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VIII.

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Withdrawn from groups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

TYPES OF ABNORMAL MOTOR BEHAVIORS


Akathisia
Displaying motor restlessness and muscular quivering the client is unable to sit or lie
quietly
Echolalia
Repeating the speech of another person
Echopraxia
Repeating the movements of another person
Parkinson-Like Symptoms
Making mask-like faces, drooling, and having shuffling gait, tremors, and muscular
rigidity
Waxy Flexibility
Having one's arms or legs placed in a certain position and holding that same position for
hours
Dyskinesia
Impairment of the power of voluntary movements

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

8. Types of delusions (Box 71-5)


a. Loss of reference, in which the client believes that certain events, situations, or
interactions are directly related to self
b. Delusions of persecution, in which the client believes that he or she is being
harassed, threatened, or persecuted by some powerful force
c. Delusions of grandeur, in which the client attaches special significance to self in
relation to others or the universe and has an exaggerated sense
of self that has no basis in reality
d. Somatic delusions, in which the client believes that his or her body is changing or
responding in an unusual way, which has no basis in reality

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

Assess the client's physical needs


Set limits on the client's behavior when it interferes with others and becomes disruptive
Maintain a safe environment
Initiate one-on-one interaction and progress to small groups as tolerated
Spend time with the client even if client is unable to respond
Monitor for altered thought processes
Maintain ego boundaries and avoid touching the client
Limit the time of interaction with the client
Avoid an overly warm approach; a neutral approach is less threatening
Do not make promises to the client that cannot be kept
Establish daily routines
Assist the client to improve grooming and accept responsibility for personal care
Sit with the client in silence if necessary
Provide brief and frequent contact with the client
Tell the client when you are leaving
Tell the client when you don't understand
Do not "go along" with the client's delusions or hallucinations
Provide simple, concrete activities such as puzzles or word games
Reorient the client as necessary
Help the client establish what is real and unreal
Stay with the client if the client is frightened
Speak to the client in a simple, direct, and concise manner
Reassure the client that the environment is safe
Remove the client from group situations if client behavior is too bizarre, disturbing, or
dangerous to others
Set realistic goals
Initially do not offer choices to the client, and gradually assist the client in making own
decisions
Use containers for food, especially with the paranoid schizophrenic client
Provide a radio or tape player at night for insomnia
Explain to the client everything that is being done
Set limits on the client's behavior if the client is unable to do so
Decrease excessive stimuli in the environment
Monitor for suicide risk
Assist the client to use alternative means to express feelings, through music or art therapy
or writing

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

Assess for suicide risk


Diminish suspicious behavior
Establish a trusting relationship
Promote increased self-esteem
Remain calm, nonthreatening, and nonjudgmental
Provide continuity of care
Respond honestly to the client
Follow through on commitments made to the client
Acknowledge the client's feelings, but tell the client that you do not share his or her
interpretation of an event
Provide a daily schedule of activities
Assist the client to identify diversionary activities
Gradually introduce the client to groups Refocus conversation to reality-based topics
Use role playing to help the client identify thoughts and feelings
Provide positive reinforcement for successes
Do not argue with delusions
Use concrete, specific words
Do not be secretive with the client
Do not whisper in the client's presence
Assure the client that he or she will be safe
Involve the client in noncompetitive tasks
Provide the client opportunity to complete small tasks
Monitor eating, drinking, sleeping, and elimination patterns
Limit physical contact
Monitor for agitation and decrease stimuli as needed

XI. PERSONALITY DISORDERS


A. Description
1. Include various inflexible maladaptive behavior patterns or traits that may impair
functioning and relationships
2. The individual usually remains in touch with reality and typically has a lack of
insight into his or her behavior
3. Stress exacerbates manifestations of the personality disorder
4. In severe cases, the personality disorder may deteriorate to a psychotic state
B. Characteristics
1. Poor impulse control
a. Acting out to manage internal pain
b. Forms of acting out include physical and verbal attacks, manipulation, substance
abuse, promiscuous sexual behaviors, and suicide attempts
2. Mood characteristics
a. Experiences abandonment and depression
b. Moods include rage, guilt, fear, and emptiness
3. Impaired judgment
a. Has difficulty with problem solving
b. Unable to perceive the consequences of behavior
4. Impaired reality testing: Distorts reality and often projects own feelings onto others
5. Impaired object relations: Rigid and inflexible and has difficulty in intimate
relationships
6. Impaired self-perception: Distorted self-perception and experiences self-hate or self-
idealization
7. Impaired thought processes
a. Concrete or diffuse thinking
b. Difficulty concentrating
c. Impaired memory
8. impaired stimulus barrier
a. Unable to regulate incoming sensory stimuli
b. Increased excitability
c. Excessive response to noise and light
d. Poor attention span
e. Agitated
f. Insomnia
C. Schizoid personality disorder
1. Description: Characterized by an inability to form warm, close social relationships
2. Assessment
a. Social detachment and lack of dose relationships
b. Interest in solitary activities
c. Aloof and indifferent
d. Restricted expression of emotions
e. Lack of interest in others
D. Schizotypal personality disorder
1. Description: Exhibits abnormal or highly unusual thoughts, perceptions, speech, and
behavior patterns
2. Assessment
a. Suspicious
b. Paranoia
c. Magical thinking
d. Odd thinking and speech
e. Relationship deficits
E. Paranoid personality disorder
1. Description: Characterized by suspiciousness and mistrust of others
2. Assessment
a. Suspicious and distrusting
b. Argumentative
c. Hostile aloofness
d. Rigid, critical, and controlling of others
e. Grandiosity
F. Histrionic personality disorder
1. Description
a. Characterized by overly dramatic and intensely expressive behavior
b. The client is lively and dramatic and enjoys being the center of attention
c. Interpersonal relations may be poor
2. Assessment
a. Attention seeking
b. Needs to be the center of attention
c. Sexually seductive or provocative
d. Self-dramatizing and theatrical
e. Overly concerned with appearance
f. Has romantic fantasies and controls partners
g. Bores easily
h. Displays dependency
G. Narcissistic personality disorder
1. Description
a. Characterized by an increased sense of self-importance
b. The client is preoccupied with fantasies and unlimited success and has a constant
need for attention and admiration
2. Assessment
a. Grandiosity
b. Requires admiration and inflated accomplishments
c. Overestimates abilities and underestimates contributions of others
d. Lacks empathy and sensitivity to needs of others
H. Avoidant personality disorder
1. Description: Characterized by social withdrawal and extreme sensitivity to potential
rejection
2. Assessment
a. Feelings of inadequacy
b. Hypersensitive to reactions of others and reacts poorly to criticism
c. Social inhibition
d. Lack of support system
I. Dependent personality disorder
1. Description
a. The individual lacks self-confidence and the ability to function independently
b. Passively allows others to make decisions and assume responsibility for major
areas in his or her life
2. Assessment
a. Difficulty making decisions
b. Lacks autonomy
c. Cannot tolerate being alone and must always have a close relationship
d. Needs others to assume responsibility and make decisions
J. Obsessive-compulsive personality disorder
1. Description: The client has difficulty expressing warm and tender emotions and
reflects perfectionism, stubbornness, the need to control others,
and a devotion to work
2. Assessment
a. Orderliness and perfectionism
b. Overly conscientious
c. Inflexible and preoccupied with details and rules
d. Devoted to work and lacks leisure activities and friendships
e. Miserly and stubborn
f. Hoards worthless objects
K. Antisocial personality disorder
1. Description
a. A pattern of irresponsible and antisocial behavior
b. Characterized by selfishness, inability to maintain lasting relationships, poor
sexual adjustment, failure to accept social norms, irritability, and
aggressiveness
2. Assessment
a. Perceives the world as hostile
b. Superficial charm and hostility
c. No shame or guilt
d. Self-centered
e. Unreliable
f. Easily bored
g. Poor work history
h. Unable to tolerate frustration
i. Views others as objects to be manipulated
j. Poor judgment
k. Impulsive
L. Borderline personality disorder
1. Description
a. Characterized by instability in interpersonal relationships, mood, and self-image
b. Behavior may be impulsive and unpredictable
2. Assessment
a. Unclear identity
b. Unstable and intense
c. Extreme shifts in mood
d. Easily angered
e. Easily bored
f. Argumentative
g. Depression
h. Self-destructive behavior
i. Manipulation
j. Unable to tolerate anxiety
k. Chronic feelings of emptiness and fear of being alone
l. Splitting
M. Passive-aggressive personality disorder
1. Description
a. Characterized by passively expressing covert aggression rather than dealing with
it directly
b. The behavior can interfere with both social and work activities
2. Assessment
a. Procrastination
b. Stubbornness
c. Intentional inefficiency
d. Forgetfulness
e. Dependency
N. Implementation
1. Maintain safety against self-destructive behaviors
2. Allow the client to make choices and be as independent as possible
3. Encourage the client to discuss feelings rather than act them out
4. Provide consistency in response to the client's acting-out behaviors
5. Discuss expectations and responsibilities with the client
6. Discuss the consequences that will follow certain behaviors
7. Inform the client that harm to self, others, and property is unacceptable
8. Identify splitting behavior
9. Assist the client to deal directly with anger
10. Develop a written contract with the client
11. Encourage the client to keep a journal recording daily feelings
12. Encourage the client to participate in group activities, and praise nonmanipulative
behavior
13. Set and maintain limits to decrease manipulative behavior
14. Remove the client from group situations in which attention-seeking behaviors
occur
15. Provide realistic praise for positive behaviors in social situations
XII.ELECTROCONVULSIVE THERAPY (ECT)
A. Description
1. An effective treatment for depression that consists of inducing a grand mal (tonic-
clonic) seizure by passing an electrical current through
electrodes that are attached to the temples
2. The administration of a muscle relaxant minimizes seizure activity, preventing
damage to long bones and cervical vertebrae
3. The usual course is 6 to 12 treatments given two to three times per week
4. Maintenance ECT once a month may help to decrease the relapse rate for the client
with recurrent depression
5. ECT is not a permanent cure
6. Not necessarily effective in clients with dysrhythmic depression or those with
depression and personality disorders, those with drug dependence,
or those with depression secondary to situational or social difficulties
7. At-risk clients include those with recent myocardial infarction, cerebral vascular
accident, or cerebral vascular malformation, or clients with
intracranial mass lesions
B. Uses
1. Clients with major depressive and bipolar depressive disorders, especially when
psychotic symptoms are present such as delusions of guilt,
somatic delusions, and delusions of infidelity
2. Clients who have depression with marked psyhomotor retardation and stupor
3. Manic clients whose conditions are resistant to lithium and antipsychotic
medications and clients who are rapid cyclers (a client with a bipolar
disorder who has many episodes of mood swings close together)
4. Clients with schizophrenia (especially catatonia), those with schizoaffective
syndromes, and psychotic clients
C. Indications for use
1. When antidepressant medications have no effect
2. When there is a need for a rapid definitive response, such as when a client is suicidal
or homicidal
3. The client is in extreme agitation or stupor
4. The risks of other treatments outweigh the risk of ECT
5. The client has a history of poor medication response, a history of good ECT
response, or both
6. The client prefers it
D. Preprocedure
1. Explain the procedure to the client
2. Encourage the client to discuss feelings, including myths regarding ECT
3. Teach the client and family what to expect
4. Informed consent must be obtained when voluntary clients are being treated
5. For involuntary clients, when informed consent cannot be obtained, permission may
be obtained from the next of kin, although in some states die
permission for ECT must be obtained from the court
6. NPO after midnight or at least 4 hours prior to treatment
7. Baseline vital signs are taken
8. The client is requested to void
9. Hairpins, contact lenses, and dentures are removed
10. Administer preoperative medication if prescribed; glycopyrrolate (Robinul) or
atropine sulfate may be prescribed to prevent the potential for
aspiration and to minimize bradydysrhythmias in response to electrical stimulants
E. During the procedure
1. Place a blood pressure cuff on one of the dient's arms
2. An IV line is inserted, and EEC and EGG electrodes are attached
3. A pulse oximeter is placed onto the client's finger
4. Blood pressure is monitored throughout the treatment
5. Medications administered may include a short-acting anesthetic such as
meuhohexital sodium (Brevital Sodium) or thiopental sodium (Pentothal)
and a muscle relaxant such as sucdnylcholine (Anectine)
6. 100% oxygen by mask via positive pressure is administered throughout the
procedure
7. An airway or bite block is placed to prevent biting of the tongue
8. Electrical stimulus is administered, and the seizure should last 30 to 60 seconds
F. Postprocedure
1. The client will be transported to a recovery room with the blood pressure cuff and
oximeter in place, where oxygen, suction, and other
emergency equipment are available
2. Once the client is awake, talk to the client and take vital signs
3. The client may be confused; provide frequent orientation (brief, distinct, and simple)
and reassurance
4. The client returns to the nursing unit when a 90% oxygen saturation level is
maintained, vital signs are stable, and mental status is satisfactory
5. Assess the gag reflex prior to giving the client fluids, food, or medication
G. Potential side effects
1. Major side effects with bilateral treatment are confusion, disorientation, and short-
term memory loss
2. The client may be confused and disorientated upon awakening
3. Memory deficits may occur, but memory usually recovers completely, although
some clients have memory loss lasting up to 6 months
XIII. COGNITIVE IMPAIRMENT DISORDERS
A. Autism: Refer to Chapter 33
B. Attention deficit hyperactivity disorder (ADHD): Refer to Chapter 33
C. Tourette's disorder: Refer to Chapter 33
D. Dementia and Alzheimer's disease
1. Dementia
a. Organic syndrome with progressive deterioration in intellectual functioning
b. Long- and short-term memory loss occurs, with impairment in judgment, abstract
thinking, problem-solving ability, and behavior
c. Results in a self-care deficit
d. The most common type of dementia is Alzheimer's disease
2. Alzheimer's disease (Box 71-12)
a. An irreversible form of senile dementia resulting from nerve cell deterioration
b. Individuals with Alzheimer's disease experience cognitive deterioration and
progressive loss of ability to carry out ADLs
c. The client experiences a steady decline in physical and mental functioning and
usually requires nursing home placement in the final stages of the
illness

BOX 71-12
Alzheimer's Disease

Amnesia: inability to learn hew information or to recall previously learned information


Agnosia: failure to recognize or identify objects despite intact sensory function
Aphasia: language disturbance in understanding and expressing the spoken word
Apraxia: inability to perform motor activities despite intact motor function

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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