Professional Documents
Culture Documents
BIPOLAR DISORDER
A. Description (Box 71-2)
1. Characterized by episodes of mania and depression with periods of normal mood
and activity in between
2. The medication of choice is lithium carbonate, which can be toxic and therefore
necessitates the regular monitoring of serum lithium levels
B. Implementation for mania
1. Remove hazardous objects from the environment
2. Assess the client closely for fatigue
3. Use comfort measures to promote sleep
4. Provide frequent rest periods
5. Monitor the client's sleep patterns
6. Provide a private room if possible
7. Administer a hypnotic or sedative medication as prescribed
8. Encourage the client to ventilate feelings
9. Use calm, slow interactions
10. Help the client focus on one topic during the conversation
11. Ignore or distract the client from grandiose thinking
12. Present reality to the client
13. Don't argue with the client
14. Limit group activities and assess the client's tolerance level
15. Provide high-calorie finger foods and fluids
16. Supervise the client's choice of clothing
17. Reduce environmental stimuli
18. Set limits on inappropriate behaviors 19. Provide physical activities and outlets for
tension
20. Avoid competitive games 21. Provide gross motor activities, such as walking
22. Provide structured activities or one-to-one activities with the nurse
23. Provide simple and direct explanations for routine procedures
24. Supervise the administration of medication
BOX 71-2
BOX 71-2
Assessment of Bipolar Disorder
MANIA
Inappropriate affect
Restlessness
Flight of ideas
Inability to eat or sleep because of involvement in more important things
Extroverted personality
Delusional self-confidence
Initiation of activity
High and unstable affect
Becomes angry quickly
Pressure of speech
Grandiose and persecutory delusions
Inappropriate dress Urgent motor activity
Significant decrease in appetite
Inability to steep yet still active
Sexually promiscuous
Distracted by environmental stimuli
Unlimited energy
DEPRESSION
Decreased emotion and physical activity
Inability to make quick decisions
Introverted personality
Lack of initiative
Lack of self-confidence
Internalizing hostility
Loss of interest in appearance
Lack of energy
Easily fatigued
Withdrawn from groups
Lack of sexual interest
IX. SCHIZOPHRENIA
A. Description
1. A group of mental disorders characterized by psychotic features, inability to trust
others, disordered thought processes, and disrupted
interpersonal relationships
2. Disturbances in affect, mood, behavior, and thought processes
B. Assessment
1. Physical characteristics
a. Disheveled appearance
b. Body image distortions
c. Preoccupied with somatic complaints
d. Neglects eating, sleeping, and elimination
2. Motor activity (Box 71-3)
a. Catatonic posturing: holding bizarre postures for long periods of time
b. Catatonic excitement: Moving excitedly with no environmental stimuli present
c. May be totally immobilized
d. Unable to respond to commands, or responds only to commands
e. Waxy flexibility
f. Movements may be repetitive or stereotyped
g. Motor activity may be increased, as evidenced by agitation, pacing, inability to
sleep, loss of appetite and weight, and impulsiveness
h. May be unable to initiate activity, known as lack of volition or anergia
BOX 71-3
Abnormal Motor Behaviors
DESCRIPTION
Abnormal motor behavior or activity, displayed by the mentally ill client, occurring as a
result of a psychiatric disorder
3. Emotional characteristics
a. Mistrust
b. Views the world as threatening and unsafe
c. Feelings not easily interpreted
d. Ambivalence manifested as compulsive rituals, negativism, and overcompliance
e. May display feelings of helplessness, anxiety, anger, guilt and depression, and
decreased self-esteem
4. Compulsive rituals: Attempts to solve conflicting feelings by constant, repetitive
activity, which may be stereotyped or seem meaningless
5. Overcompliance: Attempts to deny responsibility for any action by doing only what
another exactly instructs
6. Affective disturbances
a. Flat affect or inappropriate affect
b. Altered thought processes
7. Thought processes (Box 71-4)
a. Impaired reality testing
b. Fragmentation of thoughts c. Blocking
d. Loose associations
e. Autistic thinking
f. Perceives environment in a totally self-centered way
g. Neologisms
h. Magical thinking
i. Unable to conceptualize meaning in words or thoughts
j. Unable to organize facts logically
k. Delusions
BOX 71-4
BOX 71-4
Abnormal Thought Processes
DESCRIPTION
Abnormal thought processes, displayed by the mentally ill client, occurring as a result of
a psychiatric disorder
NEOLOGISMS
Words that an individual makes up that have meaning only for the individual; often part
of a delusional system
LOOSENESS OF ASSOCIATION
The individual's thinking is haphazard, illogical, and confused, and connections in
thought are interrupted; seen mostly in schizophrenic disorders
FLIGHT OF IDEAS
A constant flow of speech in which the individual jumps from one topic to another in
rapid succession; there is a connection between topics, although it
is sometimes difficult to identify; seen in manic states
BLOCKING
A sudden cessation of a thought in the middle of a sentence; the client is unable to
continue the train of thought; often sudden new thoughts, unrelated
to the topic, come up
CIRCUMSTANTIALITY
Before getting to the point or answering a question, the individual gets caught up in
countless details and explanations
CONFABULATION
Filling a memory gap with detailed fantasy believed by the teller; the purpose of
confabulation is to main-tain self-esteem; seen in organic conditions
such as Korsakoffs psychosis
WORD SALAD
A mixture of words and phrases that have no meaning
BOX 71-5
Delusions
DESCRIPTION
A false belief held to be true even when there is evidence to the contrary
TYPES
Persecution
The thought that one is being singled out for harm by others
Grandeur
The false belief that one is a very powerful and important person
Jealousy
The false belief that one's partner or mate is going out with other people
BOX 71-6
9. Perceptual distortions
a. Illusions that may be brief experiences with a misinterpretation or exaggeration of
reality
b. Hallucinations such as perceiving objects, sensations, or images with no basis in
reality (Box 71-6)
10. Language and communication disturbances (Box 71-7)
a. Related to disorders in thought process
b. Unable to organize language
c. Difficulty communicating clearly
d. Inappropriate responses to a situation
e. A single word or phrase may represent the whole meaning of the conversation,
and the client may feel that he or she has communicated
adequately
f. May develop private language
C. Types of schizophrenia (Box 71-8)
1. Paranoid schizophrenia
a. Suspiciousness
b. Hostility
c. Delusions
d. Auditory hallucinations
e. Anxiety and anger
f. Aloofness
g. Persecutory themes
h. Violence
BOX 71-7
BOX 71-6
Preoccupation in Thought Content
HALLUCINATION
A sense perception for which no external stimuli exist; can have an organic or a
functional etiology
TYPES
Visual
Seeing things that are not there
Auditory
Hearing voices when none are present
Olfactory
Smelling smells that do not exist
Tactile
Feeling touch sensations in the absence of stimuli
Gustatory
Experiencing taste in the absence of stimuli
BOX 71-7
Language and Communication Disturbance
Neologism: a new word devised that has special meaning only to the client
Echolalia: repetition of words or phrases heard from another person
Verbigeration: purposeless repetition of words or phrases
Metonymic speech: mental confusion exhibited by the use of a word that is not the
precise term intended, but is of similar meaning
Clang association: repetition of words or phrases that are similar in sound but in no other
way
Word salad: form of speech in which words or phrases are connected meaninglessly
Stilted language: an inappropriate and overly formal communication pattern, usually
written, that seems artificial and intellectual
Pressured speech: person speaks as if the words were being forced out quickly
Mutism: absence of verbal speech
BOX 71-8
BOX 71-8
Types of Schizophrenia
Paranoid
Disorganized
Catatonic
Undifferentiated
Residual
2. Disorganized schizophrenia
a. Extreme social withdrawal
b. Disorganized speech or behavior
c. Flat or inappropriate affect
d. Silliness unrelated to speech
e. Stereotyped behaviors
f. Grimacing mannerisms
g. Inability to perform activities of daily living (ADLs)
3. Catatonic schizophrenia
a. Marked psychomotor disturbances
b. Immobility
c. Stupor
d. Waxy flexibility
e. Excessive purposeless motor activity
f. Echolalia
g. Automatic obedience
h. Stereotyped or repetitive behavior
4. Undifferentiated schizophrenia
a. Does not meet the criteria for paranoid, disorganized, or catatonic schizophrenia
b. Delusions and hallucinations
c. Disorganized speech
d. Disorganized or catatonic behavior
e. Flat affect
f. Social withdrawal
5. Residual schizophrenia
a. Diagnosed as schizophrenic in the past
b. Time limited between attacks but may last for many years
c. The client exhibits marked social isolation and withdrawal and impaired role
functioning
D. Implementation: Refer to Box 71-9
E. Implementation: Active hallucinations
1. Monitor for hallucination cues
2. Intervene with a one-on-one contact
3. Decrease stimuli or move the client to another area
4. Avoid conveying to the client that others are also experiencing the hallucination
5. Respond verbally to anything real that the client talks about
6. Avoid touching the client
7. Encourage the client to express feelings
8. During a hallucination, attempt to engage the client's attention through a concrete
activity
9. Accept and do not joke about or judge the client's behavior
10. Provide easy activities and a structured environment with routine ADLs
11. Monitor for signs of increasing fear, anxiety, or agitation
12. Provide seclusion as necessary
13. Administer medications as prescribed
F. Implementation: Delusions
1. Interact on the basis of reality
2. Encourage the client to express feelings
3. Do not dispute with the client or try to convince the client that delusions are false
4. Initially initiate activities on a one-on-one basis
5. Alter hospital routines as necessary, such as using canned or packaged food or food
from home
6. Recognize accomplishments and provide positive feedback for successes
BOX 71-9
BOX 71-9
Implementation for Schizophrenia
X. PARANOID DISORDERS
A. Description
1. The client demonstrates suspiciousness and mistrust of others
2. The client is often viewed by others as hostile, stubborn, and defensive
3. Concrete, pervasive delusional system characterized by persecutory and grandiose
beliefs
B. Behaviors
1. Suspicious and mistrustful
2. Emotionally distant
3. Distorts reality
4. Poor insight
5. Hypervigilance
6. Low self-esteem
7. Highly sensitive, difficulty in admitting own error, and takes pride in being correct
8. Hypercritical and intolerant of others
9. Hostile, aggressive, and quarrelsome
10. Evasive
11. Concrete thinking
C. Delusions
1. Serves a purpose in establishing identity and self-esteem
2. Grandiose and persecutory delusions
3. Process of delusion includes denial, projection, and rationalization
4. As trust in others increases, the need for delusions decreases
D. Types (Box 71-10)
1. Paranoid personality
a. Suspicious
b. Nonpsychotic
c. No hallucinations or delusions
d. No symptoms of schizophrenia
2. Paranoid state
a. Onset abrupt in response to stress and subsides when stress decreases
b. No hallucinations but experiences paranoid delusions
c. May be sensitive and suspicious before the development of delusions
d. Psychotic state
e. No symptoms of schizophrenia
3. Paranoia
a. Client appears normal except for delusional system
b. Single, highly organized delusional system
c. Not bizarre
d. No hallucinations
e. Reserved and sensitive before onset
f. Psychotic state
g. No symptoms of schizophrenia
4. Paranoid schizophrenia
a. Prior to the onset client becomes cold, withdrawn, distrustful, resentful,
argumentative, sarcastic, and defiant
b. Bizarre, numerous, and changeable delusions
c. Delusions become less logical as the client becomes more disorganized
d. Persecutory hallucinations
e. Psychotic state
f. All symptoms of schizophrenia are present
E. Implementation (Box 71-11)
BOX 71-10
BOX 71-10
Types of Paranoid Disorders
Paranoid personality
Paranoid state
Paranoia
Paranoid schizophrenia
BOX 71-11
BOX 71-11
Implementation: Paranoid Disorders
BOX 71-12
Alzheimer's Disease
3. Implementation
a. Identify and reinforce retained skills
b. Provide continuity of care
c. Orient to the environment
d. Furnish environment with familiar possessions
e. Acknowledge the client's feelings
f. Assist the client and family members to manage memory deficits and behavior
changes
g. Encourage the family members to express feelings about caregiving
h. Provide the caregiver support, and identify the resources and support groups
available
i. Monitor ADLs
j. Remind the client how to perform self-care activities
k. Maintain independence
l. Provide consistent routines
m. Provide exercise, such as walking with an escort
n. Avoid activities that tax the memory
o. Allow plenty of time to complete a task
p. Use constant encouragement in a step-by-step approach
q. Provide activities that distract and occupy time, such as listening to music,
coloring, and watching TV
r. Provide mental stimulation with simple games or activities
4. Wandering
a. Provide a safe environment
b. Prevent unsafe wandering
c. Provide close supervision
d. Close and secure doors
e. Use identification bracelets and electronic surveillance
5. Communication
a. Adapt to the communication level of the client
b. Use a firm volume and a low-pitched voice to communicate
c. Stand directly in front of the client and maintain eye contact
d. Call the client by name and identify self; wait for a response
e. Use a calm and reassuring voice
f. Use pantomime gestures if the client is unable to understand spoken words
g. Use slow, clear, verbal communication techniques
h. Use short words and simple sentences
i. Ask only one question at a time, and give one direction at a time
j. Repeat questions if necessary, but do not rephrase
6. Impaired judgment
a. Remove throw rugs, toxic substances, and dangerous electrical appliances from
the environment
b. Reduce hot water heater temperature
7. Altered thought processes
a. Call the client by name
b. Orient the client frequently
c. Use familiar objects in the room
d. Place a calendar and a clock in a visible place
e. Maintain familiar routines
f. Allow the client to reminisce
g. Make tasks simple
h. Allow time for the client to complete a task
i. Provide positive reinforcement for positive behaviors
8. Altered sleep patterns
a. Allow the client to wander in a safe place until he or she becomes tired
b. Prevent shadows in the room
c. Avoid the use of hypnotics, as they cause confusion and aggravate the sundown
effect
9. Agitation
a. Assess the precipitant of the agitation
b. Reassure the client
c. Remove items that can be hazardous during the time of agitation
d. Approach the client slowly and calmly from the front; then speak, gesture, and
move slowly
e. Remove the client to a less stressful environment
f. Use touch gently
g. Do not argue with the client or restrain the client
h. Distract the client with questions about the problem, and gradually turn the
attention to something else
XIV. PSYCHOSEXUAL ALTERATIONS
A. Sexuality
1. One's sense of being a sexual individual
2. Includes how one looks, behaves, and relates to others
B. Sexual expression
1. Heterosexuality: Male-female sexual relationships
2. Homosexuality: Sexual attraction to a member of the same sex
3. Bisexuality: Sexual attraction to and activity with both sexes
4. Transvestism: Obsession with wearing clothing of the opposite sex
C. Alterations in sexual behavior
1. Transsexualism: Feeling that one's sex is inappropriate and desiring to acquire
sexual characteristics of the opposite sex
2. Exhibitionism: Sexual urges and fantasies and exposing genitals to strangers
3. Fetishism: Using nonliving objects for sexual gratification
4. Pedophelia: Desiring sexual activity with a child underage 13
5. Sexual masochism: Sexual gratification that involves receiving pain
6. Sexual sadism: Sexual gratification that involves inflicting pain
7. Voyeurism: Sexual gratification through observing others disrobing or engaging in
sexual activity
8. Zoophilla: Intense sexual arousal or desire for sexual contact with animals
9. Frotteurism: Intense sexual arousal or desire when rubbing against a nonconsenting
person
D. Implementation
1. Assessment of sexual history and precipitating event for sexual disorder
2. Encourage the client to explore personal beliefs
3. Provide a nonjudgmental attitude
4. Provide supportive psychotherapy
5. Initiate psychoanalysis as prescribed
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