess whether other methods of teaching would be more appropriate,

such as videos, Web sites, interactive tutorals on the computer, role- playing, pamphlets with more pictures, or pamphlets written at a lower reading level. Minimize any distractions during teaching sessions.

• Incorporate principles of adult learning in educating adult patients. For example, explain rationale, avoid lecturing or belittling the patient, involve patient in discussion, and allow patient to identify ways teaching can be incorporated into his or her lifestyle.

INEFFECTIVE MANAGEMENT OF THERAPEUTIC REGIMEN (INDI- VIDUALS) evidenced by acceleration of illness symptoms or verbalized diffi- culty with regulating or integrating prescribed regimens related to complexity of therapeutic regimen or health care system.

Patient Outcomes • Identifies factors that contribute to not following medical regimen • Demonstrates adherence to treatment plan • Expected therapeutic goals realized

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Interventions • Ensure that the patient is in the best physical and emotional state for

learning to occur. Remember to repeat information that was previously given when the patient was dealing with the acute crisis. Avoid teaching if patient is in pain or has other discomforts.

• Take the time to talk with the patient about his or her understanding of the problem, why he or she is receiving this information, and what is expected to be the outcome.

• Demonstrate acceptance of the patient by use of eye contact and touch where appropriate. Take care to avoid critical comments about the patient’s situation.

• Set realistic expectation with the patient. • Assess role of family in patient’s health-care regimen. Determine who

provides care for patient at home, and determine the caregiver’s role in the noncompliance. Observe caregiver’s technique if appropriate, and provide information as needed.

• Determine patient’s understanding of using the health-care system. Review ways to get appointments, arrange additional care such as home care, and how to contact health-care providers. As needed, check with social service agencies to provide needed transportation, equipment, or other services.

• Help identify ways in which patient can individualize information. For example, if a patient works rotating shifts or travels extensively, you will need to focus your teaching on how to adapt the treatment plan to best fit into his or her lifestyle.

• Identify ways to reinforce patient’s self-esteem and sense of competency. Provide positive reinforcement and recognition of patient improvement.

• Incorporate rewards as part of the teaching. For an adult, rewards may include those activities that increase self-esteem and a sense of control.

• Be sensitive to signs that the patient is tired or is losing interest. Resched- ule teaching for another time.

INEFFECTIVE COPING evidenced by not doing, partially doing, or revamp- ing treatment plan related to anxiety about illness, inadequate coping mecha- nisms.

Patient Outcomes • Verbalizes anxieties and concerns • Verbalizes acceptance and commitment to the treatment plan • Demonstrates adherence to health-care regimen • Expected therapeutic goals realized

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Interventions • Encourage the patient to discuss worries and concerns regarding the ill-

ness. Determine patient’s understanding of the illness, prognosis, and treatment plan. If patient’s understanding is not accurate, review the appropriate information about the condition with him or her.

• Encourage the patient to express feelings verbally rather than act them out through noncompliance.

• Repeat and reinforce teaching. The patient’s learning ability may be impaired by anxiety or physical status.

• Give patient some control in treatment regimen. Seek his or her ideas for adaptations that can be made. Identify other areas in patient’s life where he or she can exert control. Consider negotiating a contract with the patient to reinforce compliance.

• For the patient who is impatient and perfectionistic, point out the need to develop realistic expectations of behavior changes. For example, he or she may not be able to lose weight and give up smoking at the same time.

• Approach the suspicious patient with the expectation of compliance. Keep directions clear and simple, and always be honest.

• Make an effort to reduce the patient’s anxiety before teaching session.

• Reinforce the idea that the patient is ultimately responsible for his or her own health.

• If major life changes must be made, break down expected changes into achievable steps that may be easier to accept and master. Develop a way patient can chart own progress.

• If patient has relapsed, provide encouragement to start again and point out positive steps that were achieved despite the setback.

• Continually assess emotional blocks.

ALTERNATE NURSING DIAGNOSES

Anxiety

Decisional Conflict

Knowledge Deficient

Powerlessness

Self-Care Deficit

Therapeutic Regimen Management, Ineffective: Families

Thought Processes, Disturbed

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PATIENT AND FAMILY EDUCATION

• Determine appropriate materials available to assist in patient education including pamphlets, videos, closed-circuit health education channels in the hospital, or flip charts.

• Determine if appropriate educational materials are available from pharma- ceutical and medical equipment companies. Many times, they have excellent materials available at no charge.

• Identify appropriate times to provide education to patient and family. Real- ize that at times, the patient may not be ready for teaching when the nurse is available. Other alternatives need to be identified.

• Provide information in patient’s primary language if possible. • Before starting an education session, ensure that the patient and family have

needed tools to enhance comprehension including glasses, hearing aids, and pain controlled. Patients may be too embarrassed or intimidated to tell you that they need these items.

• Identify other resources, such as diabetes educators, ostomy nurses, phar- macists, or dieticians, to assist in teaching. Be sure to coordinate teaching so that no conflicting information is given.

• Use appropriate adult learning principles for all education (see Box 12–2).

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WHEN TO CALL FOR HELP

• Patient refuses to comply with medical regimen, with life-threatening implications.

• Family or caregiver abuses patient or interferes with patient’s compli- ance.

• Patient uses folk remedies or alternative health practices that compli- cate current medical condition.

• There is evidence of suicidal or psychotic thinking as reason for non- compliance.

• There is increased staff conflict over dealing with patient’s noncom- pliance.

WHO TO CALL FOR HELP

• Attending physician • Manager • Psychiatric Team • Social Worker • Educators, Advanced Practice Nurses

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• To promote compliance with prescribed medications educate the patient and family on: potential side effects, what to do if a dose of medication is missed, where to call if concerned about a negative reaction to a drug, keep- ing of diary of medications taken, and utilization of a pill box.

• If patient and family are using the Internet for health-care information, give information on identifying reputable sites. Encourage patient and family to bring information they are obtaining on the Internet to medical appoint- ments so it can be evaluated. See Box 12–4 for Tips on Teaching Patients About Health Internet Sites. Many sites offer information in several lan- guages as well.

CHARTING TIPS

• Document all identified factors that contribute to noncompliance. • Use objective, nonjudgmental terms to describe behavior. • Document the teaching plan and patient goals to ensure that all health-care

team members are providing the same information. • Document all teaching given and patient and family response to the

education. • Document patient’s verbalized reason for and effects of noncompliance.

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BOX 12–4 Teaching Patients About Health Internet Sites • Look for sites that are affiliated with a university or professional health-

care organization to have more credibility (may include web sites ending in .edu or .org). Many professional and governmental Web sites have specific information written for the layman in easy to understand language, such as healthyminds.org (American Psychiatric Association), National Institutes of Health. Websites ending in .com are generally supported by for profit com- panies that may influence content.

• Looks for credentials, educational backgrounds, and board certification of those providing the information

• View any site with skepticism where sweeping claims of health or cure are promised

• Check for the date of the posting • Check for commercial sponsorship of the site–this may influence the infor-

mation • Bring copies of website materials to your health-care provider to review and

discuss • Online chat rooms and blogs can provide support but can also expose a

person to misinformation

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COMMUNITY-BASED CARE

• Refer the patient for home health follow-up to evaluate home situation and its influence on compliance. Inform home health nurses of concerns regarding patient’s compliance and any effective or ineffective strategies you have used.

• Identify practical issues that inhibit compliance such as lack of transporta- tion, funds, or insurance. Then seek potential resources for assistance. Involve social worker, case manager, or community resources advisor for assistance.

• Refer to support groups, community education programs, or volunteer sup- port programs, such as Reach for Recovery, or ostomy visitors. These peo- ple may provide needed reinforcement or role models for motivation and support. Online chat rooms and blogs can also provide support.

• Ensure that the patient and caregivers have adequate information for fol- low-up appointments and future treatment and that they have needed phone numbers and resources to call for more assistance.

• Refer patient for follow-up counseling if persistent noncompliance is related to inadequate coping skills or psychiatric disorder.

The Demanding, Dependent Patient

Learning Objectives • List the possible causes of underlying anxieties that could escalate a

patient’s demanding, dependent behavior. • Select effective interventions for a patient who consistently needs to be

the center of attention. • Identify possible nurses’ reactions toward demanding, dependent

patients.

Glossary Dependent personality disorder – Behavior characterized by a pervasive and

excessive need to be taken care of, leading to: submissive and clinging behaviors; fears of separations; a severe lack of self-confidence; difficulty making everyday decisions; difficulty expressing disagreement.

Entitlement – An unreasonable expectation that others will provide espe- cially favorable treatment and automatic compliance.

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(Healthy) narcissism – An adequate amount of self-love, acquired during early childhood, providing a healthy self-esteem without negating the needs of others.

Hidden dependency – Dependent behavior that is not obvious. Person may try to coerce others into behaving in ways that meet his or her needs.

Histrionic personality disorder – Behavior characterized by pervasive and excessive expression of emotion and attention-seeking behavior.

Interdependence – Having the capability for a normal balance between dependent and independent behaviors.

Narcissistic personality disorder – Behavior characterized by a pervasive pat- tern of an inflated sense of self-importance, need for admiration, and lack of empathy for others.

Regression – An individual’s response to overwhelming anxiety by moving back to a much earlier, more comforting phase of childhood.

Both demanding and dependent patients can consume an enormous amount of nursing resources. When patients exhibit these behaviors, it is essential to

identify the problems early so that efforts are not counterproductive and resources are not drained (Manos & Braun, 2006). Very dependent patients can stir up resentment in caregivers, and that inhibits the setting of limits (Groves, 2004). Setting baseline behavior goals help the patient contain or deal with his or her needs to a tolerable degree for both the staff and the patient and prevent dys- functional behavior from interfering with the planned healthcare regime. Demon- strating a healthy narcissism is seen when an individual speaks up for him/herself and displays self-care behaviors.

The demanding patient consistently wants more than the nurse can or should give and asks for more than is reasonable. A request is usually expressed as an emergency, with absolute insistence that it is a legitimate, rightful claim. The dependent patient wants to be taken care of in more ways than is normal for an adult. Unable to function independently or with self-reliance, this individual has a sense of helplessness and powerlessness and either actively or passively expects others to take responsibility to meet his or her needs, make personal decisions, and provide support. Traits of dependency are found in many patients with psy- chiatric disorders (Sadock & Sadock, 2007).

When a person is hospitalized, a dependent relationship occurs because basic rules of living, such as when to eat, are set by others. An adult with healthy cop- ing mechanisms can usually adjust to this dependency role appropriately. How- ever, the response is not so predictable in individuals who have consistently learned to use maladaptive coping mechanisms throughout their lives or in those whose situational stress have exhausted their normal coping abilities. When the patient deviates too much from commonly expected behaviors, misunderstand- ings and battles can be generated between the patient and staff. Maladaptive responses can include growing resentment at feeling so helpless, regression to a clinging neediness more characteristic of earlier years in life, fighting and refus-

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ing to follow rules, covert expressions of the need to be cared for with an overem- phasis on physical symptoms, or relentless demands for affection.

Patients with certain types of personality disorders, particularly dependent, narcissistic, or histrionic types, normally exhibit a relentless demand for atten- tion, and need to be dependent on others. Criteria for each of these personality disorders are listed in DSM-IV-TR (2000). These individuals believe that their views are correct and that others must adapt to them. Because these behaviors are long-standing, they are very resistant to change. Additionally, the stress of illness and hospitalization can cause other individuals who normally function without the need to be demanding and dependent to exhibit these behaviors. This may occur when there is a growing resentment at being helpless or when normal cop- ing mechanisms have been exhausted. This behavior can also be a normal tem- porary response in an individual faced with adjusting to a chronic condition, such as quadriplegia. An individual may express his or her intolerance for the depend- ent role by fighting, refusing to follow rules and meet expectations, or by overem- phasizing physical symptoms. Patients with dependent personality disorder tend to get others to assume responsibility for major areas of their lives and experience intense anxiety when alone (Sadock & Sadock, 2007).

ETIOLOGY

Psychological theories examine early developmental experiences that inhibit suc- cessful independence contributing to demanding or dependent adult behavior and may even result in a personality disorder. For instance, a child may learn that to be heard and acknowledged, he or she must persist in making demands on parental attention. Both inadequately met needs and overindulgence during the first 18 months of life can discourage independence. If the child was not allowed to ask directly for what is needed, he or she may learn to get needs met by hav- ing physical symptoms, particularly if extra attention is received only during early bouts of illness, when physical care provided the only expressions of sup- port and nurturing. If the child assumed the caretaker role for an ill parent, he or she may view illness as the main vehicle for obtaining care and assistance.

Patients who feel unloved and worthless or who are afraid to be alone may make frequent requests for the nurse to do things in an attempt to get attention. With attention given, the patient’s anxiety decreases, and he or she becomes less demanding.

In hidden dependency, the patient can be very controlling, intimidating, dom- inating, or possibly even an overly caring caretaker. The patient does not seem obviously dependent but attempts to coerce others to behave in ways designed to meet his or her needs.

Patients with chronic personality disorders have a limited repertoire of coping skills and can respond to anxiety by becoming more dependent and demanding, regardless of whether such behavior is appropriate to the situation. These are also associated with low self-esteem and depression. Contributing factors include

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demanding, perfectionistic parents and parents living vicariously through their children.

RELATED CLINICAL CONCERNS

Independent decision making and initiative taking can be adversely affected by dementia, depression, hearing and other sensory problems, and limited intellec- tual abilities. Dependent individuals may use drugs as a method of coping with intolerable feelings of anxiety and helplessness, which can lead to a pattern of substance dependency.

LIFE SPAN ISSUES

Children Infants are expected to be totally dependent. Younger children are still expected to be dependent in the areas in which they have not yet matured to the point of being able to do things for themselves. As children grow older and physical, psy- chological, cognitive, and social spheres develop, they are expected to do age- appropriate tasks, make decisions, interact, and exhibit independent behaviors. Children who must be more dependent because of illness or disabilities may have more struggles with these issues.

Adolescents The struggle with dependence and independence is the hallmark of adolescence. At times teenagers are children and at other times they act like adults. They can have an inflated sense of self and self-importance, with little empathy for others as a nat- ural part of trying to form their own identities; however, this does not mean that they will develop a personality disorder. People in this age group may be influenced more by their peers, who are supports against the pressures of the adult world and its expectations. They often become dependent on peers for recognition and grat- ification. Parents can become confused by the frequent vacillation between respon- sible behavior and childlike dependency, especially in earlier adolescent years.

Adults Dependency can be manifested in fears of leaving the home of origin, difficulties maintaining jobs, and remaining financially dependent on parents. Brief periods of dependency during times of stress can be normal.

Older Adults As individuals age, they may experience an accompanying increased dependence based on losses in agility, speed, or strength. Some elderly people face illnesses along with the loss of previous support systems. Old friends and relatives may die or become preoccupied with their own growing limitations. Elderly persons who

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are treated as children incapable of making independent decisions and behavior may eventually respond with dependent and demanding behaviors. However as people age and experience increased frailty, they may need to begin accepting more dependency and assistance from others.

For an older individual with a narcissistic personality disorder, adjusting to physical and occupational limitations can be particularly difficult, often straining family relationships.

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POSSIBLE NURSES’ REACTIONS • Nurses have different tolerance levels for demanding, dependent behaviors.

Patient may be considered difficult by one nurse but not by another. The extremes of these behaviors are usually considered difficult by all.

• May experience frustration and anger with the constant demands. • Resentful when patients appear to demonstrate sense of entitlement • May expect thanks or reward for meeting patient’s needs. • May feel guilty about not meeting all the patient’s stated needs and question

own competence. May try to avoid the patient. • May not recognize that giving too much to patients who can do things for

themselves is detrimental to the patients’ emotional and physical health. • May confuse appropriate limit setting with being overly harsh and with-

holding. • May be punitive or hesitate to be firm with patients because of anger and

fear about being punitive. It may also seem easier just to give in to the patient’s demands.

• Nurses with strong dependency needs or who are inexperienced may ini- tially overidentify with patients and try to meet all of their demands. May resent giving so much and not being appreciated.

ASSESSMENT

Behavior and Appearance • Intrudes into personal space and time of others • Unkempt appearance, either actual inability to provide self-care or an

unconscious attempt to get others to provide care • Demanding assistance although able to do things for self • Manipulative behavior, such as:

• Arguing or begging • Crying, clinging • Calling nurse “mean,” “hardhearted,” “a bad person,” “incompetent” • Dwelling on health problems and medical history

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• Complaining of feeling used and victimized by others • Constantly seeking attention, suggestions from others

• Disregard of facility rules • Regression; wanting to be totally taken care of, fed, repeatedly reassured, or

comforted • Frequent use of call lights • Repeated visits to nurses’ station • Demands to have physician called several times each day • Use of family visits to demonstrate helplessness; getting relatives to make

demands on staff • Sense of entitlement

Mood and Emotions • Frequently angry; may be expressed in passive-aggressive behavior • Fears being alone or abandoned • Anxiety

Thoughts, Beliefs, and Perceptions • Believes that each request is an actual problem requiring instant attention • Low self-esteem with chronic feeling of helplessness and inadequacy • Resistant to interpretations that point out reason for behavior (may experi-

ence this as an attack)

Relationships and Interactions • Self-absorbed, with little interest in others’ concerns or problems • Frequently clings to others • Sometimes nagging • Fights or reverses roles and becomes a helper to others if unable to tolerate

or acknowledge own dependency needs • Dependent relationships with significant others (SOs), in which other per-

son makes all decisions, answers for patient • Others dislike caring for or being with patient for long periods

Physical Responses • Overconcern about health and preoccupied with symptoms • Frequent requests for and preoccupied with medications, especially for pain

or anxiety • Adverse drug interactions if prescriptions taken from several different doc-

tors who are not aware of each other’s involvement

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Pertinent History • Long history of medical problems, some of which linger atypically for an

unusually long time or do not quite match patterns of usually diagnosed dis- eases; does not respond to usual treatments

• Goes from one doctor to another in search for diagnosis and treatment for complaints that show no physical basis

• Multiple hospitalizations • Unnecessary surgery • Diagnosed in the past with histrionic, narcissistic or dependent personality

disorder

COLLABORATIVE MANAGEMENT

Pharmacological Multiple medications, perhaps from different prescribers, can generate a host of problematic adverse effects. Psychiatric medicines may also be used. A tendency for dependency may lead to increased risk for dependency on medications. Confusion and lethargy in elderly patients, which can lead to more dependent behavior, can be caused by overmedicating or too many types of medications. A pharmacologi- cal review can be helpful in these instances. Antidepressants can be used for depres- sive symptoms. Anxiolytics for anxiety and panic attacks may be used.

NURSING MANAGEMENT

POWERLESSNESS evidenced by demanding, dependent behaviors related to anxieties generated by illness, disability, and/or hospitalization.

Patient Outcomes • Displays less demanding, dependent behavior and conveys needs more

directly and appropriately • Provides increased amount of self-care as physical condition permits • No longer exaggerates physical complaints to gain attention, support,

and concern

Interventions • Assess baseline:

• Consult with family or significant other to determine if behaviors are normal for the person.

• Evaluate if the patient is demanding in all situations or only in specific ones and if he or she exhibits this behavior only with certain people.

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• Identify the specific behaviors the patient uses to express dependency. • Determine whether the patient’s helplessness is consistent with his or

her medical problem or if patient is more independent when not in view of others.

• State limits and rules in advance. Discourage unnecessary or excessive time spent at the nurses’ station. Discourage asking for nurses’ assistance when the patient is aware that the nurse is on break, at lunch, or leaving at the end of the shift.

• Assess the required amount of assistance the patient needs and provide help when it is needed. Diplomatically point out unreasonable demands: “We’re concerned about your overall well-being. In our experience, patients feel more effective and better about themselves when they do as much as they can. Let’s discuss what you’re realistically able to do right now and what the nurses need to provide.”

• Make an extra effort to communicate concern:

• Demonstrate active listening. Sit down rather than stand up during the talk. Repeat statements or reflect feeling being expressed, as necessary.

• Be consistent. If you have told the patient that you will speak with him or her at a specific time and are unable to do so, explain reasons and reschedule.

• Give feedback to demonstrate that you understand what patient is ask- ing for, feels, or needs. Encourage patient to describe his or her fears and anger over the loss of control.

• Explain that identifying each situation as an emergency makes it difficult to determine what is an actual emergency.

• Determine if the patient has had previous bad experiences with health- care providers or institutions. He or she may need reassurance that proper treatment is being given.

• Give support and reassurance to allay fears when first attempting behav- iors that will lead to more independence. Assure the patient that you will be available if needed.

• Help patient to distinguish between feeling helpless and being helpless. Provide a progress list of at least one new activity per day, however small, that he or she can do independently.

• Encourage the patient to identify and verbalize real sources of anger. Ask how he or she usually handles anger. Suggest ways to redirect anger into positive activities.

• Encourage patient to make independent choices. Accept different prefer- ences and opinions.

• Do not take an overly directive approach because it can reinforce dependency.

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• Identify and point out patient’s strengths; provide praise whenever used. • Determine whether some of the patient’s expressed needs are better met

by other professionals.

INEFFECTIVE COPING evidenced by demanding, dependent behavior related to continuous and ongoing personality disturbance that hinders ability to do health-care tasks effectively and communicate concerns appropriately.

Patient Outcomes • Uses less dependent behavior with fewer unnecessary demands for

nurses’ attention • Uses appropriate methods to gain attention and support • Verbalizes appropriate degree of health concerns • Makes informed choices • Initiates and carries through tasks

Interventions • Obtain history from patient and significant others to determine patient’s

baseline style of interaction before illness or hospitalization. Those who have displayed demanding and dependent behaviors as a lifelong pattern may present more complexities.

• Be aware that patients who have long-standing, ingrained, demanding, dependent patterns will be resistant to change. Be patient and explain limit setting as often as needed.

• Determine realistic expectations for behavioral changes and expect that any changes will occur in small gradual steps.

• If the patient becomes upset because you are not presently able to spend time with him or her, determine a convenient time and provide assur- ances that patient will have your undivided attention.

• Assess whether the patient is inappropriately using other health-care workers or volunteers or is interacting inappropriately with visitors or other patients.

• Do not personalize remarks made by patients who need to feel superior. If the patient wants to speak only with the charge nurse or doctor, let those individuals explain the limits of their availability.

• Be aware when patients are using seductive behaviors to gain attention, control, or unnecessary assistance. Mild behaviors can be ignored to dis- courage future use. Persistent behaviors need firm confrontation.

• Assess for the use of manipulative behaviors to gain attention or depend- ence. Encourage methods to increase self-esteem that can decrease the patient’s need for approval from others.

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• Analyze behaviors to determine what needs the patient may be express- ing when he or she asks the staff to perform tasks that could easily be done independently.

• Point out to the patient ways in which he or she has control of some sit- uations.

• Assess the cause of a problem with independent decision making. If it is caused by a lack of information, provide all the information you can. If the patient always has difficulty making decisions, teach effective prob- lem-solving skills.

• Recognize your own tolerance for demanding, dependent behavior. Ask for assistance or temporary reprieve if necessary. For extremely depend- ent patients, strive for a balance between rotating staff to help decrease dependency on one nurse and providing consistent nursing care.

• Be especially diplomatic in correcting patient’s behavior. Narcissistic patients may react to criticism or defeat with rage, disdain, or counterat- tack. If this occurs, help the patient regain a perspective on feedback and response.

• Maintain your own perspective when receiving praise from dependent or histrionic patients as well as the devaluing or ignoring of your efforts and contributions by more narcissistic patients, who tend to take all the credit.

• Praise independent and interdependent functioning. Reassure the patient that he or she will not be forgotten nor abandoned by the staff when more independent. Reward less demanding behavior by spending more time with the patient.

ALTERNATE NURSING DIAGNOSES

Anxiety Decisional Conflict Self-Care Deficit Self-Esteem Disturbed Social Interaction, Impaired

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WHEN TO CALL FOR HELP

• When the patient is “burning out” staff with insatiable, unreasonable requests

• When the patient’s demands or needs for assistance become so unre- alistically prolonged that it impairs staff’s ability to adequately care for other patients

• When the patient is not getting good medical care because of staff anger • If the patient seems resistant to all interventions attempted

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PATIENT AND FAMILY EDUCATION

• Teach decision-making skills, such as problem identification, listing possible solutions, considering possible outcomes of each, and evaluating each out- come. Teach the patient to draw upon past experience and intuition when making decisions. Point out potential stumbling blocks such as choices that lower self-esteem or violate values or goals. Caution the patient that there may not be a perfect solution. Teach the concept of collaborative decision making.

• Teach the patient to recognize personal strengths. • Explain to the patient that in delegating personal decision making to

another, one still must retain personal responsibility for one’s own life. He or she will have to live with the consequences of the decision.

• Teach the patient to distinguish situations that require immediate attention from those that do not. Explain that identifying each situation as an emer- gency makes it difficult to determine what is an actual emergency.

• Teach the patient to identify which problems require assistance. Teach the patient to use frustration as an opportunity for problem solving.

• Teach relaxation techniques. • Teach the family members to identify when they are promoting dependent

behaviors and to examine alternatives. Teach approaches that the staff members have found effective.

• Teach the patient the difference between providing good nursing care and catering to excessive demands.

CHARTING TIPS

• Document specifics of demands and their frequency. Note if they occur at similar times or in relation to similar events.

• Document actual patient responses to specific interventions listed in the treatment plan. Avoid subjective opinions about the behaviors.

• Document frequency of requests for PRN medications. • Document details of unusual physical complaints.

WHO TO CALL FOR HELP

• Critical Incident/Employee Assistance • Psychiatric Team • Attending Physician • Manager • Social Worker

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COMMUNITY-BASED CARE

• Anticipate increased dependency and demanding behavior as discharge from one level of care becomes imminent; reduce anxiety by discussing con- cerns as early as possible.

• Involve patient in discharge arrangements. • Anticipate that discharge will probably be a difficult time if the patient will

be going to a facility with different caretakers and less staff. • If patient is going home assess what services patient will need at home and

discuss arrangements with patient and family. • Ensure that patient has specific plans for follow-up appointment with physi-

cian. • Remind patient who is about to be transferred to another level of care to

continue to use the methods learned for expressing needs. • Discuss with the next caregivers the interventions that have been effective. • If the patient’s behavioral patterns continue to significantly impair health

care and the patient is distressed about this, discuss the possibility of seek- ing psychotherapy.

• Communicate patient concerns and behaviors to referring agencies.

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Problems with Substance Abuse

The Patient Abusing Alcohol

Learning Objectives • Identify factors that contribute to the etiology of alcoholism. • Formulate appropriate nursing interventions for patients experiencing

problems with alcohol abuse. • Describe common nurse’s reactions to the patient abusing alcohol. • Describe the characteristics of codependency.

Glossary Alcohol intoxication – Excessive alcohol use that leads to maladaptive

behavior and at least one of the following: slurred speech, incoordination, unsteady gait, nystagmus, impairment in attention or memory, and stupor.

Alcoholism – A complex progressive disease characterized by significant physical, social, or mental impairment directly related to alcohol depend- ence and addiction.

Binge drinking – Pattern of periodic intervals of heavy use of alcohol (usually defined as five or more drinks on one occasion) with intervals of no or little use.

Blackouts – Lapses of memory resulting from persistent heavy drinking. Dur- ing blackouts the person may appear to function normally while drinking but cannot recall events afterward.

Codependency – Maladaptive coping behaviors that prevent individuals from taking care of their own needs because they are preoccupied with the thoughts and feelings of another. Also known as “enabling behavior.”

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Detoxification – The process of withdrawal of alcohol from the body through supervised medical interventions to prevent complications.

Dual diagnosis – Diagnosis of both a substance dependency and a major psychiatric disorder. May also be called co-occurring or co-existing disorder.

Korsakoff’s syndrome – Severe memory impairment related to thiamine defi- ciency from long-term alcohol use. Characterized by confabulation and inappropriate cheerfulness.

Tolerance – The need for increasing amounts of a substance to achieve desired effect.

Alcohol remains the most used and misused drug in America. Alcohol use is socially accepted throughout our culture, is included as part of celebrations,

religious rituals, and social occasions, and is often used as a relaxant. Nearly 90% of all American adults have used alcohol at some time in their life (DSM- IV-TR, 2000).

The move from social use of alcohol to alcoholism can occur very quickly in some people and over many years in others. In the past, alcoholism was viewed as a defective character trait, a weakness, or a moral flaw. Since the 1950s, it has been realized that alcoholism is a complex disease that responds to proper treat- ment. Today, the role of brain dysfunction is viewed as key to etiology.

Studies indicate that about 8% of Americans are dependent on alcohol at any one time and 18% report an alcohol problem at some time in their lives (Kessler, et al, 2005). This includes daily or binge drinking that negatively affects the way one lives. Binge drinking is more common in young adults. Three times as many men as women are reported to have a drinking problem; however, it is suggested that women are more secretive in their drinking behaviors, and therefore, drink- ing by women may be underreported. Alcohol is often used along with other sub- stances, especially in younger individuals, often to alleviate or enhance the effects of other drugs (e.g., to relax after using a stimulant). Heavy drinkers often have periods of enforced abstinence to try to control the problem.

Alcohol is a central nervous system depressant that produces mind-altering and mood-altering effects. Twenty percent of alcohol consumed is absorbed directly into the bloodstream through the stomach. The remainder moves through the digestive system and is absorbed more slowly. Drinking rapidly on an empty stomach or consuming drinks with higher alcohol content will lead to a more rapid rise in blood alcohol level. One ounce of distilled liquor, 5 ounces of wine, and 12 ounces of beer have equivalent amounts of alcohol. It is known that, given the same amount of alcohol, women have higher blood alcohol con- centrations than men, even when size is taken into consideration. This is because of differences in fat and body water content, making women more prone to long- term effects of alcohol. Problem drinking is identified by the National Institute of Alcohol Abuse and Alcoholism (2007) for men as having more than four

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drinks/day or greater than 14 drinks per week and in women and older men as greater than three drinks per day or more than seven drinks per week.

Alcoholism has a tremendous impact on the individual, the family, and soci- ety. Spouses and especially children are particularly vulnerable to become victims of alcohol-related abuse. They may experience violence or emotional and physi- cal neglect, and they may blame themselves for the alcoholic’s abusive state. Amazingly, 43% of U.S. adults have been exposed to alcoholism through a spouse or blood relative. Alcoholism is truly a family crisis (National Council on Alcoholism and Drug Dependence, 2002). The impact of alcohol abuse on soci- ety includes crime, traffic accidents and fatalities, suicide, industrial accidents, fires, and decreased workplace productivity.

People with major psychiatric disorders may also have an abuse problem if they use alcohol to self-medicate for the psychiatric symptoms. The co-occurrence of a psychiatric diagnosis with alcohol or other substance abuse is very common in the mentally ill population. These patients are referred to as having a dual diag- nosis or co-occurring disorder. These patients may use alcohol and other sub- stances to self-medicate the distressing psychiatric symptoms of agitation, anxiety, or hallucinations. Alcohol or abuse of other substances may also trigger a psy- chotic episode leading to a dual diagnosis. Nearly half of all people with severe mental illness are affected by substance abuse, and 37% of alcoholics have at least one mental illness (NAMI, 2003). Goldsmith and Garlapati (2004) report that 47% of schizophrenics, 56% of bipolar patients, and 27% of patients with major depression have a dual diagnosis. The most common psychiatric diagnoses asso- ciated with substance abuse are mood and anxiety disorders, attention deficit dis- orders, and antisocial personality disorders (Miller & Grady, 2004). Patients with co-occurring disorders tend to have poorer outcomes with treatment of both diag- noses. Acute intoxication or withdrawal from alcohol and/or other substances can complicate accurate diagnosis of a primary psychiatric disorder. These patients require interventions specially geared to this population as they often do not fit in standard substance abuse treatment as Alcoholics Anonymous. Collaboration between the psychiatric treatment team and addiction specialists is essential.

ETIOLOGY

Because alcoholism runs in families, there is current support for the genetic and biological theories as the cause of alcoholism. Alcoholism runs in families with a four-fold increase in close relatives of the alcoholic (Schuckit, 2006). The risk re- mains even if the children are not raised in the same home as the alcoholic parent.

The current biological theory for abuse of alcohol and other substances is that intrinsic reward pathways in the brain create a biological basis for craving the sub- stance that induces a sense of well-being. The two main pathways are gluta- matergic tracts in the prefrontal cortex and dopaminergic tracts. Each time a drink is taken for persons with altered brain function, an intense state of craving for the

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substance develops. This theory is the basis for the two pharmacological treat- ments of alcohol abuse: replacement therapy and neuromodulation. Replacement therapy substitutes the abused chemical with a safer alternative as in detoxifica- tion. Neuromodulators interact with the receptor system affected by the substance and eventually decrease the craving (e.g., Naltrexone or Acamprosate for alcohol).

A number of psychological factors are recognized as contributing to alcohol abuse. One of the most important looks at the link between depression and alco- holism. Alcoholics may have a higher incidence of depression and low self- esteem. Alcohol becomes a way to relieve those feelings. Each time a drink makes the person feel better, it reinforces this behavior. Difficulty managing anxiety and low self-esteem has led to identification of common coping styles (Table 13–1). Denial is the major defense mechanism used when the person is unable to acknowledge the role that alcohol plays in his or her life.

Alcohol use can severely affect the dynamics of the family relationship. Family members use protective behaviors, sometimes called codependent or enabling behaviors, to control or hide the alcoholic’s behavior so that a sense of normalcy can be maintained. Affected family members care for and attempt to control the behavior of the alcoholic at the expense of their own needs. The fam- ily does not realize that this type of behavior reinforces the drinking patterns and dysfunctional behavior. Examples of these behaviors include minimizing the drinking, finding excuses for the drinker’s alcohol use, attempting to control the drinking by diluting bottles or pouring out liquor, covering up for the drinker’s unacceptable behavior, and self-blame for the drinking. Family members and friends of the person abusing alcohol are also at an increased risk of emotional or physical abuse.

Social and cultural factors may also contribute to the development of alco- holism. Certain cultural groups have higher incidences of drinking problems, which may represent genetic factors combined with an increased acceptance of heavy alcohol use. It may be part of socially expected behavior. One’s social cir- cle may play a role in how alcohol is used as one observes its use by friends or family to avoid problems, become a risk taker, and so on.

RELATED CLINICAL CONCERNS

Alcohol abuse plays a major role in a variety of health problems including gas- tritis, liver failure, heart disease, and pancreatitis. Twenty-five percent of admis- sions to general hospitals are related to an alcohol problem, including being treated for consequences of drinking (National Institute of Alcohol Abuse and Alcoholism, 2001). This statistic supports that need for all healthcare profes- sionals incorporating some form of screening in their assessment. Assessing patients for alcoholism abuse can be helpful to prevent complications from with- drawal post-operatively (Sullivan, Sykora, Schneiderman, Narajo, & Sellers, 1989). Alcoholism is the third leading cause of preventable death in the United States (Kessler et al, 2005).

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Chapter 13 ■ Problems with Substance Abuse 235

TABLE 13–1 Common Coping Styles Of Alcoholics

Coping Style Definition Behaviors

Denial

Projection

Rationalization

Minimizing

Manipulation

Grandiosity

Person minimizes or does not acknowledge the problem or the results of the problem even when strong evidence is pre- sented.

Blames others for their drinking and behavior.

Justifies intolerable behavior by giving plau- sible excuses.

Avoids conflict by reduc- ing the impact of the behavior.

Plays one person against another in order to get one’s way or cover up or avoid a problem.

Maintains a sense of superiority and irrespon- sibility particularly evi- dent when intoxicated.

• “I only have two drinks a day, I could stop any time.”

• Refuses to admit drinking problems that are obvious to others.

• Family may participate in denial by covering up the problems created by the drinker.

• Avoids taking responsibility for own unacceptable behavior.

• “My brother is the one with the problem. He drinks more than I do.”

• “I’d stop if everyone would leave me alone.”

• Excuses reinforce denial. • “My kids are always in trou-

ble. They make me drink.” • “I only drink beer.”

• Places less value on the behavior and the impact of the problem.

• “You worry too much.” • “I’m not hurting anyone.”

• Convinces one or two peo- ple that he or she will improve if they will help.

• If he or she fails it is the fault of the helper.

• Lacks concern for others feelings.

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Alcohol is toxic to many major organs, especially the heart and liver. The patient with heart disease who abuses alcohol is at increased risk of complica- tions, including hypertension. Liver metabolism may be compromised, and there- fore, drugs metabolized by the liver may need dosage adjustments. Alcohol contributes to complications of diabetes.

Hingson (1993) noted that alcohol is a contributing factor in the following: 50% of trauma fatalities, 40% to 50% of falls, and 30% of motor vehicle acci- dents. If alcohol problems persist throughout a lifetime, the person will die 15 years earlier on average, with major causes being heart disease, cancer, accidents, and suicide (Rivara, Garrison, Ebel, McCarty, & Christakis 2004; Schuckit, 2006). Suicide assessment needs to be included in depressed patients abusing alcohol. Alcohol abuse also contributes to unwanted pregnancies, workplace accidents, and HIV exposure due to high-risk sexual activity.

LIFE SPAN ISSUES

Neonates Fetal alcohol syndrome is recognized as being caused by alcohol abuse during pregnancy, when rapidly growing fetal brain cells are exposed to alcohol. The end result can be an infant born with mild to moderate developmental disabilities, hyperactivity, facial malformations, heart defects, and growth deficiencies.

Children and Adolescents Alcohol use by children and adolescents has shown an alarming increase in recent years. Access to alcohol from the home or from friends can make it readily avail- able. Seventy-seven percent of high school seniors have used alcohol (National Institute of Alcohol Abuse and Alcoholism, 2007). Teens who start drinking at age 15 years are four times more likely to develop alcoholism than those who start at age 21 (National Council of Alcoholism and Drug Dependence, 2001).

When teens are found to be drinking, they need to be evaluated for use of other substances as well as high-risk sexual activity and criminal behaviors (Schuckit & Tapert, 2004).

As with adults, children learn from parents, peers, or television and movie images suggesting that alcohol can be a defense against feelings of depression, low self-esteem, or anxiety. It may also represent an acting out against parental authority or enhance a sense of closeness with peers. Children who grow up in a home where one or both parents have an alcohol abuse problem may have an increased risk of abusing alcohol. However, even those children who intensely dislike their parents’ drinking behavior may use alcohol as a coping mechanism because they have not learned more appropriate ones. Children and adolescents who become intoxicated are at increased risk of injury related to motor vehicle and bicycle accidents because they usually do not drink in the home. They are also at increased risk of alterations in growth and development because of

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nutritional deficiencies and because they often do not learn to deal effectively with normal anxiety and other uncomfortable emotions. Adolescents and young adults are more prone to binge drinking, which has been associated with life threatening effects from alcohol intoxication.

Older Adults Alcohol abuse is often unrecognized and undertreated in the older-than-65 age group. Our society generally does not view the older population as an at-risk group. Because alcohol abuse is often a life-long pattern, elderly people may con- tinue their earlier struggles with alcohol. Because of changes in metabolism with age, it may take less alcohol to begin to cause intoxication or other problems. Others may start drinking in later life because they face increasing problems, such as isolation, loss of spouse, and changes in health status. Alcohol may produce significant health problems in elderly persons, particularly if they have impaired liver function. Mental changes from alcohol use may be confused with dementia. It is a major factor in falls, burns, and suicide attempts. The brain in older adults is more susceptible to the depressant effect of alcohol, and therefore, depression may mask the signs of alcoholism. Other signs might be unexplained falls, poor nutrition, and self-neglect. Use of multiple medications with alcohol can exacer- bate alcohol’s effects. Withdrawal programs for this age group may require spe- cialized care because of the increased health risks.

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POSSIBLE NURSES’ REACTIONS • May view alcohol abuse as a personality defect or weakness rather than a

health problem. • May avoid, criticize, or reject the patient. This may trigger guilt feelings,

and the nurse may try to make up for these feelings by being overly sympa- thetic.

• May have feelings of disgust for the patient. • May have unresolved feelings related to a past family or personal history of

substance abuse. • May feel helpless to facilitate change, especially in a patient with a long his-

tory of alcohol problems.

ASSESSMENT

Behavior and Appearance • Signs of intoxication include odor of alcohol, slurred speech, loud talking,

loss of inhibition, loss of coordination, and poor judgment • Sudden onset of signs of withdrawal

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• Frequently talks or brags about alcohol use • Exhibits extremes of behavior from euphoria to irritability • Justifies drinking or the need to drink • Refuses to discuss drinking or lies about drinking • Drinks large quantities of alcohol • Needs to drink increasingly more to get same effect • Unable to stop drinking once he or she starts • Overreacts when questioned about drinking pattern • Reports drinking a much smaller amount than is accurate • Suicide attempts • Two or more affirmative responses to the CAGE questionnaire (Box 13–1)

suggests dependence, further assessment required

Mood and Emotions • Depression • Remorse after a binge • Low frustration tolerance • Anxiety • Low self-esteem

Thoughts, Beliefs, and Perceptions • Evidence of defense mechanisms of denial, rationalization, projection, and

minimizing • Thinking about alcohol supply and plans to obtain it • Blackouts • Hallucinations

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BOX 13–1 Cage Questionnaire To determine the patient’s perception of his or her drinking problem, you may ask the following questions. Two or more affirmative answers strongly suggest dependence on alcohol. 1. Have you ever believed that you should Cut down your drinking? 2. Have people Annoyed you by criticizing your drinking? 3. Have you ever felt bad or Guilty about your drinking? 4. Have you ever had a drink first thing in the morning to steady your nerves

or get rid of a hangover (Eye Opener)?

Source: Mayfield, D., McLeod, G., & Hall, P. (1974). The CAGE Questionnaire: Validation of a new alcoholism screening instrument. American Journal of Psychiatry, 131, 1121–1123, with permission.

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Relationships and Interactions • Dependent • Resentful of authority • Manipulates others to avoid confrontation, conflict • Blames others for drinking • Argues with family about drinking

Physical Responses • Blood alcohol level (0.08 to 0.10 is legal limit to define intoxication in most

states) or positive polydrug panel (may be negative, depending on time since last consumption). Blood level is less useful in elderly people because of altered metabolism. Urine testing can be a less invasive approach.

• Amylase may be elevated if liver damage is present. Blood sugar measure- ment may indicate hyper- or hypoglycemia. Serum magnesium may be low from alcohol damage to the nervous system. Hemoglobin may be low if bleeding is present

• History of falls, burns, accidents • May have signs of gastrointestinal bleeding, ascites, or jaundice • May be underweight and show signs of malnutrition and dehydration • Korsakoff’s syndrome from prolonged thiamine deficiency creates a second-

ary dementia marked by ataxia, confabulation, and peripheral neuropathy • Withdrawal symptoms may occur 8 to 24 hours after last alcohol use. Anal-

gesics and recovery from anesthesia can precipitate an acute withdrawal reaction. This emphasizes the importance of quick diagnosis to institute detoxification. Assessment of alcohol use in the hospital can be helpful to reduce risk of complications. See Box 13–2 for Clinical Institute With- drawal Assessment of Alcohol Scale (CIWA-AR). A score of greater than 15 predicts a severe alcohol withdrawal.

• Withdrawal grand mal seizures can occur in a small group of chronic alco- holics

• Alcoholic hallucinosis when hallucinations develop during the withdrawal period. Most often these are visual hallucinations.

• Alcohol-related delirium (also known as delirium tremens) is a medical emergency with a 20 percent mortality rate if left untreated. Complications include pneumonia, dehydration, electrolyte imbalance, respiratory failure, and status epilepticus (Box 13–3).

Pertinent History • Previous history of alcohol or polydrug use • History of heart disease, liver disease, gastrointestinal bleeding or varices • Psychotic, depressed, or manic behavior

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240 Chapter 13 ■ Problems with Substance Abuse

BOX 13–2 Clinical Insitutue Withdrawal Assessment of Alcohol Scale, Revised (CIWA-AR) Patient:______ Date:_____ Time:______ (24 hour clock, midnight � 00.00)

Pulse or heart rate, taken for one minute: ______ Blood pressure: ______

NAUSEA AND VOMITING — Ask “Do you feel sick to your stom- ach? Have you vomited?” Observa- tion.

0. no nausea and no vomiting 1. mild nausea with no vomiting 2. 3. 4. intermittent nausea with dry

heaves 5. 6. 7. constant nausea, frequent dry

heaves and vomiting

TREMOR — Arms extended and fingers spread apart. Observation.

0. no tremor 1. not visible, but can be felt finger-

tip to fingertip 2. 3. 4. moderate, with patient’s arms

extended 5. 6. 7. severe, even with arms not

extended

PAROXYSMAL SWEATS — Observation.

0. no sweat visible 1. barely perceptible sweating,

palms moist

2. 3. 4. beads of sweat obvious on fore-

head 5. 6. 7. drenching sweats

ANXIETY — Ask “Do you feel nervous?” Observation.

0. no anxiety, at ease 1. mild anxious 2. 3. 4. moderately anxious, or guarded,

so anxiety is inferred 5. 6. 7. equivalent to acute panic states

as seen in severe delirium or acute schizophrenic reactions

AGITATION — Observation

0. normal activity 1. somewhat more than normal

activity 2. 3. 4. moderately fidgety and restless 5. 6. 7. paces back and forth during

most of the interview, or con- stantly thrashes about

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Chapter 13 ■ Problems with Substance Abuse 241

TACTILE DISTURBANCES—Ask “Have you any itching, pins and needles sensations, any burning, any numbness or do you feel bugs crawl- ing on or under your skin?” Obser- vation.

0. none 1. very mild itching, pins and nee-

dles, burning or numbness 2. mild itching, pins and needles,

burning or numbness 3. moderate itching, pins and nee-

dles, burning or numbness 4. moderately severe hallucinations 5. severe hallucinations 6. extremely severe hallucinations 7. continuous hallucinations

AUDITORY DISTURBANCES— Ask “Are you more aware of sounds around you? Are they harsh? Do they frighten you? Are you hearing anything that is disturbing to you? Are you hearing things you know are not there?” Observation.

0. not present 1. very mild harshness or ability to

frighten 2. mild harshness or ability to

frighten 3. moderate harshness or ability to

frighten 4. moderately severe hallucinations 5. severe hallucinations 6. extremely severe hallucinations 7. continuous hallucinations

VISUAL DISTURBANCES—Ask “Does the light appear to be too bright? Is its color different? Does it hurt your eyes? Are you seeing any-

thing that is disturbing to you? Are you seeing things you know are not there?” Observation.

0. not present 1. very mild sensitivity 2. mild sensitivity 3. moderate sensitivity 4. moderately severe hallucinations 5. severe hallucinations 6. extremely severe hallucinations 7. continuous hallucinations

HEADACHE, FULLNESS IN HEAD—Ask “Does your head feel different? Does it feel like there is a band around your head?” Do not rate for dizziness or lightheaded- ness. Otherwise, rate severity.

0. not present 1. very mild 2. mild 3. moderate 4. moderately severe 5. severe 6. very severe 7. extremely severe

ORIENTATION AND CLOUD- ING OF SENSORIUM—Ask “What day is this? Where are you? Who am I?”

0. oriented and can do serial addi- tions

1. cannot do serial additions or is uncertain about date

2. disoriented for date by no more than 2 calender days

3. disoriented for date by more than 2 calender days

4. disoriented for place/or person

Continued

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242 Chapter 13 ■ Problems with Substance Abuse

BOX 13–3. DSM-IV Criteria for Diagnosis of Alcohol-Related Syndrome Alcohol abuse—Maladaptive pattern of alcohol use that is manifested by one or more of the following within the same 12 months:

1. Inability to fulfill major role obligations at work, school, and home 2. Recurrent legal or interpersonal problems 3. Reduction or absence of important social, occupational, and recreational

activities 4. Participation in physically hazardous situations while impaired, for exam-

ple, driving a car, exacerbation of a symptom

Alcohol dependence—Maladaptive pattern of alcohol use leading to impair- ment by three or more of the following occurring at any time during the same 12 months:

1. All criteria for alcohol abuse 2. Presence of tolerance to drug 3. Presence of alcohol withdrawal syndrome 4. Ingestion of alcohol to relieve or prevent withdrawal 5. Taking more alcohol over longer period of time than intended 6. Unsuccessful or persistent desire to cut down or control use 7. Great deal of time spent in getting, taking, and recovering from alcohol

Alcohol withdrawal—Cessation of alcohol use which has been heavy and pro- longed and has at least 2 of the following within several hours to a few days:

BOX 13–2 Clinical Insitutue Withdrawal Assessment of Alcohol Scale, Revised (CIWA-AR) (continued)

The CIWA-Ar is not copyrighted and may be reproduced freely. Patients scoring less than 10 do not usually need additional medication for withdrawal.

Total CIWA-Ar Score ______ Rater’s Initials ________

Maximum Possible Score 67

Source: Sullivan, J. T., Sykora K., Schneiderman, J., Naranjo, C. A., & Sellers E. M. (1989). Assess- ment of alcohol withdrawal: the revised Clinical Institute withdrawal assessment for alcohol scale. British Journal of Addiction, 84, 1353–1357.

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• Suicide attempts • Blackouts, seizures, or delirium • Alcohol-related police record, possibly including motor vehicle violations or

accidents, physical violence, or child or spouse abuse • May have history of being abused as a child • Erratic work record because of alcohol abuse • One or both parents with history of alcohol problems

COLLABORATIVE MANAGEMENT

Pharmacological Symptoms from alcohol withdrawal generally start within 4 to 12 hours of ces- sation of heavy drinking. Symptoms are the most intense on the second day. Pro- tocols for detoxification from alcohol include pharmacologic treatment to prevent or reduce the development of alcohol-related delirium. Sedation with longer-acting central nervous system depressants is substituted for shorter-acting alcohol. Benzodiazepines such as diazepam (Valium) and chlordiazepoxide (Lib- rium) are the drugs of choice because they have anticonvulsant actions and are relatively safe. The drugs are usually administered on a routine basis and then

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1. Autonomic hyperactivity (high blood pressure, tachycardia, fever) 2. Hand tremor 3. Insomnia 4. Nausea and/or vomiting 5. Anxiety 6. Transient visual, tactile, or auditory hallucinations or illusions 7. Grand mal seizures

Alcohol-induced delirium—An organic mental disorder with symptoms in excess of the usual withdrawal (formerly called “delirium tremens”) or intox- ication symptoms that occurs after cessation or reduction of long-term heavy drinking or during intoxication. In someone with a history of substance use, symptoms include

1. Impaired consciousness 2. Changes in cognition including memory, language, disorientation, halluci-

nations (especially tactile such as feeling bugs crawling on one’s body) 3. Develops over short period of time (hours to days) and fluctuates over a day.

Source: American Psychiatric Association (APA). (2000). Diagnostic and statistical manual of mental disorders—text revision (TR.) Washington, DC: American Psychiatric Association.

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tapered down by 20% to 25% per day until withdrawal is complete—usually about 5 days. Shorter acting tranquilizers such as oxazepam and lorazepam (Ati- van) may be used if patient has liver disease. Anticonvulsants may also be needed. Detoxification may be done in an alcohol treatment unit or hospital or at home, if adequate supervision is available. Fluid, vitamins, and electrolyte supplemen- tation is also part of the treatment plan. The inpatient setting needs to be used if the patient is at risk for alcohol related delirium, has multiple comorbidities, or is elderly.

Disulfiram (Antabuse) has been used for chronic alcohol abuse. This drug inhibits impulsive drinking because it produces an extremely uncomfortable physical reaction when alcohol is ingested. The drug is taken daily and stays in the system for 5 days after the last dose. If the patient is exposed to alcohol while the drug remains active, he or she may experience headache, tachycardia, nausea, vomiting, flushing, sweating, and changes in blood pressure, as well as potentially serious reactions including shock and cardiac arrhythmias. Because of the risks involved with using this drug, the patient must have the ability to under- stand the reaction if alcohol is ingested and give informed consent. The patient must be instructed to avoid inhaling substances that could contain alcohol, such as paint or wood stains, and refrain from using any substances with alcohol, including those with hidden sources such as some mouthwashes, elixirs, skin preparations, or colognes. The drug metronidazole (Flagyl) may cause a disulfi- ram-like reaction when alcohol is also ingested. Antabuse is best used for the motivated patient who is less subject to impulsive behavior and does not have a psychiatric history.

Acamprosate and naltrexone are also being used to treat alcohol cravings and the physical signs associated with withdrawal. These work as neuromodulators to treat the brain dysfunction causing the addiction. These should be used in con- junction with psychological support. Other commonly used medications include beta blockers, clonidine, and haloperidol (for hallucinations).

Dual-diagnosis patients present a challenge because they usually need to con- tinue to take their psychiatric medications during the detoxification process. These medications need to be closely monitored.

Alternative approaches for withdrawal may include herbs and plants such as chamomile for insomnia, valerian for anxiety (should not be taken with sedatives), and kava kava for anxiety (should not be used with sedatives or alcohol). Multi- vitamins, thiamine, and magnesium therapy are indicated in chronic alcoholics to prevent neurological complications. Patients must also maintain hydration.

Twelve-Step Program The Twelve-Step Program of Alcoholics Anonymous (AA) is generally accepted as part of every alcoholic’s treatment program. AA’s philosophy mandates that the individual become sober and never drink or use mood-altering substances again. The person acknowledges that he or she is powerless over alcohol, is always considered recovering, and is never cured. One drink could cause a down-

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ward spiral to heavy drinking. The best outcomes occur when the AA group members are of similar age and cultural background.

AA uses sponsors who have been sober for longer periods to support new members. The alcoholic needs to attend regular, even daily group support meet- ings and work on the Twelve-Step Program. AA chapters are found in virtually every community in the United States. The only requirement for membership is the desire to stop drinking. AA has been the model for other self-help groups, including Gamblers Anonymous and Cocaine Anonymous. Family members of alcoholics can participate in self-help groups following the same model, includ- ing Al-Anon for spouses and friends, Al-a-Teen for adolescents, and Adult Chil- dren of Alcoholics (ACoA).

Additional approaches may include behavioral, group, and marital therapies.

NURSING MANAGEMENT

INEFFECTIVE DENIAL evidenced by lack of acknowledgment of alcohol abuse related to impaired ability to accept consequences of own behavior.

Patient Outcomes • Acknowledges own drinking problem • Expresses feelings while under nurse’s care • Demonstrates problem-solving skills • Abstains from alcohol and drug use or significantly reduces intake • Asks for assistance with drinking problem

Interventions • Help patient identify disturbing feelings by listening to concerns and

helping him or her put labels on possible emotions. Patient may have used alcohol to deny feelings and needs assistance to identify them.

• Foster problem solving. Explore with the patient, the coping mechanisms that are more appropriate than alcohol to deal with the specific causes of stress and anxiety.

• Talk with patient about the normal range of personal emotions. • Discuss behavioral inconsistencies. • Maintain a positive attitude. Communicate the idea that patient can

overcome his or her problems. • Work with patient to set realistic small goals for abstaining from alcohol

and managing his or her problems. This may require structured planning for how to get through the next day without a drink. Encourage use of readings and meditations.

• Reinforce the Alcoholics Anonymous philosophy of “one day at a time.” This means setting a goal of not drinking today rather than thinking about not drinking for the next year.

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• Develop a trusting relationship. When the patient feels safe with a staff member, encourage examination of the negative consequences of his or her behavior. Recognize that this relationship could become too threat- ening to the patient and he or she may try to sabotage it or reject the nurse. This is all part of the struggle to face one’s problems.

• If patient states, “I could stop drinking any time,” have him or her iden- tify what could be done right now to stop. Look for windows in denial that might indicate the slightest insight and focus.

• Set limits on manipulative behavior. Some patients may have learned to be very charming. The goal of these behaviors is to avoid dealing with the real problems.

RISK FOR INJURY evidenced by disorientation, lack of coordination, or aggressive or disruptive behavior related to acute alcohol intoxication, with- drawal, and/or delirium.

Patient Outcomes • Remains free from injury while under care of the nurse. • Sleeps at least 6 hours at night. • Has reduced incidence of medical complications. • Exhibits appropriate behavior.

Interventions • Monitor vital signs, seizures, and changes in mental status closely for 5

days after withdrawal from alcohol. • Monitor closely for signs of withdrawal and report to physician to begin

early treatment. With appropriate management, severe complications can be prevented. Recognize that the patient may be using several drugs, so the signs of alcohol withdrawal may be masked or delayed.

• Follow agency policy or protocol for detoxification for high-risk patients. • Maintain a quiet, calm environment. Use a soft voice and calm, support-

ive approach to reassure patient. • Make sure there is a night light in the room. Institute fall precautions.

Encourage staff or family to stay with patient to ensure safety. • Avoid restraints if at all possible by adequate use of medication. • If the patient has pain from another medical condition, such as trauma

or surgery, be sure to treat the pain. Do not withhold analgesia out of fear that it will reinforce addictive tendencies.

• Institute appropriate precautions if patient at risk for seizures, hallucina- tions, violent behavior.

• Promote use of relaxation techniques and herbal teas to reduce tension and help with possible insomnia.

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• Monitor for complications, including cardiac arrhythmias or diabetes. • Monitor food intake. Encourage fluids and a high-carbohydrate diet. Dis-

courage use of dehydrating foods and fluids such as coffee, tea, and chocolate. Administer vitamins as ordered.

• Provide emotional support for patient and family.

FAMILY COPING: COMPROMISED evidenced by over-responsible behavior to control the alcoholism related to anxiety in the family system.

Patient Family Outcomes

• Demonstrates assertive response when faced with abusive behavior • Expresses feelings about the impact of alcohol on the family • Demonstrates reduced number of behaviors that take responsibility for

patient’s drinking • Attends support group meetings

Interventions • Recognize that alcoholism is a health problem that affects all family

members. Monitor response of all family members to patient’s behavior. • Give feedback to individuals about over-responsible behavior. Encourage

them to recognize the signs and feelings associated with it. Explain how efforts to contain the patient’s drinking merely delay the needed con- frontation.

• Assist family members to set limits on the urge to “rescue” the patient. Give suggestions on coping mechanisms to reduce the stress. They need support to accept the idea that they are not responsible for patient’s drinking or behavior.

• Educate family members about availability and purpose of group support programs. Talk to them about meeting with a chemical dependency spe- cialist for assistance. Participate in a planned intervention technique under the supervision of the specialist when the patient is confronted by family and friends about his or her drinking problem.

• Give person permission to take care of own needs first. • Teach the family assertive responses to abuse or criticism from others,

especially the patient. • Encourage them to express emotions, both positive and negative. • Reinforce the idea that ultimately the individual with the drinking prob-

lem is the only one who can control his or her own behavior. • Recognize the fact that family members may unconsciously sabotage

patient’s recovery in order to maintain the security of the status quo. Remain as objective as possible and avoid becoming involved in family conflicts.

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• Prepare patient for changes in relationships with family and friends that may occur once he or she has stopped drinking. There may be some indi- viduals who no longer like the patient when he or she is sober. Patient needs to reexamine these relationships.

ALTERNATE NURSING DIAGNOSES

Noncompliance Nutrition, Imbalanced: Less Than Body Requirements Sleep Pattern, Disturbed Thought Processes, Disturbed Violence, Risk for

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WHEN TO CALL FOR HELP

• Escalation of aggressive, belligerent behavior to violence • Need to apply restraints • Intoxication • Complications including seizures, cardiac arrhythmias, bleeding, high

temperature • Inadequate staff available to manage behavior • Presence of increase in psychotic behavior • Sudden change in mental status

WHO TO CALL FOR HELP

• Addiction specialists • AA sponsor • Social Worker • Security • Psychiatric Team

PATIENT AND FAMILY EDUCATION

• Reinforce strategies to avoid exposure to alcohol. For example, caution patient to avoid contact with drinking friends. Teach patient to avoid his or her old habits that included drinking, and remove all alcohol from the home. Teach patient and family to read labels of products purchased. Avoid prod- ucts with alcohol in them such as mouthwashes and cough syrup. Avoid any mood-altering substance that could be used as a substitute for alcohol.

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• Provide information about the addictive process and how it affects all aspects of one’s life. Review “one-day-at-a-time” philosophy.

• Provide information on any medications being used to treat withdrawal and/or alcoholism.

• Provide information on nutrition and how to address possible vitamin and mineral deficiencies.

• Provide information on side effects of medications used to treat alcoholism

• Provide information to patient and family on managing potential seizures.

• Provide health teaching on the potential of gastrointestinal bleeding and liver disease. Encourage patient to avoid using products containing aspirin.

• Educate patient and family on the hazards of drinking in pregnancy and the effects of alcohol on driving and working.

• Teach strategies to replace alcohol with more healthy activities such as sports, hobbies, and journal keeping.

• Reinforce relaxation measures.

• Prepare patient for need to develop social contacts who do not drink.

• Reinforce education to family on avoiding overresponsible responses.

• Prepare the patient for the fact that intense emotions may be more painful without alcohol. He or she may need extra help at these times.

• Remind patient to tell every physician seen about his or her history to ensure that doctor will prescribe medications appropriately.

• Useful Web sites for patients and families include ncadd.org (National Council on Alcoholism and Drug Dependence) and samhsa.gov (Substance Abuse and Mental Health Services Administration).

CHARTING TIPS

• Document vital signs and any evidence of symptoms of withdrawal and delirium.

• Describe in detail the patient’s level of consciousness and mental status.

• Document the patient’s response to the medications being used for with- drawal.

• Document the family’s response to patient’s behavior.

• Document any observations of continued alcohol use.

• Document any actions taken to prevent violent behavior.

• If restraints are necessary, document the type, the time the patient was in restraints, the reason why they were applied, the patient’s response to treat- ment, when limbs were released, and the care given to the patient while in restraints.

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COMMUNITY-BASED CARE

• Provide information to patient and family on location and phone numbers for local chapters of AA, Al-Anon, and Al-a-Teen, as needed.

• Encourage the patient and family to begin or continue counseling or provide referral to alcohol counseling programs.

• Communicate information on all medications prescribed for alcohol with- drawal and alcoholism

• Encourage the patient to follow up with medical appointments

• Arrange for follow-up home health visits for patients being discharged from detoxification treatment to home.

• Provide information to referring agencies, such as home health agencies or nursing homes, on patient’s drinking patterns and the treatment program.

The Patient Abusing Other Substances

Learning Objectives • Differentiate between substance abuse and dependence. • Identify common reactions of the nurse to the substance abuser. • Describe important nursing considerations of abusing amphetamines,

cocaine, hallucinogens, nicotine, opioids, and sedatives. • Identify nursing diagnoses and interventions in caring for the substance

abuser.

Glossary Binge – Pattern of periodic intervals of heavy use of substances with intervals

of no or little usage. Cross-tolerance – State in which the effect of a substance is reduced because

the individual has become tolerant to a similar drug. Detoxification – Process of withdrawal of a drug from the body through

supervised medical intervention to prevent complications. Drug tolerance – Need for higher and higher doses to achieve same desired

effect.

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Dual diagnosis – Individual with a mental disorder who is also a substance abuser. The substance is often used to self-medicate to relieve psychiatric symptoms. Also called co-occurring disorder.

Flashback – Transient recurrence of a disturbance in perceptions associated with hallucinogens that are reminiscent of those experienced when taking the drug. Sometimes referred to as a “hallucinogen persisting perceptual disorder.”

Polypharmacy – Taking more than one substance at any given time. Substance abuse – The maladaptive and consistent use of a drug accompa-

nied by recurrent and significant adverse consequences often related to physical hazards, multiple legal problems, and recurrent social and inter- personal problems.

Substance dependence – Cluster of cognitive, behavioral, and physiologic symptoms indicating that the individual continues use of the substance despite significant substance-related problems.

Withdrawal – Negative physiological and psychological reactions that occur when the drug is reduced or no longer taken.

Using mind- and mood-altering substances is probably as old as the human race. Today, many people use medications or other substances to relax, sleep,

and increase energy. Prescription and over-the-counter psychoactive substances such as caffeine, tobacco, alcohol, pain killers, tranquilizers, and common cold treatments are both socially acceptable and commonly used. It is interesting that we accept these substances to help us feel better but loathe people who are dependent on or abuse drugs. People who eventually become substance abusers also take drugs to feel better, possibly as a way to avoid some problems and stres- sors. Eventually, though, the need to obtain and use the drug negatively affects all aspects of the person’s life, including family, job, friends, and other responsi- bilities. Many people who use drugs retreat to the company of others who share their lifestyle, beliefs, and drugs. Polydrug use is particularly common, as indi- viduals use one drug to counteract or enhance the effects of the first drug.

There is a significant difference between substance dependence and substance abuse. According to the DSM-IV-TR, substance dependence is characterized by a pattern of repeated self-administration of a drug that usually results in tolerance, withdrawal, and compulsive drug-taking behavior. Substance abuse is character- ized by compulsive use in which the individual continues to use the drug even in the face of problems, including inability to fulfill major role obligations at work, school, or home; recurrent use in situations in which it is physically hazardous; recurrent legal problems related to the substance use; and recurrent social or interpersonal problems related to drug use.

Substance abuse is a major health problem for individuals in all ages and socioeconomic groups; however, abuse rates are highest in the 18- to 20-year-old age group (2004 National Survey on Drug Abuse and Health). At some time in their lifetime, 14.6% of Americans have a substance abuse disorder (Kessler,

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et al, 2005). The National Survey on Drug Abuse and Health in 2004 found that 9.4% of the population has substance abuse or dependence at any one time, with marijuana being the most frequently used illicit drug. Patterns of use vary in rela- tion to cost and availability. The economic impact of drug abuse is tremendous, including crime, medical costs, accidents, and loss of work days in addition to the resulting family dysfunction.

Methamphetamine (known as crystal meth) has been increasingly abused by young people in recent years. It is more often found in rural and suburban com- munities. This drug is a long-acting amphetamine that contributes to many anti- social behaviors including violent crime, child abuse, and prostitution. Originally produced in this country in meth laboratories from over-the-counter deconges- tant pseudoephedrine, it is now smuggled in from other countries.

Anabolic steroids are another relative recent drug of abuse. Used by athletes to increase muscle mass, the pattern of addiction to this substance fits the defini- tion of substance abuse when the individual continues to use the drug despite negative effects.

Substances known as “club drugs” have been popular with young people. These include ecstasy, ketamine, and rohypnal. Rohypnal has been associated with “date rape.” When this short-acting benzodiazepine is slipped into an alco- holic drink, the victim becomes incapacitated and unable to resist a sexual assault. Ecstasy (also called MDMA) is a stimulant/hallucinogenic that can destroy neurons in the brain leading to brain damage.

It is estimated that 10% to 15% of nurses suffer from some form of chemical dependency (Raia, 2004). Alcohol is the most widely abused drug followed closely by narcotics. Stressful jobs and a tendency to perfectionism, coupled with a feeling of inadequacy; family history; and knowledge about and access to drugs increase the risk of substance abuse in this population. Because they do not fit the image of an addict, nurses often minimize or deny their problem. Many states have now developed Diversion Programs to provide treatment and rehabilitation confidentially.

ETIOLOGY

The causes of drug abuse are similar to those of alcohol abuse; however, because of the wide range of drugs abused, there are some differences.

Biological theories look at the role of specific brain dysfunction and view addiction as a brain disease. Cravings for drugs are stimulated by two path- ways—the glutamatergic tract from the prefrontal cortex and the dopaminergic tract. After using a drug that induces an altered state, brain changes that lead to increased craving for this drug again are created. Cocaine has been studied in more depth than some of the other drugs, and it is believed that there may be a deficiency of dopamine and norepinephrine that creates more of a craving for that drug. With opioids, it is theorized that there may be some abnormality in opioid receptors and endorphins.

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Psychological theories view drug dependence as an attempt to adapt to severe emotional distress. Low self-esteem and anxiety become masked under the influ- ence of the drug. Drugs relieve feelings of depression and dependency and may be used to suppress anxiety, particularly after a traumatic event such as rape or vio- lent crime. Individuals with tendencies toward antisocial behavior and difficulties with impulse control and frustration tolerance may use substances as a way to control anxiety that contributes to antisocial behavior. In addition, the role of the family and tendency to codependent relationships (see the preceding subsection on alcoholism for complete discussion) also exist with substance abuse. Drug abusers use many of the same coping mechanisms that alcoholics do, including denial, projection, and manipulation (see Table 13–1). Substance abuse can also be a way to cope with overwhelming traumas such as physical and mental abuse.

Sociocultural views recognize that certain drugs may be more likely to be used, depending on peer group, income, or culture. Acceptable behavior within a group, access to specific drugs, and status related to specific drugs may all be influencing factors. For example, crack cocaine has spread quickly within the low-income groups because of its easy availability and low cost.

As with alcohol, patients with a co-occurring disorder of substance abuse and a psychiatric disorder are very common and tend to complicate treatment for both conditions. See previous section of this chapter on patients who abuse alco- hol for more information. The National Alliance for the Mentally Ill (2006) reports that 53% of substance abusers have at least one mental illness.

RELATED CLINICAL CONCERNS

There is no evidence to suggest that an individual will become dependent on drugs by taking analgesics for pain. In fact, McCaffery and Ferrell (1994) report that less than 1% of individuals who take analgesics for a painful condition become addicted to that substance. Individuals who have developed drug toler- ance require larger amounts of medications to relieve pain. This should not be confused with addiction.

Individuals with a substance abuse problem may experience withdrawal symp- toms when hospital admission prevents them from taking the addictive sub- stance. This is an important consideration when analyzing assessment findings. For instance, when a patient who has been hospitalized and NPO for 2 days experiences headaches and irritability, it may be related to caffeine withdrawal. In certain instances, withdrawal symptoms for more potent substances can increase the risk of complications. For example, the confusion resulting from amphetamine withdrawal may cause a postoperative patient to attempt to get out of bed, tear out tubes and intravenous lines, and possibly fall.

The effects of high-risk behaviors that contribute to HIV, hepatitis, and bacte- rial endocarditis from infections and shared drug paraphernalia cause additional clinical concerns. Individuals may be more prone to high-risk behavior when under the influence of drugs because inhibitions are suppressed. Intravenous drug

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use remains a major cause of HIV. Many stimulants and inhalants contribute to cardiac arrhythmias.

Polydrug use combined with alcohol is another common finding in the substance abusing population. For example cocaine users commonly use alcohol to get to sleep or calm down. Complications related to multiple drug use include interactions between drugs and synergistic effect of some drug combinations. Detoxification from multiple drugs requires close monitoring by addiction specialists.

LIFE SPAN ISSUES

Neonates Cocaine use during pregnancy presents severe problems for the exposed neonate. Cocaine crosses the placenta and can induce premature labor. Complications include lower birth weight, decreased head circumference, preterm delivery, and placental abruption. Long-term problems can include aggressiveness and atten- tion deficit. There is often a lack of prenatal care associated with the pregnancy as well because the mother may be fearful of seeking medical care.

Children and Adolescents Children and adolescents today are at high risk for exposure to substance use and abuse because of the easy availability of drugs in the schools and community. Peer pressure, experimentation, curiosity, and rebellion, as well as trying to find ways to cope or escape from problems, may be part of the etiology. Alcohol, tobacco, and marijuana are most frequently used. Drug use often begins while experimenting with peers. When the child or teen experiences a sense of well-being and power, drug use continues. He/she may then become drawn into the drug cul- ture and possibly into a gang, which provides a support system for continued use. Children and adolescents are more likely to have abuse problems than dependence disorders. Adolescents who are victims of abuse and gay teens are particularly vul- nerable to drugs as a way to cope with painful feelings (Tweed, 1998).

Some of the most common abused substances for children and teens include easy-to-obtain over-the-counter substances like inhalants and cough/cold reme- dies. Children as young as 7 years have been identified as using inhalants. These are an easily available substance to children and younger teens when household items such as hair spray and aerosol whipped cream can be used. Over-the- counter cold and cough medicine abuse is now rising by 50% per year in teens (Partnership for a Drug-Free America, 2006). Products with dextromethorphan can contribute to hallucinations and out-of-body experiences. Use of anabolic steroids often starts in adolescence when a teen becomes active in school sports and also wants to enhance his appearance.

Signs of substance abuse in this group may be indicated by a change in func- tioning at school, loss of interest in sports, change in sleep patterns, increased iso- lation, or change in social network.

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Older Adults Substance use and abuse in elderly people are complicated because they routinely take a greater number of prescribed and over-the-counter drugs and have dimin- ished tolerance to many medications. The individual, family, and health profes- sionals often deny this problem in this age group. This may be because family members and health-care professionals are reluctant to accuse an older person of drug abuse. The signs of abuse may also be masked or mistakenly attributed to the use of another drug the person is taking. The older adult is more likely to abuse prescribed tranquilizers, sedatives (especially benzodiazepines), and some analgesics. Falls, unexplained accidents, increased lethargy, loss of memory and attention span, and unexplained confusion may be signs of a drug abuse prob- lem. Use of illicit drugs is relatively uncommon in elderly people, but it may increase in the future as young and middle-age addicts grow older.

Chapter 13 ■ Problems with Substance Abuse 255

POSSIBLE NURSES’ REACTIONS • May have strong negative feelings, viewing the patient as weak, immoral,

or responsible for his or her own problems. • May fear the patient’s manipulative, provocative behavior and potential for

criminal or violent behavior. • May tend to minimize patient’s concerns or discomforts because of resent-

ment or fear of being manipulated. • May distance self from patient because of own discomfort. • May have a rescue fantasy of being the one to help this patient. The nurse

may then become repeatedly disappointed when the patient returns to drug use.

• May view patient’s cure as hopeless. • May allow personal or family experience with substance abuse to influence

response to the patient.

ASSESSMENT (See Table 13–2)

Behavior and Appearance • May talk frequently or brag about using drugs

• May have an in-depth knowledge of drugs and how they work

• Dramatic behavior changes, for instance, may be suddenly euphoric, drowsy, more outgoing

• Wears sunglasses indoors because of photophobia or to hide dilated or pin- point pupils

• Unpredictable behavior

• Grandiosity, overconfidence (text continued on page 264)

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256 Chapter 13 ■ Problems with Substance Abuse

TABLE 13–2 Comparing Commonly Abused Substances

Nursing Drug Intoxication Overdose Withdrawal Considerations

Ampheta- mines, including dexedrine and metham- phetamines (crystal meth)

Cannabis, including marijuana and hashish

Signs: Eupho- ria, high energy, impaired judgment, anxiety, aggressive behavior, paranoia, panic disor- ders, insomnia and delusions (often seen with long- term use)

Signs: Eupho- ria; intensified perceptions; impaired judg- ment and motor ability; increased appetite; weight gain, sinusitis, and bronchitis with chronic use; anxiety, paranoia; red conjunctiva

Signs: Ataxia, high temper- ature, seizures, hypertension, arrythmias, respiratory distress, car- diovascular collapse, coma, death

Treatment: Supportive

Signs: Extreme paranoia, psychosis, delirium

Signs: Depres- sion, agita- tion, insomnia, confusion, vivid dreams fol- lowed by extreme lethargy

Treatment: Antidepres- sants, counseling, suicide pre- cautions

Signs: With- drawal syndrome not recog- nized in DSM-IV- TR though some report loss of appetite, impaired sleep, rest- lessness, and irri- tability

• Used in weight reduction pro- grams and to treat benzodi- azepine abuse.

• Tolerance can develop fairly rapidly

• User often also using alcohol and other sub- stances to relax

• May cause a paradoxical reaction in children

• Remains in urine for up to 3 days.

• Most widely used illicit drug.

• Impaired judg- ment may contribute to accidents

• Respiratory damage from inhaled sub- stances can occur

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Chapter 13 ■ Problems with Substance Abuse 257

Nursing Drug Intoxication Overdose Withdrawal Considerations

Cannabis

Cocaine, including crack

Signs: Eupho- ria, grandios- ity, sexual excitement, impaired judgment, insomnia, anorexia; nasal perfo- ration associ- ated with inhaled route; psy- chosis associ- ated with long-term abuse

Treatment: Antipsy- chotics

Signs: High temperature, seizures, transient venospasms possibly causing MI or CVA, coma, death

Signs: Fatigue, depression, anxiety, suicidal behavior

• Remains in urine for up to 7 days.

• May exacer- bate psychi- atric symptoms in mentally ill patients.

• May nega- tively affect fertility.

• May thera- peutically reduce nausea and vomiting, intraocular pressure, and stimulate appetite.

• Crack is smoked or injected IV; has a rapid onset and high dependency rate

• Tolerance develops rapidly

• Cocaine is inhaled, snorted or injected IV.

Continued

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258 Chapter 13 ■ Problems with Substance Abuse

TABLE 13–2 Comparing Commonly Abused Substances—cont’d

Nursing Drug Intoxication Overdose Withdrawal Considerations

Cocaine

Hallucino- gens, including LSD, psilo- cybin, and mescaline

Signs: Dilated pupils, diaphoresis, palpitations, tremors, enhanced perceptions of colors, sounds, depersonal- ization, grandiosity

Treatment: Supportive

Signs: Panic, psychosis with halluci- nations, cere- bral tissue damage, seizures, hyperther- mia, death

Treatment: Diazepam or chloral hydrate; quiet envi- ronment antipsy- chotics

Treatment: Support counseling, antidepres- sants

Signs: None

• High risk of acquiring HIV, hepatitis, bac- terial endo- carditis, and osteomyelitis from shared IV needles or promiscuous sexual rela- tions.

• May be used to control appetite.

• Flashbacks can occur for up to 5 years.

• Could precipi- tate a psychi- atric disorder in susceptible persons

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Chapter 13 ■ Problems with Substance Abuse 259

Nursing Drug Intoxication Overdose Withdrawal Considerations

Inhalants, including glue, gasoline, cleaning solutions, aerosol propellants like deodorants or hair spray, and paint thinner

Nicotine, including cigarettes, chewing tobacco, and nico- tine gum or patch

Signs: Eupho- ria, impaired judgment, blurred vision, unsteady gait

Signs: Pro- duces a sense of anxiety reduction, relief from depression, and satisfac- tion

Signs: Psy- chosis with hallucina- tions, cardiac arrhythmias, CNS depres- sion, coma, cerebral tis- sue damage, death

Treatment: Supportive

Signs: None

Signs: None

Signs: Insomnia, depression, irritability, anxiety, poor con- centration, increased appetite

• Most avail- able substance for younger children.

• Intoxication period is brief (15-45 min- utes)

• Can cause permanent CNS damage

• May be diffi- cult to detect specific sub- stance used.

• Particularly irritating and/or flam- mable sub- stances can cause trauma and burns in nose, mouth, and airways.

• Because most medical facili- ties do not allow smok- ing, inpatients may experi- ence with- drawal symptoms.

Continued

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TABLE 13–2 Comparing Commonly Abused Substances—cont’d

Nursing Drug Intoxication Overdose Withdrawal Considerations

Nicotine

Opioids, including heroin, morphine, meperi- dine, Oxy- contin, propoxy- phene, and codeine

Signs: Euphoria, analgesia, drowsiness, impaired judgment, constricted pupils

Signs: Dilated pupils, res- piratory depres- sion, seizures, cardiopul- monary arrest, coma, death

Treatment: Transdermal nicotine patches in decreasing doses, nicotine gum, nicotine nasal spray, and clonidine for severe anxiety, behavioral modification. Long term smokers may need to remain on nicotine ther- apy for some time.

Signs: Yawning, insomnia, anorexia, irri- tability, rhi- norhea, muscle cramps, chills, nausea, vomit- ing, feelings of doom and panic

• Less than 25% of indi- viduals are successful with first attempt to quit.

• Self-help strategies with counselling and nicotine replacement has greatest success.

• Monitor for weight gain.

• Monitor for hypotension with cloni- dine.

• High risk of acquiring HIV, hepatitis, bac- terial endo- carditis, and osteomyelitis from shared IV needles.

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Chapter 13 ■ Problems with Substance Abuse 261

Nursing Drug Intoxication Overdose Withdrawal Considerations

Opioids

Phencycli- dine (PCP, angel dust)

Signs: Impul- sive behavior, impaired judgment, belligerent, assaultive behavior, ataxia, mus- cle rigidity, nystagmus, hypertension, numbness or diminished response to pain

Treatment: Naloxone, supportive

Signs: Hal- lucina- tions, psychosis, seizures, respiratory arrest, stroke

Treatment: Gastric lavage; cranberry juice or ammo- nium chlo- ride to acidify urine (if awake); quiet envi- ronment; haloperi- dol or diazepam; fluids

Treatment: Detoxification, possibly with clonidine for severe anxiety and methadone, naloxone, and/or burenor- phine to block euphoria

Signs: None

• May be obtained illegally or through pre- scription abuse

• Monitor for hypotension with cloni- dine.

• Have ade- quate staff available because behavior is unpre- dictable and patient may become vio- lent.

• May con- sider using four-point restraints.

Continued

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TABLE 13–2 Comparing Commonly Abused Substances—cont’d

Nursing Drug Intoxication Overdose Withdrawal Considerations

Phencycli- dine

Sedatives, hypnotics, and anxi- olytics including barbitu- rates and benzodi- azepines

Signs: Slurred speech, labile mood, inap- propriate sexual behavior, loss of inhibi- tions, drowsiness, impaired memory

Signs: Hypoten- sion, nystag- mus, stupor, cardio- respiratory depression, renal failure, seizures (barbitu- ates), coma, death

Treatment: Benzodi- azepine antagonist (flumazenil); induce vom- iting, if awake; acti- vated char- coal; cardiorespi- ratory sup- port

Signs: Insom- nia, hand tremor, agita- tion, panic disorder, nau- sea and vom- iting, anxiety, tinnitus (with benzodi- azepines), seizures, and cardiac arrest

Treatment: Detoxifica- tion using gradually reduced dosages of a similar drug, anticonvul- sants, and support and counseling

• Drugs remain in urine for several weeks.

• Avoid using phenoth- iazines because they can potentiate the effects of PCP.

• Abrupt bar- biturate withdrawal can be life- threatening.

• Alcohol will potentiate drug effects.

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Nursing Drug Intoxication Overdose Withdrawal Considerations

Sedatives

Club Drugs including ecstasy (MDMA), rohypnol, ketamine

Signs: Eupho- ria, muscle relaxation, poor judg- ment

Signs: Confu- sion, hallu- cinations, severe anxi- ety, hyper- tension, seizures, high temp

Treatment: Supportive

Signs: Not physiologi- cally addic- tive, but psychologic dependence can cause depression, flashbacks

• Cross- tolerance may develop between alcohol and other CNS depressants.

• Detectable in blood and urine.

• Shorter- acting ben- zodiazepines have a greater risk of produc- ing addic- tion and more severe rebound anxiety than longer- acting ones.

• Can cause memory loss and brain damage.

• Physical response may be exacerbated by dehydra- tion.

Continued

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• Disheveled appearance

• In children and adolescents, loss of interest in school, drop in grades

Mood and Emotions • Mood swings

• Low frustration tolerance, angers easily

• Angry outbursts

• Anxiety, especially associated with discussion of drug use

• Emotional reactions related to change in medication regimen, particularly changes in analgesics

• Depressed; verbalizes self-deprecating thoughts

Thoughts, Beliefs, and Perceptions • Denies impact of drug use

• Rationalizes that he or she can stop using any time

• Persistent belief that drug is for medical use only

• Obsessive thoughts about drug use and access to drug supply

• Suicidal ideations

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TABLE 13–2 Comparing Commonly Abused Substances—cont’d

Nursing Drug Intoxication Overdose Withdrawal Considerations

Anabolic Steroids including testos- terone, stanozolol, oxymethol- one

Signs: Dra- matic increase in muscle mass, irritability, increased blood sugar, acne, edema from fluid retention, unwanted secondary sex charac- teristics

Signs: Liver damage, increased cholesterol, hyperten- sion, para- noia, hostility, hyperactiv- ity, manic symptoms

Treatment: Supportive

Signs: Depres- sion, fatigue, anorexia, decreased libido

• Masculin- ization of women and feminization of men is common

• May be self- injected

• Repeated use can produce DSM-IV dependence symptoms

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Relationships and Interactions • Change in circle of friends and isolation from family • Blames others for need to use substances and other problems • May become more isolated as fears of exposing habit to others increases • Charming, charismatic, or manipulative with others

Physical Responses • Needle tracks (raised marks from repeated IV injections) may be seen in

antecubital space, wrist, feet, behind knees, or in tattoos. • Recent injection sites may be red and swollen. • Abscesses and ulcerations may be present. • There is evidence of drug(s) in urine testing. Each drug varies as to how long

it remains in the body. Check with the laboratory for specifics. • Pupil response varies from constricted to nonreactive with different drugs.

Pertinent History • History of withdrawal symptoms, overdosage, complications from past

drug use • Psychiatric disorders • Family history of drug or alcohol abuse • Criminal record and other legal problems • Daily or binge drug abuse or dependence • History of eating disorders

COLLABORATIVE MANAGEMENT

Treatment for substance abuse frequently requires a multidimensional approach including pharmacological treatment for detoxification, individual and group counseling, Twelve-Step Program, and education. Most treatment can be done on an outpatient basis, except for high-risk detoxification.

Pharmacological Pharmacology can be used to replace the illicit substance as in Methadone. Pharmacology can also be used to neuromodulate the drug cravings by interact- ing with the receptor system in the brain affected by the substance. Examples of neuromodulators include buprenorphine and naloxone for opioid addiction. These substances also reduce the physical signs of withdrawal.

Medications are used in detoxification programs for many drugs, including opioids, barbiturates, sedatives, and tranquilizers. They are used to control with- drawal symptoms and discourage continued use of the abused substance. Most are used for only short periods until withdrawal is complete; however, in some

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cases, they may be used for longer periods to control cravings for the drug. Methadone, a synthetic narcotic that resembles morphine and heroin but does not produce the euphoric effects, is used daily on a long-term basis to treat heroin addiction. Both physical and psychological dependence are maintained on methadone, but the euphoric effects of heroin are blocked. Patients usually make daily trips to a methadone clinic to obtain the drug. Buprenorphine, an opioid with agonist and antagonist action, has been used as an alternative to methadone. Naltrexone also reduces the euphoric sensation from narcotics, and clonidine decreases discomfort during narcotic withdrawal. The newest opioid withdrawal treatment uses Suboxone (buprenorphine and naloxone). Addiction specialists must be certified to prescribe this regimen. Patients on this medication must be monitored closely if they have conditions that require use of analgesics. Admin- istering analgesics could precipitate a withdrawal syndrome. So pharmacology can be used to replace the illicit substance like methadone for heroin addiction.

Benzodiazepines and sedative withdrawal is more risky because of the risk for seizures and delirium. Tapering the dose of the identified or similar drug, along with anticonvulsants and antidepressants, is usually used.

Dual-diagnosis patients may require medications for treatment of their psy- chiatric diagnosis, but efforts are made to avoid sedatives and tranquilizers. Patients with anxiety or psychotic disorders may be using illicit drugs as a way of controlling hallucinations or anxiety.

Nicotine withdrawal has been successfully treated with nicotine replacement and also the addition of bupripion (Wellbutrin). No effective drugs are currently available for stimulant addiction but research is suggesting modofinil (Provigil) may be helpful.

Complementary approaches to treatment of substance abuse might include acupuncture, biofeedback, and massage. Herb and plant products to treat dis- tressing symptoms may be helpful and include chamomile, valerian, kava kava, and St. John’s wort. The last is contraindicated if the patient is taking antide- pressants, narcotics, or amphetamines.

Twelve-Step Program The Twelve-Step Program has been used to treat substance abuse and includes groups such as Narcotics Anonymous, Cocaine Anonymous, and Pills Anony- mous. The philosophy mandates that the individual remains free from the sub- stance and acknowledges that he or she is powerless over the chemical. Individuals need to attend group meetings routinely. Sponsors who have been drug free for longer periods provide support for new members. Family members can also participate in self-help groups following the same model.

Counseling Drug rehabilitation also includes counseling to restore physical and emotional stability, identify the person’s usual coping mechanism and work to adopt more effective ones, and develop a sense of self-worth and self-esteem.

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NURSING MANAGEMENT

INEFFECTIVE DENIAL evidenced by lack of acknowledgment of substance abuse problem related to impaired ability to accept consequences of own behavior

Patient Outcomes • Acknowledges substance abuse problem • Abstains from substance use • Demonstrates participation in treatment plan

Interventions • Convey acceptance of patient. Avoid criticizing, preaching to, or attack-

ing the patient to get his or her attention.

• Promote trust by listening to concerns and treating patient as an individual.

• Give patient specific feedback on any behavior that appears drug related. Identify defense mechanisms such as blaming others or rationalizing behavior. Encourage personal responsibility for own behavior.

• Provide information on treatment approaches, such as Cocaine Anony- mous (CA) or Narcotics Anonymous (NA).

• Help patient identify and share the possible emotions he or she is feeling.

• Help patient see link between substance use and personal and medical problems. Give the patient the opportunity to identify these, if possible.

• Assist patient to identify ways in which drug use affects daily life. Encourage being specific and honest.

• Set limits on manipulative behavior and realistic consequences for this behavior. Recognize that patient may exhibit charming, charismatic behavior, making limit setting more difficult. Never cover up for the patient or act entertained by drug use.

• Recognize that the drug effects may overwhelm the patient’s motivation to stop. However, do not ignore signs of patient intoxication. Become familiar with your institution’s policies for suspected drug use such as conducting a room search or confiscating drugs.

• If the patient indicates that he or she wants to participate in a treatment program, immediately contact appropriate resources, such as a social worker, to facilitate admittance to a program.

INEFFECTIVE COPING evidenced by anxiety, withdrawal symptoms, inabil- ity to function without drugs in recovery related to inadequate coping skills to manage stressors without drugs

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Patient Outcomes • Demonstrates participation in treatment plan • Demonstrates alternate coping mechanisms to deal with stress that do

not involve drugs • Verbalizes need to continue in treatment • Abstains from substance use

Interventions • Help patient to focus on getting through each day without drugs rather

than the overwhelming thought of never using them again. • Give reinforcement for ability to delay gratification and tolerate frustra-

tion. Provide information on possible coping mechanisms to reduce stress and tolerate discomfort. Review alternative ways to cope with anger. Role-play dealing with stressful situations.

• Explain the long-term physical effects of drug use, such as short attention span, that affect daily life.

• Prepare patient for the possibility that family and friends may have diffi- culty relating to him or her when he or she is not using drugs. For instance, friends may seem to abandon the patient who no longer wants to participate in their drug-related activities. The patient will need to pre- pare to accept this and work on changing these relationships or develop- ing new ones.

• Help the patient discuss realistic future plans and life changes to make when no longer using drugs. Help to identify steps to achieve these goals.

• Encourage participation in support groups or visits or phone contacts with sponsors.

• Monitor to see if visitors are bringing in drugs. • Provide information on drug treatment for withdrawal. Emphasize need

to remain on medications as prescribed.

RISK FOR INJURY evidenced by disorientation, lack of coordination, or aggressive or disruptive behavior related to substance intoxication, overdose, or withdrawal

Patient Outcomes • Remains free from injury • Reduced incidence of medical complications related to substance abuse • Sleeps at least 6 hours a night

Interventions • Recognize that many people who abuse drugs can function in society

fairly well. Early signs of withdrawal may occur during hospitalization

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with no access to drug supply. Suspicious symptoms should be assessed carefully so that treatment can be instituted as early as possible.

• Determine which substances the patient has been using. Take a careful history from patient or family and friends (if applicable). Obtain ordered urine and blood for drug screening, and carefully monitor the patient’s clinical condition and behavior. Recognize that many patients are using more than one substance, including alcohol.

• Institute fall and seizure precautions, as appropriate.

• Recognize that many substance abusers have poor nutritional habits because of anorexia, emotional changes, or inadequate intake. Monitor food and fluid intake. Encourage adequate fluids and nutrition.

• Administer ordered medications to ease symptoms and monitor for adverse and therapeutic effects. Monitor for signs of aggressive, agitated behavior. Avoid restraints, if at all possible.

• Promote rest and sleep by maintaining a quiet environment and encour- aging use of relaxation techniques and herbal teas.

• Patients with painful medical conditions need to have analgesics. The substance-abusing patient may need higher doses of analgesics and bene- fit from a regular dosing with a long-acting analgesic rather than as- needed administration. This avoids the euphoric effect from the analgesic.

ALTERNATE NURSING DIAGNOSES

Infection, Risk for Knowledge, Deficient Self-Care Deficit Self-Concept, Disturbed Social Interaction, Impaired Thought Processes, Disturbed

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WHEN TO CALL FOR HELP

• Escalation or onset of aggressive, belligerent behavior or violence • Change in level of consciousness unrelated to underlying medical

condition • Need to apply restraints • Inadequate staff available to manage behavior • Patient demonstrating signs of impairment of substances • Suspected criminal activity related to drug use, selling drugs

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PATIENT AND FAMILY EDUCATION

• Encourage patient to inform health-care providers about past or present drug use because this information will influence drug and dosage selections for needed medical treatments.

• Use caution when using over-the-counter drugs, diet pills, sedatives, and herbal products.

• Teach family members about need to adjust some aspects of their relation- ship with patient. Help them to identify possible behaviors that could be reinforcing substance use. Give them specific feedback if you observe any of these behaviors.

• Encourage patient to establish new routines and activities that do not involve drug use. This may include avoiding an old circle of friends and developing hobbies or new interests.

• Provide information on risks of exposure to HIV, hepatitis, and other infec- tions. Encourage patient who is at risk to obtain blood tests to determine exposure, and teach health practices to reduce risk to self and others.

• Help patient recognize potential fears and changes that may occur when he or she changes his or her life to live without drugs.

• Provide information on the health impact of specific substances patient is abusing.

• Provide information on treatment of substance abuse to patient and family. • Provide information on pharmacological treatment of addiction. • Educate patient and family on effects of drugs on pregnancy, on the job, or

operating mechanical equipment. • Useful websites for patients and families include drugfree.org (Partnership

for a Drugfree America).

CHARTING TIPS

• Document behavior associated with intoxication, overdose, or withdrawal. • Document any indications of inappropriate drug use.

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WHO TO CALL FOR HELP

• Addiction Specialist • Psychiatric Team • Security • Social Worker • Attending Physician • Sponsor from Twelve Step Program

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• Describe patient behavior after visits from family or friends. • Describe response to treatments. • Describe pain or anxiety behaviors and need for analgesics or tranquilizers.

COMMUNITY-BASED CARE

• Provide referral information on clinics, hotlines, halfway houses, drug treat- ment programs, and counseling that assist drug abusers.

• Inform referring agencies of patient’s history. • Arrange for follow-up psychiatric home health visit to reinforce drug treat-

ment program as needed. • Encourage follow-up medical appointments.

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273

14Problems with Sexual Dysfunction

The Patient with Sexual Dysfunction

Learning Objectives • Define sexuality and sexual health for adults. • Differentiate the major sexual dysfunctions found in men and women. • Identify therapeutic interventions for common sexual dysfunction • Describe common nurses’ reactions to patients with issues about sexual

functioning.

Glossary Dyspareunia – Persistent genital pain in either a man or woman before, dur-

ing, or after sex. Female sexual dysfunction – Includes inhibited desire, orgasmic dysfunction,

and vaginismus. Gender Identity Disorder – Strong and persistent cross-gender identification Impotence – Erectile dysfunction or inability to attain or maintain an erection

sufficient to complete intercourse. Male sexual dysfunction – Includes inhibited desire, erective incapacity, pre-

mature ejaculation, ejaculatory incompetence, and ejaculatory pain. Premature ejaculation – Persistent and recurrent ejaculation with minimal

sexual stimulation and before the person wishes it. Sexual dysfunction – A change in sexual health or function that the individ-

ual views as unrewarding or inadequate. Sexual dysfunction is usually related to one or more of the following: lack of knowledge or incorrect infor- mation; biological or physiological causes, such as diabetes, drug or alco-

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hol use, hormonal disorders; change in or loss of body part; ineffective cop- ing or poor relationships; or organic problems (impotence, premature ejac- ulation, vaginismus, and orgasmic dysfunction).

Sexual response cycle – Includes excitement, plateau, orgasm, and resolution. Gender, age, culture, experience, and expectation affect each of these stages.

Sexually transmitted disease – Any disease that can be contracted by sexual contact; also called venereal disease. Symptoms range from merely annoy- ing to life threatening.

Vaginismus – Involuntary spastic constriction of the lower vaginal muscles.

Human sexuality is a complex phenomenon encompassing biological, psy- chological, and sociocultural aspects. Biological aspects include the

anatomy and physiology of sexual development and sexual activities; psycholog- ical aspects include gender identity, sexual self-concept, and valuing one’s self as male or female; and sociocultural aspects include sexual orientation learned from the value systems of family, peers, and community. All of these aspects are inter- related, influencing the individual to experience and value the self as masculine or feminine, seeking and giving affection, and striving to meet basic needs for love and belonging

A sexually healthy person has the following characteristics:

• Behavior agreeing with gender identity (persistent feeling of one’s self as male or female)

• Ability to participate in loving and committed relationships • Physical ability to find erotic stimulation pleasurable • Ability to make decisions about sexual behavior that are compatible with

values and beliefs, cultural norms, and social mores • Ability to make adjustments in sexual functioning appropriate to limitations

and changes resulting from illness, injury, or other events such as unavail- ability of a partner.

Human sexuality can be healthy, satisfying, and enriching, as defined by the preceding characteristics; or it can be the source of physical and mental distress (LeMone & Jones, 1997; Fergusson, 1999). Sexuality encompasses a person’s feelings about himself or herself and how to interact with others. Sexuality and sexual behaviors are influenced by age, knowledge, marital status; resources; val- ues; social, spiritual, and cultural norms; and emotional and physical health (Poorman, 2001).

Society today allows people to experience various types of adult relationships. Once believed to be the legal and moral right only of married people, sexual activity is now considered by many individuals to be acceptable for any consent-

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ing adult. More people are involved in relationships that were not considered acceptable just a decade or two ago, such as premarital sex, open marriages, remarried or blended families, unions of never-married adults, single-parent families, and homosexual relationships. Although homosexuality was once considered a mental illness, sexual preferences are now considered a matter of personal choice (King, 1999; Levine, 1999; Torkelson & Dobal, 1999).

All aspects of human sexuality may be affected by acute and, especially, chronic illness. Ill health is one of the greatest detriments to sexual expression, not only because it focuses energies toward recuperation but also because it often lowers an individual’s sense of personal worth and attractiveness, and indirectly, sexual desire. The most common dysfunctions in women are arousal and orgasmic dys- function. Common dysfunctions in men are impotence and premature ejaculation.

A diagnosis of sexual dysfunction is made when an individual identifies a problem with sexuality (not when the caregiver is uncomfortable with the patient’s sexual preference) or when antisocial sexual behavior results in harm to others. Individuals have the right to make choices regarding their sexual options and should be offered education about them, such as information on appliances and strengthening exercises for cord-injured patients. However, they do not have the right to inflict discomfort or harm on others (Taylor, 1999). Changing social norms for sexual behavior have recently made deviations from “traditional” sex- uality more acceptable. Some individuals who adopt alternative modes of sexu- ality (e.g., homosexuality) experience little or no conflict internally or externally and thus may not be subject to problems of sexual dysfunction. However, some members of society continue to experience extreme discomfort with less tradi- tional sexual expression (Townsend, 2006).

Gender identity disorders can be manifested by repeated persistent desire to be the opposite sex, cross-dressing, and cross-gender role in play as a child (DSM- IV-TR, 2000). Although rare, this condition requires much sensitivity on the part of health-care providers to accept the person as he or she sees himself or herself. Gender identity disorders may be first observed in childhood as the child main- tains persistent interest in being the opposite gender and may eventually lead to surgery in adulthood.

Competence and success in handling problems with sexual dysfunction depend on the nurse’s knowledge, experience, and comfort with his or her own sexuality. It can be difficult for some nurses to assess a patient’s sexual problems or inter- vene for inappropriate sexual behavior. It may be useful in these situations to confer with a nurse colleague, especially a nurse specialist or a mental health practitioner with training in sexual counseling (Poorman, 2001). Incorporating a sexual history or assessment can be useful to promote an environment of accept- ance for a patient and promote needed education (Smeltzer & Bare, 2004). Nurses are in a key position to help patients cope with sexuality concerns related to serious illness (Wilmoth, 2006).

Nurses should not feel that they need to be sex therapists. They can, however, help resolve some sexual problems created by the patient’s illness and the

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limitations it creates. To be prepared to deal with this aspect of patient care, the nurse should:

• Be knowledgeable about sexuality and sexual norms.

• Use this knowledge to understand others’ behavior and reactions to sexual- ity in health and illness.

• Be aware of differences in cultural and individual attitudes and perspectives regarding sexuality.

• Assist patients’ adaptation to an optimal level of health regarding their sexuality.

• Make appropriate referrals for patients with more complex sexual dysfunc- tion.

ETIOLOGY

The human sexual response cycle stages describe the type of responses people have during sexual activity. Sexual dysfunction can occur at any of these stages. There is seldom any single cause of unsatisfying or inadequate sexual experi- ences.

The National Health and Social Life Survey (2001) has identified that 39% of men and 41% of women have had some type of sexual dysfunction in their lives that has lead to some decrease in well-being. A wide range of common sexual dysfunction including erectile dysfunction and decreased desire can be traced to side effects of medications for common medical and psy- chiatric illnesses (DSM-IV-TR, 2000). Virtually all antipsychotic and antidepres- sant medications and a variety of other psychotropic medications can cause disruptions in sexual function. Antihypertensives are also implicated in disorders of sexual desire, arousal, and orgasm (Table 14–1). Illicit drugs and alcohol should not be overlooked in evaluating sexual disorders. Many patients believe that alcohol and other drugs decrease sexual inhibitions, whereas in real- ity, they decrease sexuality and ability to perform sexually. Major tranquilizers, cocaine, and even tobacco have been implicated in sexual disorders (Finger, Lund, & Slagle, 1997).

Physiological causes of sexual dysfunction include disruption of neural path- ways as seen in spinal cord injury or prostate surgery; impaired circulation as seen in diabetes or peripheral vascular disease; and hormonal changes as in testicular or ovarian dysfunction. Physiological factors are likely to be consistent across time and situations, whereas disorders with psychogenic causes are likely to be situation or mood specific. Psychological causes include unresolved internal conflicts, low self-esteem, discordant relationships with cur- rent or past partners, feelings of dependency or abandonment, and depression. Sociocultural factors include cultural or religious myths or beliefs that inhibit sexual activity.

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TABLE 14–1 Drug Categories that Alter Sexual Behavior

Drug Type Probable Effects

Antihypertensives

Antidepressants

Antihistamines

Antispasmodics/ anticholinergics

Sedatives and tranquilizers

Oral contraceptives

Alcohol

Opioids

Cancer chemotherapy agents

Estrogen

Diuretics

Source: Adapted from Finger, W. W., Lund, M., & Slagle, M. A. (1997). Medications that may contribute to sexual disorders. Journal of Family Practice, 44, 33–34; Carpenito-Moyet, L. J. (2006). Nursing diagnosis: Application to clinical practice (11th ed). Philadelphia: Lippincott Williams and Wilkins.

Produce vasodilation and decreased cardiac out- put, depress CNS; cause impotence in men and decrease vaginal lubrication in women

Peripheral blockage of nervous innervation of sex glands; may have positive effect because they decrease depression

Block parasympathetic nervous innervation of sex glands

Inhibit parasympathetic innervation of sex glands

Block autonomic innervation of sex glands; may have positive effect as they produce tranquiliza- tion and relaxation, may have negative effect influencing libido

Remove fear of pregnancy

In small amounts, may increase libido, in large amounts, impairs neural reflexes involved in erec- tion and ejaculation, chronic use may cause impotence

Central sedation causes impotence in chronic users

May produce temporary sterility or neurotoxicity in men, causing impotence

Suppresses sexual function in men

Chronic use may cause impotence

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Sexual disorders are categorized by DSM-IV-TR (2000) into six major categories:

1. Sexual desire disorders, including hypoactive sexual desire in men or women, and extreme aversion to genital sexual contact

2. Sexual arousal disorders, including female sexual arousal disorder and male erectile disorder

3. Orgasmic disorders in both men and women, also known as delayed or premature ejaculation in men

4. Sexual pain disorders, including dyspareunia in men or women, vaginismus in women

5. Sexual dysfunction caused by general medical condition and substance- induced sexual dysfunction

6. Paraphilias, which are repetitive sexual fantasies or behaviors involving use of a nonhuman object (fetishism), nonconsenting partners (voyeurism, and exhibitionism), or activity that causes humiliation or harm (masochism, sadism, and pedophilia)

RELATED CLINICAL CONCERNS

In nonpsychiatric settings, most nurses see sexual dysfunction related to medical problems, traumatic injuries, or surgical procedures. Sexual dysfunction may be a temporary concomitant of an illness or treatment, or it may be a permanent consequence of chronic illness or injury. Sexual problems associated with illness or injury can be classified into four groups:

1. Lack of interest in or desire for sexual activity 2. Physical incapacity for or discomfort during sexual activity 3. Fear of precipitating or aggravating a physical illness through sexual

activity 4. Use of illness as an excuse to avoid feared or undesired sexual activity

Serious, advanced illness can disrupt sexual functioning due to the presence of fatigue, pain, dyspnea, neuropathies, and impaired range of motion (Lamb, 2006). Surgical procedures resulting in changes in sexual functioning include urologic pro- cedures for prostatic hypertrophy; intestinal surgery for colitis, ileitis, or Crohn’s disease; and most other fecal or urinary diversion surgeries for neoplasms. Loss of external or internal body parts or functions; relocation of orifices, such as hys- terectomy, mastectomy, colectomy, and cystectomy; and amputations can all lead to changes in both physical and mental components of sexual functioning. How a surgical procedure influences postoperative sexual functioning depends on the:

• Reason for surgery, diagnosis, and prognosis related to sexual functioning • Significance of loss of childbearing and fertility functions

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• Knowledge of anatomy and physiology of sexual structures and functions • Meaning, assumptions, and values related to sexual identity • Type and rationale for premorbid sexual activity

The main difference between a health disruption resulting from chronic illness and surgical or accidental trauma is the irreversible effect on nerves, blood ves- sels, and hormonal supply usually associated with surgery and trauma.

Most of the drugs reported to affect sexual functioning directly (see Table 14–1) act on specific neurotransmitters. There is evidence that the primary neurohormone in mobilizing sexual behavior is dopamine, whereas serotonin is the major inhibitor. Therefore medications that block dopamine receptor sites and drugs that deplete dopamine interfere with central control of sexual function, whereas drugs that depress serotonin concentrations in the brain are expected to stimulate sexual function.

Many sexual responses are mediated through the parasympathetic nervous system; therefore, parasympatholytic or cholinergic blocking drugs may cause impotence in men and problems with vaginal lubrication in women. Orgasm and ejaculation are primarily functions of the sympathetic, adrenergic, and nervous system, and therefore, drugs such as anticholinergics may interfere with potency and orgasm.

Ganglionic blocking drugs, such as antispasmodics, impair both sympathetic and parasympathetic nervous system function. Drugs that stimulate or depress the central nervous system can affect sexuality, particularly antianxiety agents and narcotics and many of the substances used socially such as caffeine, alcohol, cocaine, marijuana, and amphetamines. Many therapeutically useful drugs have some adverse effect on sexual function.

LIFE SPAN ISSUES

Children Masculinity and femininity are defined culturally. Although chromosomes deter- mine sexual identity before birth and by physical appearance of the genitals at birth, postnatal factors greatly influence the way children perceive themselves and others sexually. Gender identity is usually firmly established by the age of 18 months. In rare cases in which gender was misassigned at birth because of phys- ical abnormality or accidental damage was suffered, it is considered almost impossible to reassign a child to the opposite sex after age 2 years.

Research on infantile sexuality indicates that both male and female infants are capable of sexual arousal and orgasm. By age 3 years, children are very aware of how they are alike or different from their parents. Research supports that early masturbation experiences are seen in 5- to 8-year-old children. By age 10 to 12 years, children are preoccupied with pubertal changes and beginnings of roman- tic interest in the opposite sex.

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Adolescents American culture has very ambivalent feelings about adolescent sexuality. Although teachers and parents realize the importance of psychosocial develop- ment, most want to avoid anything that will encourage teenage sex. Trends in teen sex for the past 2 decades include more teens engaging in premarital inter- course, and the average age of first intercourse is decreasing. Nationally, 16 years is most common age for first sexual experience in boys and 17 years for girls (Sadock, 2005). Recently the previously increasing trend in incidence of teen pregnancy has decreased in most areas of the United States. A major concern at this time is sex education regarding sexually transmitted diseases, birth control, and the development of satisfying, long-term relationships with same-sex and opposite-sex friends.

Adults During this period of the life cycle, from about age 20 to 65 years, every adult must deal with numerous issues that may lead to temporary or long-term sexual dysfunction. Developing sexual relationships, choosing a marital partner, atti- tudes about premarital or extramarital sex, infidelity, divorce, remaining single, and raising children are just a few of the issues. After age 45 to 50 years, a decrease in hormonal activity, menopause, and other physical changes in both men and women may decrease biological drives. In general, health-care providers should feel comfortable encouraging both sexes to continue healthy sexual activ- ity during adulthood (Townsend, 2006).

Older Adults There are many myths and stereotypes about sexuality and older people. The most common barriers to sexual relationship in advancing age is health of the partners and in many cases lack of a partner due to death or illness of a signifi- cant other rather than lack of desire (Sadock, 2005). A 2004 study by AARP (2005) found that although the amount of sexual activity generally decreases with age, the amount of sexual interest and ability remains fairly constant. Sig- nificant health issues affecting sexuality for older people include fear of heart attack, poststroke dependency, fatigue related to chronic illness, erectile dysfunc- tion related to diabetes and treatment for prostate cancer in men, inadequate lubrication in women, and arthritis causing movement limitations. Surgical procedures that are more common in the elderly persons, such as prostatectomy, mastectomy, hysterectomy, and ostomies, also affect the older adult’s sexuality. Institutionalization is a particular problem for elderly people because the staff at such facilities may not understand or be sensitive to the sexual needs of their residents.

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ASSESSMENT

See Box 14–1 for guidelines for an interview with a patient with a sexual problem.

Behavior and Appearance • Reluctance to answer questions related to sexual functioning • Concern over changes in sexual performance, body image • Withdrawn, isolated, embarrassed • Inappropriate sexual acting out, such as pinching or teasing the nurse,

exposing genitalia, or wearing seductive clothing • May verbalize changes in functioning caused by illness, injury, or surgery

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POSSIBLE NURSES’ REACTIONS • May be shy or insecure about the sexual aspects of their professional role,

even though they are sanctioned to touch others in an intimate and personal manner and to ask personal questions, including questions about sexual matters, related to their patients’ health.

• May experience anxiety, even revulsion, when dealing with sexual questions or behaviors while caring for their patients.

• May deny their own or their patients’ sexuality by avoiding any verbal or behavioral interaction regarding sexual function, for instance, avoiding sub- ject of sex, responding to sexually oriented questions in a vague manner, or using euphemistic expressions like “private parts” or “down below” when referring to genitalia.

• May use hospital rules to sidestep patients’ sexual concerns. For example, may assign male staff members to male patients when sexual behaviors or concerns develop.

• May not recognize or may actually encourage patients’ becoming emotion- ally involved with them.

• May experience pity for patients who are unable to perform some sexual acts after injury such as spinal cord injury. May feel insulted, denigrated, or angered by patient behaviors such as flirting, pinching, and exposing body parts.

• May feel uncomfortable dealing with sexual dysfunction in patients. • May have a mistaken belief that the seriously ill do not have sexual needs

or desires and may show a lack of tolerance and empathy for a patient’s sex- ual concerns during illness.

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Mood and Emotions • Fear about future limitations of sexual performance or attractiveness • Fear, anxiety, or guilt about sexual abilities or loss of function resulting

from illness, injury, or surgery • Presence of stressors affecting sexual functioning, such as job problems,

financial worries, religious conflict, value conflict with family or partner, or separated or divorced partner

• Discomfort over lack of privacy, frequent physical examinations, or invasive procedures

• Depression over lack of sexual satisfaction or loss of relationships

Thoughts, Beliefs, and Perceptions • Lack of knowledge or incorrect information about sexual functioning • Change in self-concept or body image caused by illness, injury, or surgery • Denial or misinterpretation of partner’s reactions to sexual functioning • Denies any concerns about sexual functioning but acts in a sexually inap-

propriate manner with staff or others

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BOX 14–1 Guidelines for an interview with a Patient Having a Sexual Problem These questions serve as a guideline. Adjustments in the focus and depth of the assessment depend on the nature of the patient’s problem and the nurse’s level of comfort in discussing sexual concerns. 1. Does patient’s current physical condition affect level of sexual function? 2. Does patient have concerns about body image or self-esteem related to ill-

ness, injury, or surgery? 3. What does patient know about potential or expected changes in sexual

function related to the illness, injury, or surgery? 4. What significance does the physical change or limitations have on the

patient’s perceptions and understanding of sexual function? 5. What are patient’s previous sexual patterns? 6. What does patient’s spouse or partner understand and believe about the

patient’s sexual function and the impact of the illness, injury, or surgery? 7. What is patient’s outlook and prognosis regarding sexual function? 8. What is patient’s level of comfort and willingness to discuss sexual func-

tion with health professional, spouse, others? 9. Would patient and partner benefit from more education, counseling, or

therapy?

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Relationships and Interactions • Sexual dissatisfaction or decreased sexual desire • Altered relationship with significant other • Partner unavailable, unwilling, or abusive • Poor past sexual relationships, absent or negative sexual teaching

Physical Responses • Painful intercourse • Inability to complete intercourse, early ejaculation, impotence in men • Menopausal changes in women because of age, surgery, or medications

(such as chemotherapy) causing vaginal dryness and lack of interest

Pertinent History • Physical diseases or injuries affecting sexual functioning • History of depression • History of sexual abuse or rape • Alcohol or other substance abuse • Previous sexual dysfunction, such as impotence, painful intercourse, pre-

mature ejaculation, or lack of lubrication in women

COLLABORATIVE MANAGEMENT

Pharmacological Any patient experiencing sexual dysfunction needs a thorough assessment of all medications being taken. Then alternative drug choices as well as changes in doses and timing can be tried. Hormonal therapy may be appropriate treatment in some cases. For example, postmenopausal women may benefit from estrogen replacement therapy or estrogen creams to reduce discomfort during intercourse. Antidepressants can contribute to sexual dysfunction in some, but in others, they have been known to increase desire and reduce depression. Any medications that would increase patient comfort such as analgesics may also be helpful to reduce pain during sexual contact. Medications to treat erectile dysfunction are now readily available. They include sildenafil (Viagra), tadalafil (Cialis), and varde- nafil (Levitra). These medications block the actions of an enzyme that inhibit an erection. These medications do not result in sexual arousal but contribute to an erection in the presence of arousal.

Nonpharmalogical treatments for erectile dysfunction include penile implants. Androgen replacement therapy is now being used to treat reduced sexual desire in women (Cameron & Braunstein, 2004). A variety of herbal products are used by individuals of different cultures to enhance sexual functioning (e.g., ginseng, saw palmetto).

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Sex Therapy A patient may need to seek out individual, couple, or group therapy to treat sex- ual dysfunction. Many mental health professionals have specific training for sex- ual dysfunction. In addition, the patient may wish to seek out a professional who has obtained certification as a sex therapist from a national organization.

NURSING MANAGEMENT

SEXUAL DYSFUNCTION evidenced by erectile dysfunction, premature ejac- ulation, vaginismus, dyspareunia, or other changes in sexual behavior related to illness

Patient Outcomes • Relates valid, accurate information regarding sexual anatomy and func-

tion • Able to verbalize correct information about previously believed myths

and misinformation about sexual matters • Identifies alternate sexual expressions that are pleasurable • Discusses sexual functioning using correct information

Patient and Partner Outcomes • Participate in treatment or practices that mediate problem or facilitate

and enhance current sexual functioning

Interventions • Create an atmosphere of understanding, openness, and acceptance

between patient and nurse. • Eliminate or reduce causes for patient to feel embarrassed while dis-

cussing sexual functioning. • Provide privacy, and be nonjudgmental and supportive. • Begin with other subjects, such as physical or family questions, then

move on to questions on biologic aspects of sexuality, such as age at menarche and onset of sexual development, before discussing sexual behaviors or fears. Focus on general knowledge and expectations before moving on to specific individual concerns.

• Determine patient’s knowledge and attitudes about sexuality and sexual function.

• Focus on patient’s knowledge of anatomy and functioning of body parts that may be affected by disease, injury, or surgery.

• Pay attention to attitudes and words used by patient.

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• Identify any misinformation, myths, or beliefs that may affect patient’s adjustment to changes in sexual functioning. Validate correct informa- tion and correct erroneous information.

• Accept person’s feelings and concerns; explore cultural, social, religious, and parental influences on current beliefs.

• Provide new information appropriate to patient’s maturational or educa- tional level; include spouse or partner as appropriate.

• Discuss with patient and partner the various etiologies for specific diag- noses; explain cause of problem, if known; provide information about its treatment and prognosis.

• Explore alternatives such as lubricants, estrogen creams, pharmacologi- cal treatment for erectile dysfunction.

• Encourage couple to talk over the effect of dysfunction on their relation- ship.

• Discuss alternate methods of sexual gratification with patient or partner. • Refer to a urologist or other specialist for further evaluation regarding

surgical procedures for penile implants, or vaginal reconstruction when appropriate.

• Refer for further evaluation, counseling, or therapy, if indicated.

SEXUAL DYSFUNCTION evidenced by impotence, premature ejaculation, lack of sexual desire or arousal or other dissatisfying changes in sexual behav- ior related to inability to adapt to life stressors, e.g., divorce, death, loss of job, depression.

Patient Outcomes • Identifies stressors affecting sexual function • Identifies constructive coping patterns and sexual practices • Resumes previous sexual activity

Interventions • Assess for factors causing patient’s ineffective coping and their influence

on sexual function.

• Help the patient to understand and discuss the relationship between life stressors and poor sexual functioning.

• Help patient to determine which stressors can be changed and which he or she has no control over.

• Discuss the modifications of or changes in ways of dealing with stressors. Assist in problem solving for alternatives.

• Help the patient identify alternative methods to reduce sexual energy when partner is unavailable or unwilling, such as the role of regular phys-

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ical exercise, alternative sexual practices (self-stimulation, increased social activities if spouse or partner is absent or deceased). Provide edu- cational materials, as needed.

• Refer patient or partner for further counseling or therapy, as indicated, such as consider referrals to marriage counselor, sex therapist, social services as indicated by patient’s specific problems.

INEFFECTIVE SEXUALITY PATTERNS evidenced by actual or anticipated negative changes in sexual activity and/or identity related to changes in or loss of body part or physiologic limitations.

Patient Outcomes • Shows increased acceptance of change in or loss of body part

• Identifies practices that assist in restoration of sexual function despite change in or loss of body part

• Identifies practices that conserve energy and oxygen requirements for sexual activity

• Discusses change in or loss of body part and its influence on sexual func- tioning

Patient and Partner Outcomes • Identifies mutual concerns • Shows increased acceptance of change or loss • Identifies and uses practices that assist in satisfying sexual functioning

Interventions • Determine the level of acceptance or adaptation of the patient or partner

to the changed or lost body part or function. Note patient’s reactions, such as anger, depression, or denial. Explain normal feelings about loss, grief, and change.

• Convey an attitude of acceptance. Be sensitive to the patient’s cues that a concern exists, and encourage any attempts to discuss the problem or fear.

• Respect the patient’s need for privacy.

• Facilitate the partner’s and family’s understanding of patient’s condition and concerns.

• Encourage need to share by listening and answering questions.

• Include spouse or partner in counseling and teaching if he or she express readiness. Also include spouse or partner in discussions about fear of future losses, fear of rejection by loved ones, and fear of physically hurt- ing partner.

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• Help the patient realize that body changes and losses are acceptable to others by spending time with the patient, appropriate touching, and teaching about care during regular nursing care.

• Ask about strengths of relationship with partner and encourage discus- sion of alternative sexual activities.

• Do not assume that patient knows about how the illness or injury affects sexuality. Many patients do not ask questions or give any indication at all about their concerns.

• Check to determine whether the patient understands medical terminology by asking for feedback on what he or she comprehends. Use pictures and verbal explanations when providing information or giving instructions.

• Provide information over short, repeated visits so that patient has time to think over what you have discussed and to formulate questions for later clarification.

• Check which medications the patient is taking, and inform the patient about any adverse effects on sexual function.

• Encourage the patient to resume sexual activity as close to previous pat- tern as physically possible. Teach specific information applicable to indi- vidual physical condition:

• For the patient with an ostomy, provide information on ways to con- trol drainage odor.

• Refer to enterostomal nurse specialist for assistance with appliances. Refer to other specialists as needed.

• For the patient with cardiac or respiratory disease, teach techniques for conserving oxygen and reducing cardiac workload.

• Identify the symptoms that indicate sexual activity should be termi- nated.

• Provide information on specific techniques if patient is unable to move legs because of arthritis or spinal cord injury.

• Teach patient to take pain medication before sexual activity for pain caused by arthritis, cancer, and so on.

• Promote the use of alternative methods of sensory and perceptual stimu- lation, such as body massage.

• Refer the patient and partner to further educational material, self-help support organizations, and therapy as needed. Many self-help groups offer support related to sexual concerns; these include the United Ostomy Association, Arthritis Foundation, American Cancer Society, organiza- tions for the disabled, and Reach for Recovery.

INEFFECTIVE SEXUAL BEHAVIOR PATTERNS evidenced by inappropri- ate sexual behavior in the medical setting related to ineffective coping.

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Patient Outcomes • Decreases or eliminates sexual acting-out behavior

• Demonstrates willingness to discuss meaning of behavior and its impact on others

• Demonstrates other behaviors for maintaining sexual identity

• Identifies appropriate ways to meet sexual needs in medical setting

Interventions • Assess meaning of sexual behavior as release of sexual needs or anxiety,

aggression, fear of loss of identity, reaction to change in or loss of body part, or need for closeness.

• When inappropriate behaviors occur, identify what happened before act- ing out.

• Discuss behaviors with patient, and attempt to understand meaning of behavior to patient.

• Give patient feedback about staff reactions to behaviors. Help patient to understand their impact on other patients and staff. Point out which behaviors are most disturbing.

• Set clear limits with patient about what specific behavior is inappropri- ate.

• Discuss more appropriate ways for patient to meet sexual needs, such as exercise, reading, or spending private time with partner.

• Ensure that the patient knows that sexual acting out is not needed to maintain nurse’s interest or concern as a person.

• Provide time to talk with or give physical care to patient when sexual behaviors are not occurring.

• Provide opportunity for the patient to express feelings about sexual iden- tity and the impact of illness, injury, or surgery on body image and self- concept.

• Discuss and negotiate ways to provide privacy during long-term hospi- talization.

• Provide structured activity or active games. If appropriate, ask volunteers to arrange for activities outside the current environment.

• Conduct care plan conference to discuss problem and appropriate inter- ventions. When embarrassed or frustrated by sexually acting-out patient, get backup from other staff members, consultants, or administrator who can assist in setting limits and determining care plan goals.

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ALTERNATE NURSING DIAGNOSES

Coping, Ineffective Knowledge, Deficient Self-Concept, Disturbed Social Interaction, Impaired Social Isolation

PATIENT AND FAMILY EDUCATION

• Review with the patient and sexual partner, if requested, any effects of med- ications that may affect sexual function. Reinforce need to report these to physician so that alternatives can be found.

• Teach probable causes and treatment for sexual dysfunction if patient and partner request this information.

• Provide information on birth control and prevention of sexually transmit- ted diseases, as appropriate.

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WHEN TO CALL FOR HELP

• Onset of sexually “acting-out” behaviors inappropriate to medical setting

• Increased staff complaints or conflict over management of patient behavior

• Increased staff anxiety over dealing with sexually inappropriate behavior

• Increased sexually inappropriate behavior in other patients • Patient’s sexual behavior interfering with treatment • Staff inability to provide needed information or counseling to patient

WHO TO CALL FOR HELP

• Mental health professional • Social Worker • Nurse manager or educator • Psychiatric Team • Advanced Practice Nurse • Chaplain • Attending Physician

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• Provide information on the impact of surgery, illness, and medication on sexual functioning.

• Ensure patient has needed information about use of special devices and drugs, e.g., penile implants, Viagra.

CHARTING TIPS

• Use objective, nonjudgmental terms to describe the patient’s sexual behavior. • Document the patient’s sexual concerns even if you do not feel comfortable

providing information or education. • Document the selected interventions for dealing with inappropriate sexual

behavior on the patient care plan for consistency. • Document the patient’s understanding of cause and treatment of sexual dys-

function. Include responses of family members if they are involved in patient education and treatment.

COMMUNITY-BASED CARE

• Consult with physician and inform patient and partner about appropriate resources related to sexual dysfunction.

• Provide referrals to appropriate support groups. • Inform other health-care professionals of patient’s inappropriate sexual

behavior if patient is being transferred to another facility. • Inform patient and partner about expected changes in sexual behavior or

dysfunction as disease progresses or patient is rehabilitated. • Provide referral information for further sexual counseling or therapy if

needed.

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15

291

Problems with Pain

The Patient in Pain

Learning Objectives • Differentiate between acute, recurrent, and chronic nonmalignant and

malignant pain. • Examine the reasons for underassessment and undertreatment of pain. • Describe important factors to be considered in the assessment of pain. • Describe the role and routes of opioid and nonopioid analgesics in pain

management. • Discuss the importance of alternative (nonpharmacological) methods of

pain relief.

Glossary Acute pain – Pain, usually of shorter duration, that acts as a warning and

protective mechanism. Usually subsides as healing takes place. Addiction – A psychological process, in contrast to drug tolerance, that

involves the repeated use of a drug or drugs for psychological, not medical, reasons. Patients who are psychologically dependent on a drug (addicted) will continue to desire the drug even though the pain is resolved.

Cancer pain – Usually placed in a category of its own. Even if it lasts for more than 6 months, it is often treated like acute pain because of its progressive nature. Sometimes referred to as malignant pain.

Chronic pain – Pain that lasts beyond the ordinary duration of time that an insult or injury to the body needs to heal. Types of chronic pain include recurrent acute pain with potential for recurrence over a prolonged period, with pain-free intervals between episodes; chronic acute pain, which may

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last months or years, but has a high probability of ending; and chronic, benign (noncancer) pain, which occurs almost daily and has existed for 6 or more months. It is now believed that different mechanisms may be involved in development of chronic pain and it is not just a matter of a longer occurrence of acute pain.

Drug tolerance – A physiological response of the body, not under the person’s control, in which the drug loses its effectiveness after repeated use. Occurs in almost all patients using opioids longer than 7 to 10 days. Needs to be taken into consideration when determining correct dosage of analgesic because the patient may require increased doses to achieve the same effect.

Pain – An unpleasant sensory and emotional experience arising from actual or potential tissue damage caused by a noxious stimulus.

Pain tolerance – Duration and intensity of pain that an individual is willing to tolerate at any one time. Pain tolerance changes within an individual from one pain experience to another.

Placebo – Any medical or nursing measure that works because of its implicit or explicit therapeutic intent rather than its chemical or physical properties.

Pseudo-addiction – Patient behaviors that may mimic drug-seeking behav- iors and occur when pain in undertreated.

Referred pain – Pain felt at a site other than the injured or diseased organ or body part. The pain of coronary artery insufficiency, for example, is often referred to the left shoulder, arm, or jaw, and pancreatic pain may be referred to the middle back.

Pain is what the person experiencing it says it is, exists when and where he or she says it does. The patient is the authority about his/her own pain. (McCaffery, 1968)

Pain is a universal experience occurring in all age groups and is the most frequent reason why people seek health care. It is also the most feared

symptom (Daudet, 2002). Much progress has been made over the last decade in understanding pain mechanisms and the epidemiology of pain. The subject is important for all clinicians because the frequency and perhaps the severity of pain may increase now that progress in medical science has increased sur- vival through old age and chronic illness, and now affects more people than ever before.

Studies continue to show that pain is underassessed and undertreated by health-care professionals. The American Pain Society (2003) reports that the most common reason for unrelieved pain in the American health-care system is the failure of medical personnel to routinely assess pain and pain relief. The clas- sic study by Marks and Sachar (1973) reported that 73% of hospitalized medical patients experienced moderate to severe pain despite receiving parenteral opioid analgesics. Recent research indicates that nurses and physicians continue to undertreat pain in patients because they do not understand pain management

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principles, they fear causing the patients’ dependence on opioids, and they have poor knowledge of opioids, adjuvant therapies, and the components of pain assessment (McCaffery & Ferrell, 1997). Despite the establishment of federal guidelines on pain management (Agency for Healthcare Policy and Research, 1992, 1994), many patients of all ages still suffer unnecessary pain in all health- care settings and at home (Twycross, 1999; Weiner, Peterson, Ladd, McConnell, & Keefe, 1999; Paice & Fine, 2006). In 2001, the Joint Commission on Accred- itation of Healthcare Organizations implemented pain management standards that mandate frequent assessment and appropriate interventions.

Pain is a multidimensional and complex phenomenon, requiring effective assessment and management. Many disciplines are involved in pain management in a variety of clinical settings. Optimal pain management depends on coopera- tion among the different members of the health-care team throughout the patient’s course of treatment (Stratton, 1999).

The nurse usually has the most significant influence on management of the patient’s pain because of having the most frequent contact with the patient. Con- sequently, the nurse is in a unique position to identify the patient who has pain; to appropriately assess the pain and its impact on the patient and family, to ini- tiate action to alleviate pain using available resources, and to evaluate the effec- tiveness of those actions.

Patients vary greatly in their responses to pain and its interventions, as well as in their personal preferences and expectations regarding pain relief. Therefore rigid prescriptions for the management of pain are inappropriate. An effective pain management program will incorporate the following requirements and prin- ciples (McCaffery, 1999; American Pain Society, 2003):

1. Pain intensity and relief must be assessed and reassessed at regular intervals in a consistent manner (Fig. 15–1).

2. Patient preferences must be respected when selecting methods of pain man- agement.

3. Each institution must develop an organized program to evaluate the effec- tiveness of pain assessment and management.

4. Establishing positive relationships between patients and health-care profes- sionals is an important part of successful pain control. Patients should be informed that information about options to control pain is available and they are welcome to discuss their concerns and preferences with the health- care team.

5. Unrelieved pain has severe negative physical and psychological conse- quences. Aggressive pain prevention and control can yield both short-term and long-term benefits. Although complete elimination of some pain may not be practical or even desirable, techniques are now available to make pain reduction a realistic goal.

6. Prevention is better than treatment. Pain that is established is more difficult to control. The goal should be reduced pain at all times, with “round-the- clock” medications if needed.

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Initial Pain Assessment Tool

AgePatient’s Name Room Date

Diagnosis

Right Left

Right Right

Right

Right

Right

R RL

LEFT RIGHT

L Left Left

Left

Left

Left

1. LOCATION: Patient or nurse mark drawing.

2. INTENSITY: Patient rates the pain. Scale used Present: Worst pain gets: Best pain gets: Acceptable level of pain:

Physician Nurse

3. QUALITY: (Use patient’s own words, e.g., prick, ache, burn, throb, pull, sharp)

4. ONSET, DURATION, VARIATIONS, RHYTHMS:

9. OTHER COMMENTS:

5. MANNER OF EXPRESSING PAIN:

10. PLAN:

6. WHAT RELIEVES THE PAIN?

7. WHAT CAUSES OR INCREASES THE PAIN?

8. EFFECTS OF PAIN: (Note decreased function, decreased quality of life.)

Accompanying symptoms (e.g., nausea) Sleep Appetite Physical activity Relationship with others (e.g., irritability) Emotions (e.g., anger, suicidal, crying) Concentration Other

FIGURE 15–1. Initial Pain Assessment Tool. (Source: From McCaffery M., & Pasero C: Pain: Clinical manual (2nd ed.) (p. 60). St. Louis: Mosby, with permission.)

ETIOLOGY

The exact mechanism of transmission and perception of pain are not completely understood; however, neurophysiological, psychological, and sociological research has contributed to the formation of pain theories.

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The Gate Control theory, originally proposed in 1965 by Melzack and Wall, suggests that pain occurs when smaller diameter type A nerve fibers and very small diameter type C fibers are stimulated. These afferent, or sensory, fibers pen- etrate the dorsal horn of the spinal cord and end in the substantia gelatinosa. When the sensory stimulation reaches a certain critical point, the “gate” opens and allows nearby transmission cells to project the pain message to the brain. In contrast, the large-diameter type A sensory fibers inhibit pain transmission. When these fibers are stimulated, fast-conducting afferent fibers oppose the smaller fibers’ input and activate the substantia gelatinosa “gate” to close, thus blocking nerve transmission.

This theory explains why external methods of pain control work. For example, stimulating the large-diameter type A fibers by massage, applying heat or cold, acupuncture, or transcutaneous electric nerve stimulation (TENS) can override sensory input in the smaller diameter type A fibers and block pain transmission at the gate. Cognitive techniques, such as distraction, biofeedback, relaxation, and guided imagery, operate through the efferent fibers, closing the gate.

In the 1970s, the body’s own internally secreted opioid-like substances, called endorphins, were identified. Research found that the brain triggers the release of endorphins, which lock into the narcotic receptors at nerve endings in the brain and spinal cord to block the transmission of pain signals, preventing the impulse from reaching consciousness. This research has helped to explain why pain per- ception and the need for analgesia can vary greatly from one person to another. Endorphins are depleted with prolonged pain, recurrent stress, and the prolonged use of morphine or alcohol. Endorphin levels are increased during brief pain episodes, brief stress, physical exercise and sexual activity, massive trauma, some types of acupuncture, and some types of TENS, and possibly with placebos. Much of the recent research in this area supports patient-controlled interventions for pain (Ellis, Blouin, & Lockett, 1999).

A number of neurotransmitters have been discovered that are found to con- tribute to the carrying of the pain impulse. These include glutamate and sub- stance P. A number of drugs are being investigated that inhibit binding of excitatory amino acids such as glutamate that normally binds to N-methyl-D- aspartate (NMDA). NMDA antagonists including drugs that contain dextro- mathorphan and ketamine seem to block the transmission of the pain impulse. This may be one of the mechanisms of actions of methadone.

The multiple opioid receptor theory recognizes that not all opioids work the same way and some cannot be switched back and forth without adverse conse- quences. There are at least three types of opioid receptor sites in the spinal column. Each type binds somewhat differently with different types of opioids. For exam- ple, opioids like butorphanol tartrate (Stadol) or nalbuphine (Nubain) (agonist- antagonist drugs) antagonize the effects of other narcotics like morphine and can contribute to withdrawal rather than pain relief. Knowledge of this theory enhances appropriate selection of analgesics (Ripamonti, Zecca, & Bruera, 1997).

Gender and social and cultural factors also affect the pain response by influencing how the individual interprets pain and how he or she responds

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emotionally. Through family, social, and cultural values and attitudes, the patient learns which types of pain responses are appropriate within his or her group. Of course, family and social influences change as a child matures. By the time adult- hood is reached, the individual may have modified or even rejected many family values or taken on the values of another subgroup. If the patient’s values conflict with those of his or her family, additional stress and anxiety may be felt. This may explain why certain patients act differently when family members are pres- ent (Fillingim, 2000; Wessman & McDonald, 1999).

Other factors influencing pain behaviors may include the body part involved, the patient’s socioeconomic status and religious beliefs, and experience with folk medicine or alternative therapies. A patient’s language and vocabulary affect the way in which pain is described. Do not be too quick to assume that you under- stand what the patient is trying to say, especially if his or her native language and ethnic background are different from yours.

RELATED CLINICAL CONCERNS

Chronic pain is a significant health problem. For example, 10% to 15% of adults in the United States are estimated to have some form of disability from back pain (Borsook, McPeek, & Lebel 1996). One in five Americans suffer from chronic pain (Sternberg, 2005). In addition to disrupting employment, chronic pain can contribute to family problems and social isolation.

Although acute pain is associated with anxiety, chronic pain is more associated with depression. Chronic pain patients are also at higher risk for dependence and abuse of medication because their pain is often not relieved and they begin taking larger doses in hopes of obtaining relief and treating their depression. Health-care professionals may become frustrated and eventually deny the patient the pain med- ications, making assumptions that the patient is drug-seeking (pseudo-addiction). The chronic pain patient usually requires a multidisciplinary pain team.

The physiological and psychological risks associated with untreated pain are greatest in frail patients with other illnesses, such as heart or lung disease; those undergoing major surgical procedures; and very young or very old patients. Untreated pain can contribute to complications because the patient is unable to cough or deep breathe or get adequate rest or nutrition. Uncontrolled pain in dying patients contributes to the wish to hasten death and is the most frequently stated fear. In patients with psychiatric diagnoses such as depression, schizophre- nia, dementia, malingering, and hypochondriasis, pain may be the chief present- ing complaint. Treating the underlying psychiatric disorder should lead to reduction in pain. Patients with alcohol or drug withdrawal syndromes need spe- cial consideration in their pain management, especially if they also have other medical problems.

Patients with a history of substance abuse are often undertreated for pain lead- ing to increased hospital length of stay, frequent readmissions, and increased out- patient and emergency visits (Kirsh & Passik, 2006; Grant, Cordts, & Doberman,

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2007). Long term use of opioids can result in hypersensitivity to pain resulting in further complications. Undertreatment of these patients is often caused by health- care professionals’ misconceptions about addiction.

Each individual experiences and expresses pain in a unique manner, depend- ing on age, gender, culture, and previous pain experience (Box 15–1). All pain is real to the person experiencing it, regardless of its physical or psychological eti- ology. Each person’s ability to tolerate pain is also unique. Depending on the sit- uation, pain tolerance can vary even in the same individual. Anxiety or depression can decrease pain tolerance. Most people with severe or prolonged pain also have emotional changes related to their pain.

About one third of all patients with a diagnosed physical cause for their pain respond to placebos. Nurses should be aware that a positive response, meaning that the patient gets relief after taking the placebo, cannot be used to prove that the pain is psychologically induced. Sometimes just listening to the patient,

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BOX 15–1 Factors Influencing Pain Tolerance Factors that may increase or decrease tolerance: • Past experiences with painful stimuli (e.g., surgery, trauma, illness) • Knowledge about cause of pain, its treatment, and probable outcome • Personal meaning of pain (e.g., recurrence of cancer, day off from school or

work) • Knowledge and experience in coping with pain, willingness to try new tech-

niques • Stress, fatigue, energy levels • How others treat person when he or she has pain (e.g., secondary gains) • Available resources (e.g., money for treatment) • Interactions with healthcare providers (e.g., preventive approach: pain is

treated early or patient has to prove that pain is “real” before anything is done to help relieve it)

• Cultural background: some cultures encourage the expression of even mild discomfort, whereas others expect stoic, quiet tolerance of even very severe pain

Factors that usually decrease pain tolerance: • Disbelief on the part of others • Lack of knowledge about pain, pain-relief measures • Fears about addiction, loss of control over pain • Poor experiences with past pain-relief efforts • Disability, increasing or long-term • Fatigue and monotony

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acknowledging the pain, and the act of giving a medication can enhance pain relief. Today, it is generally considered unethical for a doctor to prescribe a placebo to treat pain without informing the patient that he/she may be receiving one (Oncology Nursing Society, 1996).

The benefits of adequate and consistent pain management are significant. Ben- efits include earlier and easier mobilization, shorter hospital stays, increased productive rehabilitation, and earlier return to previous work or lifestyle; or if the patient’s condition is terminal, increased comfort and peace of mind. These out- comes should be expected and worked toward with every patient experiencing pain (de Rond, deWit, vanDam, & Miller, 2000; Raines, 2000).

LIFE SPAN ISSUES

Children As with adults, pain is one of the most feared symptoms in children (Collins & Walker, 2006). Research indicates that younger children, including neonates, may experience some pain more intensely than older children. For children who can- not communicate verbally about their pain, one needs to assess pain by observ- ing physiologic changes, nonverbal behavior, and vocalizations, such as crying or groaning. Consult parents or guardians about how the child expresses pain at home. Knowledge of the child’s age, health status and developmental level gives insight into how pain may be expressed (McGrath & Finley, 1999; Twycross, Moriarity, & Betts, 1998; Hunt, 2006).

If painful procedures are needed, be sure they are performed outside the child’s room or playroom so that his or her bed, room, and playroom continue to be safe places. If the child is verbal, try to use his or her words for pain when asking about the discomfort. The Wong-Baker Faces Pain Rating Scale is particularly geared to children as well as adults with dementia (Fig. 15–2).

Most dosage recommendations for opioid analgesics in children are not sup- ported by double-blind studies, and underdosing is especially common. Using weight in kilograms to determine doses is useful in many cases when opioids are needed. Initial recommended doses must be viewed as educated guesses and should be adjusted either up or down according to the individual child’s response. Toddlers and older children may obtain pain relief from cutaneous stimulation such as massage and TENS and distraction, similar to adults. Adolescents may report more pain than younger children, especially if the pain is chronic.

Older Adults Pain is not an inevitable part of aging; however, elderly people are at greater risk for many disorders that may result in pain, such as arthritis, cardiovascular dis- ease, osteoporosis, falls, hip fractures, and cancer (Horgas & Elliot, 2004; Barkin, Barkin & Barkin, 2005). Older patients may deny pain more frequently than other age groups because they fear the consequences of admitting pain, such as longer hospitalization or more tests, or they have the mistaken belief that pain

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is normal for their age. Special efforts must be taken to adequately assess pain, especially in confused elderly people. Dementia patients are particularly vulnera- ble to undertreatment of pain because of their inability to express themselves. Some myths about pain in older adults include that pain is a normal part of aging and opioids cannot be used safely with this population (Curtis, 2006).

Polypharmacy is of special concern in elderly persons. Because of the physio- logical changes that occur with aging, drug half-life and clearance times are increased. This can lead to increased and unexpected side effects and toxic- ity, making pain control more difficult in this group. Unrelieved pain may also contribute to confusion and dementia. Adjuvant analgesics must be used with caution in elderly patients because sedation, confusion, and the sedative and anticholinergic effects of many of these drugs can contribute to many other problems. Low starting doses are recommended. Long-acting analgesics may be more likely to cause side effects. A trial of low-dose immediate release

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0 1 2 3 4 5 6 7 8 9 10 No

pain Moderate

pain Worst

possible pain

No pain

Moderate pain

Mild pain

Worst possible

pain

Severe pain

Very severe pain

Simple Descriptive Pain Intensity Scale

0-10 Numeric Pain Intensity Scale

A

0 1 2 3 4 5 No Hurt Hurts

Little Bit Hurts

Little More Hurts

Even More Hurts

Whole Lot Hurts Worst

Which Face Shows How Much Hurt You Have Now?

B Wong-Baker FACES Pain Rating Scale

FIGURE 15–2. Pain Rating Scales (Sources: [A] Agency for Health Care Policy and Research. (1994). Management of cancer pain. Clinical practice guideline. Rockville, MD: Public Health Service, US Department of Health and Human Services (DHHS); [B] From Hockenberry, M. J., Wilson, D., & Winkelstein, M. L. (2005). Wong’s essentials of pediatric nursing [7th ed.] [p. 1259]. St. Louis: Mosby. Used with permission. Copyright, Mosby.)

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analgesics given on a routine basis can be helpful to determine if the dementia patient’s behavior is due to pain.

Older adults are more likely to be fearful of using narcotic analgesics owing to long-held beliefs that morphine is associated with death or narcotic use leads to addiction. This can present a significant barrier to effective pain relief. Assess any fears the patient may have regarding taking narcotics. Fear of constipation is also a frequently seen barrier.

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POSSIBLE NURSES REACTIONS • May rely more on physiological changes or signs such as vital signs, body

movement, facial gestures, and other nonverbal behavior than on patients’ own verbal reports to assess patient’s pain.

• May become insensitive to patient’s expressions of pain. • May have difficulty accurately assessing the patient’s pain. Varying opinions

among staff members over interpretation of behaviors suggesting pain and selected pain control modalities can lead to very divisive conflicts among staff members.

• May feel extremely frustrated over what can be done to help the patient. • May fear causing a patient’s addiction if the patient requires narcotics for

an extended period of time. • May think that the need for greater pain control is more acceptable for cer-

tain types of pain, such as cancer pain. • May believe that patients will always accurately report pain when they

have it. • May become frustrated over what to do when a patient denies having pain

to the physician but continues to request pain medication from nursing staff. • May feel manipulated by patients who staff members believe are faking

pain for the purpose of obtaining more medication.

ASSESSMENT OF ACUTE PAIN

Behavior and Appearance • Verbalizes pain rating and describes location and character of pain • Guarded positioning • Tense or grimacing facial expression • Rubbing, pulling at, splinting, or protecting painful area • Fatigued, lethargic • Crying or moaning • Restless

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Mood and Emotions • Fearful, anticipating more pain • Angry, irritable, frustrated • Depressed, hopeless, withdrawn • Feeling out of control or helpless about pain if relief is inadequate

Thoughts, Beliefs, and Perceptions • Wide variations in beliefs about pain, its causes, and methods for relief • May be confused and unable to concentrate • Lack of information or misinformation about pain control methods • Decreased motivation to participate in activities of daily living • Unwillingness to try alternative pain-relief methods • Lack of trust in caregivers if pain is not relieved

Relationships and Interactions • Patient may withdraw socially or have angry outbursts related to pain. • Secondary gains may influence pain behaviors. For instance, family mem-

bers may cater to patient’s needs more attentively if he or she is in pain. • Caregivers may avoid the patient because of previous experiences when he

or she was in pain, may have feelings of helplessness.

Physical Responses • Increased blood pressure, pulse, respirations • Diaphoresis • Tremors • Redness and swelling around painful area

Pertinent History • Previous pain experiences • Effect of pain on work, sleep, eating, elimination, and sexual patterns • Previous and current use of narcotics or other analgesics • Drug or alcohol dependency • Litigation pending after injury or an accident • Medical problems, surgical procedures, and injuries

ASSESSMENT OF CHRONIC PAIN

Behavior and Appearance • Verbalizes pain rating or describes pain • Presence of pain for longer than expected

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• Difficulty maintaining job or other activities • Frustration, fatigue • Changes in muscle tone and reflexes

Mood and Emotions • Depression • Hopelessness • Suicidal ideations • Anger and bitterness • Preoccupied with pain • Fear that caregiver will give up on patient and pain problem

Thoughts, Beliefs, and Perceptions • Fear that pain is intractable and will always affect family, work, social life,

finances, and mood • Perceives others as not believing that he or she is in pain • Fears losing control over the pain and that the medication will lose effec-

tiveness or be withdrawn before pain resolves • Has misinformation about effectiveness or alternative pain-relief methods • Lacks trust in caregivers who do not acknowledge or treat his or her pain

Relationships and Interactions • Social isolation and withdrawal • Family or work relationships may have changed since pain became chronic • Patient’s dependency increases with pain • Patient withdraws from usual activities and friends • Patient experiences decreased social activities and reduced satisfaction with

relationships and diminished sexual interest • Family experiences fear and frustration about the patient’s using pain for

secondary gains

Physical Responses • Anorexia or weight gain • Impaired mobility • Insomnia • Intermittent pain relief with rest; pain recurring with increased stress or cer-

tain activities

Pertinent History

• Pain of long duration • Changes in mood, sleep, appetite, and activity patterns

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• Constipation related to prolonged use of narcotics • Litigation pending after injury • Prolonged use of medication without effective pain relief • Physical dependency on pain medications, other drugs, or alcohol since pain

became chronic • Financial problems caused by cost of medical care • Possible multiple medical complaints, little satisfaction with treatment • Seeking out numerous doctors for treatment

COLLABORATIVE MANAGEMENT

Pharmacological Several types of drugs are available to treat pain. Selection is based on the cause of the pain, its intensity and duration, and the patient’s response. Mild intermit- tent pain may be treated with salicylate analgesics, acetaminophen, or nons- teroidal anti-inflammatory agents (NSAIDS). These drugs have specific upper dose limits due to their side effects. More severe, acute pain may need opioid analgesics such as morphine or oxycodone. Determining the most effective med- ication requires careful assessment of the cause of the patient’s pain and his or her perception of the pain and underlying condition. Opioid analgesics generally have no upper dose limits short of side effects.

Factors that influence the effectiveness of medication to relieve pain include:

• Route of administration (Table 15-1) • Amount and frequency of dosage • Anticipated onset and duration of action • Method of drug’s action (central versus peripheral) • Previous experience with medication

The patient experiencing pain needs to be constantly reevaluated to ensure that he or she receives maximal relief with the least potent drug. For instance, a surgi- cal patient may require parenteral opioid analgesics immediately after surgery. As healing occurs, the drug can be titrated to a less invasive method and a lower dose while still maintaining adequate pain control. An equianalgesic list (Table 15–2) gives the dose and route of administration of one drug that produces approxi- mately the same degree of analgesia as the dose and route of administration of another drug. There are many differences among individual patients, so these lists serve only as guidelines to the relative equivalences of various analgesics. Dose and time intervals must be titrated for each patient (Agency for Health Care Pol- icy and Research, 1992, 1994). Patients with chronic pain may need opioids, and the long-acting preparations are particularly useful because they avoid the fluctu- ating blood levels of analgesics. The World Health Organization Pain Ladder is a useful model to follow for cancer pain (WHO, 2006).

Chapter 15 ■ Problems with Pain 303

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304 Chapter 15 ■ Problems with Pain

TABLE 15–1 Analgesic Routes of Administration

Oral Sublingual • The preferred route • Cost effective • Safe easy administration • Variety of forms (pills, liquid) • Must be able to swallow and

absorb

IV Push IV Infusion • Fast onset for intermittent pain • Short-acting • Less painful than SQ if IV in place • Can be prone to side effects

Patient Control Analgesia Subcutaneous • Fast onset for intermittent pain • Short-acting • Patient has control • Patient must be awake and able to

comprehend instructions

Subcutanous Infusions Rectal • Effective alternative to IV drip

when no IV access • Only small volume (1-2 cc/hr) can

be given.

Transdermal Epidural • Effective for constant pain when

stable dose of analgesia needed. • Route of choice if patient unable

to swallow, unable to absorb, or is noncompliant.

• Can be prone to side effects

Source: Adapted from Pasero, C., Portenoy R. K., & McCaffery, M. (1999). Opioid analgesics. In M. McCaf- fery & C. Pasero (Eds.), Pain: clinical manual (2nd ed.) (pp. 161-299). St Louis: Mosby.

• Easy administration even if patient sedated

• Most long-acting products cannot be given this route.

• Absorption sometimes erratic

• Effective for constant pain • Allows for rapid dose titration • Preferred access is central line • Accumulation of drug can con-

tribute to side effects

• Faster onset than oral/slower than IV

• No IV access needed • May be painful

• Safe alternative to oral • Many oral drugs can be given this

route. • Contraindicated in thrombo-

cytopenia, neutropenia

• Most effective in intractable pain when traditional routes ineffective

• May have less side effects since lower doses used

• Requires surgical placement of catheter and more monitoring.

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305

TABLE 15–2 Opioid Analgesics Commonly Used for Severe Pain

Equianalgesic Starting Oral Name Dose (mg) Dose

Morphine- Adults Children Precautions and like agonists Oral Parenteral (mg) (mg/kg) Comments Contraindications

Morphine

Hydromorphone (Dilaudid)

Continued

30

7.5

10

1.5

15–30

4–8

0.30

0.06

Standard of comparison for opioid analgesia.

Sustained- release preparation (MS Contin, Oramorph SR) release drug over 8–12 hours.

Slightly shorter dura- tion than morphine

For all opioids, cau- tion in patients with impaired ven- tilation, bronchial asthma, increased intracranial pres- sure, liver failure

1 5 G o r m a n ( F ) - 1 5 1 1 / 5 / 0 7 4 : 5 6 P M P a g e 3 0 5

306 TABLE 15–2 Opioid Analgesics Commonly Used for Severe Pain—cont’d

Equianalgesic Starting Oral Name Dose (mg) Dose

Morphine- Adults Children Precautions and like agonists Oral Parenteral (mg) (mg/kg) Comments Contraindications

Oxycodone

Methadone (Dolophine)

Levorphanol (Levo-Dromoman)

Fentanyl

20

10

4 acute 1 chronic

–

5

2 acute 1 chronic

0.1

10–20

5–10

2–4

0.30

0.20

0.04

Good oral potency, long plasma half- life (24–36 hours)

Long plasma half-life (12–16 hours)

Transdermal fentanyl (Duragesic) 25 mcg/hour, roughly equivalent to sustained

Accumulates with repeated dosing, requiring decreases in dose size and frequency, espe- cially on days 2–5

Accumulates on days 2–3

Because of skin reservoir of drug, 12-hour delay in onset and offset of transdermal patch; fever increases dose rate.

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307

Equianalgesic Starting Oral Name Dose (mg) Dose

Morphine- Adults Children Precautions and like agonists Oral Parenteral (mg) (mg/kg) Comments Contraindications

Oxymorphone (Numorphan)

Continued

— 1 — —

release mor- phine, 50 mg/ day. Oral transmucosal fentanyl citrate available for treatment of breakthrough pain in chronic cancer pain patients already taking around-the- clock opioids. Buccal form of fentanyl (Fen- tora) now available.

5 mg rectal sup- pository � 5 mg morphine parenteral

Transdermal patch must be applied to area of body with subcuta- neous fat to ensure absorp- tion.

Like parenteral morphine

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308

TABLE 15–2 Opioid Analgesics Commonly Used for Severe Pain—cont’d

Equianalgesic Starting Oral Name Dose (mg) Dose

Morphine- Adults Children Precautions and like agonists Oral Parenteral (mg) (mg/kg) Comments Contraindications

Meperidine (Demerol)

Mixed agonist- antagonist

Nalbuphine (Nubain)

Butorphanol (Stadol)

Source: Adapted from American Pain Society. (2003). Principles of analgesic use in treatment of acute pain and cancer pain (5th ed). Skokie, IL: American Pain Society.

300

—

—

75

10

2

Not recom- mended

—

—

Not recom- mended

—

—

Slightly shorter act- ing than morphine

Not available orally, not scheduled under Con- trolled Sub- stances Act

Like nal- buphine

Normeperidine (toxic metabo- lite) accumulates with repeti- tive dosing, causing CNS excitation; avoid in children with impaired renal function or who are receiving mono- amine oxidase inhibitors

Side effects profile makes this drug unacceptable to use for most pain

Incidence of psychoto- mimetic effects lower than with pentazocine; may pre- cipitate withdrawal in nar- cotic dependent patients

Like nalbuphine

1 5 G o r m a n ( F ) - 1 5 1 1 / 5 / 0 7 4 : 5 6 P M P a g e 3 0 8

Chapter 15 ■ Problems with Pain 309

Patients on one or more other medications need to be evaluated for possible drug interactions. Drug pharmacokinetics may change because of alterations in cardiac, renal, and liver function; respiratory rate; and gastrointestinal absorp- tion. Fever, sepsis, burns, and shock also affect drug effectiveness. Patients with psychiatric conditions who take antianxiety agents or psychoactive drugs must also be evaluated for possible drug interactions, in particular, the added sedative effects of opioids and many of the psychotropic drugs. Clinicians should be aware that patients in these categories might not respond as expected to pain medication (Borsook, McPeek, & Lebel, 1996).

A factor contributing to undertreatment of pain can be created by the patient who fears taking opioids. Some patient barriers to taking adequate analgesics include fear of side effects (particularly constipation and sedation), and associa- tion of opioids with addiction and death.

A variety of herbal products are being used to treat pain, including capsicum ointments, evening primrose for arthritis, and chamomile for migraines. A vari- ety of alternative approaches that may be used include acupuncture, magnet ther- apy, and biofeedback.

NURSING MANAGEMENT

PAIN, ACUTE evidenced by report of moderate pain, changes in autonomic nervous system (increased heart rate and blood pressure), and reduced ability to perform ADLs related to surgery, injury, or illness

Patient Outcomes • Reports decreased pain levels • Identifies previously successful pain-relief techniques to use now to

decrease pain • Identifies and minimizes factors that precipitate or aggravate pain • Participates in assessment of pain and effectiveness of pain-relief methods • Demonstrates increased mobility and activity

Interventions • Perform a thorough pain assessment. Ask patient to rate pain on a con-

sistent scale such as 0 to 10, with 0 being no pain and 10 being the worst possible pain. Determine if the patient can relate more to a visual pain scale (Fig. 15–2). Use the same tool each time you assess that patient’s pain. Be sure to determine the patient’s perception of his or her pain, pre- vious effective pain methods used, and any misperceptions the patient has about effective pain-relief methods.

• To reduce the patient’s anxiety, explain the causes of pain, if known. • Teach the patient and family about factors that may increase or decrease

pain. Try to minimize factors that increase pain perception.

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• Teach about any necessary painful procedures before they occur to reduce stress over anticipating the procedure. Patient teaching should include:

• Basic description of the procedure or test, its purpose, and equipment to be used

• A description of any sensations likely to be experienced • Anticipated duration of procedure and discomfort • Measures that can be used to reduce discomfort

• Provide accurate information about analgesics to reduce fear or miscon- ceptions about addiction, tolerance, and physical dependence. Recognize that the patient or family may become anxious when medications are changed. Discuss any changes in medication, dose, or frequency with physician, and plan how to inform the patient about the pain control goals and parameters.

• Provide relief measures at regular intervals rather than on an as-needed basis, even when the pain is still tolerable. Do not expect the patient to wait until pain is unbearable to administer the next dose.

• Use the following approaches when administering analgesics:

• Determine whether and when to give as-needed medications. • Choose the appropriate analgesic when more than one is ordered. • Evaluate the effectiveness of administering medications at regular

intervals. • Monitor responses to administered medications and report promptly

any adverse reactions and when they are ineffective. • Suggest appropriate changes based on knowledge of the patient and

previous response to pain-relief measures.

• Check with patient 30 minutes after administering a pain medication to assess its effectiveness. Include patient in rating level of pain before and after medication or other pain-relief method used. Use the same pain rat- ing scale each time you assess the patient to ensure accurate evaluation.

• Encourage patient’s participation in using alternative pain-relief methods such as relaxation exercises or use of heat or cold. Instruct the patient about rigid body position, which can increase pain, and techniques to reduce muscle tension:

• Select a time when patient is relatively comfortable and able to con- centrate so that teaching will be more effective.

• Use pillows or other supports to splint and support body parts and reduce muscle tension.

• Discuss effects of stress, monotony, fatigue, and distraction on pain per- ception.

• Provide for privacy for pain expressions if the patient desires. • Try to limit the number of caregivers interacting with patient and mak-

ing decisions about pain management.

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• Provide opportunities for rest and therapeutic use of distraction, such as visits or watching television, between uncomfortable treatments.

• If patient has a current or past history of drug or alcohol abuse, he or she still needs strong opioids to treat an acute pain problem. Putting this patient on an around-the-clock dosing schedule of analgesics is usually recommended to avoid euphoria. Other suggestions include long-acting analgesics and making a contract with the patient about what medica- tions can be given. Discuss patient’s concerns about taking opioids.

• Consult with other staff members or the physician about increased med- ication at bedtime and before painful procedures to keep pain at tolera- ble levels throughout the day and to maximize patient’s participation in required activities.

• Institute measures to reduce any adverse effects of narcotics. For instance, administer stool softeners and stimulant laxatives (e.g., senna- based products) to combat constipation, antiemetics for nausea, and nonalcohol-based mouthwashes or mouth moisturizers for dry mouth.

• Help the patient to cope with the consequences of pain by encouraging discussion of fears, anger, and frustrations; acknowledge difficulty of sit- uation; and praise and reinforce any efforts to handle pain.

• Consult with pharmacist and physician about alternative opioid and analgesic combinations.

• Consider using aspirin or acetaminophen simultaneously with opioid for maximal effect if appropriate. Also consider use of NSAIDs for periph- eral pain.

PAIN, CHRONIC evidenced by ongoing episodes of pain, difficulty perform- ing usual activities, and other effects of chronic pain, such as sleep distur- bance or poor nutrition related to effects of illness, surgery, or injury more that lasts beyond the ordinary duration of time that body needs to heal.

Patient Outcomes • Participates in assessment of pain • Uses one or more alternative measures to manage pain • Demonstrates reduced intensity of depression • Increases participation in activities • Decreases use of pain behaviors for secondary gain • Decreases dependence on analgesics when pain controlled

Interventions • Assess patient’s previous and current pain behaviors. • Encourage the patient to learn and use noninvasive pain-relief methods,

such as muscle relaxation, deep breathing, guided imagery, distraction, TENS, and application of heat or cold.

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• Incorporate family or caregivers in alternative pain-relief measures. • Use analgesic medications in conjunction with alternative pain-relief

measures to effectively control pain. • Discuss with physician or pharmacist plan for weaning patient off opi-

oids and onto non-narcotics. Titrate parenteral pain medications and switch to oral doses as soon as possible while ensuring adequate pain control.

• Teach patient and family that oral medication, when prescribed in appro- priate dose and frequency, can be as effective as parenteral.

• Administer a loading dose and then maintain a therapeutic drug level of oral medications when first switching to gain the patient’s confidence in new treatment.

• Ask patient to participate in evaluation of pain-relief methods by keep- ing his or her own pain diary.

• Help family or caregiver to recognize and decrease pain behaviors for secondary gain.

• Promote optimal mobility and meaningful activity in patient. • Assess patient’s nutrition and elimination functions related to use of med-

ications and decreased mobility or activity. • Assess patient’s sleep pattern, levels of depression, or other psychological

reactions to prolonged pain. Consider use of adjuvant treatments, as indicated.

• Provide the patient and family with the opportunity to discuss fears, anger, and frustration in a private setting. Acknowledge the difficulty of the situation and any of the family’s efforts to help the patient cope.

• As indicated, refer the patient for evaluation at a multidisciplinary pain clinic if problems are not improved before discharge.

ALTERNATE NURSING DIAGNOSES

Anxiety Comfort, Impaired Coping, Ineffective Fear Powerlessness Self-Concept, Disturbed Sleep Pattern, Disturbed Spiritual Distress Thought Processes, Disturbed

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PATIENT AND FAMILY EDUCATION

• Provide information about all pain-relief methods available to the patient. Keep the patient and family informed about changes in treatment plan.

• Teach relaxation techniques (Box 3.2). • Instruct the patient and family on the use of the pain rating scale. • Allow the patient to make choices about relief methods used. Involve him

or her in assessment of pain; teach how to use pain flow sheet or keep a pain diary, and select appropriate alternative pain-relief measures based on activ- ities and effectiveness of relief methods.

• Initiate teaching with the patient, family, or caregiver related to pain-relief methods to be used after discharge. Review with them the ordered discharge medications, potential adverse effects and how to manage them, what to report to physician, and effective alternative pain-relief measures.

• A useful website for patients and family is www.painfoundation.org/ (Amer- ican Pain Foundation).

Chapter 15 ■ Problems with Pain 313

WHEN TO CALL FOR HELP

• Pain-relief measures are ineffective. • Pain levels increase. • Patient or family is unwilling to learn about alternative methods of

pain relief. • Psychiatric problems are interfering with patient’s use of prescribed

pain-relief methods. • There is increased frustration from dealing with the patient’s or fam-

ily’s pain behaviors. • Analgesics ordered are ineffective and physician refuses to make

changes. • Patient continues or increases use of pain behaviors for secondary gain. • There are concerns over patient’s or family’s ability to manage pain

after discharge. • Evidence of abuse of opioids.

WHO TO CALL FOR HELP

• Pain team • Addiction specialists • Social Worker • Palliative Care Team/Hospice • Attending Physician

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CHARTING TIPS

• Include the selected pain rating scale in the assessment and evaluation doc- umentation. Besides the pain rating, document location and description of the pain.

• Use objective, nonjudgmental terms to describe pain behaviors and responses to pain relief measures. When possible, use the patient’s own words to describe the pain.

• Document the response to all pain relief measures. • Document any factors or activities that increase or decrease pain. • Note all side effects of analgesics.

COMMUNITY-BASED CARE

• Review with the patient, family, or caregiver the patient’s progress with pain management since admission.

• If patient is being discharged with prescriptions for opioids, give referrals for local pharmacies that carry these medications.

• Allow sufficient time for the patient to adjust to the change from parenteral to oral administration of pain medications and to practice alternative pain- relief measures before discharge.

• Consult with the physician if patient’s pain is not controlled before dis- charge or if pain is expected to continue for some time thereafter. Obtain a home health referral to assess pain at home and follow up with medication compliance and monitor side effects.

• Instruct the patient, family, or other caregivers on how to use a pain flow sheet or maintain a pain diary at home.

• Suggest that the patient be referred to an appropriate pain treatment center where multidisciplinary treatment is offered.

• Include the selected pain rating scale in all assessment and evaluation docu- mentation.

• Use objective, nonjudgmental terms to describe pain behavior and responses to pain-relief measures. When possible, use the patient’s own words when describing the pain.

• Document patient’s responses to all pain-relief measures used. • Document any factors or activities that the patient or family can identify

as an increase or decrease in pain tolerance or effectiveness of pain-relief methods.

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16

315

Problems with Nutrition

The Patient with Anorexia Nervosa or Bulimia

Learning Objectives • Describe the similarities and differences between anorexia nervosa and

bulimia. • Formulate nursing diagnoses and interventions for patients with anorexia

nervosa or bulimia. • Identify common nurses’ reactions to the patient with anorexia nervosa

or bulimia. • Describe the complications of anorexia nervosa and bulimia.

Glossary Anorexia nervosa – A potentially life-threatening eating disorder character-

ized by self-starvation in a relentless pursuit of thinness, an intense fear of becoming fat, and delusional disturbance of body image.

Binge eating disorder – Recurrent episodes of binge eating that lead to feel- ings of distress. Not associated with purging.

Binge – Rapid consumption of large amounts of food in a short period of time (usually less than 2 hours).

Bulimia (bulimia nervosa) – An eating disorder characterized by some of the following: consuming large quantities of food in a short time terminat- ing in abdominal pain, sleep, social interruption, self-induced vomiting, and laxative use.

Compulsive overeating – Consuming large volumes of food without purging.

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Eating disorders – Gross disturbances in the patterns of ingesting food. Purge – Planned or unplanned episode to undo damage of binge, including

self-induced vomiting, laxative use, or diuretic use.

Dieting is a national obsession, especially with women. Numerous fitness clubs are filled with individuals trying to attain the idealized thin, muscular body.

Cochrane (1998) reports that more than 50% of American women are on a diet at any one time. Extreme thinness is increasingly common in models and actresses as the idealized image. It seems that it has become accepted behavior to be obsessed with body weight and shape, and to view food as a source of stress. Self- esteem and happiness in young girls are often linked to weight and body shape. Adolescent girls may be rewarded for dieting with either increased social accept- ance or praise from parents (White, 2005). When this social influence is combined with certain biological, psychological, and family dynamics influences, it could be the beginning of an eating disorder (Yager & Anderson, 2005). Eating disorders have little to do with simply not eating enough or overeating. Rather, they are psy- chiatric disorders with substantial emotional and physical consequences.

Anorexia nervosa and bulimia (sometimes called “bulimia nervosa”) most commonly occur in young women, and the incidence of these disorders is on the rise. One to five percent of young women suffer from them (Wolfe, 1998). Women and girls are 10 times more likely to suffer from these disorders than men and boys. Male reports of eating disorders may be underreported though (Spader, 2007). Patients with an eating disorder may be treated in psychiatric facilities, but may require admission to an acute-care hospital for treatment of complica- tions or for initial diagnosis to rule out other conditions. There are many simi- larities between these two eating disorders and long-term anorexics may develop bulimia in later life (Table 16–1).

The term anorexia (as in anorexia nervosa) is really a misnomer because this condition has very little to do with appetite. It has more to do with the person’s morbid fear of obesity causing obsessive fear of losing control of food intake. In fact, the person is often hungry and views the discomfort of hunger as a reminder of the deprivation he or she needs to inflict on himself or herself. Only in the late stages is appetite actually lost. The distorted body image causes the patient to view himself or herself as fat even though appearing emaciated. No amount of weight loss relieves the anxiety, causing this deadly cycle to continue. Complica- tions can continue for years, even after successful treatment.

The American Psychiatric Association (2000) reports 0.5% to 3.7% of women suffer from anorexia nervosa in their lifetime. Often diagnosed in adolescence, anorexia nervosa is often viewed as representing struggles with autonomy and sexuality. Poorer prognosis is associated with an older age of onset, a lower minimum weight, and vomiting. Purging, which promotes electrolyte imbalance and arrhythmias, is usually combined with compulsive exercise, making a most lethal combination. Successful treatment is measured by weight gain, return of menstruation (usually absent in anorexic women), and reduced number of

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compulsive behaviors. Early intervention is associated with improved prognosis. Full recovery of weight, growth and development, menstruation, and normal eating behavior occurs in at least 50% to 70% of treated adolescents (Yager & Anderson, 2005).

Bulimia was officially designated as a psychiatric disorder in 1980 and is harder to diagnose than anorexia. It is more common than anorexia and affects a larger cross-section of the population. Sadock and Sadock (2003) report that the inci- dence is 1% to 3% of young women. As with anorexia, bulimia is mainly a con- dition of younger women; however, some studies show that about 10% of bulimics are male (DSM-IV-TR, 2000). Men with bulimia tend to be older at onset. Both men and women often demonstrate difficulties with impulse control, associated

Chapter 16 ■ Problems with Nutrition 317

TABLE 16–1 Comparing Anorexia Nervosa and Bulimia

Anorexia Nervosa Bulimia

Epidemiology

Appearance

Family

Behavior

Signs

Prognosis

• More than 95% female • Younger adolescent onset • Fairly rare

• Emaciated • Below normal weight

• Rigid, perfectionistic • Overprotection

• Introverted • Socially isolated • High achiever • Excessive exercise

• Cachexia • Hair loss • Amenorrhea • Dry skin • Pedal edema

• 5%–18% mortality rate • Frequent life-long prob-

lems with food • Bulimia • Depression

• 90% female • Young adult onset more

likely • 2–3 times more frequent

than anorexia

• Normal or overweight • Weight fluctuations

• More overt conflict

• Impulsive • More histrionic, acting

out

• Dehydration • Chronic hoarseness • Chipmunk facies

(parotid gland enlarge- ment)

• Death is rarer • Life-long problems with

food

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with higher incidence of drug abuse and acting-out behavior such as petty crime. The long-term prognosis is unclear because the relapse rate remains high.

Unlike the patient with anorexia, the one with bulimia uses food as a tempo- rary relief of stress, which leads to binge eating. The resulting sense of shame and disgust then causes the patient to purge by induced vomiting or use of laxatives. The cycle of bingeing and purging may begin as a way to lose weight but can become a compulsive behavior.

Bulimia is associated with fewer life-threatening complications than anorexia, but it can lead to chronic conditions including sore throat, dental erosion, and parotid gland enlargement from chronic vomiting. Electrolyte imbalances from chronic use of laxatives, diuretics, enemas, and emetics can occur. A bulimic indi- vidual can consume thousands of calories in a short time.

A third eating disorder recently listed in the DSM-IV-TR (2000) is binge eat- ing disorder, which involves eating large quantities without purging. People suf- fering from this disorder are most often obese or exhibit fluctuations in weight. Weight-loss programs report seeing more clients with this disorder. This disorder is believed to be much more common that anorexia or bulimia.

ETIOLOGY

Individuals with eating disorders report a premorbid history of dieting and attempts to control their weight. What makes this progress to anorexia ner- vosa or bulimia is unclear, but most likely genetic, biological, psychological, and family factors are all involved. There are many similarities in etiological theories between these two conditions. Both disorders are also significantly associated with depression and family dynamics, in which food plays a large symbolic role.

Anorexia nervosa may have genetic influences because there is an increased incidence of its occurrence among daughters and sisters of anorexics. The bio- logic influence may be multifactoral. Research suggests that there is an interrela- tionship between multiple neurotransmitters, including dopamine that regulates appetite, body size, and fat distribution. Dysfunction of the hypothalamus has also been implicated. Because the symptoms usually begin in adolescence, hor- monal changes may be an important contributor.

Psychoanalytic theory suggests that the core of anorexia can be a child’s fear of maturing and unconscious avoidance of developmental tasks. By not eating, the person forestalls sexual development and maintains his or her role as child in the family. Other dynamics include perfectionist tendencies developed through demanding, overachieving parents and a profound disturbance in the mother- child relationship. Anorexia gets out of control as the person tries to achieve the perfect image. Many family therapists believe that anorexia symptoms represent a dysfunctional family situation. The patient tries to present a “perfect good girl” image, trying to meet the family’s distorted view of perfection. Also, the eating disorder gives the patient a sense of control that counteracts the feelings of loss of control, anxiety, and need to avoid conflict. Some reports indicate that a

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mother’s preoccupation with weight and food can be a source of conflict between mother and child, and the eating disorder becomes a means of control for the child. An overwhelming sense of worthlessness in the child may also be respon- sible. Comorbid psychiatric disorders include major depression, anxiety disor- ders, and obsessive-compulsive disorder (Yager & Anderson, 2005).

Specific theories on the cause of bulimia are limited. Biological views regard low levels of the neurotransmitters norepinephrine and serotonin as associated with bulimia. Low serotonin is known to increase the need for intake of carbo- hydrates and is also associated with depression. Bulimia may be related to impaired satiety mechanism.

Family dynamics in bulimia are often characterized by a high degree of con- flict, marital discord, and acting out. This may contribute to the patient’s devel- oping increased anxiety with intimate relationships and a fear of abandonment and conflict surrounding parental authority. Low self-esteem contributes to feel- ings of inadequacy and a deep-rooted sense of shame and guilt. Some studies have noted an increased incidence of family members with a history of alcoholism and the possibility of physical or sexual abuse. These individuals are more likely to have comorbid psychiatric disorders, including borderline, panic disorder, and major depression.

RELATED CLINICAL CONCERNS

Anorexic and bulimic patients may have a history of being overweight when young. Anorexics have been noted to weigh more at birth. Bulimics may have a history of anorexia when younger, as well as a tendency for obesity within the family.

Life-threatening complications from anorexia include cardiac arrhythmias, electrolyte imbalance, and cardiomyopathy. Serious bulimia complications can include electrolyte imbalance and erratic blood sugars.

LIFE SPAN ISSUES

Children and Adolescents Anorexia and bulimia remain a condition generally seen in adolescence and young adulthood. Children as young as 8 years old often admit to preoccupation with diet and atypical eating habits. A sense of self-consciousness and insecurity with one’s body is a normal part of growth and development; however, children whose self-esteem becomes more closely tied to satisfaction with their body size tend to become more prone to eating disorders. This is often influenced by the way in which adult caregivers perceive and respond to them. Children who are overweight may experience increased criticism and demands made upon them, leading to low self-esteem. In adolescence, awareness of cultural ideals becomes even stronger. Adolescents may notice that thinner contemporaries have more friends or dates.

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ASSESSMENT OF ANOREXIA NERVOSA

Behavior and Appearance • Emaciated

• Tends to cover up body with large clothing in attempt to hide appearance, although some may exhibit thinness with a sense of pride

• Avoids being weighed; may try to manipulate weight by putting weights in pocket

• High achiever in school and work

• Ritualistic behavior surrounding food (such as eating every third bean)

• Spends time with food-oriented activities, such as cooking or shopping for others

• At mealtimes, tries to hide not eating by:

• Cutting up food to give appearance of less food present

• Moving food around plate

• Hiding pieces of food in pockets or under plate

• Exercising obsessively (possibly in secret)

• Using laxatives or foods with a laxative effect excessively

• Not giving a realistic picture of his or her eating patterns

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POSSIBLE NURSES’ REACTIONS • May feel shocked or disgusted by patient’s behavior or appearance. • May resent the patient because of the belief that the disorder is self-inflicted.

This may make it difficult to express empathy, which, in turn, may make the patient feel rejected.

• The nurse may feel helpless to change the patient’s behavior, leading to anger, frustration, and criticism.

• The nurse may inadvertently re-create family power struggles with patient by trying to make the patient eat by nagging, cajoling, arguing, or even tricking. This will inhibit a trusting nurse-patient relationship.

• The nurse may feel overwhelmed with the patient’s problems, leading to feelings of hopelessness or to the setting of rigid limits to feel more in con- trol of the patient’s behavior.

• Many nurses become embroiled in power struggles with these patients, which may trigger angry responses in the nurses.

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Mood and Emotions • Has high anxiety associated with mealtimes, weight gain, being weighed,

and especially any control issue • When under stress, may feel need to starve self more • Experiences feelings of sadness and low self-esteem • May feel need to punish self for feelings of pleasure • Denies feelings of sadness or anger and often appears pleasant and compliant

Thoughts, Beliefs, and Perceptions • Distorted attitude toward appearance, weight, and food that overrides

hunger and reason • Distorted body image: sees self as fat despite others saying that the opposite

is true • Perfectionist, compulsive, rigid • Seeing self as helpless and dependent; great difficulty making decisions • Possible mental status changes from malnutrition such as memory lapses,

poor attention span, poor judgment, and bizarre behavior • Denying seriousness of low body weight

Relationships and Interactions • Introverted; avoids intimacy and sexual activity • Secretive • Fears trusting others; needs to be in control

Physical Responses • Extreme weight loss; weight less than 85% of that expected for age and

height • Cachexia • Fatigue • Amenorrhea • Hair loss; presence of lanugo (fine body hair covering) • Low pulse rate, low blood pressure, low body temperature • Chronic constipation • Dry skin • Altered laboratory values including low hemoglobin and hematocrit (or

high if dehydrated), hypokalemic (especially if using laxatives or diuretics), high blood urea nitrogen (BUN), and serum creatinine

• Insomnia

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• Consuming large volumes of fluid to distend stomach, which may lead to hyponatremia

• Pedal edema related to malnutrition • In late stages, may exhibit arrhythmias and congestive heart failure • Pathological fractures caused by bone loss from estrogen deficiency and

ovarian dysfunction

Pertinent History • Involved in activities in which small size is important, such as ballet or gym-

nastics • Uses food-oriented coping mechanisms, such as stopping eating or excessive

eating, to deal with stress • Family history of depression, eating disorders

ASSESSMENT OF BULIMIA

Behavior and Appearance • Weight is normal, slightly overweight, and fluctuating. • Routinely goes into the bathroom shortly after meals. • Eats normally or sparingly when with others, and binges in private. Purging

behaviors may follow, including self-induced vomiting, laxative or diuretic misuse, fasting, or excessive exercise.

• May appear normal without obvious problems. • Functions normally. • Behavior is sometimes histrionic or impulsive. • Tends to act out.

Mood and Emotions • Binge triggered by some emotional stress; initially some relief of anxiety

during the binge but tension slowly increases as feelings of remorse and guilt build

• Purge in response to feelings of remorse and guilt • Anxiety over appearance and weight • Anxiety around mealtimes as patient fears loss of control • Feelings of anxiety, depression, self-disgust

Thoughts, Beliefs, and Perceptions • Perfectionist • Preoccupied with appearance, weight • Self-critical

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• Very aware that own behavior is abnormal • Feels powerless over binge-purge cycle • Believes he or she is unable to change • Suicidal thoughts

Relationships and Interactions • Overt conflict within family • Goes to great lengths to keep binge-purge behavior a secret from others • Generally social and gregarious, with a strong need to be accepted by others • Sexually active

Physical Responses • If bingeing: abdominal pain, malaise, fluctuating blood sugars. • If vomiting, chronic hoarseness, parotid gland enlargement causing chip-

munk facies, dental caries, loss of enamel on teeth, skin changes over dome of the hand (if use finger down throat to induce vomiting). Use of ipecac to induce vomiting can induce cardiac symptoms including palpita- tions, chest pain.

• If abusing laxatives, abdominal pain and diarrhea. • Other symptoms may include dehydration, hypokalemia, and cardiac

arrhythmias.

Pertinent History • Anorexia nervosa as a teenager • Drug or alcohol abuse (especially cocaine as a way to control appetite) • Involvement in activities in which weight must be kept down such as mod-

eling, ballet, athletics

COLLABORATIVE MANAGEMENT

Pharmacological The Agency for Healthcare Research and Quality (2006) found that medications were of limited value in treatment of anorexia. Antidepressants, particularly flu- oxetine (Prozac), and other selective serotonin reuptake inhibitors (SSRIs) have been used in patients with clinical depression, anxiety, and obsessive-compulsive symptoms for both anorexia and bulimia (Yager et al, 2006). Fluoxetine in higher doses has been helpful in bulimia. Some antidepressants and atypical antipsychotic drugs also cause weight gain as a side effect. Antipsychotic med- ications may be used in patients who are extremely obsessive compulsive. Tri- cyclic antidepressants and monoamine oxidase inhibitors are generally not used in anorexia because of increased side effect profile in malnourished individuals.

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Antianxiety medications have also been useful. Bulimics have also been treated with lithium and phenytoin (Dilantin). Anorexics may resist taking medication just as they do food, and it becomes another part of the power struggle to get the patient to comply.

Over-the-counter diet aids and herbal products may be used in the hopes of promoting weight loss.

Dietary The dietary regimen for the anorexic patient generally involves a slow, steady weight gain of no more than 3 pounds per week (Yager & Anderson, 2005). Too- rapid weight gain can put undue stress on the heart and precipitate complica- tions. Management by a clinical dietitian or nutrition support team is essential. These patients need careful assessment of their nutritional needs. In severely ill patients, malnutrition must be treated before any improvement from psychother- apy can be expected. For life-threatening situations, aggressive nutritional inter- ventions are required. This may include enteral feedings with nasogastric or gastrostomy tubes or total parenteral nutrition. Some patients do well with these aggressive measures because they are relieved that they do not need to make deci- sions about food. Others may react with resentment and feel an increased loss of control, causing the patient to take more drastic control measures such as increasing exercise, using laxatives, or changing the drip rate or solution being infused. Bulimic patients need dietary education and supervision to control weight. Patients who have bariatric surgery need close nutritional monitoring and special attention to vitamin and mineral intake.

Psychiatric Individual and group psychotherapy is essential in treating patients with bulimia and anorexia nervosa. Because patients with both conditions also commonly exhibit troubled family relationships, family therapy is also needed. The treat- ment plan for anorexia nervosa may include a behavior modification and cogni- tive therapy program. Patients are given rewards for any weight gains and increased restrictions for any weight loss or self-destructive behaviors. To increase the chance of success, patients should participate in developing the treatment plan. Written contracts that clearly explain the patient’s behavioral expectations have been effective.

Bulimics may also benefit from keeping a diary of their food intake, feelings, and binge-purge behaviors. Patients who are hospitalized in the acute setting may benefit from evaluation by a psychiatrist.

NURSING INTERVENTIONS

NUTRITION IMBALANCED: LESS THAN BODY REQUIREMENTS evi- denced by weight loss, avoidance of food, excessive exercise, hiding food, self- induced vomiting related to self-starvation, binge-purge cycle.

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Patient Outcomes • Increased oral intake (anorexia nervosa) • Weight gain at rate of no more than 2 pounds per week or per prescribed

treatment plan (anorexia nervosa) • Reduced incidence of strenuous exercise (anorexia nervosa) and/or purg-

ing (bulimia)

Interventions • Recognize that patient may be very defensive about eating behavior and

attempts to keep it secret. Mealtimes may be very stressful. Create envi- ronment of acceptance to encourage a trusting nurse-patient relationship.

• If personnel are available, stay with patient during meals to be sure food is actually eaten. Create a social atmosphere rather than a supervi- sory one.

• Give patient as much control as possible around eating behavior. Encour- age him or her to select some foods. Set limits, however, on length of mealtimes. Lengthy mealtimes tend to increase anxiety and acting-out behaviors.

• Monitor food and fluid intake. Measure urinary and fecal output. Assess skin turgor. Do this in a matter-of-fact manner. Avoid power struggles or criticism. For example, note what patient has eaten without scowling or making demands. Recognize that telling a patient, “You have to eat more” will create tremendous anxiety and probably lead to defiance. For the patient at home, recognize that monitoring food intake and con- trolling bingeing may be more difficult and require a commitment from family members.

• Weigh patient regularly, using same scale. Treatment plan may include setting a minimal safe weight range that must be maintained. This can remove the power struggle from mealtimes because patient knows what is expected.

• Set limits on dysfunctional behaviors such as strenuous exercise and use of bathroom after eating.

• Set limits on time spent alone in the bathroom after meals. Also insist that patient wait at least 30 minutes after eating before using bathroom.

• Present meals without threat, coercion, or criticism. Recognize that argu- ing about food will only increase the problem. In addition, avoid cajol- ing or tricking patient into taking more calories.

• If you suspect that patient is trying to sabotage the treatment plan, talk openly with patient about your concerns. Be aware that patient may have a need to hide food to give impression that he or she is eating.

• Reinforce the idea that patient can avoid more aggressive interventions, such as tube feedings, by meeting acceptable minimal weight standards,

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per treatment plan. For example, patient may need to gain 2 pounds a week. This can be a way for patient to maintain control because he or she can decide how to accomplish it.

• For the patient who binges and/or purges, assess specifically what the patient does including method of self-induced vomiting, laxative, or diuretic use.

DISTURBED BODY IMAGE evidenced by inaccurate perception of appear- ance and morbid fear of obesity related to distorted thoughts and inability to perceive body size and physical needs realistically.

Patient Outcomes • Verbalizes more realistic perception of his or her body • Refers to body in a more positive way

Interventions • Encourage patient to express feelings, especially about the way he or she

thinks about or views himself or herself. • Avoid overreacting to self-deprecating comments patient may make

about his or her body. Recognize that these feelings and images are very real to the patient. For example, the patient may dwell on having “fat” legs even though they may be very normal or even emaciated looking. Listen to patient, and explore how the fear of fat creates distress. For example, “I understand you see yourself as fat; however, I do not see you the same way.” Avoid responding to patient’s self-deprecating remarks by minimizing the patient’s statements.

• Encourage discussion of positive personal traits, especially regarding patient’s body image.

• Encourage patient to dress attractively and to use makeup and jewelry, as appropriate.

• Avoid insincere compliments about patient’s appearance.

INEFFECTIVE COPING evidenced by bingeing-purging behavior, obsessive behavior around food related to disturbance in impulse control.

Patient Outcomes • Verbalizes feelings to others while in care of the nurse • Demonstrates reduced number of behaviors that would sabotage treat-

ment plan • Demonstrates more adaptive coping mechanisms while in care of the

nurse • Participates in decision making

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Interventions • If patient is panicked over personal feelings or behavior, remain calm and

help patient focus on ability to remain in control. For example, patient may feel panicked over a weight gain and want to exercise or purge. Help patient focus on short-term goals that he or she can achieve. Identify one area over which the patient has some control. Reinforce coping abilities.

• Communicate support and empathy to patient. Be nonjudgmental to encourage sharing of feelings and coping mechanisms. Demonstrate acceptance by use of support and concern to help the patient feel lovable and accepted.

• Recognize the importance of developing a trusting relationship with patient. One or two staff members who attempt to develop a therapeutic alliance with patient can be particularly helpful. Recognize that patient may be very angry about entering treatment program. Developing a trusting relationship will take time. Show acceptance by use of touch, and if appropriate, talking about interests. Avoid just focusing on food.

• Be consistent in treatment plan. All staff members need to be aware of how to handle sabotaging of plan, such as hoarding food or self-induced vomiting.

• Listen for signs of perfectionist thinking and explore ways to challenge unrealistic expectations. Recognize that patient may have very rigid, fixed beliefs.

• Encourage patient to make small decisions. This tends to empower the patient and assists in imparting a sense of control and accomplishment.

• Assess patient for depression, suicidal risk, and substance abuse, and intervene as appropriate.

• Be aware of the family’s role in patient’s behavioral responses. Patient may need help in seeing himself or herself as a capable person outside the family unit.

POWERLESSNESS evidenced by feeling out of control in presence of food related to inability to control bingeing and vomiting cycles.

Patient Outcomes • Reduce incidence of bingeing and purging • Able to describe triggers for bingeing and purging

Interventions • Educate about the binge and purge cycle and how it perpetuates itself. • Explore with patient the triggers that bring on desire to eat excessively.

Once triggers are known, explore alternative ways to address them as in call a friend, write in diary, exercise.

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• Explore the signals the patient feels that lead to purging. Encourage him/her to write down feelings at that time.

• Encourage keeping a calendar of tracking symptoms and feelings. • Challenge irrational thoughts that may take over when tension is build-

ing toward binging.

ALTERNATE NURSING DIAGNOSES

Anxiety Denial, Ineffective Family Coping: Compromised Fluid Volume Deficit Knowledge, Deficient Self-Mutilation, Risk for Sexual Dysfunction Thought Processes, Disturbed

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WHO TO CALL FOR HELP

• Psychiatric Team • Dietitian • Internist • Social Worker • Attending Physician

WHEN TO CALL FOR HELP

• Patient expresses suicide thoughts or makes a suicide attempt. • There is evidence of psychotic thinking, hallucinations, or

severe obsessive-compulsive behavior including repetitive obsessive thinking.

• There are signs and symptoms of severe malnutrition or serious com- plications including cardiac symptoms, hypokalermia, or renal impairment.

• Patient demonstrates signs of substance abuse. • Staff is in conflict over treatment plan.

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PATIENT AND FAMILY EDUCATION

• Provide information on the long-term effects on the body of anorexia ner- vosa and bulimia.

• Involve family in what symptoms to identify and report. Review with them how to deal with self-destructive behaviors so as not to reinforce them.

• Provide information on the Twelve-Step Program as in Overeaters Anony- mous for dealing with addictions if appropriate. This is helpful for some people with eating disorders.

• Review nutritional information and recommended dietary program. • Teach stress management and relaxation techniques to reduce anxiety, espe-

cially at mealtimes or when feeling need to binge-purge. • Educate patient and family on the need to continue long-term treatment. • For patients who use self-induced vomiting, encourage adequate dental care. • Reinforce need for close medical supervision. • Teach central line care and tube feeding administration, as appropriate. • Provide education on health effects of laxative and diuretic abuse.

CHARTING TIPS

• Document intake and output. • Document description of behavior at mealtimes, purging behaviors. • Document description of interactions with family. • Document patient’s verbalization about his or her body image. • Document all self-destructive behavior. • Review assessment of potential complications, for example, cardiac status.

COMMUNITY-BASED CARE

• Psychiatric follow-up is essential, including family therapy. Referrals need to be made for appropriate treatment.

• Refer for adequate nutritional support follow-up if appropriate, including management of enteral feedings and central line care. If patient is being fol- lowed by a home health agency, encourage referral to dietitian. Home health agency social work and psychiatric home health referral may also be helpful to encourage compliance with psychiatric care, for family support, and for behavioral management.

• Refer patient and family to support groups, if available. • Refer patient to dental care follow-up if patient is vomiting. • Refer patient to Overeaters Anonymous, if appropriate.

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The Morbidly Obese Patient

Learning Objectives • Differentiate obesity from morbid obesity. • Identify potential lifestyle restrictions and prejudices faced by morbidly

obese persons. • Describe effective interventions to enhance self-esteem for these patients. • Identify common emotional reactions of nurses to the morbidly obese

patient.

Glossary Body mass index (BMI) – Describes body weight relative to body fat. It is cal-

culated by dividing weight in pounds by height in inches squared, then mul- tiplying by 704.5.

Bariatric surgery – Surgery performed on morbidly obese to achieve restric- tion in food intake.

Chronic obesity – Life-long overweight condition with few fluctuations. Developmental obesity – Obesity that began in childhood or adolescence

and is often associated with problems of self-concept. Ideal body weight – Standards based on actuarial tables of height and

weight. Morbid obesity – A condition in which an individual is 100 pounds or 100%

over his or her ideal body weight or body mass index of greater than 40. Obesity – Having an excess of adipose tissue and being at least 15% over

ideal body weight or body mass index of greater than 30. Pickwickian syndrome – Extreme obesity in which demands of body size on

a small chest wall lead to cardiovascular and respiratory changes, includ- ing hypoxemia, cyanosis, reduced vital capacity, and pulmonary edema.

Reactive obesity – Obesity that starts later in life and is the result of mal- adaptive coping styles at times of stress such as death of a loved one or leaving home.

The cultural ideal of the thin body has no greater dichotomy than the image of those with extreme obesity, also known as morbid obesity. Although aes-

thetic preferences for body size and shape vary from culture to culture, today the thin, fit body is idealized for both women and men in America. Prejudice against

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the obese has a significant impact on anyone with a serious weight problem, but morbidly obese people often face outright discrimination.

The American population has been steadily gaining weight over the last 30 years. Currently two-thirds of Americans are classified as overweight and 30% as obese (National Health and Nutrition Examination Survey, 2000). Extreme or morbid obesity is seen in only a small percentage of the population, but its impact on health care is great because of the multiple medical compli- cations caused by this condition. BMI is now the standard used to determine obesity because it is more reflective of body fat percentages than the older ideal body weight tables.

Morbid obesity affects all ages and races, although it is much more common in lower socioeconomic groups. Obesity is equally distributed between men and women. Potential health problems include a wide range of chronic conditions, including hypertension, cardiac problems, diabetes, respiratory insufficiency, and joint and back disorders. Risk of death increases with a BMI greater than 30. Nutritional deficiencies are also extremely common because the obese person may lack a well-balanced diet or experience protein deficiencies related to crash dieting. Obesity is not classified as a psychiatric disorder in DSM-IV-TR, but because of the emotional factors associated with it, it may be considered under the psychiatric diagnosis Psychiatric Factors Affecting Medical Conditions (Townsend, 2006).

Society often views these individuals as undesirable. They may be abused by strangers and treated with contempt by family members. Even health-care pro- fessionals may view them as emotionally disturbed, even though there is no increased incidence of psychopathology in morbidly obese people. Others may view these individuals as lazy, unkempt, and lacking in self-control. Many experts promote viewing these individuals as having a chronic illness rather than a cos- metic problem.

Morbidly obese people face discrimination particularly in the workplace because they are viewed as less healthy, less diligent, and less intelligent than their thinner peers. Certainly, with this kind of reaction, it is no wonder that these peo- ple often experience poor self-esteem, feelings of isolation and helplessness, and loss of control.

Morbidly obese individuals often have subjected themselves to many weight- loss strategies, only to regain the weight, which increases the stress on the body. Some studies suggest that individuals whose obesity has persisted for more than 5 years have very limited success with treatment.

Obesity is a complex issue, and any weight-loss program needs to include a multidisciplinary approach. Successful weight-loss programs need to include medically supervised diet and exercise programs, and emotional and social sup- port. When these measures have been unsuccessful, some people pursue surgical interventions, called bariatric surgery. Although many types of surgery for obe- sity have been tried, the most successful today is the vertical band gastroplasty, in which a smaller stomach pouch is created through gastric stapling (Weber & Clavien, 2006). Another procedure is the lap band adjustable gastric banding

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system which is done laparoscopically. An access port is created to adjust the band to restrict or increase food intake. These procedures are generally consid- ered only for people with a BMI greater than 40 or those with BMI over 35 with serious medical complications related to weight.

Some educators have noted that fewer than 50% of health-care professionals advise obese patients to lose weight (Goldsmith, 2000). Some reasons for this low percentage include discomfort about addressing the subject, lack of time to talk with the client, and a belief that this recommendation will not make any differ- ence. Yet a client is three times more likely to try to lose weight if he or she is advised to by a health-care professional. However, extremely obese people may avoid regular medical care because of shame about their weight.

ETIOLOGY

Extreme obesity is a complex problem, and its etiology is probably multifactoral. Most often it begins early in life.

The biological view considers that early onset is related to childhood develop- ment of large-size adipose or fat cells. The cellular hypertrophy results from increased food intake and decreased energy expenditure. Other factors may include impaired hunger-satiety mechanism in the hypothalamus and endocrine disorders, leading to slower metabolism or changes in insulin or cortisol produc- tion. The set point theory focuses on the body as being programmed to maintain a certain level of fat stores. This could explain why some people gain weight so easily. Genetic studies have found that 60% of obese subjects have at least one or both obese parents (Galzis & Kempe, 1989). A protein called leptin has been identified to contribute to delayed satiety in some people.

Psychoanalytical theory views obesity as an expression of an intrapsychic con- flict that occurred during the oral stage of psychosexual development. Unmet needs and stress in an infant can lead to overeating to decrease anxiety, express hostility, and compensate for lack of love. Unmet oral needs may contribute to behaviors such as being demanding and impatient. Weight can provide a shield against intimacy. This can explain why individuals who lose large amounts of weight without adequate psychological support may experience intense anxiety and feelings of vulnerability.

Learning theory looks at how overeating occurs in response to tension, stress, or boredom. This can be a learned behavior from childhood, when parents used food as a source of reward and attention. Increased obesity has also been found in people with a history of sexual trauma. Large size can be an unconscious mechanism for defense against an abuser. Binge-eating disorders may also be present. These individuals may use food as escape from stress and depression. Problems with bingeing are the most common reason for seeking counseling asso- ciated with being overweight.

Sociocultural factors must be included because food and eating are such important parts of our society. Social customs are often centered on food. Meal- times may be an important part of family life and family traditions.

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RELATED CLINICAL CONCERNS

Sedentary lifestyle, possibly related to a medical condition that limits mobility, is a significant factor in developing morbid obesity. In addition, treatment regimens for some conditions may increase the risk of severe obesity. Steroids can quickly contribute to increased adipose tissue development, and some antidepressants, antipsychotics, and estrogens can cause weight gain.

Obesity is particularly associated with heart disease, hypertension, and increased total cholesterol.

LIFE SPAN ISSUES

Children and Adolescents The rate of childhood obesity has dramatically increased in the past 30 years. At least 15% of American children and adolescents are obese (National Health and Nutrition Examination Survey, 2000). Obesity in childhood is linked to obesity in adulthood (developmental obesity). In addition, obesity in adults in the child’s life contributes to childhood obesity. The child may learn to use food for com- fort, solace, reward, and love. Some other contributing factors include more sedentary lifestyles with emphasis on television and computers, fast foods high in calories and fat, and reduction in sports programs in schools. Obese children are often seen by others as sloppy, less intelligent, lazy, and less likeable. Obese chil- dren are often victims of teasing and social isolation, adding to poor self-image and causing these children to retreat to food as a coping mechanism. Poor self- image often remains throughout life regardless of the person’s educational or vocational success. Childhood growth spurts may resolve some overweight ten- dencies, but other children go on to be morbidly obese. Weight loss in children must be approached cautiously to prevent nutritional imbalances.

Older Adults A past history of obesity is the major contributor to obesity in elderly people. An increased sedentary lifestyle as a result of failing health or medications, or poor nutrition because of low income, low energy, or depression also contribute.

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POSSIBLE NURSES’ REACTIONS • May view patient as sloppy, lazy, weak, lacking impulse control, mentally ill • May feel overwhelmed and hopeless with patient’s problems • May resent the demands placed on the staff with the increased workload

created by patient’s size and need for special equipment • May tend to focus on patient’s size rather than view him or her as an indi-

vidual with unique feelings • May feel guilty for these negative feelings

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ASSESSMENT

Behavior and Appearance • Binge eating, secretive night eating, hoarding food • Repeated dieting • Dressing in large, oversized clothing • Sedentary lifestyle, may avoid chance to exercise • May exhibit night eating syndrome with cycle of insomnia, increased

hunger, eating large amounts, morning anorexia

Mood and Emotions

• Depression • Difficulty being assertive • Guilt, shame associated with overeating • Strong emotions that trigger need to eat • May feel hopeless, overwhelmed, out of control • Unrealistic expectations, leading to disappointment

Thoughts, Beliefs, and Perceptions

• Finds many powerful meanings in food, such as comfort, love, and security • Distorted body image • May see self as thinner, possibly indicating denial, or larger than true self • May respond to external cues and thoughts rather than hunger in deciding

what and when to eat • If weight is lost, possible fears of success or intimacy on an unconscious

level when patient can no longer hide behind the weight

Relationships and Interactions

• May lack social skills • May avoid social situations for fear of rejection • May cover feelings of rejection by joking

Physical Responses

• Hypertension • Diabetes • Arthritis, trauma to joints and back • High serum cholesterol

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• Cardiac disease • Malnutrition • Fatigue • Dyspnea on exertion • Pickwickian syndrome includes sleep apnea, daytime somnolence related to

carbon dioxide retention, and symptoms of congestive heart failure

Pertinent History • Multiple attempts at weight loss • Childhood obesity • Chronic illness • History of obesity and sedentary lifestyle

COLLABORATIVE INTERVENTIONS

Pharmacological The drug traditionally used in weight-loss programs is amphetamine. It is included in many over-the-counter “diet pills” even though they have been of lim- ited benefit in suppressing appetite. In addition, they frequently have adverse side effects, including hypertension, stroke, and renal failure. Antidepressants such as sertraline (Zoloft) and fluoxetine (Prozac) have a side effect of anorexia and have been used with success in long-term weight-loss programs. They also reduce irri- tability associated with depression.

Searching for weight-loss drugs is the focus of much research. New weight loss drugs include sibutramine (Meridia), which suppresses appetite by blocking serotonin and norepinephrine; and orlistat (Xenical), which reduces absorption of 33% of dietary fat. In 2007, orlistat was released as an over-the-counter version called Alli. Both drugs have significant side effects that limit their use including depression and anxiety. Phentermine, an appetite suppressant, has been available for many years and is used in many over-the-counter weight-loss products.

Administering any medications to morbidly obese people requires extra cau- tion because some may require dose adjustments. Some medications may need to be given in higher doses because of the increased body weight, whereas other drugs, such as theophyllines, may need to be administered in lower doses because the metabolism of the drug is affected by the patient’s lower protein or higher fat stores. Check with the pharmacist for specific information on the chosen drug. The route of administration can also affect absorption and distribution of the drug. Drugs administered intramuscularly may not be absorbed if the needle does not reach the muscle. If the medication is deposited in fat tissue, its absorption is slowed and onset of action may be delayed. Intravenous administration may be the most effective route. Because IV access is often difficult, central line insertion may be the most efficient.

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Dietary Beginning and maintaining a weight-loss program in morbidly obese people requires close medical and dietary supervision. It must be remembered that even large persons can still be malnourished, and proper balance in the diet must be addressed. A complete nutritional assessment needs to be done. Patients with medical problems require very close supervision to maximize outcomes.

NURSING MANAGEMENT

SELF-ESTEEM, DISTURBED evidenced by negative self-image, feelings of powerlessness related to feelings of self-degradation and response of others to the obesity.

Patient Outcomes • Verbalizes positive traits about self • Verbalizes concerns to nurse • Demonstrates fewer self-critical remarks • Participates in self-care

Interventions • Avoid preaching or criticizing about need for weight loss; these

approaches will only increase patient’s negative feelings and sense of hopelessness and powerlessness.

• Provide privacy and treat patient with modesty. Be aware that patient may be extremely sensitive to having body parts exposed.

• Have extra help available before turning or ambulating a patient to pre- vent falling and help patient feel more secure.

• Have adequate-sized and reinforced equipment such as wheelchairs and beds to avoid embarrassment of squeezing patient in to accommodate your equipment. Check to see if patient has own custom wheelchair. Have family bring clothing from home if hospital gowns are inadequate.

• Recognize that patient may feel very anxious about being stared at by strangers, particularly in a hospital situation. Prepare other departments for patient’s appearance and needs.

• Listen for cues as to how patient views self and appearance. If patient makes self-deprecating remarks, explore these feelings. Focus on positive traits other than body size. Patient does not need to be reminded of his or her large size.

• Give patient the opportunity to share feelings. He or she needs to be viewed as an individual and encouraged to identify feelings.

• Explore use of makeup, hairstyle, and dress, as appropriate, to increase feelings of self-esteem.

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• Encourage the patient’s participation in treatment plan to avoid passiv- ity. Provide encouragement to make decisions about all aspects of care. Work with patient to problem-solve ways to maintain participation.

• Assess patient’s support system and encourage his or her involvement.

NUTRITION, IMBALANCED: MORE THAN BODY REQUIREMENTS evidenced by morbid obesity related to excessive intake, emotional factors, or altered health maintenance.

Patient Outcomes • Begins to identify feelings or thoughts that contribute to overeating • Demonstrates changes in eating patterns • Identifies one short-term goal to attain • Demonstrates nonfood-related coping mechanisms

Interventions • Assess patient’s condition and priorities of care before assuming that

treatment plan should include weight loss. Patient must be involved in deciding if weight loss is a realistic objective at this time. Patient motiva- tion is essential to the success of a weight-loss program.

• Obtain baseline weight. Identify scales adequate to handle patient’s weight beforehand. Also, consider using two scales or, in the hospital set- ting, use a bed with adequate built-in scales.

• Assess the patient’s eating patterns and typical daily intake. Provide a supportive environment so that patient can feel secure to be honest. Rec- ognize that patient may feel need to minimize his or her intake.

• Assess patient’s knowledge level about eating patterns. Be alert to beliefs held about weight and weight loss by patient and family. For instance, patient may say that the entire family is “fat” or “it’s genetic.”

• Assess skin and mobility. Patient may be prone to skin breakdown and complications related to poor mobility or hygiene.

• Identify coping mechanisms to deal with stress and anger that do not involve food, such as taking a walk, deep breathing, or talking to a friend. Give patient feedback on alternative coping mechanisms and iden- tify the link between stress and desire to eat.

• Focus on short-term goals to identify successes in weight loss or improved mobility. Help the patient identify nonfood rewards when goals are met.

• For the patient at home, explain that removing easily accessible high-fat and high-calorie foods from the house will lessen temptation.

• Assess family involvement. Recognize that family can consciously or unconsciously sabotage weight-loss plans by exposing patient to old eat- ing habits. Encourage the family to eat foods similar to those eaten by the patient for shared meals.

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ALTERNATE NURSING DIAGNOSES

Activity Intolerance Body Image, Disturbed Coping, Ineffective Gas Exchange, Impaired Health Maintenance, Ineffective Noncompliance

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WHEN TO CALL FOR HELP

• Patient experiences serious complications from diabetes, hyperten- sion, or heart disease.

• Patient expresses desire to start a potentially dangerous quick weight loss program.

• Patient exhibits signs of severe depression or self-destructive behaviors. • Patient demonstrates signs of substance abuse.

WHO TO CALL FOR HELP

• Weight loss specialists • Internist • Psychiatric Team • Social Worker

PATIENT AND FAMILY EDUCATION

• Provide information on starting an exercise and weight-loss program. • Strongly encourage patient to maintain medical supervision for any weight-

loss or exercise program. • Provide information on behavior techniques for weight loss, such as eating

slowly and serving smaller portions. • Teach patient to become more aware of body signals of hunger and satiety. • Teach appropriate exercises within patient’s ability. Explain that even mini-

mal exercise, such as short walks several times a day, can help reduce weight and promote health.

• Teach patient how to monitor for possible complications such as diabetes and cardiac problems.

• Give family information on weight loss, nutrition, and ways to support patient’s health.

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• Consider focusing education on reducing medical complications and increasing activity rather than just weight loss.

• Teach coping mechanisms to reduce anxiety that do not involve food. • Encourage patient to continue in psychosocial support program after weight

loss is achieved to learn skills to deal with new image.

CHARTING TIPS

• Document baseline weight, mobility, and skin condition. • Document response to activity. • Document eating patterns. • Note coping mechanisms in response to stress. • Note indications of motivation regarding treatment.

COMMUNITY-BASED CARE

• Provide referral information to support groups such as Weight Watchers or Overeaters Anonymous as appropriate.

• Encourage nutritional and medical follow-up. • Assess whether patient needs assistance with transportation to medical care. • Provide information to home health agency or other health-care providers

on patient’s special equipment needs and other concerns.

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Problems Within the Family

Family Dysfunction

Learning Objectives • Differentiate between traits of functional and dysfunctional families. • Discuss the role of systems theory related to the family. • Describe the signs of caregiver role strain. • Identify effective nursing interventions to help the family cope with the

illness of one of its members.

Glossary Family dysfunction – A family that develops ways of interacting with one

another that leads to impaired functioning, both among the members and outside the family boundaries.

Extended family – Family network beyond family of origin, including step- parents, grandparents, aunts and uncles, and others.

Family – Two or more individuals who depend on one another for emotional, physical, and economic support

Family of origin – Family into which one is born or adopted.

As the basic unit of society, the family is the most important influence on shap- ing who we become. The traditional nuclear family, with two parents and

child or children, has undergone tremendous changes in the last few decades, and some of these changes will affect generations to come. Changes from 20 years ago include increased likelihood to be smaller, presence of multiple wage earners, required child care assistance, and the presence of stepchildren. According to the

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most recent U.S. census data available, less than 25% of all U.S. families fit the description of a traditional nuclear family. This is down from 44% in 1960. The 2000 U.S. census showed a 25% increase in female single-parent households and a 62% increase in male single-parent households since the 1990 census. Single- parent households represent the single biggest change in U.S. family life. Chang- ing economic needs, changes in women’s and men’s roles, and a decreased tendency to accept unsatisfactory relationships have contributed to a high divorce rate and significant changes in family structures. Economic changes in the United States have been a major contributor to the changing American family. This is seen in more women working, the need for childcare, young adults still living with their parents, and senior adults moving in together or with other fam- ily members (Casper & Haaga, 2005).

Another new trend is the great increase of never married mothers (Casper & Haaga, 2005). Single-parent households, stepfamilies, childless couples, and a variety of combinations of cohabiting individuals are increasing. These new fam- ily constellations are increasingly accepted in our society (Friedman, 1998; Thornton & Young-DeMarcko, 2001; Harmon Hanson, 2005). The increasing presence of immigrants from a variety of countries also influences families with linguistic diversity and cultural conflicts between generations.

Stresses caused by relationship adjustments can influence one’s health status. Also, a change in the health of any member of the family can create family dis- organization or even a crisis when roles, patterns, or routines must be restruc- tured. Anger, guilt, and denial may all occur as the members try to adapt.

Even in families that function satisfactorily, an illness may cause a tremendous crisis as the family shifts life patterns to meet the demands created by the illness. A family member may need to take on the added demands of being a caregiver to an ill person at the same time as he or she is handling other major family responsibilities. Even the healthiest functioning family may enter a crisis period in response to a devastating illness or death. Relatives may need to move in, which changes the social structure of the family, or the family may need to out- lay large amounts of money to provide extended care, affecting the family’s future goals. Changes in health of parents and siblings from one’s family of ori- gin and extended family may require helping with caregiving.

Because of the impact illness has on the family and the family members have on the patient’s recovery, members need to be involved in the patient’s treatment plan. Family response can represent a major source of stress to the nurse as fam- ily conflicts and dynamics are acted out. Family members’ own fears, lack of sleep, conflicts with each other, and loss of emotional support can all contribute to their sense of isolation and possible mistrust of healthcare professionals.

ETIOLOGY

Bowen’s family system theory, developed in the 1950s, views the family as a homeostatic system of relationships. This theory remains generally accepted. A

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change in functioning of one member results in compensatory changes in the other members in an attempt to maintain equilibrium. For example, when a fam- ily member becomes ill, other members will adapt to fill the roles of the ill mem- ber while he or she is sick. The family system is always changing as it adapts to internal and external stimuli in its attempt to remain stable.

All families have unwritten, covertly expressed rules, such as “conflict is wrong,” and roles, such as “Dad makes the final decision.” These covert roles are often more obvious when the family copes with stress and often requires an enor- mous amount of adjustment when roles must be reversed. For example, if the father, who makes all the decisions, becomes ill, a normally dependent member may accept more of the decision-making responsibilities, reversing the established roles. If past relationship problems do not support the changes, family members may exhibit unhealthy behaviors such as anger (possibly directed at the hospital staff) and guilt. The illness can also exacerbate any relationship problems among other family members.

In stressful situations, family members may exhibit behaviors that seem to tem- porarily help the relationship while they focus on the current crisis, reducing the anxiety and intensity of existing relationship problems. Some of these attempts at solutions can create more stress for a family member. At times, one member is identified as the “problem” and the rest of the family focus attention on that mem- ber and his or her problem. This is called scapegoating and allows the family to avoid confronting the real conflicts within the family. For example, parents with marital relationship problems may focus their attention on their child’s behavior problems rather than their own.

Breakdown in family function occurs when dysfunctional communication is predominant and rules of communication are ambiguous (Goldenberg & Gold- enberg, 2004).

RELATED CLINICAL CONCERNS

The family can play a key role in how a person responds to illness. Support and love from family may encourage a patient to concentrate on healing and strengthen his or her will to survive. In some families, however, the sick individ- ual may be viewed as dependent and unacceptable, reducing his or her will to sur- vive and remain a burden to the family.

LIFE SPAN ISSUES

Children The family represents the young child’s whole world. The family ideally gives the child a supportive environment in which a sense of trust and seeing one’s self as a separate, competent person is developed. As the child grows, the world expands

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outside of the family, exposing him or her to new ideas, conflicts, and inconsis- tencies. Separation from this comfort can create an enormous amount of stress for both child and family.

Other outside factors may influence this separation anxiety. Because more and more children are being cared for by babysitters or in day care, adjustment to an environment outside the home may be less stressful. However, if the child has experienced a loss of a loved one, such as through death or divorce, separation may be even more stressful.

The great increase in the number of stepfamilies has created new, compli_ cated relationships. Children must adapt to new family members, yet maintain relationships with parents, siblings, and others. The last few decades have also seen an increase in the number of single fathers and men involved in child rearing.

Middle Age Sandwiched between caregiving for younger family members and older family members can create added burdens at a time of life when the individual had hoped to be free of extra responsibility. Bringing in parents or other older rela- tives into the home can create more burden, especially if they have health con- cerns. However, these older adults can also contribute to the family for emotional and possible financial support (Casper & Haaga, 2005).

Older Adults With today’s longer life expectancies, older people are more likely to become incorporated into new families as they remarry, cohabitate, or maintain some type of group living situation. Adjusting to a new spouse’s family at an advanced age can be a challenge because adult children may be ambivalent, or even resent- ful, about their parent’s new relationship. These new relationships can create some major relationship problems within the families and may result in very dif- ficult situations when the parent becomes ill.

The need to care for sick elderly relatives is also a source of family relation- ship problems. Today, because many families do not have one member who stays at home and has the ability to care for an ill parent, caregiving can become a tremendous burden, both physically and financially. The caregiver may be faced with overwhelming guilt and, possibly, anger. An ill parent may be viewed as an intrusion into a family already overwhelmed with caring for the children with both parents working. If an elderly person with a chronic illness is admitted to the hospital, it is essential to assess how well the family is coping with the situation and how well they are able to care for the elderly person. In the home, be aware of what family members are trying to verbalize. Sometimes they would like more assistance but hesitate to ask for it because they are too afraid or feel guilty.

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ASSESSMENT

Each family exhibits unique behaviors related to the normal roles established within the family. Some of the common problem behaviors are listed in the fol- lowing section.

Behavior and Appearance • May exhibit behaviors that isolate others from family interactions. • Change in behavior patterns when in the presence of various family mem-

bers. • May exhibit a defensive response to staff members. • May consistently place blame on others. • May exhibit a lack of empathy toward the ill family member. • May exhibit a lack of congruence between verbal and nonverbal com-

munication. • Some family members may be open and realistic about diagnosis, treatment,

and prognosis, and others may deny any problem, blame the staff members for the problem, or avoid the patient altogether.

Mood and Emotions • May exhibit contradictory, confusing, or inappropriate reaction to the

situation

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POSSIBLE NURSES’ REACTIONS • May anticipate problems with all families because such problems are so

common • May resent the disruption in routine that may result when family members

want to be involved in patient care • May feel uncomfortable in the presence of family members acting out their

conflicts • May resent the family’s criticisms, which may be their attempt at maintain-

ing control of the situation • May relate patient’s situation to personal family conflicts, possibly causing

uncomfortable feelings • May become overinvolved with a patient’s family and experience the emo-

tional highs and lows related to patient’s progress and family response • May incorrectly view a family as dysfunctional if their relationship styles

differ from the nurse’s past experience in a family • May feel overwhelmed with dysfunctional family’s problems

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• May be unable to express or display feelings • May avoid emotional situations

Thoughts, Beliefs, and Perceptions • Family may indicate inaccurate or unrealistic beliefs about the patient’s con-

dition or prognosis or one’s ability to provide adequate care. • Family may be operating on the basis of myths or inaccurate beliefs that

impede care. • Family may think it is wrong to share concerns with others. • Family may focus on personal reactions to the patient rather than objec-

tively viewing the patient’s needs.

Relationships and Interactions • Roles among family members may be rigid. • Individual family members may do anything to placate others to prevent an

angry response or rejection. • Family may have difficulty managing conflict. • Family may be in a state of constant conflict. • Family may pay undue attention to the ill family member. • Family may appear to get along well when the history suggests that rela-

tionship problems have existed in the past. • Family members may evade opportunities for communication. • Family may avoid visiting or having contact with the patient. • There may be inappropriate or miscommunication among family members.

Communication may be unclear, nonspecific, or indirect. • One family member may take the lead in defining the needs of the patient

and family, or several members may jockey to assume the lead role.

Pertinent History • History of child abuse, domestic violence, elder abuse, or family conflict • History of psychiatric illness or substance abuse • Recent losses or deaths in the family and past significant losses or trauma

COLLABORATIVE MANAGEMENT

Family Therapy Family therapy can be an important treatment to assist the family under stress. When problems such as a psychiatric disorder, abuse, marital conflict, and sub- stance abuse are present, a therapist can assist the family in dealing with the cur- rent stressor and finding more long-term solutions to their relationship or adjustment problems. Therapists may meet with all the family members or limit meetings to a few key members. Young children can also be included.

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Social Services Social service agencies can investigate needed support services for families in dis- tress on either a long- or short-term basis. They can direct the families to agen- cies that may provide additional finances or extra help, such as Meals on Wheels.

NURSING MANAGEMENT

INTERRUPTED FAMILY PROCESSES evidenced by inability to meet demands of its members, avoidance of making decisions, inappropriate com- munication between members related to impact of ill member on family sys- tem, dysfunctional family processes.

Patient and Family Outcomes • Participates in treatment planning and care of ill family member • Identifies resources available to assist family in coping • Acknowledges diagnosis and prognosis of ill family member

Interventions • Identify the family constellation, patterns of family interactions, and fam-

ily leaders. Assess the ways in which the family members interact with each other and the patient’s response to family involvement. Determine from the patient whom he or she considers closest family and recognize that this could be close friends rather than relatives. Avoid making assumptions about whom the patient wants involved.

• With a large family, consider asking them to identify one member who will get the information on the patient’s condition and take the responsi- bility to share it with the rest of the family. This avoids the need for mul- tiple calls for information.

• As appropriate, ask the patient whom he or she wants to be involved. • Involve these family members in treatment plan. Inform them of what is

happening according to patient wishes. Take the time to orient family to agency routines and visiting hours.

• Identify family support systems within the family. • If family members exhibit disruptive behaviors, evaluate the underlying

reasons. Talk with patient and family to determine the cause. • Analyze the family’s ability to care for the patient and what they need to

know when caring for the patient at home. Encourage family involve- ment in basic care needs if acceptable to patient. Involving the family in the care can help the patient accept his or her condition. For example, having the spouse care for a condition such as a colostomy can give the patient a sense that he or she is not disgusted by patient’s body.

• If patient does not want family informed of his or her condition, talk with patient to identify reasons and fears. Not including the family may

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be a way of maintaining denial. Respect the patient’s wishes, but con- tinue to talk regarding the risk of social isolation. If patient is seriously ill, one person will need to be identified who knows his or her wishes.

• If family wants information withheld from the patient, discuss their fears. Point out that hiding the truth is not helpful to the patient. Dishonesty inhibits future trust and communication. Help family acknowledge their fears. However, recognize that certain cultures have strict rules concern- ing sharing bad news with loved ones, especially a parent. Avoid becom- ing angry at this situation and alienating the family. The family could distrust the healthcare team and block communication channels.

• Regularly assess the family’s awareness of patient’s condition and expec- tations for recovery and future treatment. Avoid use of medical jargon.

• If the family seems to avoid involvement in the patient’s care or treatment plan, determine the reason. Consider giving them one task to do at a time to encourage their involvement without being overwhelmed.

• Encourage the family to verbalize their feelings about the illness. Respect their need for privacy to express emotions. Encourage family to leave patient’s room to discuss areas of conflict. Use open-ended questions to promote sharing of feelings and concerns about problems with family interactions.

• Allow flexibility in visiting, if possible. Recognize the need for family members to spend the night and for young children to be allowed to visit. As needed, set clear limits on disruptive behavior, and limit the number of visitors to reduce stress and fatigue on the patient. Encourage visitors to coordinate who will visit on certain days and times.

• As needed, organize a care conference with family members to discuss patient’s care needs and any conflicts the family and staff may be having. Avoid having too many staff members in attendance because this could intimidate family. Focus on reassuring the family of the care and concern of the staff for the patient. Consider involving physician, social worker, or clinical nurse specialist to help intervene if conflicts continue.

• Acknowledge and facilitate family strengths. Promote self-esteem of indi- vidual family members by acknowledging their skills and influence on patient (“Your spouse really perks up when you visit”).

CAREGIVER ROLE STRAIN evidenced by difficulty performing caregiving activities, inability to meet other family responsibilities, depression, and anger related to multiple losses and burdens associated with caregiving responsibilities.

Patient and Family Outcomes • Expresses frustrations assertively • Provides safe care to patient • Maintains personal needs along with caregiver needs • Identifies resources available for assistance

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Interventions • Assess caregiver’s ability to meet the demands of the patient’s care. Iden-

tify coping mechanisms and support systems available. • Allow caregiver the opportunity to share feelings and concerns away

from the patient. Reinforce the need to express concerns and emotions. Give caregiver permission to express negative feelings, such as anger and resentment. Provide supportive, safe setting to do this. Reinforce the idea that negative emotions are normal to reduce feelings of guilt.

• Encourage caregiver to be assertive in asking for assistance. Reinforce that others may not know what caregiver’s needs are. This is especially important if the caregiver tends to demonstrate martyr behavior.

• Be aware of outside stressors on family members influencing their reac- tions. Fatigue and working long hours with an ill family member can contribute to ineffective coping mechanisms. Talk with them about pos- sible resources to reduce stress, including enlisting other family members to help, reducing expectations, and hiring outside help.

• Assess caregiver’s expectations. Encourage caregiver to have realistic expectations of what he or she can do.

• Remind the family that past conflicts do not disappear even when some- one is ill. When family members must spend long hours providing care, resentments can increase. Encourage the family to concentrate on dealing with the immediate stressor while taking steps to work on unresolved conflicts once the situation has resolved sufficiently.

• Encourage the caregiver to develop a routine to care for his or her own needs of sleep, eating, and socializing to effectively care for the patient. Enlisting other family members or hiring outside help can provide the needed break. If the caregiver is unable to get out, help him or her iden- tify ways of maintaining contact with friends by regular phone calls, let- ter writing, and e-mail.

• At times families “promise” a loved one they will never put him or her in a nursing home. Talk openly about how these promises are sometimes made without realizing the full scope of the situation.

• Give caregivers recognition for the good job they are doing. • Be alert to caregivers’ signs of increasing distress including depression,

suicidal risk, hopelessness, and signs of potential physical and emotional abuse of the patient.

ALTERNATE NURSING DIAGNOSES

Anticipatory Grieving Ineffective Family Coping: Compromised Knowledge, Deficient Noncompliance

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WHEN TO CALL FOR HELP

• Indication of family not acting in the best interests of the patient, such as taking patient out of hospital against medical advice or pushing inappropriate treatments.

• Any indication of abuse within the family must be reported per agency policy and state law.

• Indications that patient is not being cared for adequately include poor hygiene, pressure ulcers, poor nutrition, and dehydration.

• Be alert for destructive behavior within the family, such as substance abuse, attacking each other, or demoralizing patient.

WHO TO CALL FOR HELP

• Social Worker • Local Family services agencies • Child or Adult Protective services agencies

Sexual Dysfunction Sleep Pattern, Disturbed

PATIENT AND FAMILY EDUCATION

• Provide specific information about patient’s illness and care needs, such as pamphlets, videos, and other patient education materials. Make sure these materials match family members’ reading level and language.

• Review with family members what to expect from patient’s illness and how it may affect communication and coping within the family. Let them know that family problems can get either worse or better during this time of stress.

• Reinforce the need for family members to maintain own self-care routines and to be aware of signs of stress that may lead to them being sick.

• Provide information on support groups and group education programs as well as appropriate Web sites.

• Work with caregivers to develop routines that will make the care as easy as possible. For example, setting up the patient’s room at home on the first floor of a two-story house will reduce the caregiver’s need to go up and down stairs all day.

• Prepare family for possible course of the illness and anticipated changes in care.

• If the family is planning to hire help, provide suggestions on identifying and managing possible problems, such as the attendant not showing up for work on time or not caring for patient appropriately.

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CHARTING TIPS

• Describe which family members visit the patient and the interactions that occur.

• Document information on family structure, which family members patient lives with, and care resources available.

• Document teaching given to family and include their response to any edu- cation given.

• Describe caregiver’s ability to provide patient care. • Document family awareness of the patient’s condition and diagnosis.

COMMUNITY-BASED CARE

• Involve family in the discharge plan early in the treatment. • Consider a home health referral after the patient is discharged from the hos-

pital to assess caregiver’s ability to provide care. • Provide specific referrals for additional help in the home or alternate care

options. • Provide specific information on appropriate support groups, such as for

family members of people with Alzheimer’s disease, stroke, or drug abuse. Also give information on hotlines or other agencies that may be useful.

• Make sure social worker is involved; consider social work evaluation in the home as well.

• Refer family to a family therapist, if appropriate. • Identify appropriate equipment that will be needed in the home to provide

care (for example, oxygen, hospital bed, and wheelchair). Assist in making arrangements for delivery or refer to social service.

• Communicate with home health agency regarding family communication problems and conflicts that may affect care.

Family Violence

Learning Objectives • Identify suspicious signs of child abuse, domestic violence, and elder

abuse. • Discuss common traits of victims of any type of abuse. • Discuss common traits of abusers. • Identify common nurses’ reactions to abuse.

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Glossary Abuse – Willful infliction of physical injury or mental anguish or the depriva-

tion by the caregiver of essential services. Domestic (intimate partner, spouse abuse) violence – Intentionally inflicting

or threatening physical injury or cruelty to one’s partner. Economic abuse (fiduciary) – Using another’s resources for one’s own per-

sonal gain without permission or making the victim financially dependent on the abuser.

Family violence – At least one family member is using physical or sexual force against another that leads to physical or emotional injury.

Incest – Any type of exploitive sexual experience between relatives or surro- gate relatives before a victim reaches 18 years of age.

Neglect – Deliberate deprivation of necessary and available resources, such as medical or dental care.

Physical abuse – Deliberate violent actions that inflict pain or nonaccidental injury.

Psychological (emotional) abuse – Deliberate and willful destruction or sig- nificant impairment of a person’s sense of competence by battering the vic- tim’s self-esteem and inhibiting normal psychosocial development.

Sexual abuse – Using the victim for sexual gratification when the victim is unable to resist or consent. This includes rape and developmentally inap- propriate sexual contact, incest, and using a child for prostitution or pornog- raphy.

Shaken-baby syndrome – When an infant is violently shaken by the extremi- ties or shoulders, usually out of frustration and rage over the child’s inces- sant crying.

Family violence may be America’s number one public health issue, yet many nurses caring for victims of this type of violence are often unaware that it is

occurring within the families of their patients. Child abuse, domestic violence (also called intimate partner abuse), and elder abuse can lead to life-long emo- tional and physical problems for the victims and tears away at the very fabric of society as a whole. Carson & Smith-DiJulio (2006) note that 50% of all Ameri- cans have experienced violence in their family. It occurs in all segments of soci- ety. Family violence is often part of the history of violent criminals and runaways.

Victims are often too fearful or ashamed to report abuse, become adept at hid- ing the signs, or use massive denial to convince themselves that the abuse is not that bad, so that a violent family situation often goes unnoticed by outsiders. Health-care professionals must be vigilant to recognize the overt and covert signs of abuse. Every state mandates that suspected child abuse be reported, and some states are enacting similar laws for domestic violence and elder abuse. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) now also

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requires that standards for identifying and providing services to victims of child abuse, domestic violence, and elder abuse be in place (2001). Nurses in all set- tings must be alert to signs of abuse. Home health nurses in particular are in a key role to identify abuse within a patient’s family.

Child abuse includes physical and emotional abuse, neglect, and sexual abuse, and occurs at all socioeconomic levels. Although statistics are difficult to attain, it is estimated that at least 1 million American children are victims of abuse and neg- lect each year (2006 Center for Disease Control and Prevention). The youngest children (less than 4 years of age) are the most vulnerable and the most likely to die from abuse or neglect. Reported cases of child abuse have steadily increased over the last few years, but many cases are not reported. Children are a most vul- nerable segment of the population because they depend on others for all their needs. Parents are the most common abusers. Shaken baby syndrome is a form of child abuse that contributes to infant deaths each year (Center for Disease Con- trol and Prevention, 2006).

Many states have passed laws for safe surrender sites of newborns if a mother is unable to keep her child. Rather than abandoning an infant, mothers can leave the infant at community locations that often include hospitals and fire stations. Many at-risk teenagers who might be pregnant are often not aware of this law, so community education that reaches teens in their communities must be pro- vided to prevent abandonment and often death of these infants.

Victims of child abuse are at an increased risk of becoming abusers as adults. Even though the child may hate the abusive situation, he or she never gets an opportunity to observe healthy parenting or to learn adaptive coping mechanisms to deal with frustration without violence. Other long-term effects include low self-esteem, high risk for substance abuse, tendency toward depression, difficulty trusting in close relationships, and violent lifestyle including crime. An early sign of child abuse in the victim can be abuse of family pets by the child. Children may try to deal with the situation by controlling another being or seeking an outlet for their anger through a more vulnerable victim. Incarcerated youths are frequently victims of child abuse and neglect (National Council on Child Abuse and Family Violence, 2004).

Girls are the most frequent victims of sexual abuse. Eighty percent of sexually abused children know their abuser, and about 50% of cases involve a parent or caregiver (Mulryan, Cathers, & Fagin, 2000). Long-term effects of sexual abuse include fear of intimacy, sexual problems, eating disorders, and an overwhelming sense of powerlessness. Victims may block out the memory of these incidents until later in life, when a major event or trauma triggers memory recall. Exploit- ing children in pornography has been increasing with access to the Internet.

Domestic violence most often refers to men abusing their female partners. However, women abusing their male partners or abuse within homosexual cou- ples does occur. This is an enormous societal problem. Like child abuse, domes- tic violence is found at all socioeconomic levels. It accounts for 22% to 35% of emergency department visits for women (Shea, Mahoney, & Lacey, 1997). Vic- tims of abuse may endure physical, emotional, and sexual abuse. The abuse may

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increase when the woman becomes pregnant if the abuser perceives competition from the baby. The battered woman syndrome refers to the common personality characteristics of these victims. These women are often economically dependent on their spouse or partner, exhibit very low self-esteem, and believe that they somehow deserve the abuse. Pediatricians may be the first to identify this victim because the woman often will not seek medical attention for herself but will seek it for her children. In addition, many times when there is domestic violence in the home, the children are victims of abuse or neglect. The National Council on Child Abuse and Family Violence in 2006 reports that women are more likely than men to be killed by someone they know and one third of female homicide victims are killed by their intimate partner (as compared with only 4% of men). The victim of the abuse may also be the killer in retaliation for past abuse.

One of the most frequently misunderstood factors in domestic violence is why these women remain with the abusers. It is important to understand that they often feel trapped and have little money, resources, or support, and fear being killed or losing custody of or potential injury to their children. Permeating all these factors is the overwhelming sense of powerlessness.

Elder abuse includes neglect as well as physical, sexual, and emotional abuse. Exploitation of the person’s financial reserves by family, hired help, or strangers is also considered abuse. This can occur in the home or in residential facilities. Gray-Vickrey (2000) notes that elder abuse affects 10% of the geriatric popula- tion. This problem is greatly underreported and will continue to increase as the population grows older. One problem in reporting it is the inconsistency of laws defining elder abuse. Some states do not include neglect or psychological abuse in their definition, so it is essential to be aware of how elder abuse is defined in the state where you are working or reside. Because the abuser is often the victim’s caregiver, even including the elderly spouse, victims rarely report the abuse. They fear reprisals or abandonment because they are dependent on the caregiver. Soci- ety’s lack of interest in elderly people may add to the underreporting. Caring for a loved one with a cognitive impairment increases a caregiver’s risk for engaging in abusive behaviors (VandeWeerd, Paveza, & Fulmer, 2005). Elder abuse can also be difficult to detect by professionals because common signs such as bruis- ing and skin tears may be common in older populations. The patient with demen- tia is particularly vulnerable because he or she is unable to speak up or will not be believed because of his or her intermittent confusion.

ETIOLOGY

There are similarities in all types of family violence (Table 17–1). A family his- tory of abuse remains a common thread, particularly in child abuse and domes- tic violence. Childhood exposure to abuse increases a general sense of low self-esteem and reduced ability to deal with frustration, as well as lack of role models to learn to interact in a healthy relationship. Another similarity is the presence of a vulnerable victim.

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Various theories examine what causes a person to abuse another. Psychological theory suggests that abuse provides the abuser with a sense of

power and prestige that boosts his or her self-image. The abuser hates the vul- nerable powerless feelings within himself or herself and is able to block them out by creating (transferring) these denigrated feelings in others.

Sociocultural views examine the role of violence in our society. With easy access to weapons and the frequent exposure to violence from the media, poten- tial abusers can identify violence as a socially acceptable coping mechanism. Another contributing factor is that abusers are often isolated with limited resources for assistance. Alcohol and substance abuse by the abuser also con- tributes by lowering impulses and inhibitions and reducing sensitivity to the impact of their behavior.

Additional traits that contribute to child abuse include a parent who sees him- self or herself in the child, the child not meeting parent’s expectations, and the

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TABLE 17–1 Characteristics of Victims

Type of Victim Characteristics

Child

Spouse/Domestic partner

Elder

• Incest generally begins after 9 years of age • Self-blame for family conflict • Low self-esteem • Fear of parent or caretaker • Cheating, lying, low achievement in school • Signs of depression, helplessness • One child sometimes singled out in family due

to being labeled as “difficult,” product of unwanted pregnancy, reminds the parents of someone they dislike or even themselves, pre- maturity (inhibited parent-child bonding)

• Low self-esteem • Self-blame for batterer’s actions • Sense of helplessness to escape abuse • Isolation from family and friends • Views self as subservient to partner • Economic dependence on abuser

• Older than 75 years of age • Mentally or physically impaired • Isolated from others • Female

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parent’s viewing the child as being there to satisfy the parent’s needs. At times, a parent has no tolerance for normal child behaviors, such as crying, because of the past experience of being unable to express these needs in childhood. So the child’s normal behavior reminds the parent of his or her own unmet childhood needs and unresolved anger toward his or her own parents. There is also a very high correlation with drug and alcohol abuse in this parent. The other parent is usu- ally aware of the abuse but remains unable or unwilling to intervene. That par- ent may unconsciously deny the existence of abuse and is often a victim of spousal abuse. Stepparents may also be abusers as hostility toward the new mate or previous spouse is projected on the child. Incest in the family may be related to sexual problems between husband and wife. Long-term effects for child abuse victims include low self-esteem, difficulty trusting others, anxiety, anger, phobias, depression, and eating disorders.

Domestic violence tends to escalate when the abuser is intoxicated. He or she often displays tremendous jealousy and fears losing the partner. At the same time, the abuser may blame the partner for his or her own problems. Inflicting injury on the woman gives the male abuser a temporary sense of power and esteem. Other factors contributing to domestic violence include the victim’s lack of finan- cial support, belief that the children need both parents, and lack of a social sup- port system.

As noted earlier, elder abusers are often caregivers. These abusers often have limited coping mechanisms and limited support, and are emotionally and finan- cially dependent on the elderly person. Most often, they live with the elderly vic- tim. At times, family members can become abusers as resentment toward the elder’s dependency increases, or as retribution for the elder’s perceived earlier fail- ures as a parent.

Walker (1979) identified the cycle theory of family violence. This theory includes the following stages:

1. Tension building stage: Minor incidents of pushing, shoving, and verbal abuse occur.

2. Acute battering stage: Built-up tension is released by the abuser on the vic- tim, leading to more brutal and uncontrollable abuse. Afterward, the abuser often does not remember the intensity of the incident. The victim is often able to remember the incident in detail without the emotion.

3. Honeymoon stage: The abuser has a sense of remorse that leads to a period of apology, and attempts to make up for the abuse by presents, special treats, and affection. The victim is finally receiving the love and attention she or he so wants and desperately desires to believe there will be no fur- ther abuse. This may allow the victim to forgive the abuser and even drop legal proceedings or plans to report the abuse. Unfortunately, this stage is usually short lived and, without intervention, becomes even briefer over time. The intensity and frequency of the cycle and severity of injuries tend to increase over time.

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RELATED CLINICAL CONCERNS

Neurological impairment and substance abuse can trigger the abuse cycle by dis- inhibiting impulse control in the abuser. Illness may be a risk factor to becoming a victim. Resentments may build from caregiving responsibilities when the poten- tial victim is dependent on the potential abuser. In addition, more violence may be inflicted on the developmentally challenged child.

Early dementia may go undiagnosed by the primary care provider unless ade- quate screening is done, along with communication from family who may be see- ing the early signs (Cotter, 2005).

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POSSIBLE NURSES’ REACTIONS • The most common reaction is anger and disgust directed at the abuser.

These strong negative feelings can cloud the nurse’s assessment and judg- ment, and interfere with selecting appropriate interventions for the abuser.

• The nurse may feel great sympathy for the victim.

• The nurse may also feel anger toward the battered woman who displays powerlessness. May blame her for staying with the abuser or being helpless and become angry if she does not take advice offered.

• The nurse may feel overwhelmed with the family’s problems and helpless to change them, especially if the possible victim denies abuse.

• The nurse may feel intense sadness and distress, which could lead to the wish to save or “rescue” the victim. The nurse may act out these feelings by making promises to the victim that in reality cannot be met or could create an unsafe situation for both of them. This could isolate the victim even more.

• Because abuse may be so upsetting, the nurse may deny evidence or refuse to believe it, especially sexual abuse.

• The nurse may fear reporting abuse because of fear of getting involved, pos- sible legal implications, or reprisals from abusers. The nurse may not want to be responsible for displacing the victim from the family. (Note: most states have Good Samaritan clauses in abuse laws that protect healthcare professionals from liability in reporting.)

• Abuser may intimidate the nurse.

• The nurse may identify with the victim or abuser if he or she has had per- sonal experience with abuse.

• May participate in a conspiracy of silence with others to avoid addressing potential problems.

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ASSESSMENT OF CHILD ABUSE (See Box 17-1 for General Warning Signs of Abuse)

Child Behaviors and Symptoms • History of injury inconsistent with child’s developmental level (for example,

baby turning on hot water) • Failure to thrive; dull or inactive demeanor • Signs of malnutrition, poor hygiene, or lack of health care • Fears discussing how injuries occurred • Lack of reaction to frightening events (for example, being given an injec-

tion) as child has learned to hide fear • Unusual injuries such as cigarette burns, rope burns, spiral fractures from

twisting injury, bite marks • Unexplained retinal hemorrhage, subdural hematoma—can be a sign of

“shaken baby syndrome” • May demonstrate magical thinking that doctor or nurse will know family

secret • Fear of returning home • Apprehension when hearing a child cry because he or she thinks another

child is being hurt • Antisocial behavior, such as lying and stealing • Wearing inappropriate clothing that covers bruises • Bruises or bleeding in external genitalia • Torn, bloody underclothing • Pain on urination or frequent urinary tract infections • Abnormal discharge or odor in genital area, indications of sexually trans-

mitted diseases • Pregnancy in adolescent • Sudden onset of sexually related behavior, such as excessive masturbation,

age-inappropriate sex play, or overseductive behavior • Child being given a variety of gifts or privileges • Change in behavior including depression, anxiety, regression, running away

from home, substance abuse, decline in school performance, inflicting abuse on family pets or other animals

Parental/Abuser Behaviors • Exaggerated or absent reaction to child’s injury • Failure to show empathy for child • Inconsistent explanations of injuries • Care sought for child’s minor complaints but not for more obvious illness

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• Demands to take child home if pressured for answers or refuses hospital- ization

• Explanations not matching injuries; attempts to blame the child • Nonabusing parent refusing to acknowledge even obvious abuse

ASSESSMENT OF DOMESTIC VIOLENCE

Victim • Injuries to head, abdomen, breasts, genitalia • Injuries while pregnant • Patterns left by item used to cause injury such as rope or teeth • Frequent urinary tract infections • Mother of abused child • History of rape • Lack of care for own chronic illness • Demonstrates guilt for seeking treatment • Use of alcohol or tranquilizers to cover hurt • Indicates acceptance of violence as a way to maintain family • Socially isolated with limited financial resources and family support • Implies a sense of deserving abuse • Stress-related complaints of headaches, insomnia, nervousness • Wearing clothes and makeup to cover bruises • Denies abuse or gives explanations that do not match injury

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BOX 17–1 General Warning Signs of Abuse • Delay in seeking treatment for injuries, minimizing injuries • History of being accident prone • Pattern of injuries not accidental looking, for example, identical burns on

bottom of feet, identical injuries on both sides of head • Multiple injuries in varying stages of healing • Conflicting stories from victim and abuser about cause of injury • Inconsistency between history and injury • Unusual, even bizarre explanation for injuries • Repeated visits to emergency rooms or clinics • Previous report of abuse • Patient reporting abuse • Patient fearful of caregiver or partner • Visits variety of doctors, emergency rooms for treatment

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Abuser • Minimizes injuries even when they become life-threatening • Speaks for victim or does not let him or her speak • Controlling, angry • Does not want victim to be alone with healthcare providers • Tends to isolate victim by eliminating his or her social support system • Insists on taking patient back home even if inappropriate • Criticizes or humiliates victim in front of others • Access to guns, other weapons • Abuses family pets • Rationalizes actions (“she deserved it”)

ASSESSMENT OF ELDER ABUSE

Victim • Evidence of malnutrition, dehydration, poor hygiene, pressure ulcers, not

receiving needed medical care • Unusual injuries such as twisting fractures, cigarette burns on face or back,

perforated eardrums from being slapped • Evidence of sexually transmitted diseases, unusual genital injuries • Deterioration in mental status including confusion and depression • Sudden lack of funds in person who previously had resources • Frail, dependent, possible mental impairment requiring care from family

member or hired help • Extreme dependency, attachment to new caregiver • Evidence of inappropriate use of restraints

Abuser • Often lives with victim, lacks resources to live elsewhere • Refusal to allow diagnostic tests, hospitalization • Much younger than patient • Cashes victim’s social security or pension checks • Sudden, intense involvement with patient with little input from other fam-

ily members • Evidence of drug or alcohol abuse or mental illness • Expects dependent elder to meet his or her needs • Caregiver overwhelmed with patient’s care needs, demonstrates frustration

and resentment, isolated with limited assistance • Elderly spouse with dementia • Coerces senior to change will to his or her benefit • Shows no guilt or rationalizes actions

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COLLABORATIVE MANAGEMENT

Psychotherapy Individual and group psychotherapy are often used to treat both victims and abusers. For the victim, individual therapy may focus on the damage done to self- esteem and facing and resolving intense emotions toward the abuser, as well as toward others who may have tolerated the abuse (often the other parent in child abuse). The victim should be removed from living with the abuser before entering treatment to reduce the fear of retaliation. In domestic violence, therapists often recommend that the couple separate for a period of time before starting treatment.

Children who are suspected victims of sexual abuse need to be evaluated by therapy professionals in this specialty. Repressed, traumatic events of the past, such as childhood sexual abuse, may also be uncovered during therapy as an adult. This repressed abuse could be influencing the patient’s current life without his or her knowledge. However, this is very controversial because repressed mem- ories have been found to be inaccurate. Group therapy may also allow the victim to learn from other victims and develop assertive skills.

More intensive psychotherapy or psychiatric treatment may be required for the abuser if psychopathology is suspected.

Because family violence is a symptom of family dysfunction, family therapy is often part of the overall treatment plan. When children are in the home where abuse has occurred, they must be part of the healing process. In addition, support group programs are available for both victims and abusers.

NURSING MANAGEMENT

FAMILY COPING: DISABLING evidenced by child abuse related to history of abuse in the family, lack of resources, isolation.

Child Outcomes • Remains free from injury or neglect • Seeks comfort and assistance from nurse

Parent Outcomes • Seeks assistance for abusive behavior • Demonstrates nurturing behavior toward child • Refrains from abusive behavior

Interventions • Establish a trusting relationship with child and parents. Avoid threaten-

ing behavior or criticizing parents in front of child. See Table 17–2, Inter- viewing an Abuser or Abuse Victim.

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• Observe parent-child interaction closely, especially when both are under stress. Observe caring and feeding behavior. In the home, observe sleep- ing arrangements and environmental conditions.

• Recognize that the child very often will not betray his or her parents. Even in the worst situations, the child may fear losing the only security he or she knows and consequently, will deny any problems.

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TABLE 17–2 Interviewing an Abuser or Abuse Victim

Do Don’t

Conduct the interview in private.

Be direct, honest, and professional.

Be understanding.

Be attentive.

Inform the patient before making the referral to child or adult protective services and explain the process.

Assess for risk of danger and help reduce that risk before discharge.

For Children

Tell the child that the interview is confidential.

Use age-specific language. Ask the child to clarify his or her meaning or words you do not understand.

Tell the child whether any future action will be required.

Source: Reproduced with permission: Smith-Dijulio, K., & Holzapfel, S. K. (1994). Families in crisis: Family vio- lence. In E. M. Varcarolis (Ed.), Foundations of psychiatric mental health nursing. Philadelphia: WB Saunders.

Conduct the interview with a group of interviewers.

Try to prove abuse by accusations and demands.

Display horror, anger, shock, or disapproval of the abuser or the situation.

Place blame or make judgments about the abuser or the victim.

Allow the victim to feel “at fault” or “in trouble.”

Probe or press for answers the vic- tim is not willing to give.

Force the child to remove clothing.

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• Involve the child in treatment plan to increase his or her sense of control. • Demonstrate support, acceptance, and affection of the child. Reinforce

child’s self-esteem by positive feedback and recognition. • If child needs discipline, discuss punishment, and clarify that no physical

abuse will be used. Consider referral for psychiatric or play therapy eval- uation to better understand what is being expressed.

• Encourage play. Be aware that child may be better able to express feel- ings through play.

• Reinforce parent’s strengths, and acknowledge importance of continuing medical care for the child.

• Reinforce positive parenting behavior. Role-model caregiving behaviors for them.

• Avoid hostility toward the parents. At the same time, maintain the child’s safety. If child is at risk for being taken inappropriately by parents, have staff remain in attendance with security nearby and inform the parents of your reasons for doing so.

• If sexual abuse is suspected, child needs to be evaluated by appropriate professionals, including psychologist, pediatrician, gynecologist.

• Be aware of agency policy and state laws on reporting suspected child abuse. Contact supervisor and/or social worker to implement appropri- ate reporting. Participate in collecting evidence, as indicated, and ensure that proper procedures are followed.

• Be sure that supervisors, physicians, and social services are informed when a suspected abuse is reported.

FAMILY COPING: DISABLING evidenced by domestic violence related to vulnerable victim, abuser with family history of abuse, isolated, limited re- sources, and/or intense jealousy.

Victim Outcomes • Acknowledges the abuse • Identifies options to escape abuser • Remains in treatment even if pressured to not obtain care

Abuser Outcomes • Seeks assistance for abusive behavior • Refrains from harming others

Interventions • Establish a trusting relationship with the victim. Avoid displaying shock

or disgust at the story. Encourage victim to share fears and concerns. Ask specific questions to avoid a vague response.

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• Assess the victim’s safety. If there is a risk, implement agency security poli- cies, as appropriate. If victim is in the hospital, restrict phone calls and vis- itors. Consider a pseudonym for the patient’s name. For patients at home, determine need to involve the police and information on legal restraining orders. If there are children in the home, determine their risk of injury. Be aware of state and agency policies for reporting domestic violence.

• Reinforce victim’s self-esteem. Identify positive traits and coping mecha- nisms. Encourage victim to talk about accomplishments and goals.

• Encourage victim’s participation in treatment plan including follow-up with medical appointments. Help victim take control of some areas of his or her life and make some decisions.

• If possible, identify available support systems and determine their aware- ness of family’s problems. Encourage patient to involve some people who can help. Support maintaining regular social contacts.

• Encourage realistic evaluation situation. Do not reinforce denial or avoidance.

• Be aware that during the “honeymoon stage” the victim may not be will- ing to discuss abuse. Describe the cycle of abuse to the victim. Give the victim written information on resources to use at another time.

• Encourage problem solving. Challenge him or her to identify realistic options, and reinforce all efforts to be assertive.

• Encourage talking about events that led up to the abusive event. Dispel any myths of guilt or responsibility for causing or deserving the abuse.

• Be sure that supervisors, physicians, and social services are informed when a suspected abuse is reported.

FAMILY COPING: DISABLING evidenced by elder abuse related to multiple stressors associated with elder care.

Elder Outcomes • Identifies resources available for assistance • Remains safe and without injury • Continues to receive adequate health care

Caregiver Outcomes • Identifies resources available for assistance in patient care • Demonstrates more effective coping mechanisms • Provides safe care to the elderly patient

Interventions • Assess the elderly patient’s condition and determine the role of caregiver

in providing adequate care. Patients with pressure ulcers, dehydration,

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lacerations, and bruises need to be evaluated; however, be aware that these may occur unrelated to abuse or neglect.

• If abuse is suspected, talk with patient and caregiver separately. With the patient, listen to his or her description of the caregiver and any com- plaints he or she may have. Then verify the information, if possible, with the caregiver, other family members, or health-care providers. Establish a trusting relationship with the caregiver by acknowledging positive accomplishments, as well as the stress of caregiving.

• If signs of abuse occur in a long-term care facility, observe patient care routines and the care of other patients. Note the use of restraints and the quality of hygiene provided. In the home, if patient is being left alone while restrained, action must be taken immediately to stop this unsafe practice.

• Provide education to staff in long-term care on identifying and prevent- ing abuse or neglect.

• Recognize that patients with altered mental status may falsely accuse caregivers of abuse. However, every accusation must be evaluated.

• Encourage the patient to be as independent as possible by remaining involved with family and friends, having his or her own telephone, and having neighbors check his or her status regularly. Appropriate inde- pendence will also promote self-esteem and self-reliance. Even in the highly dependent patient, it is important to maintain the individual’s sense of control.

• Encourage problem-solving skills in patient and caregiver. Promote their abilities to find alternate solutions under stress.

• If patient is in an unsafe environment, implement agency policies and state laws as appropriate to determine reporting mechanism and action. If patient refuses to leave environment, determine patient’s ability to make decisions. Involve physician and/or social worker as needed. Con- sider psychiatric evaluation. Involve family and friends if needed to encourage patient action.

• Determine caregiver’s stress level and determine if additional resources are available and would defuse the situation.

• Be sure that supervisors, physicians, and social services are informed when a suspected abuse is reported.

ALTERNATE NURSING DIAGNOSES

Caregiver Role Strain Family Processes, Interrupted Knowledge, Deficient Noncompliance

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Parenting, Impaired Post-Trauma Response Powerlessness Rape-Trauma Syndrome Violence, Risk for

PATIENT AND FAMILY EDUCATION

• Teach effective parenting skills, including appropriate discipline. Abusive parents need skills in disciplining children without violence and often need to learn acceptable outlets for their frustration.

• Incorporate assertive skills to teach potential victims, including young chil- dren, to speak up when rights are violated and learn to say no.

• Teach family members the signs of abuse and how to report it. • Family members need guidelines for hiring caregivers and selecting assisted

living situation. • Teach older adults how to avoid abusive situations by maintaining active

social network, and to seek legal advice before allowing anyone to take their possessions or manage their finances. The American Association of Retired Persons has written guidelines to avoid elder abuse. These can be accessed through the Web site www.aarp.org.

• Teach a victim of domestic violence to identify a plan in advance to leave home when needed. This plan should include having a place to go, setting aside money, and implementing security measures for victim and children.

• When children must be removed from their home, prepare them for the emotional grief response that may occur when they are separated from their parents. No matter how bad the home was, children will still grieve. Be sure they understand that they are not being punished.

• Suspected abusers need information on alternative ways to resolve conflicts. If appropriate, refer them to counselors who specialize in abuse and can educate them on the role of substance abuse and violence.

• Review with victims and abusers the need to involve family and friends for assistance.

• Ensure pregnant and at-risk teens know about safe surrender sites in the community where newborns could be safely dropped off if decision made not to keep the infant. (National Crime Prevention Council website can give more information at ncpc.org.)

CHARTING TIPS

• If abuse is suspected, carefully document, possibly with photos, any evi- dence of wounds, injuries, or poor hygiene. Follow institutional protocols carefully if called upon to participate in evidence collection.

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• Document the nature of interactions between victim and abuser. • Note victim’s reaction to the abuser, especially when discharging patient. • Document victim’s report of abuse. • Document interventions made, including reporting abuse and maintaining

patient safety. • Document any discrepancies between the victim and potential abuser’s

explanation of injuries.

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WHEN TO CALL FOR HELP

• Aggressive, belligerent behavior escalates to violence. • Presence of abuser leads patient to fear of violence or of being

kidnapped. • Abuser is intoxicated. • Abuser intimidates patient or staff. • Victim leaves healthcare agency to return to unsafe environment

WHO TO CALL FOR HELP

• Social Worker • Protective Service agencies • Security/law enforcement

COMMUNITY-BASED CARE

• Provide written information on appropriate resources, including parenting support groups such as Parents Anonymous; parenting education programs; shelters; safe houses; 24-hour local crisis hot lines for abuse or National Child Abuse Hotline (1-800-4ACHILD); and National Organization for Vic- tim Assistance (800-TRY-NOVA). If abuse is suspected and patient denies it, provide the information, and encourage patient to keep it in a safe place. For elder abuse, contact the local Adult Protective Services. Many Web sites are available for assistance including National Clearinghouse on Child Abuse and Neglect (www.ncadv.org), National Council on Child Abuse and Fam- ily Violence (www.nccafv.org).

• Additional Web sites include www.preventchildabuse.org and www.acf. dhhs.gov/programs/cb/

• Provide information on legal referrals and security measures. If police are involved, reinforce information they give to patient.

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• If victim is staying in abusive situation because of fear of leaving family pet, give information on local humane societies that can help with animal care if the victim leaves the home. Veternarians may become aware of abuse when a family pet is injured.

• As appropriate, refer patient for counseling or family therapy. • Refer for home health follow-up to assess home environment. Inform all

referring agencies of concerns about abuse. • Vocational counseling information may be helpful to the domestic violence

victim. • Anticipate caregiver needs in the home and provide adequate support and

equipment. • Discuss day-care options for children or elderly people.

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18

369

Problems with Spiritual Distress

The Patient with Spiritual Distress

Margaret L. Mitchell, RN, MN, MDIV, MA, CNS

Learning Objectives • Define spiritual distress. • Identify some life events and physical changes that may precipitate spir-

itual distress. • Differentiate between religion and spirituality. • Identify effective interventions for dealing with an individual experienc-

ing spiritual distress. • Describe common nurses’ reactions to patients’ spiritual distress.

Glossary Chaplain – Clergyperson who has a formal relationship with a particular

healthcare organization. Religion – A system of beliefs, worship, or conduct. Generally refers to formal,

institutionalized practices. Spiritual distress – A disturbance in the belief or value system that is a per-

sonal source of strength and hope; may be accompanied by an inability to carry out religious practices, possibly creating even more stress because the individual cannot use spirituality to cope with stress.

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Spiritual leaders – Officers and persons who provide spiritual support, includ- ing chaplains, priests, ministers, rabbis, monks, pastors, elders, deacons, mullahs, or hajjis. There is a wide and diverse range of spiritual practition- ers with a number of different titles.

Spirituality or worldview – Beliefs of individuals permeate all areas of their life and influence attitudes, beliefs, values, and health.

All people have a spiritual dimension, regardless of whether or not they partic- ipate in formal religious practices. Spirituality allows us to transcend the self

and connect with people, our surroundings, and powers outside of ourselves. Spir- ituality can give meaning to life and impact the ability to trust, love, and forgive. People need to find meaning beyond their current suffering. This allows them to make sense of that situation (Kellehear, 2000). Spirituality is uniquely human; it is universal and innate (Taylor, 2006). One of the difficulties with the Western view of spirituality is that a separation is made between the “spiritual” and “physical” realms. Other cultures, as well as alternative medicine are less inclined to have such a rigid delineation between these areas. Religion is different from spirituality, although it is complementary. Religion gives us tradition, ritual, and a specific doc- trine. Spiritual distress is an existential crisis in which the beliefs or values around which the person has organized his or her life are threatened. Various events along the health-illness spectrum as well as outside crises could result in an episode of spiritual distress. The events of September 11, 2001, for many, resulted in spiritual distress, because life as it had been known could no longer be counted on to be predictable. This also can be experienced on an individual or family basis as the result of illness or major change in health. Parents’ belief system may be shaken when they learn that their child has an incurable illness or will not recover from an accident. For individuals, it can be learning of a life-threatening illness. When people are faced with these situations, you may hear them say, “Life will never be the same” or “How can I go on living?” The very foundation of their life as they know it is threatened. They may no longer feel safe and able to go about their everyday activities. Some may question their belief in God or other higher power.

Spiritual distress may manifest itself in many different ways. Individuals are a complex combination of biological, psychological, sociocultural, and spiritual parts, all interacting and affecting all other aspects of the individual’s life. An insult to one’s spiritual dimension can affect every other dimension of the indi- vidual and influence the patient’s experience of illness.

Spiritual distress occurs when a person believes that life no longer has mean- ing or purpose, or experiences a sense of hopelessness. Like many other entities that can be viewed on a continuum, spiritual distress may be a temporary, tran- sient phenomenon in a response to a specific stressor or it may be a longer reach- ing event prompting the individual to question or reexamine assumptions and priorities. In a few rare instances, extreme spiritual distress may indicate psy- chopathology. One aspect of spiritual distress is what Mary Elizabeth O’Brien (2003) terms as spiritual pain. This includes a perception of loss or separation from God; the experience of evil or disillusionment; a sense of failing God–the

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recognition of one’s own sinfulness or shortcomings and failings; a perception of a lack of reconciliation with God; and a sense of loneliness of spirit. An example of this is a woman, early in the AIDS epidemic, who following childbirth was given a transfusion of HIV-infected blood. The mother developed AIDS. Her reli- gious community was quite conservative and taught that HIV was God’s punish- ment for those who disobeyed God. This patient and her family experienced not only spiritual pain from a sense of separation and judgment from God but also ostracism from her religious community.

In many ways, spiritual distress can follow a similar pattern to the grief response. Grief over small losses may be short-term, and with proper support, recovery will be rapid. Great losses affect the individual more profoundly and can be seen in changes in the person’s mood, affect, energy level, interest in life, and somatic condition. In the most extreme pathological grief, in which individuals are not recovering, their ability to carry out activities of daily living is greatly reduced and may sometimes require psychiatric hospitalization. Individuals expe- riencing similar events such as death of a close family member may respond in a myriad of ways.

Both grief and spiritual distress deal with loss. The major difference is that spiritual distress disrupts the meaning that governs a person’s life. There may be a perceived or real deterioration or collapse in his or her relationship with a divine Supreme Being, or with persons who represent the Supreme Being. Accord- ing to O’Brien, there can be a deep sense of hurt stemming from feelings of loss or separation from God, a sense of personal inadequacy or failure before God and profound loneliness of spirit (2003).

The presence of stressors does not necessarily predict or cause spiritual distress. The Chinese character for crisis, which is a combination of the symbols for dan- ger and opportunity, helps one to understand this. For some individuals, a stres- sor or crisis, such as a life-threatening illness or tragedy, can ultimately become the source of a tremendously positive experience. Although they readily acknowledge that they would have never chosen such events, they ultimately view them not as traumatic events but as opportunities for growth. In some ways, it parallels a wilderness experience. The arduous physical demands allow an individual to tran- scend his or her immediate surroundings and experience a sense of empowerment that results in the person being better equipped to handle the challenges of life.

Nurses may feel uncomfortable or experience conflict when providing spiritual support if the patient is religious and the nurse is not or if the patient’s expres- sion of spirituality differs from that of the nurse. In addition, nurses may experi- ence conflict with a patient’s belief system, as with a Jehovah’s Witness patient who refuses a life-saving blood transfusion. These are normal responses to the unknown. How one responds to a patient’s spiritual needs depends both on one’s education and background. It is important, however, not to evaluate the patient’s value system by personal standards. According to Stephenson, Drauker, and Martsolf (2003), some individuals find it easier to describe their spiritual life in terms of relationships and connections and disconnections. Relationships, which were used to describe life stories of persons in hospice, applied equally to others as well as God.

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The increased cultural and religious diversity of our society has led to much more diversity of religions in our health-care institutions. Nurses must be open and more sensitive to religious customs that may be foreign to them. Being pres- ent for Hindu prayers, respecting the practices of an Islamic patient, and observ- ing death rituals for an Orthodox Jewish patient are all examples of this. Nurses may need to seek out information on appropriate behaviors for religious groups that are foreign to the nurse.

Patients’ responses to illness have been found to influence nurses’ own spiri- tual beliefs. In a 1994 study by Taylor, Amenta, and Highfield, oncology nurses ranked their patients as a major source of spiritual nurturing. Nurses, however, may have difficulty providing spiritual care because of lack of skill, time con- straints, or fear of being criticized by coworkers. For nurses uncomfortable with religious language and concepts, it may be helpful to approach spiritual distress from a cultural framework. In 1999, the Joint Commission for Accreditation of Healthcare Organizations (JCAHO) added a standard on determining spiritual support services for patients on their admission to healthcare institutions. JCAHO current standards (2007) continue to emphasize spiritual care with par- ticular emphasis on spiritual care for dying patients. Hospice care requires incor- poration of a spiritual assessment and offering of chaplaincy services as part of the Medicare Hospice Benefit. Nurses who work or have worked in this type of setting have more exposure to working closely with chaplaincy and may be more comfortable with addressing spiritual distress. There are many ways that nurses can assist in spiritual caregiving as part of routine nursing care (Box 18–1).

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BOX 18–1 Nursing Activities to Promote Spiritual Caregiving • Promote spiritual readings • Advocate for finding a spiritual leader of patient’s faith • Active listening • Instilling hope • Clarifying values • Touch • Encouraging meditation and prayer • Supporting religious rituals • Promoting being with nature • Advocate for institution to provide spiritual reading material, religious

objects (prayer books, Sabbath candles, incense).

Source: Based on information from Taylor, E. J. (2006). Spirituality and spiritual nurture in cancer care. In R. M. Carroll-Johnson, L. M. Gorman, & N. J. Bush (Eds.), Psychosocial nursing care along the cancer continuum (2nd ed.) (pp. 117–131). Pittsburgh, PA: Oncology Nursing Press.

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ETIOLOGY

Spiritual distress occurs when particular stressors or life events threaten the indi- vidual’s belief system and affect biological, psychological, sociocultural, and spir- itual aspects of life. These stressors may be unique to the individual, or they may be similar to reactions experienced by others after certain shared events such as September 11, 2001. The crisis may have a variety of causes, including loss of a significant person, employment, position, or status; financial reversal; major ill- ness or loss of a body part, or a change in self-image. In some cultures, it may also result from shame. However, what is lost is not as important as the value that the individual ascribes to it.

Cognitive theory looks at the effect of beliefs on feelings, and psychodynamic theory helps one understand the underlying process of spiritual distress. For instance, a great deal of spiritual distress can be experienced, even to the point of affecting physical health, when a person believes that he or she can never be for- given. A person’s belief in the ability to be forgiven may be associated with his or her perception of how others show approval. The individual may accept forgive- ness from God or a higher power in the same manner as forgiveness was accepted from parents because the relationship with God or a higher power is often simi- lar to the relationship with one’s parents.

Psychological theories look at the various dynamics that can result in spiritual distress. A person with a high degree of inner strength, or ego functioning, may experience less spiritual distress in response to a loss than one who has a lower level of ego functioning. The way in which one normally adapts to crises and changes will also influence the risk of spiritual distress. Persons who are inflexi- ble may have more difficulty accepting major changes. Similarly, individuals who are prone to anxiety may feel overwhelmed in the face of major change and have difficulty dealing with it.

Crisis theory considers not only the normal changes in life and life event stres- sors but also looks at the impact of disaster or massive crisis on the individual. Faith or a belief system may help a person to cope with a crisis, but if the crisis is of a high magnitude, the person may feel that his or her belief system is chal- lenged or inadequate and may be of little help.

One of the hallmarks of a disaster or massive crisis, such as a devastating hur- ricane, earthquake, or crash of an airplane, is the enormous sense of an individ- ual’s loss of control and extreme feelings of vulnerability. There may be a sense of betrayal, and the events may be expressed as not being “right.” The individ- ual may reveal a sense of how things “should” be, his or her expectation of the world. The sense of betrayal and anger may be expressed in spiritual terms such as “How could God let this happen?”

A sense of mastery over one’s environment, highly prized in American cul- ture, is threatened when a major crisis occurs. When an individual no longer feels safe in usual activities, a feeling of unease can spread to other areas of life.

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RELATED CLINICAL CONCERNS

Although identifiable traumatic events may precipitate spiritual distress, it is important to be aware of physiological conditions that may exacerbate the situa- tion. Illnesses associated with increased sense of vulnerability and the possibility of death (particularly cancer) may lead to heightened spiritual awareness. Similarly, a patient’s moving from aggressive treatment to hospice care may be accompanied with a number of spiritual issues as one’s mortality can no longer be denied. Pain, suffering, and severe side effects may affect spiritual life. Patients may also have a reduction in the energy they need for their usual means of spiritual coping, such as praying and attending religious services. Advanced, serious illness may stimulate a patient’s wish to repair past relationships and seek forgiveness for past wrongdo- ings. Spiritual beliefs may support or promote these actions.

Although there is no clear relationship between specific disease entities and spiritual distress, a spiritual state can be influenced by biological changes, such as changes in neurotransmitters, endocrine levels, or blood chemistry. Just as there are differences in coping mechanisms, there are differences in the way in which the individual as an organism responds to illness. Even when an event appears to be a precipitant for spiritual distress, biological factors could also be at work. A complete physical assessment and supporting tests can help determine these bio- logic factors. Also there is interplay between the physical disorder and mental well-being. An individual who has not had mental illness or spiritual distress in the past, may be affected by both physiological changes that impact things such as moods and a general sense of well-being, as well as the emotional impact of dealing with change and loss.

Spirituality and cancer has probably been studied the most. A diagnosis of cancer can contribute to spiritual distress because the person questions the pres- ence of a higher power, seeing the disease as a punishment for past wrongdoings. It can also strengthen faith, provide motivation for increased use of prayer and self-exploration (Taylor, 2006).

LIFE SPAN ISSUES

Children Because the belief systems of young children are not as developed as those of adults, children may not be able to adequately verbalize their sense of spiritual distress. Instead, they may present with such physical symptoms as weight loss, failure to thrive, and reversal of developmental milestones. Most frequently their stress is in response to loss of a parent or caretaker or a major change affecting a parent or caretaker. The child can sense the distress of the parent. For example, a young child may not fully understand the impact of death, but he or she can sense, and be negatively affected by, the tremendous distress the loss of a child or spouse can cause his or her caretaker. The child often responds by being more clinging or dependent at times of crisis.

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Signs of distress in older children may be subtle. Some children experiencing depression may act out in different ways. Behavioral problems may be exacer- bated. It is important to pay attention to subtle changes in a child, such as a lack of interest in usual pursuits, withdrawal or isolation, or a decrease in school per- formance. One of the most traumatic events for children is loss of parents or sib- lings by death or divorce. Children may mistakenly believe that they personally caused the loss of the parent and may not comprehend other dynamics at work. Children’s spiritual or religious beliefs are strongly influenced by those of their parents. More questioning of parental values tends to occur when the child becomes an adolescent.

Adolescents Adolescents are generally more able to articulate distress, but they may be hesi- tant to confide in an adult. More aware of the complexities of life and often hav- ing a strong personal moral code, they may be traumatized by the failings of an idealized parent. Loss of parents, siblings, classmates, or acquaintances by death, divorce, or relocation can be tremendously stressful events for the adolescent. Youths whose sexual orientation differs from parental or societal expectation may either act out or experience their crisis in secret. Another traumatic event includes sexual exploitation by peers or adults. Even though sexual activity dur- ing teen years is rising, it may be exceedingly traumatic for the individual. Teens, especially girls, must deal with the dilemma of pregnancy and the changes it will make in their lives and those of their parents. Teens are also vulnerable to life’s tragedies such as the death of a parent, or loss of a peer due to accident or sui- cide, which can lead to questioning of spiritual beliefs and loss of hope.

Because adolescents are so impressionable and idealistic, they are very vulner- able to the influence of cults and religious conversions. The beginning recognition that life is not as ideal and perfect as they once believed may cause individuals to lose hope and question their former spiritual beliefs. And if they unite with a par- ticular belief system, because of their developmental stage, it would be antici- pated that they may see things in absolute terms as “all or nothing” or “black and white”. They may be as receptive to ideas that there may be a mixture of good and bad, or positive and negative attributes.

Middle Age Promoting spirituality in the family and active participation in religious commu- nity with possible leadership roles may be important in this stage of life. Multi- ple responsibilities may affect a person’s time and energy to achieve and meet all the expectations.

Older Adults Later life is a period characterized by extremes. There is tremendous variety in functioning. For some, a significant change in physical or sensory functioning may affect their view of self and their spiritual beliefs. Many individuals experience the

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death of a spouse and friends and changes in residence. Some may depend more on their spiritual life as their acquaintances diminish and limitations grow. Spiri- tual distress in older people often includes questions regarding the afterlife, values, and reflections on the satisfaction and accomplishments of their lives. Forgiveness related to past wrongdoings by themselves or others may become more important.

Religious teachings from childhood may become more important for some in later years as people face changes and losses. However, sometimes attending wor- ship services and participating in religious practices may be more difficult to accomplish because of illness and fatigue or because of changes in mobility or logistics of transportation. It may be that with age they do not have the same level of independence and autonomy that they had during their younger years. The later years can be difficult for those who have not had any particular reli- gious beliefs and have not been affiliated with any religious body.

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POSSIBLE NURSES’ REACTIONS • May not feel comfortable or adequately prepared to help patients with spir-

itual concerns.

• May be influenced by their own background, beliefs, values, and experi- ences, which may differ from those of the patient.

• May react negatively or judgmentally, or distance themselves from patients whose beliefs, practices, lifestyles, or cultures differ from their own.

• May focus attention on religious content rather than assessing other issues that may be the cause of anxiety.

• May attempt to change or argue with religious content of patient’s beliefs.

• May confuse religious with spiritual beliefs.

• May feel powerless when unable to help patients with spiritual concerns. Nurses may distance themselves from patients to cope with their own feel- ings of inadequacy.

• May not understand the meaning of the loss from the patient’s spiritual per- spective and may try to reassure the patient in ways that are not effective or meaningful.

• May resent clergy because of their closeness and ability to meet some patients’ needs.

• Conversely, out of feelings of fear and inadequacy, may refer patients to the chaplain too quickly rather than attempt to deal with the concerns.

• May reassure patients based on their own knowledge of illnesses and fail to hear the patients’ concerns.

• May feel judgmental about individuals expressing spiritual concerns or practices, especially if those concerns are unfamiliar to the nurse.

• May feel anxious when encountering unfamiliar practices.

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ASSESSMENT

Spiritual assessment is required as part of the overall patient assessment by JCAHO. There are a number of models. One model for spiritual assessment is called the HOPE Assessment as discussed in Chapter 3. Spiritual assessment pro- vides the basis for the spiritual plan of care and for communication about the care provided. The purpose of the assessment is to find out how a person finds meaning and purpose in life and identify the concomitant behaviors, emotions, relationships and practices. Fitchett (2002) points out that spiritual assessment is an ongoing process. As the nurse becomes better acquainted with the patient, there is the opportunity to develop a more comprehensive assessment and possi- bly revise a previous assessment. See Box 18–2 for suggestions on questions to ask in a spiritual assessment.

Behavior and Appearance • Often has religious items or literature at bedside

• Frequently quotes from the Bible or other spiritual literature

• May display exaggerated religious rituals or behavior such as reading the Bible excessively rather than talking

• May appear withdrawn and preoccupied with own beliefs, unable to focus on conversations and events in immediate environment

• Makes constant reference to religious themes in conversation

• Asks frequent questions such as “Is this God’s will?” or “Why is God letting me suffer?”

• Lethargic; may exhibit a lack of interest in surroundings

• May be overtly or passively suicidal

• Frequently questions others about their spiritual beliefs

• States that spiritual beliefs are no longer comforting

• Behavior changes, such as increased alcohol use or acting out

Mood and Emotions • Highly anxious • Denies emotions or concerns

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• May feel so stressed, overworked, or overwhelmed by the physical needs of the patient or their own workload that they do not consider the spiritual dimension.

• May have trouble setting personal limits on the role of the nurse and spiri- tual beliefs.

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BOX 18–2 Assessing for Spiritual Beliefs Initial Assessment 1. What is your source of strength and hope and meaning? 2. What is your religious affiliation, and how important is this in your life?

Any recent changes? 3. Is there a clergy person available to you while in the hospital? 4. Are there any religious or spiritual practices that are important to you

while in the hospital? 5. Are there any religious or spiritual articles that are important to you while

in the hospital? 6. Is there any spiritual literature that is important to you while in the hospi-

tal? Is there any religious music which is particularly significant to you? Advanced Assessment 1. Has being sick or in the hospital made any difference in your feelings

toward God or in your beliefs? 2. What has bothered you the most about being sick or in the hospital? 3. What helps you the most when you are afraid or in need of special help? 4. What religious or spiritual idea or concept is most important to you? 5. What did your family believe? What was meaningful and important

to them? 6. What exposure, if any, did you have to religious or spiritual beliefs as

a child? Has that changed? How? 7. Have your religious interests arisen gradually or out of a crisis? 8. Do you have special religious leaders? How do you view them? 9. What would help you maintain your spirituality?

10. Does prayer provide comfort for you? If you pray, about what do you pray? When do you pray?

11. What happens when you pray or meditate?

• Expresses bitterness or anger over perceived abandonment by God or belief that God is causing the suffering

• Appears depressed • Expresses feelings of helplessness or hopelessness • Does not derive enjoyment and satisfaction from formerly pleasurable

activities

Thoughts, Beliefs, and Perceptions • Believes that nothing can help • Exhibits global, all-or-nothing thinking

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• Believes that life is overwhelming and that he or she cannot continue living • Questions long-held beliefs and may doubt his or her faith • Believes that he or she has committed sins that cannot be forgiven • Believes they may be separated from God or a higher power • Is self-absorbed in own belief system • Views self as guilty and in need of punishment • Views self as spiritually superior to others • Believes that a higher power requires suffering and pain and therefore

refuses pain control measures • Views self as having a great mission to accomplish • Claims to hear voices of God, Moses, or other religious figures • Holds omnipotent view of self—a specialness that rests in the inability to be

forgiven by God or higher power

Relationships and Interactions • Feels isolated and alone even in the presence of others • May be so preoccupied that they are unable to interact with others • Withdraws from others who do not share similar beliefs • May experience change in relationship with family or friends who are

involved with religious beliefs • May seek out members of similar religious group for support, caregiving

Physical Responses • Reports increased discomforts • Change in eating or sleeping patterns • May have increase of somatic symptoms and medication-seeking behaviors

Pertinent History • Involved in specific religious groups, cults, or a variety of different religious

groups • History of emotional disorders or emotionally charged previous situations,

such as abortion or catastrophic events

COLLABORATIVE MANAGEMENT

Chaplaincy/Clergy Some health-care agencies have full-time chaplains on staff. Others may have vol- unteer chaplains or links to clergy in the community. Chaplains provide spiritual counseling and are often knowledgeable about community support resources that may be useful for the patient. Working with the social workers, they can help in making funeral arrangements or locating needed services or volunteers.

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Chaplains can help both patients and staff members to find ways to cope with the problem situation. However, not all patients hold clergy in high regard. Some can talk about spiritual concerns more effectively to a nurse. Others may view clergy negatively or with suspicion or fear that they are associated only with bad news, depending on previous life experiences. Also, depending on the situation, the patient may prefer to share concerns with a chaplain other than the one associ- ated with the place where he or she worships.

Clergy are restricted as to what information they can share with nursing staff and others. Like mental health professionals and lawyers, clergy are bound by professional ethics and law regarding what they may reveal of anything told to them in confidence.

Pharmacological Psychoactive substances can influence mood and consequently the way in which the individual perceives the situation and how well he or she functions in responding to it. This can contribute to spiritual distress. Nurses need to be aware of the many prescription drugs that have such effects, such as beta- blockers, steroids, antihypertensives, immunosuppressants, and chemotherapy. Patient’s spiritual or religious beliefs may also influence their acceptance of some medications such as analgesics and psychotropics. Individuals may believe that these medications could block their access to their higher power.

NURSING MANAGEMENT

SPIRITUAL DISTRESS evidenced by questioning beliefs, despair, hopelessness, or inability to practice beliefs related to suffering, illness, or hospitalization.

Patient Outcomes • Verbalizes “I feel better,” “I feel relieved,” “I feel at peace,” or similar

statements • Demonstrates increased social interaction • Reports feeling rested and comfortable • Demonstrates reduced crying or other signs of distress

Interventions • Empathize with patient’s degree of pain or despair. • Recognize that your own personal values and beliefs may not be effective

for others. Be willing to set aside your own beliefs when analyzing the patient’s spiritual needs.

• Become familiar with the patient’s beliefs and practices. • Use self-disclosure of own spiritual beliefs only to foster patient’s thera-

peutic goals.

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• Use questions to determine the role that religion and spirituality play in the patient’s life. For example, “The chart says you are Catholic. What religious practices are important to you during your illness?”

• Seek assistance of or referrals to hospital chaplain or other resources when you feel uncomfortable or unable to meet the patient’s spiritual needs. Recognize the role that members of the patient’s church or temple can play in providing support.

• Involve chaplains in team meetings and patient care conferences to col- laborate on treatment plan.

• Promote use of prayer and scripture when appropriate if within patient’s belief system (Box 18–3).

• Become familiar with agency policy regarding praying with patients. • Provide supportive, private environment to meet spiritual needs. • Be honest with the patient. If you are not comfortable praying, it is

appropriate to disclose this, but offer to be present while the patient says a prayer.

• Substitute supportive response for prayer when the setting or timing is inappropriate.

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BOX 18–3 Guidelines for Use of Prayer and Religious Literature 1. Prayer combined with therapeutic use of self can be used to meet the

patient’s spiritual needs and show empathy. A therapeutic relationship must already be established with the patient before engaging in prayer, a more intimate form of communication.

2. Prayer can consist of simply sharing a few brief sentences to express an immediate need or can be taken from a formally written source.

3. The request for prayer and religious literature should be initiated by the patient. If you are not comfortable, discuss with colleagues other alternatives.

4. Ask the patient to define the specific needs for which he or she is request- ing prayer.

5. Ask what passages the patient wants to read and how they are significant. 6. Validate expressed feelings such as pain, fear, anxiety, stress, helplessness,

or anger at God. 7. Know that prayer can be an affirmation of God’s presence and hope for

the patient. 8. If reading from religious literature, select passages carefully. Consult with

chaplain or other staff if in doubt. Some passages may be misinterpreted, be interpreted literally, or be beyond the level of this patient.

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• Work with patient and staff to adapt patient’s schedule or activities to incorporate religious rituals whenever possible.

• Allow patient to ventilate thoughts and feelings. Explore what precipi- tated the feeling of loss. Help patient clarify any underlying feelings of guilt. Help the patient explore and evaluate whether the source is rational or distorted.

• Help patient explore previously held false assumptions and, as indicated, refer to spiritual passages affirming hope, if within the nurse’s comfort and knowledge.

• Allow family to participate in religious rituals such as ritual body care after death or baptism of a critically ill child.

• Be open to patient’s expression of spiritual concerns. Avoid dismissing practices as inappropriate or pathologic.

• If the patient shares fears, remember that acceptance and listening are more important than having the answers.

SPIRITUAL DISTRESS evidenced by religious delusions or obsessions related to impaired thought process.

Patient Outcomes • Demonstrates improved reality orientation • Verbalizes concerns and conflicts • Verbalizes improved sense of peace and well-being • Demonstrates appropriate social interactions

Interventions • Become familiar with the norms of the patient’s particular religious group

to assess the patient’s deviation from standard practice. • Be aware that delusions may represent areas of personal conflict or con-

cerns. For example, the Messiah complex may reveal that patient has a need to feel special, and dwelling on past sins may show that patient feels badly about self. Focus on feelings the patient is having rather than on content of delusion.

• Use great caution in reinforcing religious beliefs with psychotic patients because this may perpetuate reality distortions. Seek assistance from available mental health resources as well as chaplain or clergy.

• Set limits on time spent talking about obsessions and performing ritual- istic behavior with the patient. Make a contract regarding time when you will listen. Be consistent.

• Encourage patient to discuss concerns other than religious issues. Bring patient back to recent specific experiences or events.

• Avoid arguing with the patient about the validity of his or her beliefs. Rather, acknowledge the feelings these beliefs may evoke, such as fear or sadness.

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• Recognize that reducing obsessional thoughts or compulsive behavior may result in increased anxiety or possibly even a panic reaction (see Chapter 7, Problems with Anxiety, for interventions). Discuss with the physician the need for evaluation by a mental health professional and appropriate medication.

HOPELESSNESS evidenced by depression, apathy, withdrawal, rejection of spiritual beliefs related to loss, impending death, incurable disease, lack of meaning; spiritual crisis.

Patient Outcomes • Verbalizes phrases like “I hadn’t thought of it that way” or “I feel better” • Demonstrates increased social interactions • Able to identify one or more future goals

Interventions • Encourage patient to share feelings and concerns and talk about what has

triggered the sense of hopelessness. • Maintain a concerned yet positive attitude around patient, but avoid an

overly cheerful approach that may inhibit communication. • Focus on short-term, concrete goals; identify specific things the patient

can do now. For instance, focus on the pleasure of visiting with grand- daughter today rather than the hope to be playing tennis next year. Make a plan with patient for achievable goals, such as sitting up in chair for 5 minutes longer today than yesterday. Often a patient may feel less hope- less and depressed if progress in one area can be achieved.

• Recognize that pain, fatigue, and other stressors will affect ability to maintain hope. Use interventions to deal with these stressors.

• Seek out chaplain to discuss patient’s beliefs to help challenge hopeless- ness and support a more hopeful view.

• Recognize that, with time to work through a loss or crisis, the patient may be able to focus on the future. Allow the patient time to work through the grieving process.

• Be aware of your own anxiety around patient. Patient could sense your tension and think that his or her issues are unacceptable.

ALTERNATE NURSING DIAGNOSES

Anxiety

Grieving, Dysfunctional

Spiritual Well-Being, Readiness for Enhanced

Thought Processes, Disturbed

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PATIENT AND FAMILY EDUCATION

• Educate patient and family on ways to incorporate religious practices into the treatment plan for the specific illness. For instance, the patient can adapt dietary restrictions and fasting requirements around specific beliefs.

• Educate the family on the importance of patient’s spiritual beliefs if the fam- ily is not supportive of them.

• Encourage family to not impose their beliefs on the patient if they are different.

• Encourage family to bring in Bibles or religious articles, as appropriate.

CHARTING TIPS

• Document patient’s beliefs, especially as they relate to patient’s illness. • Document conflicts between patient and family. • Document patient’s response to visit with clergy. • Document nursing interventions and patient responses to spiritual interven-

tions such as prayer, scripture reading, or meditation. • For patient’s at the end of life, document any prayers or rituals done in

preparation for death, e.g., Sacrament of the Sick.

WHEN TO CALL FOR HELP

• Patient is suicidal or homicidal. • Religious practices interfere severely with healthcare regimen. • Patient becomes psychotic.

WHO TO CALL FOR HELP

• Chaplain • Patient’s personal spiritual leader • Family members • Social Worker • Psychiatric Team

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COMMUNITY-BASED CARE

• Refer to clergy or agency chaplain, as appropriate. • Encourage attendance at religious or health-related support groups, such as

Reach for Recovery. • Encourage participation in patient’s own house of worship as indicated. • Use members of patient’s religious community to assist with home care

when appropriate.

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SECTION III Special Topics

19Nursing Management of Special Populations

The Patient with Sleep Disturbances

Learning Objectives • Differentiate between mild, moderate, and severe sleep pattern distur-

bances. • Identify factors leading to poor sleep and fatigue. • Select appropriate interventions for dealing with sleep pattern distur-

bances.

Glossary Fatigue – An overwhelming, sustained sense of exhaustion or lack of energy

and decreased capacity for physical or mental work. Insomnia – Abnormal wakefulness or an inability to fall asleep easily or to

remain asleep during the night. Narcolepsy – An infrequent but serious disorder consisting of recurrent

episodes of uncontrollable sleep. Nocturnal enuresis – Involuntary loss of urine at night in absence of physical

disease when a child is of the age when he or she would be expected to remain dry.

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Obstructive sleep apnea – A serious sleep-related breathing disorder mani- fested by daytime sleepiness or excessive loud snoring. Frequently associ- ated with cardiac dysrhythmias.

Sleep apnea – Cessation of breathing for at least 30 episodes during sleep.

Sleep deprivation – Periods without normal sleep pattern, resulting in irri- tability, fatigue, difficulty concentrating and memory, poor muscle coordi- nation, and sometimes hallucinations and illusions with delirium.

Sleep disorders – Chronic disturbance of sleep patterns affecting the amount, quality, or timing of sleep or events occurring during sleep includ- ing dysomnias (insomnia), hypersomnias (excessive sleeping), and para- somnias (abnormal behavior during sleep as in sleepwalking).

Sleep is unconsciousness from which a person can be awakened by sensory stimuli such as sound, light, and touch. Sleep disorders put an individual at

risk for experiencing a change in the quantity or quality of rest and sleep as related to biological and emotional needs. Adverse physical, mental, and emo- tional changes may occur if normal rest and sleep patterns are interrupted. Most people have suffered from at least transient sleep disturbances. Many factors lead to poor sleep, such as the environment of the sleeping area (levels of sound, light, and temperature), the age and general physical and psychological condition of the patient, and recent stressful events.

Sleep was considered a homogeneous quiet period with minimal brain activity until the discovery of the electroencephalographic (EEG) record. With this technology, the description of rapid eye movement (REM) and nonrapid eye movement (NREM) periods during sleep and their association with dreaming has provided better understanding of sleep physiology and sleep disorders.

Sleep research has shown that there are two types of sleep during a sleep period: sleep when the brain is very active (REM) and sleep with slow brain waves (NREM). The reason why these two types of sleep exist is unknown. The sleep center is located in the pons and the medulla. Most sleep at night is NREM sleep; it occurs when a person first falls asleep and is a deep and rest- ful sleep.

On the basis of EEG studies, sleep is divided into five distinct stages: REM sleep and four stages of NREM sleep.

Stage 1 NREM: Transition from wakefulness to sleep; about 5% of time spent asleep in adults; person feels very drowsy; musculature relaxes.

Stage 2 NREM: Characterized by specific EEG waveforms; occupies about 50% of sleep time; muscles relax further; cerebral activity decreases.

Stage 3 NREM: Physiological changes evident; vital signs decrease; gastroin- testinal functions and venous dilation increase to facilitate cellular metabo- lism and exchange.

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Stage 4 NREM: Known as slowwave, deepest level of sleep with lowest level of body function. Stages three and four together occupy about 10% to 20% of sleep.

During NREM sleep, pulse and respirations drop 20% to 30%, blood pres- sure decreases, muscles relax, skin vessels dilate (increasing heat loss), metabolic rate decreases by 10% to 30%, and body temperature decreases. NREM stages three and four tend to occur in the first half of the night and increase in duration in response to sleep deprivation.

REM sleep occurs cyclically throughout the night, alternating with NREM sleep about every 80 to 100 minutes, lasts about 5 to 30 minutes, and is associ- ated with dreaming that is remembered. REM sleep increases in duration toward the morning. During REM sleep, heart rate and respirations often become irreg- ular and metabolism and temperature increase.

The need for sleep decreases with age: Newborns should sleep 18 hours or more a day, school-age children and teenagers about 10 to 12 hours, adults 7 to 8 hours (National Institute of Neurological Disorders and Stroke, 2007). Sleep needs increase during illness. Lack of sleep results in progressive deterioration of mental functioning, physical fatigue, discomfort, and emotional instability. Ten percent of the population has chronic insomnia that is associated with daytime functional impairment and 30% to 40% have problems with some insomnia in any given year (National Center on Sleep Disorders Research, 2006).

Sleep deprivation is a major concern for safety. Driving while drowsy creates similar reactions as if driving while intoxicated. The National Sleep Foundation (2007) reports that a person is too drowsy to drive if they are having problems focusing their eyes, can’t stop yawning and cannot remember driving the last few miles. Those at highest risk include shift workers driving home from work, peo- ple with a history of sleep disorders, and business travelers suffering from jet lag.

Chronic insomnia can lead to the following daytime impairments: poor atten- tion, concentration or memory; anxieties about sleep; making errors or mishaps at work or driving; irritability; and tension headaches (Ramakrishnan & Scheid, 2007).

Eighty percent of patients with psychiatric disorders describe sleep complaints (Czeisler, Winkelman, & Richardson, 2005). Depression is associated with reduced total sleep time, a shift in REM activity, and early morning awakening. Manic phase of bipolar disorder is associated with insomnia, shortened REM latency, and increased REM activity. Schizophrenia is associated with frequent awakenings and reduced slow wave sleep.

More than 100 different disorders of sleeping and waking have been identi- fied. Both the American Psychiatric Association (2000) and the Association of Sleep Disorders have developed a system for classifying sleep disorders into four main categories (Box 19–1).

The term sleep hygiene is used to describe a holistic approach to sleeping that encompasses many behaviors. Everyone should practice good sleep hygiene to prevent or relieve insomnia, or simply to safeguard sleep, making it more restful and pleasurable (Box 19–2).

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BOX 19–1 Classifying Sleep Disorders DSM-IV-TR Classification

• Dyssomnias—primary insomnia, primary hypersomnia, narcolepsy, breathing-related sleep disorder, circadian-rhythm sleep disorder (jet lag, shift work)

• Parasomnias—nightmares, sleep terror, sleepwalking • Sleep disorder related to another mental disorder such as anxiety, grief,

depression, psychosis • Sleep disorders caused by a medical condition and substance-induced sleep

disorder

Association of Sleep Disorders Centers Classification

• Problems with falling and staying asleep • Problems with staying awake (excessive sleepiness) • Problems with adhering to a regular sleep-wake schedule • Sleep-disruptive behaviors (parasomnias) such as sleepwalking

BOX 19–2 Sleep Hygiene Suggestions for Increasing Adequate, Restful Sleep

• Establish a regular time for going to bed and getting up in the morning, and stick to it, even on weekends and during vacations.

• Use the bed for sleep and sexual relations only, not for reading, watching television, or working; excessive time in bed seems to fragment sleep.

• Avoid naps, especially in the evening. • Exercise before dinner. A low point in energy occurs a few hours after exer-

cise; sleep will then come more easily. Exercising close to bedtime, however, may increase alertness.

• Take a hot bath about an hour and a half before bedtime. The body tem- perature then begins dropping rapidly, which may help sleep after that time. (Taking a bath shortly before bed increases alertness.)

• Do something relaxing in the half hour before bedtime. Reading, medita- tion, and a leisurely walk are all appropriate activities.

• Keep the bedroom relatively cool and well ventilated. • Do not look at the clock. Obsessing over time will just make it more diffi-

cult to sleep.

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ETIOLOGY

Sleep disorders are often caused by a variety of medical and psychiatric disorders. Short-term insomnia is often due to stress and acute grief. Some chronic sleep dis- orders may be due to dysfunction with the sleep/wake cycle.

Before a sleep disorder diagnosis can be made, the patient should have a thor- ough physical examination; review of all medications (prescribed, illicit, and over-the-counter); and the person’s spouse or bed partner should be asked about the person’s sleeping habits. Evaluating a sleep-wakefulness complaint requires a thorough history that considers medical, toxic, and environmental conditions, as well as drug and alcohol use. If tolerance to or excessive use of drugs or alcohol is the likely cause of the insomnia, the patient must undergo withdrawal under careful supervision. Sleep problems are associated with a long list of drugs, including stimulants and alcohol. Hypnotics used over a long period of time can also cause insomnia because of the development of tolerance and suppression of REM sleep.

Insomnia is the most common sleep disorder across all ages (NIH, 2005). Anx- iety and stress are the most common causes of intermittent, short-term insomnia. Other common causes of short-term insomnia include medication side effects and jet lag. Initial treatment for short-term insomnia includes behavioral approaches and use of hypnotics for the short-term. In the absence of comorbidities, chronic insomnia is now considered to be a primary disorder unto itself. Chronic insom- nia is identified as symptoms of insomnia that last more than 30 days.

Sleep lab studies reveal that some patients with obstructive sleep apnea have about 30 episodes of upper airway obstruction each night, resulting in an inabil-

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• A light snack before bedtime can help sleep, but a large meal may have the opposite effect.

• Avoid fluids just before bedtime so that sleep is not disturbed by the need to urinate.

• Avoid caffeine in the hours before sleep. • Quitting smoking not only brings many health benefits to any smoker, it

also eliminates the effects of nicotine that contribute to sleep loss. • When unable to sleep after 15 or 20 minutes, one should get up, go into

another room, and read or do a quiet activity using dim lighting until they are sleepy again. (Do not watch television, which emits too bright a light.)

• Sleeping alone may be more restful than sleeping with another person. If a person with insomnia is distracted by a sleeping bed partner, moving to the couch for a couple of nights might be useful.

• Take a nap in the early afternoon if needed to stave off drowsiness. But remember that naps can disrupt nighttime sleep. If you must nap, do so for no longer than 30 minutes in the late afternoon.

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ity to achieve a deep sleep state because of hyperventilation, carbon dioxide reten- tion, and severe hypoxemia. Treatment possibilities include weight loss for obese patients and positive-pressure respiratory treatments (CPAP) to keep the airway open. Surgical intervention (a procedure to remove excess tissue in the pharynx or a tracheotomy) may be required for more serious cases. Sleep apnea is usually caused by obesity and history of cardiovascular disease is another risk factor.

Narcolepsy is caused by an abnormality in REM sleep. It is sometimes accom- panied by cataplexy (partial or complete loss of muscle tone), presleep hallucina- tions, and sleep paralysis. These symptoms are more debilitating than the sleepiness. Specific treatment includes short daytime napping and prescription of a central nervous system stimulant.

Parasomnias including sleepwalking and nightmares are considered REM sleep disorders. Treatment usually includes use of benzodiazepines.

Conditions most frequently associated with excessive daytime sleepiness include the following:

• Regularly sleeping 10 to 14 hours • Psychophysiological causes: Transient and situational sleepiness caused by

stress, boredom, or depression • Nocturnal myoclonus, also known as “restless legs” or leg jerking • Idiopathic central nervous system hypersomnolence not caused by head

trauma • Menstrual cycle–associated syndrome: Increased daytime sleepiness around

time of period • Self-induced insufficient sleep: Related to increased work hours, pressured

deadlines, or other self-imposed behavior.

Risk factors for sleep disorders include the following:

• Older age associated with more comorbidities • Female gender • Psychiatric disorder • Medical condition • Shift work

RELATED CLINICAL CONCERNS

Many medical and psychiatric conditions affect the patient’s ability to main- tain a normal sleep pattern. Patients with respiratory conditions, Alzheimer’s disease, and chronic pain frequently complain of sleep problems. Anxiety, depres- sion, mania, and delirium are also often accompanied by inability to sleep satis- factorily.

For hospitalized patients, institutional routines and policies, such as how late sleeping medication may be given or giving baths on the night shift, can actually

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restrict nurses in effectively intervening with the more common sleep disturbance problems. Patients often complain that hospital rules and routines are disturbing to their normal sleep patterns. After just a few days in an unfamiliar environment with multiple sleep interruptions, a patient’s usual sleep routine can be almost totally reversed, with the patient sleeping most of the day and awake most of the night (Redeker, 2000).

If the patient’s physical condition requires intense nursing care, sleep needs will be secondary until physical stability is achieved. However, the need for sleep and its role in a patient’s care plan must not be overlooked, even during acute care periods. Sleep deprivation is a major contributor to intensive care unit psy- chosis. Nocturnal sleep is severely disturbed in the critical care area even with sleep medications owing to psychological stress, physical stress, the stressful envi- ronment, and frequent interruptions. Patients with sleep deprivation may become more irritable and display other behavior changes. Efforts should be directed to incorporate the patient’s normal routine for sleep, as soon as feasible in the hos- pital setting (Kahn et al., 1998; Freedman, Kotzer, & Schwab, 1999).

Cancer patients commonly complain of increasing fatigue in their treatment. Evaluation of sleep disorders should be made to determine if they are contribut- ing to fatigue rather than assuming fatigue is just related to cancer treatment (Roscoe et al, 2007). Biochemical changes associated with neoplastic growth can contribute to the development of sleep disorders.

LIFE SPAN ISSUES

Children Sleep terrors, nocturnal enuresis, and bedtime fears are more common in toddlers and in children 7 to 12 years of age. Sleepwalking and tooth grinding (bruxism) are considered childhood sleep disorders because they are probably developmen- tally related and usually disappear before or during adolescence.

Children can develop distress at bedtime because of fears of separation and other anxieties. Providing a calm, reassuring routine is important.

Older Adults Age is the single most powerful determinant of a person’s sleep physiology. As a person ages, sleep becomes more fragmented: a 60-year-old awakens on average 22 times each night compared with about 10 times for a younger person. The cause of this sleep disturbance is usually health related as in the frequent need to urinate, restlessness from medications, shortness of breath from heart failure. Sleep disturbances increase with age and change in type during the aging process. Elderly people typically have more trouble falling asleep and awaken frequently throughout the night and early in the morning. They are more easily awakened by noise or other stimuli and are especially prone to drug toxicity with hypnotics because of reduced renal function. Antihistamines are frequently used as

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treatment for insomnia, however potential side effects of delirium and anti- cholinergic symptoms can put the patient at risk for other problems including falls and urinary retention. Insomnia is more common in women than men, although older men have more disrupted sleep than older women (Schnelle, Alessi, Al-Samarrai, Fricker, & Ouslander, 1999).

Risk of falls is a concern for the elderly with sleep pattern disruption. These patients may be getting out of bed frequently during the night in the dark. It is important to maintain a safe pathway to the bathroom.

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ASSESSMENT

Behavior and Appearance • Tired, lethargic, depressed, agitated, even delirious, depending on cause and

duration of sleep disturbance • Drawn and pale, with puffy dark circles under eyes • Frequent yawning, dozing during the day • Forgetting appointments or responsibilities • Minor accidents, such as dropping things, hitting self on cupboard or table

corners, not being able to complete or misdoing routine tasks

Mood and Emotions • Changes in mood • Less tolerance for even minor problems • More frustrated at difficult tasks • Severe anxiety • Irritable • Angry and hostile • Depressed

POSSIBLE NURSES’ REACTIONS • May experience patient-staff conflict because patient states that he or she

was awake all night and the nurses reported that the patient had slept. • May be unwilling to or feel incapable of doing anything about patients’

sleep problems. • May feel that hospital rules cannot be changed and patients will just have

to tolerate frequent interruptions. • May become frustrated because patients who are awake all night require

more care. • Nurses on the night shift or on rotating shifts may be experiencing sleep

deprivation and be less tolerant of patients sleep concerns

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Thoughts, Beliefs, and Perceptions • Minor errors in memory or ability to calculate • Confusion • Inability to retain information • Inattention and lack of concentration • Hallucinations, paranoia, or psychotic thinking

Relationships and Interactions • Spouse or partner complaints about patient’s sleep problems • Changes in sexual relationships • Change in relationship caused by patient’s irritability and fatigue

Physical Responses • Decreased energy for usual activities • Daytime sleepiness and napping • Increased fatigue • Sleep apnea • Cardiac dysrhythmias • Low arterial oxygen levels • Morning headache • Less pain tolerance • Injuries as a result of sleepwalking, narcolepsy, or sleep deprivation

Pertinent History • History of sleep disturbance • Medical diagnosis associated with sleep disturbances • Situation or lifestyle events that affect sleep pattern • Immobility as a result of casts or traction • Pain, illness • Pregnancy • Anxiety • Depression • Lifestyle disruptions, such as changes in occupation, finances, or relationships • Environmental changes, such as hospitalization or travel • Use of medication or other chemical substances, such as alcohol, caffeine,

tranquilizers, sedatives, hypnotics, antidepressants, antihypertensives, amphetamines, anesthetics, barbiturates, or steroids

• Alternative work schedules such as evening or night shift work • History of motor vehicle accidents, accidents in the work setting

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COLLABORATIVE MANAGEMENT

Pharmacological Pharmacological treatment of insomnia generally includes hypnotics and seda- tives used for short periods of time. Effective management of pain and other symptoms will enhance sleep as well. Using sedatives to induce sleep confounds the sleep stages and may actually lead to worsening of the sleep disturbance and to depression if used for more than a few days or weeks. They inhibit other men- tal and physical activities, such as respiration, cognition, circulation, digestion, and elimination. However an occasional sleeping pill may be beneficial to patients with a short-term sleeping problem (Beck-Little & Weinrich, 1998; Ford & Kamerow, 1989).

Tricyclic antidepressants, monoamine oxidase (MAO) inhibitors, and benzodi- azepines are sometimes used to help with sleep due to their side effect of drowsi- ness. These may cause sleep disturbances when discontinued or reduced. With antidepressants and some hypnotics, REM sleep is actually suppressed and, when these medications are discontinued, the REM rebound can cause agitation and frightening dreams.

Some of the newer sleep medications are now approved for longer term use for patients with chronic insomnia. These includes eszopiclone (Lunesta) and ramelteon (Rozerem). These newer sleep agents work to modify the disruption in the sleep cycle. Other newer hypnotics have long-acting formulations such as zolpidem-CR (Ambien CR) that are more effective for patients who have fre- quent awakenings throughout the night.

Herbal remedies include chamomile, kava kava, and St. John’s wort. Natural products such as melatonin and L-tryptophan are also useful. Some herbal prod- ucts, such as ephedra and ginseng, can contribute to insomnia.

Many medications used to treat medical conditions can contribute to sleep problems, including many asthma medications, levodopa, thyroxine, steroids, SSRIs, and some chemotherapies.

Nonpharmacological Cognitive-behavioral therapies, such as relaxation techniques, hypnosis, massage, guided imagery, and even aromatherapy, can break the self-perpetuating nature of some insomnias—“the less you sleep, the more you worry about losing sleep.”

Exercise is one of the best ways for persons of all ages to achieve healthy sleep. Light therapy has proven effective for delayed sleep syndrome and jet lag. Shift workers can adjust well by working in bright light and sleeping in a completely darkened room.

Sleep clinics may provide a multidisciplinary approach to chronic sleep disor- ders. These programs generally provide a thorough diagnostic work-up with the patient actually sleeping at the clinical setting while closely monitored. Sleep spe- cialists may use multichannel polysomnography at home or in the laboratory to evaluate the patient’s sleep pattern.

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Psychotherapy Many people are reluctant to seek nonmedical therapy for sleep-related prob- lems. Yet insomnia is commonly caused by emotional stress and mental disorders that can be successfully treated. For those who follow through with treatment, about three fourths benefit from psychotherapy (DSM-IV-TR, 2000).

NURSING MANAGEMENT

DISTURBED SLEEP PATTERN evidenced by difficulty falling asleep, fre- quent awakenings, and early morning rising related to sleeping in unfamiliar environment, postoperative or ICU care, or hospital care routines that inter- rupt sleep pattern.

Patient Outcomes • Able to sleep a satisfactory amount of time and awaken feeling rested • Able to rest between disturbances for required care • Has enough rest to participate in activities ordered, including pre- and

postoperative care and rehabilitation

Interventions • Assess the patient’s sleep for quantity and quality. Ask about patient’s

normal sleep habits. Determine what is promoting or inhibiting patient’s sleep in the new environment.

• To help establish a sense of security, familiarize patient with environ- ment; walk around unit, and describe building.

• Establish a sleep routine for the patient using familiar sleep habits if pos- sible, such as special activities in preparation for sleep, fixing the bed- ding, or playing music.

• Allow the patient some personal comfortable bedding and pajamas and other personal possessions, if available.

• Encourage the use of presleep relaxation measures including back rub, meditation, prayer, soft music, reading, or bedtime snack if patient desires.

• Position patient comfortably; assist in turning and using bathroom as needed.

• Minimize use of caffeine or other stimulants in afternoon and evening. • Provide a quiet, undisturbed period of sleep with comfortable room tem-

perature and nonglaring, dim lighting if needed. Adjust schedule of treat- ments where possible to allow for uninterrupted sleep.

• Use hypnotics or sedatives only as a last resort or if patient is experienc- ing unusually stressful events.

• Teach the causes and interventions for sleep disturbance provoked by new environment. If sleep-rest pattern continues to be disturbed after a

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reasonable amount of time for adjustment, reassess for other possible problems, such as depression or anxiety.

• If possible, assess patient’s sleep habits before and after surgery and observe for behavior changes that may indicate sleep deprivation, such as confusion or agitation. Plan nursing care activities with patient to limit number of disturbances and to increase sleep periods within patient safety and postoperative care requirements

• Have staff members on night shift provide the patient with feedback on his or her sleep pattern and emotional support to address anxieties.

SLEEP DEPRIVATION evidenced by pacing, agitation, inability to regulate one’s own behavior related to hyperactivity, hallucinations, and other psy- chotic symptoms.

Patient Outcomes • Remains awake during the day • Sleeps at least 4 hours every night • Demonstrates appropriate nighttime behavior

Interventions • Identify factors that increase stimulation to patient and attempt to reduce

or eliminate these factors. • Provide a calming environment. • Monitor patient safety from falls • Limit coffee and other caffeine-containing foods and drinks such as tea,

cola, or chocolate, especially after 4:00 p.m. Encourage use of decaf- feinated products.

• Establish a contract with the patient to lie down and remain quiet for a specified period of time at night.

• Discourage daytime naps. During the day, encourage patient to keep drapes open and remain active. Provide structured activities during the day if needed.

• Avoid reinforcing behaviors that encourage being awake at night such as not allowing eating, watching television, or socializing.

• Administer ordered medications as indicated. Discuss with physician and pharmacist the changing of doses or timing of medications.

• Move patient to a private room if needed.

ALTERNATE NURSING DIAGNOSES

Anxiety Breathing Pattern, Ineffective Coping, Ineffective

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Fear Gas Exchange, Impaired Hopelessness

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WHEN TO CALL FOR HELP

• Increased complaints of inability to rest or sleep to the point of phys- ical or mental fatigue affecting patient’s ability to participate in treat- ment or rehabilitation or safely perform daily activities

• Onset of delirium, paranoid thinking, or hallucinations related to sleep deprivation

• Long-term or episodic misuse or abuse of sedatives or hypnotics • Idiosyncratic response to sleep medication • Evidence of serious complications of sleep apnea, such as chest pain,

shortness of breath, cardiac dysrhythmias, or dyspnea • Presence of parasomnias such as sleep walking

WHO TO CALL FOR HELP

• Social Worker • Sleep specialist • Chaplain • Pharmacist • Attending Physician • Psychiatric Team

PATIENT AND FAMILY EDUCATION

• Teach patient and family about improving sleep hygiene. • If the patient is using sleep medications, review the potential adverse effects

and potential problems with long-term use with some of them. Instructions should include to avoid alcohol. Also patients should be prepared for side effect of memory problems with some sleep medications.

• Review negative effects of poor sleep habits, especially irregular bedtimes and use of stimulants including caffeine and nicotine before bedtime.

• Review the role of diet and exercise in helping enhance sleep. • Educate patient that sometimes short-term insomnia during times of grief or

stress is normal and will usually resolve. • Promote the use of sleep diary to document symptoms and quality of sleep. • Provide information on therapies such as CPAP and safety for patients with

narcolepsy and sleepwalking.

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• Instruct on avoiding driving when unable to get enough sleep. • Provide information on effective sleep hygiene including websites for the

National Sleep Foundation.

CHARTING TIPS

• Document the patient’s reports of poor sleep, increased tiredness, or fatigue. • Make note of the patient’s sleep history and bedtime routines to enhance

continuity of care. • Document the patient’s response to sleep interventions. • Document the use of and response to sleep medications. • Document time patient is observed sleeping.

COMMUNITY-BASED CARE

• Educate the patient and family about general benefits of a regular sleep schedule and offer suggestions for better sleep.

• Provide referrals, as indicated, to sleep disorder centers for patients with obstructive sleep apnea, narcolepsy, or other serious disorders.

• Encourage the patient to minimize use of sedatives and/or hypnotics. • Provide information about sleep problems to other staff members if patient

is transferred to another unit or facility.

The Chronically Ill Patient

Learning Objectives • Describe some important tasks that a person needs to accomplish to

adapt to chronic illness. • List common nurses’ reactions to the chronically ill. • Describe appropriate interventions for chronically ill patients with self-

care deficit, alteration in self-concept, and impaired social interactions.

Glossary Acute illness – A condition caused by a disease that produces symptoms and

signs soon after exposure to the cause, that runs a short course, and from which there is usually a recovery or an abrupt termination in death.

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Chronic illness – A medical condition or disability that required long term (greater than 3 months) management.

Disability – Any long- or short-term reduction of activity that results from an acute or chronic condition.

Exacerbation – Resumption of pronounced symptoms from an illness. Remission – Period during which the disease is controlled and symptoms are

not obvious.

Even though more Americans are affected by chronic illness than acute illness, the U.S. health-care system focuses more money and research on treating

acute illness. In 1995, there were 99 million Americans living with one or more chronic illnesses including arthritis, hypertension, diabetes mellitus, respiratory disease, visual impairments, and mental illness (Robert Wood Johnson, 1996). In 2005, the NCHS found 12% of the U.S. population were limited in their usual activities due to one or more chronic illness (National Center for Health Statis- tics, 2007). In addition, heart disease, cancer, and stroke, which are the leading causes of death in adults, can cause major disability and have significant impact on long-term care, caregiver burden, and symptom burden. Acute illness accounts for only 10% of deaths in the United States (Center for Advancement of Pallia- tive Care, 2006). Death from chronic illness is much more likely. Although the highest incidence of chronic illness is in the population older than the age of 65, all ages are affected. One third of Americans older than the age of 75 report their health as fair to poor (NCHS, 2007). By 2010, it is estimated that the number of Americans with chronic illnesses will increase to 120 million (Robert Wood John- son, 1996). The increase in the chronically ill population is a result of increased life expectancy, new technologies, pharmaceuticals that prolong life with chronic illness, and breakthroughs in treating acute illnesses such as myocardial infarc- tions and infections. Another change today is most chronic illnesses are managed at home now rather than in the hospital (Corbin, 2004).

Unlike acute illness, which is time limited, chronic illness is often permanent, with no definite timetable to give the person a frame of reference to plan for the future. Most chronic illnesses require major adjustments in the individual’s lifestyle. The periods of uncertainty, remissions, and exacerbation, and in some cases, a slow, steady decline in health can significantly strain the coping mecha- nisms of the individual and his or her family. Whether the individual and family can continue to cope effectively with the anxiety this creates depends on how long the individual’s normal routine can be maintained, how frequently medical crises require treatment, and how easily treatment can be incorporated into the individual’s normal lifestyle. In addition, changes in family routines such as care- giver responsibilities, role changes, financial strain, and changes in socializing patterns and sexual relationships significantly influence the psychosocial response to chronic illness. Some chronic illnesses can remain fairly stable throughout one’s lifetime and others will decline and eventually cause one’s death. See Table 19–1 for common phases of chronic illness.

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ETIOLOGY

Chronic illness can be due to illness, injury, or genetics (Corbin, 2004). Chronic illness requires facing a number of losses and changes that affect the patient and family. Many psychological theories address the process of adapting to a chronic illness. Grief theory is one of the most significant. During the grieving process, the individual can experience denial, anger, depression, and finally, acceptance.

Denial can occur at the time of diagnosis or during remissions or exacerba- tions as a protective mechanism against the distress and fear created by the dis- ease. Anger occurs as the individual struggles with giving up dreams and hopes because of the illness. Anger can energize the person to try to gain control over the illness. There may be a need to obsessively seek second or third opinions, call information hotlines, use the Internet, talk to others with the condition to gain information on new treatments, and go to extremes to implement lifestyle changes such as diet or giving up smoking. Depression occurs when the individ- ual feels the pain of giving up his or her former healthy self. Experiencing fear, sadness, and discouragement and reminiscing about the past can occur as part of the grieving process. Acceptance occurs gradually and may come and go as the

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TABLE 19–1 Phases of Trajectory of Chronic Illness

Phase Description

Pretrajectory

Trajectory onset

Stable

Unstable

Acute

Crisis

Comeback

Downward

Dying

Source: Adapted from Strauss, A. L. (1984). Chronic illness and the quality of life (2nd ed.). St. Louis: CV Mosby; Corbin J. (2004). Chronic illness. In S. C. Smeltzer & B. G. Bare (Eds.), Brunner and Suddarth’s text- book of medical-surgical nursing (pp. 146–157). Philadelphia: Lippincott Williams & Wilkins.

Individual at risk for chronic illness due to genetics or lifestyle

Appearance of symptoms, diagnostic work-up, diagnosis made

Symptoms under control

Reactivation of illness or symptoms become more evident

Severe and unrelieved symptoms or complications

Life-threatening complications

Gradual return to acceptable way of life within limits imposed by illness

Rapid or gradual decline

Shutting down of body processes

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illness changes. If the individual is unable to come to some acceptance, each new limitation will feel like a fresh emotional injury and the person will experience ongoing demoralization.

Poor adaptation to chronic illness can cause noncompliance, dependency, loss of self-esteem, and depression. Noncompliance may be the result of denial, used to protect one’s self from having to acknowledge the illness; anger, used to main- tain control over the situation; or fear of dependency.

Most patients with chronic illness need to accept a dependent role at some point in their illness, even if it is for a short time with dependence on medication or equipment. However, people who view themselves as weak and vulnerable may become dependent for longer amounts of time, possibly for the rest of their lives.

Because our society values independence so much, adjusting to chronic illness can be a blow to self-esteem when the individual must face relying on others for help. For those individuals who have pre-existing low self-esteem, physical or lifestyle changes such as becoming dependent on medical equipment can nega- tively affect body image and, ultimately, lower self-esteem even further. These patients may reject others because they feel unlovable. As they become more iso- lated, they are at a higher risk for depression.

Miller (2000) identifies four factors that influence adjustment to chronic illness:

1. Knowledge of the illness and therapies 2. Coping resources 3. Problem-solving skills 4. Personal mastery as well as motivation

CLINICAL CONCERNS

Chronic illnesses can influence an individual’s response to an acute illness and the potential for recovery. For example, persons with chronic pulmonary disease may have difficulty surviving major surgery. The presence of more than one chronic illness often adds to the demands made by even a relatively minor illness. The sur- vey by Robert Wood Johnson (1996) identified the five most disabling chronic conditions:

1. Mental Retardation 2. Respiratory cancers 3. Multiple Sclerosis 4. Blindness 5. Paralysis of extremities

LIFE SPAN ISSUES

Children Up to 20% of children have a chronic illness, with the most common being asthma (Copeland, 1993). In 2003, 6.9% of children had chronic illnesses that

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limited their daily activity (NCHS, 2006). How the child responds to the condi- tion depends on the child’s developmental stage and the parent’s response. Under stress, the child may regress to a previous developmental stage. Denial, overpro- tectiveness, rejection, and overcompensating are examples of poor parental responses and can significantly influence the child’s adaptation response. The child’s illness can cause dysfunction within the family as frequent doctor’s appointments, changing living arrangements, and financial stress cause disruption in family life and increase the child’s anxiety. Siblings may experience jealousy and resentment for the increased attention to the ill child, embarrassment, shame, fear of becoming ill, guilt from believing they caused the illness, or an extreme sense of overprotectiveness. These feelings are influenced by the parent’s response. The sibling may also regress to a previous developmental stage during times of stress.

Adults Chronic illness can be a devastating blow in adulthood, a time when expectations are highest. Many illnesses can impede performance of an important role such as breadwinner or parent.

Older Adults The most common chronic conditions in the group older than 75 years of age include arthritis, hypertension, heart disease, diabetes, and chronic joint symp- toms (NCHS, 2006).

Adapting to chronic illness depends on the resources available to the person, including caregiver availability, financial resources, and living arrangements. Spouses or other supportive people may be chronically ill as well. Advancing chronic illnesses may force elderly persons to move out of the home into unfamil- iar surroundings, such as to a retirement home or nursing home. Also, treatment for multiple chronic illnesses can drain one’s coping reserves, and the symptoms of one chronic illness such as reduced vision from cataracts affects the manage- ment of another one such as being able to give insulin to one’s self. Elderly spouses who must be the primary caregivers provide an additional stress and can con- tribute to poor compliance because of their inability to cope with the illness.

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POSSIBLE NURSES’ REACTIONS • May view caring for the chronically ill as depressing because of deteriorat-

ing patient health. • May have difficulty defining care goals as optimal maintenance rather than

curative. • May lack empathy and blame noncompliant patient as causing his or her

own problems. • May feel powerless to provide any hope to the patient for the future.

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ASSESSMENT

Behavior and Appearance • Obvious disability or change in appearance caused by illness • Unkempt, poor hygiene because of depression and lack of energy • May require obvious assistive devices such as oxygen or a wheelchair

Mood and Emotions • Depressed • Angry • May lack emotional reaction as a result of denial • Guilt over burden created by illness • Fear and anxiety caused by uncertain future or physical discomfort

Thoughts, Beliefs, and Perceptions • Powerless to control condition, complications, or side effects • May generalize view of self as weak and ineffectual into all areas of life • May think obsessively about his or her health or physical condition • May view body as unattractive or damaged • May be able to maintain self-esteem and sense of competence

Relationships and Interactions • May need to become dependent on others for care, transportation, financial

support • May have difficulty in maintaining personal relationships because of lack of

energy, physical discomfort, or embarrassment • May need to change living arrangements to facilitate care, causing the indi-

vidual to develop new or changed relationships with others • May experience changes in sexual relationships because of physical discom-

fort, loss of energy, or poor self-image • May experience a sense of social isolation or rejection because friends and

family may avoid patient if they are uncomfortable being around someone with a disability

Physical Responses • These vary depending on specific illness. • Symptoms must be reassessed frequently because they may or may not be

related to the chronic illness. • Ability to perform activities of daily living can be affected.

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Pertinent History • Past history of chronic illness, other conditions, or disabilities • History of psychiatric disorders, especially depression and substance abuse

COLLABORATIVE MANAGEMENT

Pharmacological Because patients with chronic illnesses often take multiple medications, there is an increased risk of interactions between medications or between medications and food. Each new symptom needs to be assessed carefully to determine if the cause is the illness or the treatment. For example, confusion and lethargy could be a sign of a deteriorating medical condition or the result of overmedication.

Individuals may utilize a variety of complementary or alternative approaches to deal with symptoms and/or treat the illness.

NURSING MANAGEMENT

IMPAIRED SOCIAL INTERACTION evidenced by inability to establish and/or maintain stable, supportive relationships related to loss of body func- tion because of chronic illness.

Patient and Family Outcomes • Patient identifies behaviors that deter socialization. • Patient demonstrates behaviors that encourage socialization. • Family provides support to patient.

Interventions • Assess the patient’s support system, living arrangements, and care needs.

Identify areas where patient needs assistance in his or her care routine. • Identify types of behavior that may impede socialization, such as manip-

ulative, dependent, hostile, depressed, or passive-aggressive behavior. As needed, help patient become aware of how these types of behaviors may discourage interactions with others. Explore ways to change these behaviors.

• Encourage patient to share worries and concerns with others, as appro- priate. Also encourage patient to make an effort to provide support to family members as they learn to adjust. If the patient consistently focuses others’ attention on his or her health problems, give the patient feedback on understanding others’ responses.

• Encourage patient to accept help from others, as needed, while main- taining independence within the limitations of the illness.

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• Address burden on caregivers and provide assistance as needed. • Patient may need assistance to express feelings and wishes to his or her

caregiver in a nonthreatening way. Role-play with patient. This promotes independence and self-esteem in patient and caregiver.

• Encourage patient and family to be aware of communication patterns when under stress, and explain how these may negatively affect their relationships.

• Allow family to share their concerns and frustrations about the patient with you. Explore with the patient ways to resolve issues. If both agree to participate, consider bringing patient and family together to discuss these issues.

• Encourage patient to participate in activities and interests that do not involve his or her illness.

• Encourage patient to maintain contact with supportive people through phone calls, letter writing, e-mail, and tapes.

• Assist patient in identifying ways to establish new relationships.

DISTURBED SELF-CONCEPT evidenced by self-destructive behaviors, unwillingness to face effects of illness, excessive dependency, depression related to alteration in body image from chronic illness.

Patient Outcomes • Remains as independent as possible within limitations of illness • Demonstrates acceptance of his or her body by such behaviors as talking

positively about self, taking care of own physical needs • Implements adaptive coping mechanisms

Interventions • Develop a trusting relationship with patient to encourage sharing feelings

with you. Providing privacy and respect for patient’s feelings and body will enhance that trust.

• Encourage patient to express feelings and thought about the illness and the way the illness has changed self-image.

• Assess the effect of illness on the patient. Clarify misconceptions, myths about illness, treatment, and functional ability. For example, patient may believe the portable oxygen tank cannot be taken in the car, so he or she no longer goes out with friends.

• Help the patient begin to accept self with the new limitations. Involve the patient in own care, gradually increasing those areas for which the patient can take responsibility. Encourage expressing feelings about the illness and body image. As appropriate, involve the family.

• Be aware of what others’ behavior communicates to patient. For example, if patient’s wife puts on disposable gloves every time she is with patient,

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she is nonverbally communicating her discomfort being around him. She needs to be encouraged to examine how this behavior affects him.

• Explore the patient’s strengths and interests. Provide encouragement to focus on these, not just on the illness. Explore ways to develop former interests that are within his or her functional abilities.

• Encourage participation in rehabilitation and education programs, as appropriate.

POWERLESSNESS evidenced by not participating in activities of daily living, anger, and depressive behavior related to the impact from chronic illness.

Patient and Family Outcomes • Demonstrates participation in care within limitations of illness • Performs activities of daily living within limitations of illness • Verbalizes one area in which he or she can have some control

Interventions • Assess patient’s ability to perform activities of daily living and to main-

tain medical regimen for chronic illness care. • Identify some aspect of patient’s care in which he or she can retain con-

trol. Then make sure all caregivers support this. • Provide needed education and resources to enhance performing these

activities to encourage independence. • Involve family and caregivers in identifying ways to promote independ-

ence. Teach them ways to help patient without taking over completely. • In areas in which patient must be dependent on others, promote patient

participation in decision making and timing of care to promote some control.

• To successfully promote independence in an activity, you may need to break down each activity into small segments and then focus on one seg- ment at a time.

• Explore the patient’s feelings regarding activities that he or she is no longer able to perform. Encourage the grieving response to express feel- ings and encourage acceptance. Then explore activities of interest within the patient’s functional abilities.

ALTERNATE NURSING DIAGNOSES

Coping, Family: Compromised Coping, Ineffective Grieving, Anticipatory or Dysfunctional

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Hopelessness Knowledge Deficit Noncompliance

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WHEN TO CALL FOR HELP

• There are indications that the patient is not being cared for ade- quately, such as poor hygiene, pressure ulcers, poor nutrition, or dehy- dration.

• Patient is not complying with treatment plan, which could lead to life- threatening complications—for example, the patient is not taking insulin or is refusing dialysis.

• Patient is demoralized by destructive behavior within his or her fam- ily, such as substance abuse.

• Severe depression, threat of suicide.

WHO TO CALL FOR HELP

• Attending Physician • Social Worker • Chaplain • Psychiatric Team

PATIENT AND FAMILY EDUCATION

• Provide appropriate education for the individual’s chronic illness and med- ical regimen.

• Encourage patient and caregivers to consolidate prescriptions with one pharmacy so interactions can be monitored.

• Provide information on prevention of complications or progression of the illness and side effects of treatment.

• Involve family and/or caregivers in this education. • Teach assertive and problem-solving skills to patient who is dependent on

others for much of his or her care to gain a sense of control over health care. • Review with family ways to promote independence and self-esteem in the

patient. • Teach relaxation techniques as a way to reduce anxiety (see Box 3–2) • Teach family the stages of grieving and ways to cope with these. • For patients with advanced, progressive illness, promote completion of

advance directive and discussion with caregivers about wishes if disease pro- gresses

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CHARTING TIPS

• Document patient and family response to health teaching. • Note caregiver responses to patient. Use specific examples rather than a sub-

jective opinion of the response. • Document patient’s reaction to illness, prognosis, and body image changes. • Document patient’s participation in treatment plan. • Document side effects to medications/treatments • Document patient expressed wishes regarding aggressiveness of treatment

COMMUNITY-BASED CARE

• Involve patient and family in the discharge plan early in treatment. • Provide specific referrals for additional help in the home or alternative care

options as needed. • Identify equipment patient will need in the home, such as hospital bed or

wheelchair, to enhance independence and caregiving. • Refer patient and family to support programs and self-help groups specific

to patient’s illness, such as ostomy or stroke groups. • Refer to counseling as needed. • Consider home health referrals to assess caregiver’s ability to provide care

and patient’s compliance in the home. • Communicate with all referring agencies regarding identified problems. • Encourage seeking out information on the illness from the Internet or library. • Refer to adult protective services or child abuse services if evidence of

patient does not appear to be receiving adequate care. • Consider referral to palliative care and/or hospice with advanced illness

The Homeless Patient with Chronic Illness

William R. Whetstone, RN, CNS, PhD

Learning Objectives • Describe the social origins of homelessness • Describe common characteristics of homelessness

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• Identify risk factors to health care for the homeless • Describe effective patient-centered nursing interventions

Glossary Homeless – A person without housing except the streets. Homeless Shelters – Temporary residences in urban areas usually open dur-

ing the night for sleeping. Some shelters do provide related services such as food, job training and skills.

Community Mental Health Centers – Funded agencies offering such core services as outpatient care, 24 hour-a-day emergency services, day treat- ment or partial hospitalization, and screening.

Marginalization – To be excluded, ignored, relegated to the edge of a social system.

Homelessness in America is an invisible and complex social problem. Mar- ginalized by our society, the homeless include men, women and children of

all races and socioeconomic backgrounds. According to the National Coalition for the Homeless (2006), the rate of our homeless population has tripled since 1981. Whereas people often think of men as the major homeless population, fam- ilies–namely women with their children–are seen increasingly in this situation. Nurses are likely to come in contact with homeless patients in all settings includ- ing acute hospitals, emergency rooms or urgent care clinics, psychiatric settings, and long-term care institutions. These patients are often viewed in a negative way by health-care professionals who may be frustrated and alarmed by their behav- ior (Saarman, Daugherty, & Riegel, 2000; Chung-Park, Hatton, Robinson, & Kleffel, 2006).

The National Mental Health Association (2006) gives the following perspec- tive on the homeless population:

• People who are homeless are the poorest of the poor. Unemployment, lack of job skills, and personal problems contribute to homelessness because the person is unable to make an adequate income. Decreases in the number of manufacturing and industrial jobs combined with a decline in the real value of the minimum wage, have left significant numbers of people without liv- able incomes.

• Cost of rental housing has increased in most urban areas. In 14 states and 69 metropolitan areas, the entire maximum Supplemental Security Income (SSI) benefits do not cover the Fair Market Rent for a one-bedroom apart- ment and no state in the nation offers SSI income equal to the federal min- imum wage.

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• The average adult man who is homeless is in his late 30s; the average adult woman is in her early 30s. Minorities, in particular, African Americans, are overrepresented among people who are homeless and have a mental illness.

• Approximately 40% of adult men who are homeless are veterans. • An estimated one third of the approximately 600,000 Americans who are

homeless on any given night have serious mental illnesses and more than one-half also have substance use disorders.

• Many people who are homeless and have addictive disorders want treat- ment, but the system is ill equipped to respond to their needs, leaving them with no access to treatment services and recovery support.

• The homeless population frequently suffers from concurrent severe mental illness and substance usage and/or dependency. The number of homeless with dual diagnosis or co-occurring disorders is difficult to estimate but the numbers have increased substantially over the past 2 decades.

• People who are homeless frequently depend on the highest cost public service systems—emergency rooms, hospital psychiatric beds, detoxification centers, residential treatment programs and, in some places, jail cells— which places a huge burden on health, mental health and correctional sys- tems.

• Because men who are homeless are more likely to have substance abuse dis- orders than women who are homeless, men are more often excluded from emergency shelters because these facilities often require abstinence as a con- dition for admission. This partially explains why more men than women sleep on the streets.

• Lack of resources for transportation for the urban homeless is a major prob- lem (U.S. Conference of Mayors, 2005). Not following through with med- ical appointments or referrals to shelters or employment programs can often be tracked back to lack of transportation.

ETIOLOGY

There are many reasons for being homeless today. The causes are complex and diverse. The causes interrelate with socioeconomic issues prevalent in our society: poverty, low-paying jobs, unemployment, alcohol and drug usage, or just tem- porarily being down on your luck. The lack of affordable housing, whether it is Section 8, single room occupancy hotels (SRO), or low rent apartments are at a premium in our urban areas. More and more urban areas are undergoing gentri- fication as the demand for trendy lofts and condo living is bringing suburbanites back to the inner core of cities that previously were on the decline. An individual may not have the financial resources to provide first and last month rent, credit card references, etc. to obtain a suitable living situation.

Mental illness and substance abuse are major contributors to homelessness. In the late 1970s and early 1980s, the advent of deinstitutionalization (Lamb,

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2006) dramatically increased the number of mentally ill on the streets. Many institutionalized mentally ill (primarily schizophrenics) were returned to the community. Our communities were not well prepared to either receive them or accept them. Community mental health services that were supposed to be providing assistance with social skills, rehabilitation or retraining, health care, counseling and psychotherapy, were not well planned (Treatment Advocacy Center, 2006).

Instead of these services being seamless, such services were often fragmented, caught up in bureaucratic red tape, and inadequate in meeting the immediate and long-term needs of the mentally ill. The trend to keep the mentally ill out of insti- tutions has continued today. Many mental health professionals, including nurses, are ill prepared to provide meaningful assistance in meeting the psychosocial needs of this population. So many of the severely mentally ill find their way onto the streets. The streets provide them the least restrictive environment, an escape from the confines of both board and care and nursing homes. However neither of these latter environments provide them with the necessary requisites for activ- ities of daily living, health promotion or wellness, consistency, medication man- agement, and reintegration into their own community.

Another large group of homeless are the many substance abusers caught up in the era of readily available street drugs–most commonly crack cocaine, heroin, and crystal meth (methamphetamine). Again, like the mentally ill, these homeless lack much needed social, rehabilitation, and welfare services. Service providers continue to offer fragmented care. Somehow, like the mentally ill, they survive; but survival is at a great cost of developing life threatening and chronic debilitating illnesses such as chronic obstructive pulmonary disease, uncontrolled diabetes, high blood pressure, cardiac problems, respiratory disorders, skin lesions, leg ulcers, sexually transmitted diseases, and HIV. The continual dangers of living on the streets without access to adequate health- care and follow up predisposes them to a variety of chronic and serious health problems. Many of the homeless have a dual diagnosis of a psychiatric disorder and a substance abuse problem. These individuals may be using drugs or alcohol to self-medicate the uncomfortable symptoms from their psychiatric problem.

Homeless families—usually women with young children—are a more recent phenomenon that may be related to mental illness and substance abuse. Women may also be victims of domestic violence and are seeking a way to escape an intol- erable living situation. With no financial assets and limited skills, these women may find their way to shelters with their children. Access to services may be lim- ited by things we all take for granted like a phone number and mailing address.

RELATED CLINICAL CONCERNS

Because of self-care neglect and lack of resources, many of the homeless suffer from hypertension, arthritis, tuberculosis, coronary artery disease, sexually

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transmitted diseases, hepatitis, and HIV (Lewis, Andersen, & Gelberg, 2004). Other common conditions include anemia from malnutrition and orthopedic conditions from repeated injuries. Lack of good footwear may lead to feet problems, poor vision due to no resources to obtain glasses, and no access to preventative dental care are just a few of the common problems seen in this population. The homeless may have little way to obtain refills on prescriptions so routine medications for chronic conditions as well as psychotropic medica- tions may be unavailable. Without psychotropic medications, the mentally ill homeless can become more of a problem contributing to this group being mar- ginalized by society.

LIFE SPAN ISSUES

Children Children and their mothers represent an increasingly frequent form of homeless- ness (National Coalition for the Homeless, 2006). Children in this situation must endure insecurity, fear, disruption of routine and education, and poor preventa- tive healthcare. Family life is disrupted and physical and emotional health of fam- ily members is affected. Children may be exposed to unhygienic living conditions, violent and inappropriate behavior, and lack of age appropriate resources that will impact their mental, physical, and psychological development. Children may also have been exposed to domestic violence and child abuse. At times, women with little resources need to escape an abusive situation and end up living in their car or on the streets with their children.

Because these mothers are at increased risk for illness and death at an earlier age than in comparison to the rest of the population, children also face the chance of being alone on the streets or moved into foster care (Lewis et al., 2004).

Adolescents The Center for Law and Social Policy (2003) estimates the homeless adolescent population can range from 500,000 to 1.3 million per year. The U.S. Conference of Mayors (2005) indicated that 3% of urban homeless are classified as “unac- companied” youths.

Unlike homeless adults, adolescents become homeless due to failure of parental support or due to a problem with foster or institutional care. Once they reach 18 years of age, their chances for assistance may be reduced even further as they no longer qualify for programs for adolescents. These teenagers find them- selves with little resources and often stigmatized by society. Many come from dysfunctional families where physical and sexual abuse as well as illicit drug abuse were the prevailing family dynamic. When family relationships are strained, parental neglect can follow (U.S. Department of Health and Human

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Services, 1995). Other precipitating factors can include adolescent behavioral problems, family financial difficulties, lack of affordable family housing, low pay- ing service jobs, uninsured parents and lack of welfare benefits (Shinn & Weitz- man, 1996).

Young girls and boys often resort to prostitution to make a living on the streets. Referred to as “survival sex,” young people may see this as their only way to obtain food and shelter. This leads to sexually transmitted diseases, HIV, vic- timization, substance abuse, and unwanted pregnancy. Other problems include criminal behavior and suicide attempts (Greene, Ennett, & Ringwalt, 1999). Because they lack health insurance, there is limited access to prenatal care or drug rehabilitation.

Homeless adolescents are also generally absent from the public school system. Even though a permanent address is no longer required, problems with accessing immunization and school records as well as grade placement make acceptance in a school problematic. Because basic needs of survival for food and shelter will take priority, education becomes a low priority.

Slesnick and Prestopnik (2005) found that the majority of adolescents in their study suffer from dual diagnosis. Also multiple street drugs may also be used. This problem demonstrates the need for better comprehensive treatment services.

Older Adults With the expected increase in the geriatric population, the number of homeless elderly is expected to increase. Statistics on the scope of this problem are sparse as the elderly may not be included in surveys and studies. The U.S. Cen- sus Bureau (2005) roughly estimates that 9.6% of seniors live below the poverty level. Of this group, a smaller percentage are permanently homeless, living pri- marily on the streets. Permanent residency on the streets for the elderly may be caused by the lack of available, affordable housing along with poverty as well as problems of mental illness and substance abuse (National Coalition for the Homeless, 2006).

These individuals remain at high risk for complications from chronic illness, lack of access to prescriptions and poor nutrition. Access to health care may be impacted by lack of transportation, isolation, lack of knowledge about services, lack of a way to be contacted for follow up, and needed social services. Accord- ing to O’Connell et al (2004), the elderly homeless may have anywhere from five to nine chronic health conditions placing them at continued risk for illness and death. These continued, untreated health risks forecast continual physical and mental decline beyond the limitations of just aging. As the elderly become more frail or suffer from advancing dementia, they may be moved to nursing homes for the remainder of their lives.

Bottomley (2001) has pointed out that many of our current policies and pro- grams for the elderly are inadequate, fragmented, and provide a limited array of much needed services.

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ASSESSMENT

Behavior and Appearance • Disheveled, torn, ill-fitting clothing • Unkempt appearance • Unshaven, dirty • Unpredictable • Demands to keep all belongings with him/herself

Mood and Emotions • Mood swings • Angry outbursts • Low tolerance for frustration • Anxiety when controlled

Thoughts, Beliefs, and Perceptions • Poor concentration • Paranoid and suspicious • Delusional • Hallucinations • Loose associations

Relationships and Interactions • Distrust of others • Lack of social skills • Poor eye contact • No evidence of close relationships

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POSSIBLE NURSES’ REACTIONS • May view the homeless as disgusting, dirty, difficult, or ungrateful • May be frightened by their behavior • May feel overwhelmed with the patient’s problems and then avoid dealing

with the patient • May view patient as being unmotivated to change • May feel conflicted when patient wishes to return to the streets rather than

accept offer of social services or a shelter • Difficulty relating to patient’s lifestyle • Want to avoid caring for patient owing to negative feelings

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Physical Responses

• Unusual or bizarre symptoms • May deny complaints • Fatigue due to poor nutrition, physical problems • Sleep disturbances • Chronic illness • Substance abuse/withdrawal syndrome • Chronic pain due to back and feet problems

Pertinent History • Psychiatric disorder • Substance abuse • Domestic violence, child abuse • Minor infractions of the law

COLLABORATIVE INTERVENTIONS

Social Services When working with the homeless population, it is essential to involve social serv- ices to access appropriate community agencies (HELP, 2006). These services can include:

• Case management • Legal aid • Assistance obtaining benefits include veteran benefits • Employment services or retraining • Day care • Mental health services • Housing placement and temporary shelters • Substance abuse treatment • Financial aid • Adult education • Follow-up health care • Obtaining prescriptions

Psychiatric and Addiction Services Because of the frequency of dual diagnoses of psychiatric disorders and substance abuse, the homeless population is at particular risk for many complications from these two disorders. Denkins (2005) recommends prioritizing treatment based on the individual’s most pressing need rather than try to treat what the healthcare pro-

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fessional thinks is the most pressing problem. When homeless patients are identi- fied as having a substance abuse problem and a psychiatric diagnosis, an integrated approach of addiction specialists and mental health professionals is needed.

NURSING MANAGEMENT

INEFFECTIVE THERAPEUTIC REGIMEN MANAGEMENT evidenced by poor management of chronic illness related to impaired mental status and/or substance abuse in the homeless

Patient Outcomes • The patient will keep medical appointments. • The patient will be able to describe his/her healthcare needs. • The patient will be able to identify symptoms that indicate immediate

need for health-care. • The patient will accept treatment for ongoing health problems including

psychiatric disorders and substance abuse

Interventions • Provide small amounts of information at one time; do not overwhelm

patient with rules, instructions. • Focus on realistic interventions that would work in the patient’s envi-

ronment • Encourage the patient to participate in self-care as soon as possible • Provide written instructions in language and reading level the patient is

able to understand. • Promote trust by communicating in a non-judgmental way, listening to

patient’s concerns • Focus interventions on here and now rather than future orientation • Encourage patient to verbalize concerns about health issues and lifestyle • Be flexible; remember that this patient may be very uncomfortable, dis-

trusting, and fearful in the healthcare setting • Make sure social worker is involved early to provide practice informa-

tion on shelters, clinics, financial services, and taxi vouchers. • Be alert for increasing frustrations with rules and restrictions that could

trigger violent outbursts • Reassure patient about safety of his/her belongings. What may look like

trash to the nurse may be a meaningful item to the patient. Patient may be very protective of them and want to keep them in view at all times.

• For patients with psychiatric disorders address the use of long-acting psy- chotropic injections that may last a few weeks

• Explain how best to access required health-care services within the com- munity

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• Assess for psychiatric diagnoses and substance abuse. Observe for signs of drug withdrawal. Promote continued psychiatric treatment and/or substance abuse treatment where appropriate.

• Assess response to psychotropic medications and discuss with patient need to follow through on obtaining prescriptions.

• Provide specific information on follow-up appointments including direc- tions, transportation, taxi vouchers.

DISABLED FAMILY COPING evidenced by parent and children living on the streets related to alcohol/substance abuse, psychiatric disorders, and abuse

Patient/Family Outcomes • The homeless family will be able to identify ways to maintain a safe and

consistent environment. • Parent will be able to identify healthcare needs and concerns of the

family • Family will accept assistance to provide a safe and stable environment for

the children

Interventions • Reassure parent about the care of the child and reinforce good parenting

practices. Provide concrete interventions to ensure good health care. • Promote resources for preventative care including vaccines for children. • Encourage family to talk about their life and share concerns. • List community resources specific for homeless families • Identify agency resources that would have information on child care

services. • Observe for any signs of child abuse and/or domestic violence. Seek out

social work input to address these concerns and promote safety for the family including appropriate shelters.

• Seek input from pediatric team to address healthcare issues and school- ing for the children

• Observe for signs of substance abuse in all members of the family and address as appropriate

ALTERNATE NURSING DIAGNOSES

Coping, Ineffective Home Maintenance, Impaired Knowledge, Deficient Social Isolation, Impaired Violence, Risk for

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CHARTING TIPS

• Document any information the patient provides about lifestyle, resources used, future plans, health problems and concerns

• Document response to education • Describe any indication of inappropriate drug use • Document any information from patient on services he/she has used in the

past

PATIENT AND FAMILY EDUCATION

• Discuss ways to maintain personal hygiene in patient’s living environment • Provide information on ways to incorporate quality nutrition into the

daily diet • Give written information that patient can understand on the illness • Give parent written information on normal growth and development of

children, vaccine needs, preventative healthcare • Review effective parenting techniques • Teach all involved signs of abuse • For patients with substance abuse problems, educate them on ways to avoid

situations where drugs are readily available • Provide information on risks of hepatitis, HIV, sexually transmitted diseases • Educate women on effects of drugs and alcohol on pregnancy. • Provide birth control information as appropriate to women • Discuss need for consistent school attendance for children

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WHEN TO CALL FOR HELP

• Escalation of anger and frustration to threats of violence • Evidence of illegal substance abuse • Evidence of extreme noncompliance with rules and procedures • Evidence of child abuse/neglect, domestic violence, or elder abuse

WHO TO CALL FOR HELP

• Security • Social Worker • Psychiatric Team • Addiction specialists • Pediatric Team

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COMMUNITY-BASED CARE

• Refer to social worker as soon as it is identified that patient is homeless so resources for health-care, shelter, financial aid, and nutrition can be devel- oped

• Provide transportation information on public transportation, taxi vouchers for medical appointments, shelters, employment/educational opportunities

• Identify resources for obtaining prescription refills • Arrange follow-up for administration of long-acting psychotropic medica-

tions where appropriate to ensure that the patient is getting needed medica- tion

• Make referrals for substance abuse programs and psychiatric treatment as needed

• Identify resources through the VA (Veterans Administration) for support and health-care where appropriate

• Work with patient to identify contact information–post office box, phone at local shelter, family member so patient can be reached

• When appropriate, encourage patient to accept short-term placement in facilities like nursing home or home health care in a shelter for continued treatment/observation of a condition.

• When patient is discharged from in-patient care, ensure that follow-up care is attempted

• Make every effort to provide a realistic discharge plan that gives the patient some resources if he/she chooses to use them.

The Dying Patient

Learning Objectives • Describe common fears faced by the dying patient. • Describe common nursing staff reactions when caring for the dying

patient. • Discuss the role of palliative care and hospice in the caring for the dying

patient and family. • Describe effective nursing interventions to help the dying patient and

family.

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Glossary Advance directive – A document prepared by an individual to provide guid-

ance to the healthcare team in the event that the person is no longer capa- ble of making decisions.

Euthanasia – The act by a physician or another person of administering a treatment with the specific intent to end a person’s life.

Hospice – A philosophy of care and a program for the terminally ill that focuses on providing dignity, comfort, control, and choices at the end of life. At home or in a facility, hospice care is provided by an interdisciplinary team of specially trained professionals who coordinate services for the patient and family to enhance the quality of life for the time remaining.

Palliative care – Management of patients with active, progressive, far- advanced disease for whom the prognosis is limited and the focus is on care to enhance quality of life. Goals for interventions are generally focused on symptom management.

Physician-assisted suicide – Means provided by a physician to be used by the patient to end his or her life. Also may be called Aid in Dying.

Facing the end of life, whether from a prolonged terminal illness, advanced age, or injuries remains the greatest and final challenge. For some people, facing

this challenge may be a gradual process as a disease advances; for others, it may come suddenly and unexpectedly. With advanced disease, some individuals may be preparing themselves all the way through the course of the illness, whereas others maintain strong optimism or denial.

The National Hospice and Palliative Care Organization reports that in 2005 75% of deaths in the United States occurred in institutions (50% in acute hospi- tals) and 25% at home. Home deaths are most associated with hospice care. It is predicted that nursing homes will be increasingly common as the site of death in the United States. Although most people report that they wish to die at home, the acute hospital remains the most common location at the end of life because some people still pursue aggressive treatment, their wishes about resuscitation are unknown, or the family is uncertain about what to do when a crisis occurs. Unfortunately, the hospital may not always be the best prepared for providing a peaceful, comfortable setting for patient and family because of the focus on aggressive interventions (Teno et al, 2004). More hospitals are now developing palliative care programs to address these issues. CAPC (Center for Advancement of Palliative Care) reports that 75% of hospitals with bed capacity over 250 have a palliative care program in 2006.

Policies need to be in place to address comfort care and provide adequate med- ications. Families and staff members need to be clear on the appropriate use of analgesics and sedatives at the end of life and that the use of these is different from physician-assisted suicide and euthanasia. Wherever the patient is, however,

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the nurse remains the key person to advocate for the patient’s care and provide care and support at the end of life.

The National Hospice and Palliative Care Organization has developed three outcomes that embody quality end-of-life care and can be adapted to any setting:

1. Safe, comfortable dying—providing appropriate symptom management to achieve comfort

2. Self-determined life closure—patient autonomy and participation through- out the process

3. Effective grieving for survivors

These outcomes provide an effective model for healthcare professionals to use when providing care to dying patients.

ETIOLOGY

As a person faces the end of life, coping takes many forms. There are no consis- tent expected behaviors, although generally the person copes in the same way as he or she has at other times of crisis. For example, if a person has tended to be angry and isolated, it is common to see the same reactions during the dying process. The following are some of the common fears faced by the dying patient and family that influence how they will cope.

Fear of Pain and Suffering This is often listed as the greatest fear of the dying. Images of loved ones who died in severe pain are particularly associated with cancer. These memories may cloud the perceptions of what the end of life will be like. Fear of pain and suf- fering has received more attention in the last few years because pain and hospice professionals are attempting to educate the public and health-care professionals that the vast majority of pain can be treated by relatively simple means (Agency for Healthcare Policy and Research, 1994; Paice & Fine, 2006). Nearly all pain and suffering from end-stage disease can be effectively controlled with the knowl- edge and technology available today. The experience of pain and suffering can create isolation and depression for the patient and guilt for the family, so address- ing this fear is essential to enhance physical and emotional comfort.

Fear of Abandonment Increasing weakness and loss of control can increase anxiety and a sense of vul- nerability in being left alone. This fear can be experienced in relation to the patient’s physician, who may be less involved once aggressive treatment has stopped. This can even be reinforced if a physician communicates, “There is nothing more to do.” It is important for the physician to remain involved throughout the course of the terminal illness. Family members and physicians who feel helpless and anxious may inadvertently avoid the patient to escape

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distress or because they do not know what to say. It is important to realize how this affects the dying patient.

Loss of Control Because our society values self-reliance and independence, loss of control is par- ticularly frustrating. Weakness, fatigue, confusion, incontinence and distressing symptoms can all contribute to this fear. Individuals who value their independ- ence may try to retain it as much as possible, even to their detriment. For exam- ple, a patient who lives alone may refuse to hire a live-in caregiver, even though he or she is no longer able to care for basic needs. Families often struggle to try to help their loved one maintain valued independence, yet provide for their safety. Loss of control can induce feelings of guilt as the patient needs to rely on others. Making the decision to stop aggressive treatment in the face of advanced disease can represent a major loss of control because the patient may feel that he or she is “giving in” to the disease.

Loss of Hope Hope is a natural part of human existence, and as death approaches, it may be more and more difficult to retain. This can contribute to depression and loss of control. Hoping for a peaceful death and hoping to achieve a specific goal before death are examples of reframing hope at the end of life.

Fear of the Unknown Death presents the greatest unknown to many people. Questions such as “What will happen to my family, my life plans, my body?” are difficult to face. They are also very difficult for others such as family members and even caregivers. Yet the patient may need to express them. Even though we may not have answers to these questions, providing an environment in which fears can be expressed is a great support. Spiritual support may also provide more comfort at these times.

The dying person also faces grief in facing the loss of his or her self, body, and loved ones. Family members may experience many of these same fears.

RELATED CLINICAL CONCERNS

The three leading causes of death today in the U.S. (National Center for Health Statistics, 2003) are

1. Heart disease 2. Cancer 3. Stroke

All of these causes of death are most often associated with chronic, long-term illness characterized by exacerbations and progressive symptoms. Pain, suffering, and distressing symptoms are all associated with long-term illnesses. Uncon-

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trolled pain is by far the greatest fear and a major contributor to patient wishes for hastening death.

Patients in the final weeks of life report fatigue and weakness as the most dis- turbing symptoms, contributing to emotional distress.

LIFE SPAN ISSUES

Children Addressing the needs of dying children takes a dedicated team experienced in working with children and their families. Because of their young age, children are often medically treated very aggressively until the end, making preparation for death more difficult. Professionals may be ambivalent about when to bring up these issues. Parents, especially younger ones, may have little experience with death and will need special assistance in preparing for it. Accidents remain the most common cause of death of children but congenital conditions and cancer remain as frequent causes (NCHS, 2006).

Parents and professionals often struggle with how to prepare the child. Adults who do not want to face this may expend most of their energies denying the pos- sibility of the child’s death. Children are very sensitive to their parents’ reactions and may very well realize what is happening without being told directly. The sick child needs to be approached according to developmental level as to how much he or she can understand. Adults need to stress a sense of comfort, security, and family closeness. A pediatric hospice can provide parental support and education in this area. Pediatric hospice remains underused in many settings though because treating physicians and parents continue to maintain hope (Levetown et al, 2001). The growth in recent years of Pediatric Palliative Care Programs provides a family-centered approach for children with life-threatening conditions to address suffering, goals, coordination of care amongst other services (Himelstein, 2006) even if the family continues to pursue aggressive treatment.

Siblings often need special attention at these times, yet their needs may be overlooked because of the crisis with the sick child. Siblings often struggle with many anxieties about their own health, jealousy for the sick child who gets spe- cial attention, and even feeling responsible for the illness. As with the sick child, the use of play and drawings can be used to help them express feelings that they are too young to verbalize. Siblings should also be included in the care of the ill child, but still be given permission to live a normal life. Seeking help from pedi- atric professionals is essential.

Older Adults The major developmental task of old age is to prepare for death. Life review, let- ting go of responsibilities and possessions, and adjusting to health changes are normal parts of the life cycle that elderly people must face. The death of close friends may occur much more frequently as one ages. Women in particular have

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a greater likelihood of losing their spouse and living alone. Death is not as feared in this age group. For many, a gradual giving up of plans, hopes, and dreams may provide preparation. Maintaining independence for as long as possible, along with respect, support, and good symptom management, are important contribu- tions to good end-of-life care in this population.

As more older adults spend more time in nursing homes, this will become a more common place to provide end-of-life care (Teno et al., 2004). Hospice care can be provided in a nursing home.

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POSSIBLE NURSES’ REACTIONS • May become detached from the dying patient to avoid the pain of losing

him or her • May have unrealistic expectations of how the patient should die (e.g., that

family members will all get along) • May fear losing control of own emotions around the patient and family, as

well as coworkers • May fear participating in hastening the patient’s death when aggressive

symptom management is ordered or when a patient requests that life-pro- longing measures such as tube feedings be stopped

• May identify with a patient of similar age or circumstances, leading to more anxiety

• Facing the death of a patient may stir up past unresolved losses for the nurse, leading to feelings of sadness or anger

• May experience intense anger with family of a dying patient who are not providing the type of support the nurse thinks is appropriate

ASSESSMENT

Behavior and Appearance • Crying, agitation • Unable to concentrate • No apparent reaction • Extreme change in usual behavior patterns • Life review • Completing efforts for estate planning, mortuary arrangements, distribution

of personal belongings

Mood and Emotions • Shock, numbness • Depression

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• Anxiety, panic

• Mood swings

• No obvious emotional reaction

• Anger

• Guilt, remorse

Thoughts, Beliefs, and Perceptions • Maintaining hope for a variety of things, including cure, more time, com-

pletion of goals

• Difficulty making decisions

• Denial, avoidance of preparation

• Reviewing one’s life work and seeking validation for one’s contribution

• Seeking the meaning of one’s life

• Pursuing spiritual beliefs, especially regarding the afterlife

Relationships and Interactions • Seeks support from others

• Fears being alone

• Withdrawal

• Projection of anger onto others

• Need to see loved ones to say good bye

• Wish to resolve past conflicts

• Wish to pass on thoughts, memories, stories to others

Physical Responses • Disrupted sleep • Confusion, agitation • Pain, other symptoms that can be exacerbated by emotions • Possibility that family may develop symptoms similar to those of patient

Pertinent History • Unresolved or multiple past losses • Ambivalent relationship with loved ones • Tendency to isolate self • History of psychiatric disorder or substance abuse • Experiencing traumatic, painful death of a loved one

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COLLABORATIVE INTERVENTIONS

Pharmacological Adequate pain and symptom management must be achieved before any psy- chosocial issues can be addressed. The vast majority of pain and other symptoms of end-stage disease can be controlled with analgesics, anxiolytics, antiemetics, and other drugs as needed. Fears about addiction by patients, families and as health-care providers need to be addressed to ensure that no one is allowing need- less suffering to occur. Side effects of medications used must also be anticipated and measures used to treat them must be provided.

Because depression and hopelessness can affect the quality of life, antidepres- sants can be useful at the end of life, even in a patient with only weeks to live. The side effect profile needs to be carefully reviewed before selecting any medications. Antidepressants with shorter time to onset of effect should be considered in this population. Consultation with a pharmacist and/or psychiatrist might be helpful.

Patient and family may use a variety of complementary and alternative approaches to treat the symptoms of advanced disease or even to retain hope for a cure. Shark cartilage, Laetrile, and other unproven methods are sometimes con- tinued at the end of life. The nurse needs to become familiar with possible side effects to help patients and families weigh the risks and benefits of using these products. For example, inserting a nasogastric tube just to administer shark car- tilage may be too great a burden given the poor prognosis. Other approaches for relief of pain and other symptoms may include magnet therapy, acupuncture, biofeedback, and hypnosis.

Palliative and Hospice Care Palliative care provides symptom management and support for patients with life- limiting illnesses when the goal may be to try to prolong life but still focus on comfort. Patients may still be receiving aggressive treatments such as chemother- apy to control symptoms. Palliative care is most associated with end-of-life care (Gorman, 2006) but in fact can be appropriate early in the disease trajectory of a life limiting illness. Increasingly available in acute hospitals, Palliative care pro- grams provide an important link to quality end-of-life care. National standards entitled the National Consensus Project (2004) for Quality Palliative Care are now in place to establish guidelines for programs.

Hospice care provides an interdisciplinary approach to care of the dying patient and his or her family when the goal is comfort. Medicare has provided a model for hospice services for patients with less than 6 months to live that has also been adopted by Medicaid in most states as well as by most private insur- ance companies. The hospice benefit will provide multiple services to patients and families under the direction of a hospice-trained physician and nurse to enhance comfort and support of the patient, family preparation, education, support and bereavement follow-up, along with the chaplain, social worker, and volunteers. See Table 19–2 for Comparison of Palliative Care and Hospice. Hospice cares for patients with any type of terminal illness. In recent years there has been an

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increase in patients with non-cancer diagnoses such as dementia and heart failure (NHPCO, 2007).

Spiritual Care Some people seek out spiritual support when facing the end of life. They may wish to renew past religious ties, address personal suffering, and seek to find meaning to their life and perhaps their suffering. The role of religious leaders and particularly chaplains at the end of life can be an important intervention. Most hospitals, as well as hospices, offer these services.

NURSING MANAGEMENT

ANTICIPATORY GRIEVING evidenced by distress at facing own death, including depression, anger, and guilt related to the terminal illness.

Patient Outcomes • Acknowledges terminal illness • Expresses concerns, feelings of grief

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TABLE 19–2 Comparison of Palliative Care and Hospice

Palliative Care Hospice

Generally acute hospital based

Patient criteria: Advanced life lim- iting illness with patient in need of symptom management, addressing goals of care or future planning. Aggressive treatment can be continued.

Multiple models including inter- disciplinary consultation team, unit, clinic. Make up of team varies.

National Consensus Project has established standards

Palliative care can provide a bridge to hospice care by identi- fying appropriate patients earlier

Care provided in home or nursing home generally

Patient criteria: Patient with terminal illness with prognosis of less than 6 months; aggressive, curative treat- ment is completed or stopped

Interdisciplinary team defined by Medicare to include physician, regis- tered nurse, social worker, spiritual care and volunteers amongst others

Medicare establishes regulations

Hospice uses the acute hospital setting for short-term admissions if symp- toms cannot be controlled at home

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• Verbalizes feelings of being supported in the grieving process • Identifies potential coping mechanisms, support systems

Interventions • Accept grieving behavior. Recognize that responses to grief are highly

individual. • Use open-ended questions and reflection to give the patient the opportu-

nity to share feelings and concerns. Listen for patient readiness to discuss issues concerning death. For example, a patient may say, “I don’t think I’ll be around much longer.” The nurse can respond by saying, “Tell me what you’re worried about.”

• Recognize that your role may be that of listener if patient needs to vent feelings. Providing an accepting environment to share these feelings is extremely important. Let the patient determine what issues he or she needs to explore. The patient may feel more comfortable discussing his or her grief with a nurse because of not wanting to upset family and friends.

• Facilitate communication between family and patient, if appropriate. Ask patient if he or she would like you to share personal concerns with the family if communication has been blocked. Prepare family for some of patient’s concerns if patient agrees to this.

• Be aware of the need to preserve hope. Recognize that hope may take on many faces in the dying process. It could move from hope for a miracle to hope for less pain to hope to live until a grandchild’s wedding. Cau- tion yourself and others not to promote inappropriate hopefulness based on your own needs or discomforts.

• Recognize that behaviors such as frequent demands, criticisms, and fre- quent questioning may be indicative of patient or family sense of loss of control. Provide those involved with a role in decisions and allow some control where possible. Acknowledge the family’s important role as patient advocate.

KNOWLEDGE DEFICIENT evidenced by frequent questioning, lack of knowledge of the dying process related to facing the death of a loved one.

Patient Outcomes • Demonstrates increased awareness of what to expect in the dying process • Able to identify resources available for assistance • Expresses questions and concerns

Interventions • Keep the family informed about the patient’s condition. Provide infor-

mation on what they can do for the patient and what the staff is doing.

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Discuss with family how they want to be informed about the patient’s death. For example, some families want to be called at any sign of dete- rioration; others want to be notified only of the death.

• Assess family members’ understanding of patient’s prognosis and aware- ness that patient will die soon. Then tailor education based on their level of awareness and readiness to accept more information.

• Reassure patient and family about options available to maintain comfort without euthanasia or physician-assisted suicide.

• Support cultural and religious beliefs during the dying process. Recognize that mourners may have rituals that need to be carried out at a death such as chanting or lighting candles.

• Determine patient and family readiness to discuss issues around goals of care. Code status, hospice care, degree of sedation wished, and continu- ing life-prolonging measures such as TPN or dialysis need to be addressed. Families and patients may need more information on the risks and benefits of all decisions made. Identify if patient has advance direc- tive or has expressed his/her wishes for end-of-life care.

• Talk to family members about what to expect throughout the dying process. Review the symptoms the family may be seeing. When the patient is very close to death, provide information to help them prepare for when death is likely to occur.

• If children are present, ensure that they are included in general discussion to prepare them for what will happen. Speak with the adults away from the children when reviewing some information. Assist them on how to prepare the child. Adults should be encouraged to inform the child’s teachers of what is happening.

• Provide information on local hospice programs, if appropriate. Give information on bereavement support programs available in the area.

• Remember that family members have other responsibilities such as child care and jobs. Talk with them about how they are managing and support their decisions about when to stay with the patient and when to leave. Assess whether they are getting adequate sleep and nutrition. They may need permission to take care of themselves.

• Once the patient has died, inform family members in private. Give them the opportunity to have some private time with the patient. Assist them in getting other family members to the bedside if possible to provide support. Provide information as appropriate on procedures regarding mortuary arrangements, organ donation, autopsy, and so forth.

ALTERNATE NURSING DIAGNOSES

Anxiety Body Image, Disturbed

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Coping, Family: Compromised Coping, Ineffective Powerlessness Self-Esteem, Disturbed Sleep Pattern, Disturbed Pain Spiritual Distress (Distress of the Human Spirit)

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WHEN TO CALL FOR HELP

• Long periods of depression • Patient and family avoiding dealing with important issues around end-

of-life planning, code status • Family behavior that affects patient’s comfort (e.g., withholding anal-

gesics) • Patient with suicidal thoughts, requests for physician-assisted suicide

or euthanasia • No emotional reaction to impending death • Patients’ symptoms not managed

WHO TO CALL FOR HELP

• Palliative care • Hospice • Chaplain • Pain Team • Attending Physician • Social Worker • Psychiatric Team • Pharmacist

PATIENT AND FAMILY EDUCATION

• Prepare patient and family for normal stages of grieving. • Review the role of hospice in end-of-life care. • Provide information on issues around care such as code status, need for

analgesics, side effect management, and so forth. • Provide information on advance directives. Encourage patient to clarify his

or her wishes and share these with loved ones.

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• If appropriate, encourage the dying patient to make a videotape, audiotape, memory book, or other form of legacy for the family, especially for young children who might not remember the patient.

• Review the signs and symptoms of death with loved ones throughout the dying process.

• Review information on organ donation, mortuary arrangements, and so forth as needed.

• Educate caregivers on patient care needs. • Provide patient and family with education resources to prepare including

Web sites for the Hospice and Palliative Nurses Association (hpna.org), National Hospice and Palliative Care Organization (NHPCO.org), and CAPC (getpalliativecare.org). Pamphlets on making difficult decisions such as Hard Choices for Loving People by Hank Dunn may be available through many hospice and palliative care programs.

CHARTING TIPS

• Document grieving behaviors. • Document patient’s pain and comfort level. • Avoid documenting judgments about patient and family behaviors. • Document patient and family awareness of prognosis, goals, and wishes. • Document presence and content of an advance directive and patient’s ver-

balizations of any change in wishes.

COMMUNITY-BASED CARE

• Refer to hospice care if patient is going home or to assisted living or a nurs- ing home.

• Refer to support programs for patients with advanced disease as well as bereavement groups for the family.

• Refer to pain clinics, palliative care programs as appropriate. • Provide legal referrals for completing wills, managing finances. • Refer family to caregiver support group, education programs.

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20

435

Disaster Planning and Response—Psychosocial Impact

The Disaster Victim/Patient The Disaster Responder/Nurse

Carl Magnum, RN, MSN, PhD(c), CHS, FF

Learning Objectives • List interventions a nurse could use in working with a patient/victim of

disaster. • Identify possible nursing staff reactions to disaster. • Describe signs and symptoms of stress related of victims and responders

in a disaster. • Describe interventions to reduce the risk of post-traumatic stress disor-

der after a disaster.

Glossary Critical incident stress debriefing – An organized, structured approach to sup-

port emergency personnel and survivors who are exposed to extreme stress that revolves around discussion, feelings, and reactions to the event.

Disaster – Tragic events that disrupt normal functioning and safety of a com- munity.

Disaster Psychiatry – Psychiatric specialists who address an epidemiological approach to understanding the treating of effects of mass casualty situations.

Human-made disaster – Occur through human actions (accidental or inten- tional).

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Natural Disaster – Occur by acts of nature. Post-traumatic stress disorder (PTSD) – Anxiety and stress symptoms that

occur after a massive traumatic event; often includes the feeling that the event is recurring. PTSD can last for weeks, months, or years.

The past 2 decades have been a learning curve for nurses related to disasters and their victims. The Oklahoma City Bombing, September 11 attacks,

anthrax scares, and Hurricanes Katrina and Rita have set the standard for mod- ern disasters. Local community disasters can include such events as school shoot- ings and factory explosions. Disasters are usually grouped as natural and human-made. The effects on victims from each are the same. Some people are even affected before the actual event. Psychosocial problems occur throughout the phases of a disaster. Some people do not present with psychosocial difficul- ties until the recovery phase.

Citizens in the disaster area are always the first concern. The response com- munity also has concerns for responders/nurses during and after the disaster. Responders are also affected by many of the responses that citizens have. There are a few differences in how to prepare for and operate during a disaster.

When a disaster occurs, there are three types of victims (Williams & Boyd, 2005). First are the victims who suffer trauma from the disaster itself. These people are vulnerable to physical injury, post-traumatic stress disorder (PTSD) and depression after the event. The second type of victims are the rescuers/responders who are likely to be exposed to trauma and PTSD at seeing others suffer, as well fear for their own well-being. The third victim is the community at large, who may suffer psychological effects from observing the events from afar. These victims may experience anxiety, sadness, helplessness, and fear that the disaster could have happened to them. For example, after the terrorist attacks on September 11, a study of Americans across the country demonstrated that 90% experienced at least one stress symptom immediately after the event (Schuster et al, 2001).

Because nurses may be among the first responders in a community disaster, preparation and knowledge about the impact of a disaster on oneself and others is essential. Nurses suffer from the same emotional trauma as others and need to take precautions to take care of themselves as well as others.

More information is now available on disaster preparation that includes psy- chological preparation. Health-care providers, law enforcement officials, and school officials are important areas to concentrate preparation (Norwood, Ursano, & Fullerton, 2006). Involving mental health professionals, including spe- cialists in Disaster Psychiatry, is important to address potential fears and help responders identify emotionally “at-risk” individuals.

One consistency seen in a disaster is that some individuals step up and rise above their training and position to help. In many disasters, we hear inspiring stories of responders and victims who put themselves at risk to help strangers. After the initial shock, victims may try to do something to resolve the situation and help others. Nurses, as leaders in a helping profession, are often active in this

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role. For example after Hurricaine Katrina in 2005, many nurses sought out ways to help victims and local healthcare professionals. Many nurses went to the dis- aster area to help set up emergency medical care for the victims.

ETIOLOGY

There are many factors that influence emotional response to a disaster. Biological: The stress response prepares the individual for “fight or flight.”

During the fight response, the individual is physiologically prepared to attack. The flight response involves efforts to conserve body resources. During a disas- ter, these physiological responses affect the initial response.

Psychological: Many psychological factors contribute to the emotional response to a disaster. Fear, anger, shock, sadness, and disbelief are all common and normal emotional responses. These responses may be based on the person’s personality and normal coping patterns, coping reserves, and support system available. After a disaster, common responses can include sleep disturbances, and increased use of alcohol, tobacco, and illicit drugs to treat uncomfortable, resid- ual symptoms,

Sociocultural: During a disaster, the community response as people rush to help can promote a sense of support and reassurance to victims. This social support from all levels of the community can expose victims to many strangers from other cultures and walks of life. This sense of support and community can be reassur- ing to victims, who realize that they are not alone. It is common that traumatic events can bring out some of the best in people (Deeny & McFetrige, 2005).

CLINICAL CONCERNS

The presence of chronic illnesses, required medical treatments, and dependency on medications may be factors on how individuals respond in a disaster. Victims and responders may also be dealing with physical injury, exposure to toxins, dehydration, lack of sleep, and no access to normal medications, which can cre- ate more complicated emotional responses. Patients who are being treated for serious illnesses like cancer may have many concerns when they are unable to access their health care providers (Tariman, 2007).

LIFE SPAN ISSUES

Children Younger children may experience separation anxiety from parents. Older chil- dren may be mad, sad, or afraid the event may happen again. Difficulty concen- trating and obsession with the event may be prevalent. Sleep disturbances, night terrors, and fear of the dark may be seen after the disaster. Regression to an ear- lier developmental stage, including bedwetting, clinging behaviors, and an inabil- ity to articulate, may be seen for short periods.

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Children who are experiencing feelings of anxiety and helplessness can bene- fit from participating in altruistic activities like fundraising and volunteer activi- ties such as food or clothing drives to help others (American Psychiatric Association, 2004).

Adolescents They may respond similarly to adults (Norwood, Ursano, & Fullerton, 2007). Others may regress to a more childlike phase. They may be afraid to leave home and not want to spend time with their friends. Emotions may lead to increased friction, arguing, and even fighting with siblings, parents, and other adults. Teens may be put into adult roles for a short period to help others. This can lead to feel- ings of guilt and anxiety when faced with decisions that they are not prepared to handle. They may become preoccupied with decisions they made. An increase in high-risk behaviors after a traumatic event is sometimes seen.

Older Adults Although older adults have many life experiences, a major disaster can have a tremendous impact. The unexpected, unfamiliar, and uncontrollable events bring fears for safety, loss of life-long treasures, and can affect chronic conditions. Lack of access to regular medications may contribute to additional emotional problems.

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POSSIBLE NURSES’ REACTIONS • Fear for own safety and victim’s safety • Sympathy for victims • Anxiety related to the situation • May identify with victims’ suffering and fears • Guilt over leaving one’s own family or focusing on personal fears/needs • Resentment over victim’s emotional reactions • Overwhelmed with responsibilities and needs • Feeling need to flee disaster

ASSESSMENT OF THE DISASTER VICTIM/PATIENT

Behavior and Appearance • Suspicion • Irritability • Arguments with friends and loved ones • Withdrawal • Excessive silence • Inappropriate humor

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• Increased/decreased eating • Change in sexual desire or functioning • Increased smoking • Increased substance use or abuse

Mood and Emotions • Shock • Numbness • Feeling overwhelmed • Depression • Feeling lost • Fear of harm to self and/or loved ones • Feeling nothing • Feeling abandoned • Uncertainty of feelings

Thoughts, Beliefs, and Perceptions • Poor concentration • Confusion • Disorientation • Indecisiveness • Shortened attention span • Memory loss • Unwanted memories • Difficulty in making decisions

Relationships and Interactions • Close attachment with other victims or responders • Distant from family and friends • Others avoiding victim due to volatile emotions

Physical Responses • Nausea • Lightheadedness • Dizziness • Gastrointestinal problems • Rapid heart rate • Tremors • Headaches • Grinding of teeth

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• Fatigue • Poor sleep • Pain • Hyperarousal • Jumpiness

Pertinent History • History of psychiatric disorders • History of violent behavior • Past experience in a disaster situation

ASSESSMENT OF THE DISASTER RESPONDER/NURSE

See Box 20–1 for Normal Responses to a Disaster and Box 20–2 for Signs of Stress after a Disaster.

Behavior and Appearance • Intense anger • Withdrawal • Temporary loss or increase of appetite • Emotional outbursts • Excessive alcohol consumption • Inability to rest, pacing

Mood and Emotions • Anxiety • Guilt • Grief

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BOX 20–1 Normal Reactions to a Disaster • No one who responds to a mass casualty event is untouched by it. • Profound sadness, grief, and anger are normal reactions to an abnormal

event. • You may not want to leave the scene until the work is finished. • You will likely try to override stress and fatigue with dedication and com-

mitment. • You may deny the need for rest and recovery time.

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• Denial • Severe panic (rare) • Fear • Irritability • Loss of emotional control • Depression • Sense of failure • Feeling overwhelmed • Blaming others or self

Thoughts, Beliefs, and Perceptions • Confusion • Nightmares • Disorientation • Heightened or lowered alertness • Poor concentration • Memory problems • Poor problem solving • Difficulty identifying familiar objects or people

Relationships and Interactions • Arguments with friends and loved ones • Suspicion of others • Change in sexual desire or functioning

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BOX 20–2 Signs of Stress after a Disaster • Difficulty remembering instructions • Difficulty maintaining balance • Uncharacteristically argumentative • Difficulty making decisions • Limited attention span • Unnecessary risk-taking • Tremors/headaches/nausea • Tunnel vision/muffled hearing • Colds or flu-like symptoms. • Disorientation or confusion

• Difficulty concentrating • Loss of objectivity • Easily frustrated • Unable to engage in problem-

solving • Unable to let down when off duty • Refusal to follow orders • Refusal to leave the scene • Increased use of drugs or alcohol • Unusual clumsiness

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Physical Responses • Chest pain • Difficulty breathing • Shock symptoms • Fatigue • Nausea/vomiting • Dizziness • Profuse sweating • Rapid heart rate • Thirst • Headaches • Visual difficulties • Clenching of jaw • Nonspecific aches and pains

Pertinent History • Type and amount of training the responder/nurse has had. • Actual disaster experience. • Has responder/nurse been personally affected by the event. • Predisaster preparation.

COLLABORATIVE MANAGEMENT

Pharmacological Antianxiety medications are used for relief of feelings of tension and anger. The choice of medications is dependent on the diagnosis and the availability of med- ications. During a large-scale disaster, medications become limited and it may be days or weeks for a medication of choice to be available. Many victims may try to self-medicate.

Mental Health Interventions Mental health professionals are developing more strategies to address these issues. The American Psychiatric Association has developed principles for Disas- ter Psychiatry to provide training for mental health professionals on appropriate interventions to minimize exposure to traumatic stressors, education about nor- mal responses to trauma and disasters, consultation with other health-care pro- fessionals and community leaders, and professional treatment for PTSD (Norwood, Ursano, & Fullerton, 2007).

Critical incident stress debriefing training can be completed by nurses, social workers, clergy, physicians among other professionals. People with this struc-

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tured training can be helpful in assisting all types of victims or potential victims to prevent long-term emotional trauma. The American Psychiatric Association (2004) has cautioned that anxiety can be increased by the process of retelling about the event.

NURSING MANAGEMENT FOR THE DISASTER VICTIM/PATIENT

POST-TRAUMA SYNDROME (ACUTE), evidenced by anxiety, hypervigi- lance, anger, altered mood states, nightmares or flashbacks, headaches, loss of interest in normal activites, hopelessness, gastric irritability related to expo- sure to a disaster

Patient Outcomes • Reports reduced anxiety when memories occur • Demonstrates ability to deal with emotional reactions in an individually

appropriate manner • Demonstrates appropriate changes in behavior or lifestyle • Reports absence of physical manifestations

Interventions • Observe for and elicit information about physical or psychological injury

and note associated stress-related symptoms such as numbness, headache, tightness in chest, nausea, pounding heart, and so forth.

• Identify psychological responses: anger, shock, acute anxiety, confusion, and denial.

• Provide crisis intervention techniques to assist with extreme reactions of panic, hysteria by remaining calm and providing consistent reassurance. See Chapter 5.

• Assess patient’s knowledge of and anxiety related to the situation. • Ascertain ethnic, background/cultural, and religious perceptions and

beliefs about the occurrence. • Determine degree of disorganization. • Identify whether incident has reactivated pre-existing or coexisting situ-

ations. • Determine disruptions in relationships. • Note withdrawn behavior, use of denial, and use of chemical substances

or impulsive behaviors. • Be aware of signs of increasing anxiety. • Note verbal or nonverbal expressions of guilt or self-blame when patient

has survived in which others have died.

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• Assess signs/stage of grieving for self and others. Recognize that trau- matic bereavement can occur if the victim feels survivor guilt when oth- ers did not survive the disaster.

• See Box 20–3 for Communicating with Disaster Victims including sug- gestions on phrases to avoid that can increase the victims’ anxiety, sense of loss, and powerlessness.

RELOCATION STRESS SYNDROME evidenced by feeling of powerlessness, lack of adequate support system, little or no preparation for the impending move, anxiety, depression, sleep disturbance, insecuirty, gastrointestinal dis- turbances, sad affect, withdrawal related to disruption of living arrangements after a disaster.

Patient Outcomes • Verbalize understanding of reasons for change. • Demonstrate appropriate range of feelings and lessened fear. • Verbalize acceptance of situation. • Demonstrates no escalation of emotions

Interventions • Ascertain patient’s perceptions about changes and expectations for the

future. • Monitor behavior, noting presence of suspiciousness or paranoia, irri-

tability, defensiveness • Note signs of increased stress, reports of new physical discomfort or

pain, or presence of fatigue.

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BOX 20–3 Communicating with Disaster Victims Things to Avoid Saying:

• “I understand.” • “Don’t feel bad.” • “You’re strong/You’ll get

through this.” • “Don’t cry.” • “It’s God’s will.” • “It could be worse” or

“At least you still have…”

More Helpful Phrases:

• “There are people here to help you” • “We won’t leave you alone” • “It’s OK to let out your emotions” • “I know you are scared” • “We are in this together”

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• Determine the involvement of family and significant others. • Encourage visiting new surroundings before transfer, when possible. • Orient to surroundings and schedules. Introduce to staff members, room-

mate, and other residents. Provide clear, honest information about actions and events.

• Encourage free expression of feelings. Acknowledge the reality of the sit- uation and maintain hopeful attitude regarding move or change.

• Identify strengths and successful coping behaviors the individual has used previously.

• Deal with aggressive behavior by imposing calm, firm limits. Control environment and protect others from patient’s disruptive behavior.

• Involve patient in formulating goals and plan of care when possible. • Discuss benefits of adequate nutrition, rest, and exercise to maintain

physical well-being. • Identify and provide concrete information on what happened to family

and pets, condition of victim’s home/belongings where possible. Recog- nize that victims may be fearful leaving the disaster site because of losing touch with family, friends, pets, belongings.

• Encourage participation in activities, hobbies, and personal interactions as appropriate.

INEFFECTIVE COMMUNITY COPING evidenced by deficits in social sup- port services and resources, ineffective or nonexistent community systems, community powerlessness, high illness rates, increased social problems related to community response to a disaster

Patient Outcomes • Recognize negative and positive factors affecting community’s ability to

meet its own needs. • Identify alternatives to inappropriate activities for adaptation/problem

solving. • Report a measurable increase in necessary and desired activities to

improve community functioning.

Interventions • Provide support for victims who are frustrated with community response

to the disaster. Recognize that community may be ill prepared for this event. Allow expression of anger

• Promote adaptive coping mechanisms that will not alienate others • Seek out alternative resources available to the victims. • Promote victims to participate in altruistic activities to help others if

possible.

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ALTERNATE NURSING DIAGNOSES FOR VICTIMS

Anxiety Family Processes, Compromised Fear Hopelessness Injury, Risk for Powerlessness Social Interaction, Impaired Spiritual Distress, Risk for Violence, Risk for

NURSING MANAGEMENT FOR THE DISASTER RESPONDER/NURSE

CAREGIVER ROLE STRAIN evidenced by caregiver health impairment, increasing care needs, unpredictability of care sitiuation, presence of violence, inadequate physical environment for providing care, caregiver isolation, insuf- ficient information and finances or supplies, inadequate tranportation and equipment for providing care related to being present during or after a disaster.

Outcomes • Identify resources within self to deal with situation. • Identify outside resources to deal with the situation. • Acknowledge limitations due to the extent of the disaster

Interventions • Inquire about and observe physical condition of care provider and sur-

roundings as appropriate. • Assess caregiver’s current state of functioning. • Identify safety issues concerning caregiver and receiver. • Determine availability of support systems and resources. • Discuss caregiver’s view and concerns about the situation. • Acknowledge the difficulty of the situation for the caregiver. • Discuss stress management techniques. • Remove caregiver from situation, if needed. • Contact other resources for assistance. • Acknowledge feelings of being overwhelmed with situation • Seek out assistance from others in the area who may want to help.

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• Help caregivers and responders take breaks from the situation and encourage them to incorporate self-care where possible.

INEFFECTIVE COPING evidenced by situational crisis, high degree of threat, inadequate resources available, inadequate level of confidence in ability related to being called to help in a disaster.

Outcomes • Assess the current situation accurately. • Identify ineffective coping behaviors and consequences. • Verbalize awareness of own coping abilities. • Meet psychological needs as evidenced by appropriate expression of feel-

ings, identification of options, and the use of resources.

Interventions • Evaluate the ability to understand events, provide realistic appraisal of

situation. • Assess current functional capacity and note how it is affecting the indi-

vidual’s coping ability. • Observe and describe behavior in objective terms. • Actively listen and identify the nurse’s perceptions of what is happening. • Evaluate nurse’s decision-making ability. • Assist with relaxation techniques. • See Box 20–4 for ways to manage stress after a disaster.

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BOX 20–4 Ways to Help Manage Responder Stress in a Disaster • Limit on-duty work hours to no more than 12 hours per day • Make work rotations from high-stress to lower stress functions • Make work rotations from the scene to routine assignments, as practicable • Use counseling assistance programs available through your agency • Drink plenty of water and eat healthy snacks like fresh fruit and whole

grain breads and other energy foods at the scene • Take frequent, brief breaks from the scene as practicable. • Talk about your emotions to process what you have seen and done • Stay in touch with your family and friends • Participate in memorials, rituals, and use of symbols as a way to express

feelings • Pair up with a responder so that you may monitor one another’s stress

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ALTERNATE NURSING DIAGNOSES FOR RESPONDERS

Anxiety Comfort, Impaired Fear Grieving Hopelessness Spiritual Distress, Risk for

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WHO TO CALL FOR HELP

• Other team members on the scene. • Command staff • Local law enforcement • Local medical providers • State medical providers • Federal medical providers • Volunteers and bystanders

WHEN TO CALL FOR HELP

• Threats against personal safety. • Victims who become violent, threaten aggression • Presence of firearms, other weapons • Inability to handle patient load. • Another event pending. • Environmental hazards. • Unable to continue response duties

PATIENT AND FAMILY EDUCATION

• Planning and preparations by families is critical to getting through a disaster. • Contact information for family, insurance, medical, and emergency

personnel. • Having current medication names and doses. • Disaster kits for the home and the car. • Promote the development of individual family disaster plans with a plan for

how to contact each other in the event of being separated.

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CHARTING TIPS

• Records are difficult to create and maintain during disaster situations. • Basic information name and contact information. • Include location of the treatment center; remember landmarks may not be

available. • Write down pertinent medical information. • Identify if patients’ medical records available electronically.

COMMUNITY-BASED CARE

• Planning and preparedness is the key. • Be aware of disaster preparation in your work setting including information

on where the command center would be, locate other communication resources, identify local radio stations that will have latest information.

• Seek out information in advance of a disaster in your community. The American Nurses Association has information on preparations for a disas- ter for nurses at www.nursingworld.org/news/disaster/. The Centers for Dis- ease Control and Prevention (CDC) has a website on preparation of health professionals at www.bt.cdc.gov/masscasualties/copingpro.asp.

• Participate in a program on disaster preparation in schools and hospitals that includes psychological preparation.

• Be aware of humane resources for care of pets as it is well established that victims may not be willing to leave the disaster area if their pets would be left behind in potential danger.

• Participate in disaster exercises in your community that give potential responders and victims some preparation for the emotional reactions seen in a disaster.

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Psychopharmacology: Database for Patient and Family Education on Psychiatric Medications Yoshinao Arai, RN, MN, CNS

Learning Objectives • Identify the indications and clinical uses for antianxiety, antidepressant,

mood stabilizers, and antipsychotic medications. • List safe administration practices for patients taking these drugs. • Select the appropriate nursing interventions and patient education

strategies for patients taking these drugs.

Glossary Agonist – A chemical compound (drug or neurotransmitter) that produces a

biochemical response when it binds to a receptor. A receptor is a complex molecule located on a cell membrane. When an agonist binds to a recep- tor, this forms an agonist-receptor complex, and the formation of this com- plex leads to a biochemical response.

Antagonist – A chemical compound that blocks or reverses the effect of agonists by coupling with a receptor without triggering a physiological response. Antagonists and agonists can bind to a receptor, but they cannot do so at the same time. The degree to which an antagonist dominates an agonist depends on the binding strength and the concentration of the antagonist.

Elimination half-life – Time required to decrease the plasma concentration of a drug by 50%. If the half-life of a drug is shorter than 24 hours, its daily dose needs to be divided into two or three doses a day to maintain steady- state concentration in the body. It takes about five times the half-life for a drug to reach its steady state when a new drug is started or about five

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half-lives for a drug to be washed out of an individual’s system after a drug is discontinued.

Neurotransmitters – Chemical compounds that serve as messengers in the neuronal system. Each neurotransmitter has its specific type of recep- tors to couple with. Common neurotransmitters for psychopharmacology include dopamine, serotonin, norepinephrine, acetylcholine, and gamma- aminobutyric acid (GABA). Others include oxytocin, growth hormone (GH), calcitonin, angiotensin, insulin, substance P, beta-endorphin, and prolactin.

Potency – A comparative, not absolute, measure of the strength of a drug to produce a response. The higher the potency of a drug, the lower the rec- ommended dose will be to create a given physiological response. For example, a dose of haloperidol (Haldol) of 2 mg is thought to produce the same clinical response (antipsychotic effect) as a dose of chlorpromazine (Thorazine) of 100 mg. The potency of haloperidol is 50 times higher than that of chlorpromazine.

Psychoeducation – Educational intervention with a focus on skills training for managing mental health issues for patients and families to achieve behav- ioral changes with increased knowledge

Psychiatric medications do not cure psychiatric disorders, but they can alleviate the symptoms caused by the disorders. The medications can minimize the dis-

turbing impact of mental illness on a person’s ability to function. The ideal treat- ment outcome is the removal of all the negative impact of the illness on the person’s ability to achieve his or her goals in life. This is the purpose of psychopharmaco- logical interventions when augmented with psychoeducation and rehabilitation. Both pharmacological and nonpharmacological interventions are effective because they work in the brain to adjust its biochemical brain activity. The resulting bio- chemical changes in the brain enhance the process of psychiatric rehabilitation in a similar manner to that of neurological rehabilitation. To attain the best benefits from psychiatric medication, the person with a psychiatric disability must see how medications can help to eliminate roadblocks in his or her life. This is best accom- plished by identifying specific and concrete target symptoms with each individual.

Because people with psychotic symptoms are not aware of the difference between reality and symptoms, it is often difficult for them to see a need for the use of medication. Even if they are aware of their need for medication, it can still be difficult for them to assess a medication’s efficacy because they cannot clearly distinguish what is reality and what is a symptom. Medication education, which is usually provided only at the beginning of a particular treatment, is not suffi- cient. Giving written information about a medication may only make the person feel more anxious. Psychoeducational support should be an ongoing process that helps to maximize the efficacy and safety of the medication regimen. With this support, the people with psychiatric disabilities will be able to value the phar- macological therapies in relation to their life goals.

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This chapter provides the essential information on the psychiatric medications and their safety issues (Table 21–1). This can be used in psychoeducational inter- ventions to clarify the value of the medications in terms of the difference they can make in the lives of people with psychiatric disabilities. This information is pre- sented in the following order:

• Basic Concepts • Medications for Symptoms of Anxiety Disorders • Medications for Mood Symptoms

• Antidepressants • Mood Stabilizers

• Medications for Psychotic Symptoms

• Typical Agents • Atypical Agents

• Managing Side Effects of Antipsychotic Agents • Collaborative Management for Advocacy • Charting Tips • Community-Based Care

BASIC CONCEPTS

Pharmacokinetics and Pharmacodynamics It is necessary to have some basic understanding on what the body does to med- ications (pharmacokinetics) and what medications do to the body (pharmaco- dynamics).

Pharmacokinetics

Once a medication is taken orally, intramuscularly, sublingually, transdermally, or intravenously into the bloodstream, it can be eliminated in many different ways. Plasma proteins bind part of the medication, making this part inactive, or not bioavailable. Some of the medication is carried to the kidney, where it may be excreted unchanged in the urine. Some of the medication is carried to the liver, where it is transformed into a more water-soluble, active or inactive metabolite. Once transformed by the liver, the medication may be excreted in the urine or in the bile (then in the feces) and out of the body. Individual differences in the bio- transformation through known or unknown mechanisms contribute to the observed wide range of clinical responses to a standard dose.

Pharmacodynamics

Psychiatric drugs can produce clinical responses even when only a small portion of the medication can reach their sites of action, that is, the receptors in the synapses.

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TABLE 21–1 Summary of Safety Issues on Psychiatric Medications

Type of Adverse Event Related Medications

Dose-related toxicity

Lowered seizure threshold

Hepatic toxicity

Agranurocytosis

Myocarditis

Significant weight gain

Type II diabetes mellitus

Increased mortality due to medical conditions in the elderly with dementia and psychosis

Movement disorders (tardive dyskinesia, neuroleptic malig- nant syndrome, extrapyrami- dal symptoms, akathisia)

Increased suicidality in children and adolescents

Paralytic ileus

Glaucoma

Altered cardiac conduction

High blood pressure

Increased toxicity or decreased efficacy due to drug interac- tions with other drugs, food

Lithium

Clozapine, clomipramine, bupropion

Nefazodone, duloxetine, valproic acid

Clozapine, mirtazapine, carmabazepine, phenytoin, TCAs

Clozapine

Olanzapine, clozapine, quetiapine,

Olanzapine, clozapine, quetiapine

Atypical antipsychotics

Typical and atypical antipsychotics

SSRI, TCA, and MAOI antidepres- sants

Benztropine, clozapine, chlorpro- mazine, quetiapine

Benztropine, chlorpromazine, clozapine

Lithium, ziprasidone, clozapine, TCAs

Venlafaxine, MAOI antidepressants

SSRIs, MAOIs, lithium, cimetidine, carbamazepine, phenytoin, erythro- mycin, ketoconazole, nicotine, caf- feine, grapefruits

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The drug molecules can facilitate or inhibit the effect of neurotransmitters by inter- acting with receptors on neuronal cells in different neurotransmitter systems. These systems are often described by the predominant neurotransmitter present. Examples include the dopamine, serotonin, norepinephrine, acetylcholine, hista- mine, and gamma-aminobutyric acid (GABA) systems.

The dopamine system in the brain has been thought to play a major role in causing psychotic symptoms. Blockade of certain types of dopamine receptors has been associated with alleviation of psychotic symptoms. It is recognized that blockade of other types of dopamine receptors causes neurological or endocrine side effects, as discussed later.

The serotonin system has been thought to be associated with symptoms of depression, anxiety, and hallucinations. It is also postulated that blocking of cer- tain serotonin receptors may be associated with controlling negative symptoms of schizophrenia, as discussed later. However, blocking of other types of sero- tonin receptors is associated with such side effects as hypotension, sedation, and ejaculatory dysfunction.

The norepinephrine system may be associated with mood and motivation. Some of the new antidepressants target this system. Blockade of certain norepi- nephrine receptors is thought to be associated with such adverse effects as pos- tural hypotension, dizziness, tachycardia, and sexual dysfunction.

The acetylcholine system may be associated with memory and smooth muscle functions.

Different types of pharmacological interactions with the muscarinic type of acetylcholine receptors have been associated with alleviating parkinsonian symp- toms or causing such side effects as dry mouth, constipation, blurred vision, uri- nary retention, electrocardiographic (ECG) changes, and memory impairment.

The histamine system is thought to be associated with the sedative effects of medications that interact with the histamine receptors. It is also postulated that postural hypotension and weight gain can be caused by pharmacological manip- ulation of the histamine system.

The GABA system in the brain is an inhibitory network that lowers the activ- ity levels of all other neurotransmission systems. The efficacy of the benzodi- azepine (BZ) family of medications is associated with their effect of blocking the activity of this system.

Major Categories of Common Psychiatric Medications Major advances in psychopharmacology include discoveries of psychiatric uses of chloral hydrate (1860s), barbiturates (1900s), antipsychotic medications (1950s), nonselective (tricyclic) and monoamine oxidase inhibitor (MAOIs) antidepres- sants (1950s), BZs (1960s), lithium (1970s), selective serotonin reuptake inhibitors (SSRIs, 1980s), atypical antipsychotics (1990s), serotonin and norepi- nephrine reuptake inhibitors (SNRIs, 1990s), and selective BZ receptor agonists (1990s). Most of these categories of medications are currently in use except the barbiturates, most of which were replaced by relatively safer agents such as BZs and SSRIs.

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Commonly used psychiatric medications for adults can be identified under the following conventional categories: antianxiety agents (anxiolytics, sedatives, and hypnotics), antidepressants (older and newer agents), mood stabilizers, antipsy- chotic agents, and medications to control side effects. The generic and trade names for the medications are listed in boxes in each section. The possible daily dosage ranges (usually in milligrams per day) are also provided for each drug.

Target Symptoms When the pharmacological interventions are considered, the treatment team and the patient or family should specifically define the psychiatric symptoms that the drugs of each category are treating.

Refer to the appropriate chapters to review common psychiatric symptoms as targets for pharmacological treatment. After defining specific target symptoms with the patient or family, each symptom may be rated on a 10-point scale before the therapy is started and periodically afterward. This way, both the treatment team and the patient or family can keep better track of changes in reactions to medications over time.

Patient and Family Education Educational needs of patients and their families should be assessed in the follow- ing areas in relation to psychopharmacological treatments:

• Names of the medications • When and how to take them • What are the target symptoms • Skills to identify expected benefits • Time it takes to be able to identify the beneficial effects • Possible adverse effects • What to do if the adverse effects are too disturbing to tolerate • How long the medication or medications should be taken • Possible drug interactions with alcohol, other medications, nutritional sup-

plements, and food • What to do if the target symptoms worsen

GENERAL CONSIDERATIONS FOR VULNERABLE POPULATIONS

Children Children are generally more prone to serious disruptions by psychiatric medica- tions that may interfere with development. Their livers and kidneys may not be

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developed enough to efficiently eliminate the drugs out of the body, although the opposite is generally the case when relatively higher doses are required for effi- cacy, partly because of children’s faster metabolic capacity. However, few con- trolled studies have been done to obtain data on the efficacy and safety of psychiatric medications in children (Birmaher & Axelson, 2005). In addition, how these drugs effect growth and development with long-term use has not been well studied.

Adolescents Adolescents often fall in between children and adults in terms of proper dosing based on body size. As with children, long-term effects and efficacy for adoles- cents have not been well studied. Teens may also be particularly concerned with drug side effects that negatively affect body image like weight gain and hair loss.

Older Adults Older adults may be vulnerable to side effects of the medications in general for the following reasons:

• Decreased body water may lead to higher concentrations of medications.

• Decreased plasma proteins may lead to increased serum level of a drug that is not bound to proteins in the bloodstream.

• Increased portion of fat in the body may cause retention of a fat-soluble psychiatric medication and prolong its elimination half-life.

• Decreased liver and kidney function may also prolong elimination half-life of a medication.

• In addition, complex drug regimens which may be from multiple prescribers may be associated with poor compliance.

MEDICATIONS FOR SYMPTOMS OF ANXIETY DISORDERS

Certain clusters of anxiety symptoms can suggest various anxiety disorders (Table 21–2). However, anxiety symptoms are also common in most other psy- chiatric disorders such as schizophrenia, major depression, and bipolar disorders. In these cases, the primary conditions need to be treated as well. The same is true for anxiety symptoms that are secondary to other medical disorders such as mitral valve prolapse, hyperthyroidism, arrhythmia, inner ear infection, asthma, or to use of substances such as cocaine, caffeine, methamphetamines.

The most common antianxiety medications are in the categories of anxiolyt- ics, sedatives, and hypnotics. These can be classified into two groups of BZs and non-BZs (Box 21–1). Other categories of medications for anxiety include antide- pressants and beta blockers.

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TABLE 21–2 Common Symptoms of Anxiety

Origin Symptom

Physical symptoms of brainstem origin

Emotional symptoms of limbic system origin

Cognitive symptoms of neocortical system origin

Fatigue, cold chills, headaches, difficulty breathing, difficulty sleeping, dizziness, shaking, sweating, muscle tension, restless- ness, GI disturbances, numbness in fingers and toes, and palpitations

Nervousness, fear, panic, apprehension, feel- ing detached from part of own body, or feeling that the surroundings are unreal

Intrusive thoughts or concerns about losing one’s mind, losing control, frightening scenes, having physical illnesses, being inadequate, being disapproved, fainting, difficulty concentrating

BOX 21–1 Most Common Antianxiety Medications Benzodiazepines Dosage Chlordiazepoxide (Librium) Diazepam (Valium) Lorazepam (Ativan) Oxazepam Temazepam (Restoril) Alprazolam (Xanax) Flurazepam (Dalmane) Clonazepam (Klonopin) Non-Benzodiazepines Zolpidem (Ambien) Zaleplon (Sonata) Eszopiclone (Lunesta) Antihistamines and Anticholinergics Diphenhydramine (Benadryl) Serotonin Antagonist Buspirone (BuSpar)

15–100 mg/day 2–60 mg/day 0.5–6 mg/day 30–90 mg/day 7.5–30 mg hs 0.25–10 mg/day 15–30 mg hs 0.25–10 mg/day

5–15 mg hs 5–20 mg hs 2–3 mg hs

25–50 mg hs

15–60 mg/day

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HYPOTHESES OF MECHANISMS OF ACTION

The mechanisms of action of anxiety medications are unknown. However, two hypotheses on how medications alleviate anxiety symptoms involve the serotonin and GABA-BZ neurotransmission systems.

The serotonin system is supposed to be one of the mediators of a “fear net- work,” which involves the brainstem, the hypothalamus, and the amygdala. The amygdala is a critical temporal lobe structure associated with the expression of anxiety and mammalian stress responses. It is hypothesized that medications influencing the serotonin system desensitize the “fear network” (Gorman, Kent, Sullivan, & Coplan, 2000).

The GABA system has an inhibitory function on the brain. When its function is enhanced by coupling of the BZs with the GABA-BZ receptors on surfaces of neurons, neurotransmissions are inhibited in most parts of the brain. Thus, some overexcitation can be leveled off to aid relaxation.

EFFICACY IN TREATING SYMPTOMS

Anxiety Symptoms Anxiety symptoms respond well to BZs such as lorazepam (Ativan), clonazepam (Klonopin), chlordiazepoxide (Librium), diazepam (Valium), and alprazolam (Xanax). However, if it is expected that the symptoms will require treatment for more than several weeks, antidepressants or buspirone (BuSpar) will become the first drugs of choice. BZs can be used on an as-needed basis or only for the first several weeks until the antidepressant or buspirone takes effect because of the possible development of dependence on BZs.

Among the antidepressants used for anxiety, serotonergic agents such as paroxetine (Paxil), fluoxetine (Prozac), sertraline (Zoloft), and fluvoxamine (Luvox) are thought to be the best choices as primary medications for long-term treatment of most anxiety symptoms. Other medications for anxiety include some beta-adrenergic blockers such as propranolol (Inderal) or anticonvulsants such as gabapentin (Neurontin) (Pollack, Mathews, & Scott, 1998).

Anxiety-Related Insomnia BZs used as central nervous system (CNS) depressants reduce anxiety (anxiolytic effect) at lower doses and produce sedative effects at slightly higher doses. Most BZs also induce sleep (hypnotic effect) at higher doses. However, unlike the case with barbiturates, the central nervous system depressant effect of BZs does not increase to cause coma or death, even if the doses are further increased, as long as they are not used with other CNS depressants such as alcohol.

BZs generally have rapid onsets (i.e., 15–60 minutes after oral administration) except temazepam (Restoril) which may take 45 to 120 minutes to begin taking effect. The long half-life (48–150 hours) of flurazepam (Dalmane) is associated with morning hangover.

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OTHER USES

Dual-Diagnosis Patients Who Have Both Psychiatric Disorders and Substance Abuse Problems BZs and tricyclic antidepressants (TCAs) should not be used in this population. BZs tend to be abused by this population (Schatzberg & Nemeroff, 2004). TCAs may have additive cardiotoxicity when they are taken with cocaine. Better choices are SSRI antidepressants or anticonvulsants (e.g., gabapentin) for anxiety symptoms.

Use of SSRIs for Obsessive-Compulsive Disorder (OCD) Higher doses of SSRIs such as fluoxetine (Prozac) 40 to 80 mg/day, fluvoxamine (Luvox) 150 to 300 mg/day, sertraline (Zoloft) 100 to 200 mg/day, or paroxetine (Paxil) 40 to 60 mg/day can be useful. Clomipramine (Anafranil), which is also a serotonin reuptake inhibitor in the class of TCAs, can be the second-line option for SSRI nonresponders. Its poor side effect profile includes dose-related risk of seizures.

COMMON SIDE EFFECTS OF ANXIOLYTICS, SEDATIVES, AND HYPNOTICS

Disinhibition BZs can cause behavioral dysfunction, including irritability and personality changes. Children, adolescents, and elderly people may be more prone to this paradoxical side effect.

Cognitive Deficits High-potency BZs such as lorazepam (Ativan), clonazepam (Klonopin), and alprazolam (Xanax) are associated with memory impair- ment. These BZs may exacerbate preexisting cognitive impairment.

Dependence The use of BZs as hypnotics for temporary insomnia should be for a maximum of 2 to 4 weeks only. Continued efficacy may last as long as 5 weeks, but there is no guarantee of efficacy afterward. For persistent insomnia, regular or intermittent use of BZs as hypnotics should be re- evaluated every 2 to 4 months. In the case of zolpidem (Ambien) or zaleplon (Sonata), the duration of use should be 7 to 10 days with re- evaluation if the use exceeds 2 to 3 weeks.

Withdrawal Symptoms Anxiety symptoms, delirium, seizures.

Overdose Ataxia, hypotonia, nystagmus, coma. BZ antagonist is flumazanil.

Respiratory Depression Use of BZs for sleep disturbance caused by sleep apnea can worsen the respiratory condition. Concomitant use with alcohol, TCAs, anticonvulsants, or clozapine (Clozaril) may increase sedative effects or cause respiratory depression.

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RELATED CLINICAL CONCERNS

Children BZs have been known to have a paradoxical effect on children contributing to personality changes and irritability. The use of any kind of sedatives in sleep dis- turbances is not well investigated in controlled studies in children.

Adolescents Anxiolytics may interfere with common teen activities including school, driving and sports contributing to safety and compliance issues.

Older Adults The best choices for antianxiety medications in elderly persons are short-acting, low-potency agents without active metabolites, such as oxazepam. The minimum effective dose is 50% of the usual adult dose. This should be given as needed only for 1 to 2 weeks. Paradoxical reactions from BZs are more common in the eld- erly contributing to agitation rather than the desired effect.

Pregnancy The association of fetal damage with BZs is controversial (Barki, Kravitz, & Barkin, 1998). However, it is recommended that BZs be tapered off sufficiently before delivery to minimize neonatal and infant withdrawal. Lorazepam (Ativan) and oxazepam have less potential for accumulation in neonates. BZs at relatively low doses are not contraindicated in nursing mothers (Rubey & Lydiard, 1999).

PATIENT AND FAMILY EDUCATION

• Advise patient to avoid discontinuing BZs abruptly to avoid rebound or withdrawal symptoms.

• Advise patient to avoid adjusting dosing of BZs without consulting pre- scriber for the above-mentioned reason.

• Teach patient that, unlike BZs, buspiron (BuSpar) has no tolerance or dependence effects.

• Teach patient that beta blockers can cause bradycardia or exercise intoler- ance.

• Tell patient not to take BZs with alcohol or over-the-counter medications for insomnia.

• Teach patient to avoid making important decisions if BZs disturb concen- tration.

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MEDICATIONS FOR MOOD SYMPTOMS

There are two categories of medications for mood symptoms: antidepressants and mood stabilizers.

ANTIDEPRESSANTS

The newer antidepressants (SSRIs and SNRIs) are gradually replacing the older agents like tricyclics and MAOIs as the treatment of choice for various symptoms of depressive and anxiety disorders (Boxes 21–2 and 21–3). This change occurred because the newer agents have better side effect profiles. Owing to the broader mechanism of action of SNRIs on more than one neurotransmitter (e.g., norepi- nephrine and dopamine) they can be effective when SSRIs are not.

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BOX 21–2 Target Symptoms of Depression • Apparent/reported sadness: Sad mood reflected in speech, posture, and

facial expressions. Depressed mood reported nonverbally regardless of the verbal messages (e.g., looks distressed but brightens up at times; appears miserable all the time).

• Anhedonia or inability to experience pleasure: Reduced interest in sur- roundings or activities that used to give pleasure (e.g., failure to feel any positive emotions).

• Change in appetite: Reduced desire for food or increased need to force one- self to eat (e.g., slightly reduced interest in food; eating because one has to).

• Change in sleep pattern: Reports experience of reduced duration or depth of sleep (e.g., slight dissatisfaction with sleep; sleep less than 3 hours a night).

• Inner tension: Feelings of vague discomfort, restlessness, or edginess leading to dread or panic (e.g., occasional edginess, irritability, restlessness; over- whelming panic).

• Difficulty getting started: Slowness initiating or performing daily activities (e.g., some sluggishness; unable to do anything without help).

• Negative thoughts: Representing thoughts of guilt, remorse, or inferiority (e.g., ideas of low self-esteem, failure, self-accusations; absurd and unshak- able pessimism).

• Poor concentration: Representing difficulties in comprehending messages (e.g., difficulties in reading; inability to follow a conversation).

• Thoughts of death: Stating that a natural death would be welcome, that life is not worth living (e.g., weary of life; ending own life is considered as a possible option; active preparation for suicide).

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HYPOTHESES ON MECHANISMS OF ACTION

The exact mechanisms of action of antidepressants are unknown, but the fol- lowing are hypotheses concerning the various types of antidepressants.

Tricyclic Antidepressants TCAs may work by affecting serotonin, norepineph- rine, and dopamine neurotransmitter systems. Their major side effects may be caused by interacting with muscarinic cholinergic receptors.

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BOX 21–3 Antidepressants Older Agents Tricyclic Antidepressants (TCAs) and their derivatives Dosage Imipramine (Tofranil) Amitriptyline (Elavil) Clomipramine (Anafranil) Doxepin (Sinequan) Amoxapine (Ascendin) Desipramine (Norpramin) Nortriptyline (Pamelor/Aventyl) Monoamine Oxidase Inhibitors (MAOIs) Phenelzine (Nardil) Tranylcypromine (Parnate) Selegiline transdermal patch (EMSAM) Newer Agents Selective Serotonin Reuptake Inhibitors (SSRIs) Fluoxetine (Prozac) Fluvoxamine (Luvox) Paroxetine (Paxil) Sertraline (Zoloft) Citalopram (Celexa) Escitalopram (Lexapro) Non-SSRIs Serotonin and Norepinephrine Reuptake Inhibitor (SNRI) Venlafaxine (Effexor) Duloxetine (Cymbalta) Serotonin 2A Blocker Nefazodone (Serazone) Trazodone (Desyrel) Serotonin 2A/C and Norepinephrine (alpha-2) Blocker Mirtazapine (Remeron) Dopamine and Norepinephrine Reuptake Inhibitor Bupropion (Wellbutrin, Zyban)

50–300 mg/day 50–300 mg/day 50–250 mg/day 25–300 mg/day 50–300 mg/day 50–300 mg/day 25–150 mg/day

15–90 mg/day 10–60 mg/day 6–12 mg/day

20–80 mg/day 50–300 mg/day 10–60 mg/day 50–200 mg/day 20–60 mg/day 10–20 mg/day

75–375 mg/day 40–60 mg/day

50–600 mg/day 200–600 mg/day

15–45 mg/day

75–450 mg/day

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