mental health test 2

problems may still occur

• •This is ongoing
• •Consists of problem solving
• •Consists of coping- simple tasks to complex
• •Children may be sensitive during specific growth periods
• •Children may be sensitive to positive AND negative influences

• •Infant- Colic
• •Behavior typically peaks at about 2-3 months
• •Can persist to age 4-5 months
• •Dx- based on s/s- crying with eating and after
• -Cries for more than 3 hours/d for 3 weeks or more

• •Night terrors, sleepwalking
• •Insomnia
• •Night time waking
• •Bedwetting
• •Establish a routine for a restful night
• •Limit pm fluid intake
• •Bathroom routine
• •Reassure the child

• •Physical development- 2 areas- physical maturation & Sexual development
• -Physical maturation- developing an adult body form- wght/hght increase, major organs double in size
• -Sexual development- hormones and puberty
• * Girls- puberty 8-14, menstruation begins about 12 years and 9 months- average (can be as early as 10 and as late as 16)
• •Boys- develop more slowly
• -Puberty about 10-12 years
• -Last till about age 18

• •Internal- identification of ones-self seperate from the family
• •Introspection- of thoughts, beliefs, actions, attitudes
• •Brings on change in mood, behavior, and attitude
• •External- environmental problems
• -3 areas = family, social, environmental
• *Family- about 11-14- independence begins
• -14-17- full push for independence
• -Some kids are over-protected and yet some may be abused or neglected or both
• -Some may have parents in jail or parents with drug/etoh problems- these kids may have difficulties in areas of development
• -Same sex friends important early in adolescence, but later on there is interest in the opposite sex (around 14)

• •This is the non-physical realm of human function
• •Teens may feel inadequate
• •Cognitive development- thinking and learning
• •Self esteem and body image at a bout 10-13
• •Coping with physical and psychosocial changes can be confusing
• •Teens can be very moody and have outbursts
• •Teens tend to become private- somewhat normal
• •By about 18*- may be somewhat in control of emotions and have established self-concept
• •Identification with a peer group
• •By 18- many having intercourse, dating is important
• •Spiritual development may be present
• •Some question beliefs and values they were raised with
• •Some may stop going to church and family functions
• •Some swing the other way and attend church more often
• •Planning for the future

• •Many emotional problems in the adult can be traced back to childhood issues
• •There are 7 categories of mental health problems in the child:
• -Environmental, parent-child conflict
• -Emotional problems, behavioral problems
• -Problems with eating/elimination, developmental problems, and pervasive developmental didorders

• •Poverty, homelessness, abuse, neglect
• •By age 5- poverty stricken kids score lower on IQ tests and have increased feelings of anxiety and unhappiness
• •Homeless infants have a high mortality rate
• •Illness is 2X the norm and serum lead levels are elevated often
• •May have inappropriate social interactions

• •Abuse- mistreating or causing harm
• •Neglect- not meeting basic needs (includes love and belonging)
• •Death of children under age 4 due to abuse and neglect outnumber choking, falls and MVA deaths
• •Burns, bruises, fractures, head and abdominal injuries common- also sexual abuse
• •Neglect can be physical and emotional
• •Causes chronic anxiety and depression
• •Aggressive behavior and risk taking
• •Children who are disabled or unwanted? Incidences increase-
• •Chroinc parental stress can = abuse/neglect
• •YOU must recognize signs! It is your responsibility legally and morally to report
• •Educate

• •Can start when a child cannot successfully cope with situations
• •Can be depression, anxiety, suicide
• •When children are loved and nurtured- most will learn to successfully cope with life’s anxieties
• •But sometimes they may require assistance from outside sources

• •Uneasy feeling of threat- some is normal throughout the life span
• •Separation anxiety-infants/toddlers
• •If over age 4- may present an issue if more than a few weeks
• •Confront the issues (best as you can with this age group), and make a plan for success
• •Reassure
• •Attachment Disorder-
• •This is a bit more exaggerated-
• •May need anti-depressants for sever anxiety/ depression
• •If on meds: watch for s/s of more severe depression and suicidal thoughts
• •Increase water intake and high fiber- may cause constipation
• •Sever anxiety not helped here- May be OCD

• •On the rise in children??
• •If parent or parents depressed- child has increased risk
• •= in boys and girls, school age tend to act out
• •Adults tend to withdraw
• •Treatment- help those in the child’s life to respond to childs needs and relieve discomfort
• •Provide emotional support and try to identify problems and remove or change it

S I G E C A P S

• •Sleep problems
• •Interest is decreased
• •Guilty feelings
• •Energy decreased
• •Concentration decreased
• •Appetite up or down
• •Psychomotor function decreased
• •Suicidal ideations
• •Assess!!

• •What is this? Child (or adult) has s/s of illness or disease with no traceable cause
• •Children- HA, stomach ache, pains
• •Not unusual in school aged children
• •Thought is- expression of another underlying conflict/stress
• •Sometimes mimics what may be going on in another family member/parent
• •Children need support and understanding

• •Child has been exposed to repeated acts of violence
• •The psyche attempts to protect them
• •Usually develops after an extremely traumatic experience
• •Children may appear disorganized in thought and aggitated- nightmares, insomnia, outbursts
• •Somatic d/o may start
• •Early recognition and support is the treatment

• •Attention Deficit Hyperactivity Disorder
• •Also adult ADHD and ADD
• •7 to 1- boys
• •Inattention and impulsivity
• •Subgroups:
• - With learning disabilities, with speech disorder, with
• psychiatric disorder, with brain dysfunction

• 1)Fussy as an infant
• 2)“Difficult” child
• -May be considered a “handful”, immature, short attention
• span
• -Has to win, has trouble taking turns, is impatient, has
• poor self-control
• -Difficulty completing assigned tasks
• -Usually academically an underachiever- but most are very
• smart! Above average in intelligence
• •Many have trouble with authority
• •Some with problems with anxiety, depression, and aggression
• •Some isolate because they have trouble with interpersonal relationships
• •Many are risk takers- safety can be an issue
• •Assess and be aware

• •Educate family and caregivers
• •Some need special education allowances
• •Positive reinforcement and structure
• •Limit setting
• •Pharm- ritalin, aderall, concerta, anti-depressants,
• anti-anxieties
• •Conner testing- filled out by each parent and by 2 teachers- sent to Dr. for eval

• •ADHD and ADD- be aware of misuse of meds
• •Conduct disorders- defiance and aggression toward others
• -Common factor- harsh parental discipline and physical punishment
• -More common in boys
• -Fighting, running away, destruction of property, violence, truancy, vandalism

• -Defy authority
• -Are aggressive to others, may be violent
• -Violate others rights
• -May be from broken homes, drug/etoh, abusive homes
• -Outlook long term is poor if s/s displayed before age 10
• or if anti-social behavior is present by the surrounding adults
• -Early dx. And txt. Is a must!

• •Oppositional Defiance Disorder
• •Disobedient defiance, hostile to authority
• •Argue with adults, deliberately annoy and argue, refuse to compromise
• •Blames others for behavior
• •Violent- losses temper daily, fighting, vandalism, carries weapons, threatens others, etoh/drugs, hurts animals, risk-taker, details acts of violence

• •Feeding disorders- anorexia nervosa, pica, bulimia
• •Encopresis, enuresis = elimination d/o’s
• •Eating disorders first:
• -Children do not eat enough or eat wrong foods
• -Weight loss or gain for one month without GI issues? Dx.
• •Food available- child does not eat
• •Most feeding d/o’s seen under age 1, but can be seen in 2-3 years of age as well
• •Developmental delay and malnutrition- increased risks
• •Abuse, neglect, excessive sleep, parental mental health issues = increased risks
• •R/o physical causes first
• •Educate

• -Bulimia- can start about 12 and go into adulthood, but sharp decrease after mid-30’s
• -Self-imposed starvation may be between purges
• -Many medical complications- esophogeal erosion, erosion of tooth enamel, abnormal lytes, pancreatitis, loss of hair, liver dysfunction

• -So.. Stabilize
• physical abnormalities/conditions

• -Re-feeding programs,
• no force feeding*

• -Psych treatment is a
• must- pt. and family

• •Persistent eating of non-foods for > 1 month
• •Infants and younger children- paint, plaster, hair, string, cloth
• •Older kids- pebbles, insects, animal droppings
• •Adults- laundry detergent, starch, clay, soil
• •Often in those with MR or autism
• •Assess…

• •r/o physical problems first- vitamin/mineral deficiencies
• •Remove the items, replace with acceptable foods
• •May require therapy
• •May be due to other mental health issues
• •Assess and educate

• •Infants regurgitate food and rechew
• •Most often in 3-12 months, but older if with MR and also in adults with MR
• •Satisfaction with regurgitation?
• •Malnutrition- if food brought back into mouth very soon after ingestion
• •D/o often disappears as the child grows older

• •Enuresis- invol. Urination 5 or older
• •Can be familial
• •3 types
• 1)Primary nocturnal- boys more common
• 2)Diurnal- daytime- less common, children often shy or
• with ADHD, = in boys/girls
• 3)Secondary- develops after child develops normal bladder
• control, due to stress/anxiety
• treatment:May need drug therapy- desmopressin, imipramine
• •Emotional support parents and patient
• •Educate a routine at bedtime
• •Have child express feelings associated with symptoms- so…
• •Therapy

• •Repeated, usually voluntary passage of feces in inappropriate places
• •Age 4 and over with no physical problems
• •Rarely seen in adolescents
• •Focus treatment on a routine
• •Praise child for continence
• •Have child clean own garments
• •Those with little emotional effect- harder to treat

• •MR- powerful label
• •Based on more than 1 standard IQ test
• •Score < 70
• •Stages:
• 50-70 on IQ test = mild MR
• 35-50 = moderate MR
• 20-35 = severe MR
• Below 20 = profound MR
• •Adaptive functioning is the true measure- how does this child cope with basic demands in life?
• •Skills training, home care, social interaction, communication skills, school?, self-direction
• •Safety is a must here- many are taken advantage of…
• •FAS- fetal alcohol syndrome- leading cause of MR
• •Sometimes- inborn errors in metabolism, birth injuries, Down’s syndrome, shaken baby, illness and disease as an infant/child, falls, poisonings..
• •Heredity is a factor as is- pregnancy problems, environmental influences, 30-40% idiopathic
• •Treatment- help them attain highest possible potential, meet basic needs, safety, life skills

• •May have normal achievements on reading, writing, math tests, but falls below that of his peers in same age group
• •About 5% of children in America have learning disabilities of some sort
• •Often have low self-esteem and become discouraged easily
• •Early drop outs
• •Can be due to many factors

• •Assess vision and hearing, speech and any other possible physical difficulties
• •Consider culture…
• •Dyslexia- letters and numbers configured correctly but child does not see it this way
• •Words often substituted, omitted, twisted
• •Early diagnosis important
• •Many to be diagnosed may be overlooked

• •Trouble receiving or sending messages
• •Stuttering
• •Usually seen by age 3
• •May speak slowly, rapidly or may have trouble with expression
• •If it interferes with learning or ADL’s- it is diagnosed a disorder
• •Support, love and be patients- encourage

• •Pervasive- means that several areas of functioning is affected
• •Many have great trouble with social skills communication and learning
• •Reasons unknown-
• - May be due to MR, congenital disorders, infection and
• abnormal CNS function

• •Appears for the most part at birth
• •Problem with nervous system?
• •Serious social interaction problems
• •Communiation and immagination problems
• •Restricted scope of activity
• •Seen more in boys
• •Majority score low on IQ tests
• •Motor skills may be inappropriate
• •Some can be functioning adults
• •R/O CNS problems first- educate and support

• Development of motor, language and social problems
• -Loss of previously learned skills that occur between 5 months and 4 years of age
• -Head growth declines
• -Hand movements resemble wringing, speech impairment
• -Loss of interest in all skills and socialization

• •Repeated behavioral patterns
• •Interests and activities repeated in excess
• •Severe and long lasting impairment of social interaction
• •Appears at birth

• •Period of regression
• •Many areas affected including socialization
• •Usually happens after age 2 with normal development up until that time

• •Most who experiment do not become addicted
• •Accidents common die to lack of jugement
• •May experience interpersonal violence, abuse, depression, worsening relationships with others
• •Increase in risk behavior- lowered inhibitions and memory lapses

• •Most who experiment do not become addicted
• •Accidents common die to lack of jugement
• •May experience interpersonal violence, abuse, depression, worsening relationships with others
• •Increase in risk behavior- lowered inhibitions and memory lapses
• •4 stages:
• -Experimentation
• -Active seeking
• -Preoccupation
• -Burnout
• •Changes in attitude and behavior, may become rebellious
• •Family history???
• •Treatment is focused on finding the problem underlying
• •Replace the chemicals with more effective coping skills
• •In or out patient txt, counseling, group therapy
• •Keep a safe environment
• •Watch for risk taking, talking and behavior
• •Suicidal ideations

• •Have you ever tried to Cut back on your use?
• •Have you ever been Annoyed or Angered when questioned about your use?
• •Have you ever felt Guilt about your use?
• •Have you ever had an Eye-opener to get your day started?

• •Steroids- associated with MI, CVA, CVD
• •Increases acne and causes baldness
• •Affects mood and increases hostility
• •Needle risks
• •“Roid rage” behaviors
• •“Shotgunning” behavior
• •“Stacking”- use of many kinds

• •Adolescent girls attempt 3X more often than boys, but boys are typically more successful
• •Why?
• •Suicide attempt IS A CRY FOR HELP!
• •Teens who attempt:
• -Depression? Anxiety?
• -Trying to influence others? Mental health issues?
• -Getting back at someone? Attempt to scare?
• -Seriously ill with no way out?

• •Older adolescent boys who have voiced a true wish to die
• •Previous plans
• •Written plans
• •Available tools
• •All of these heighten the risks!
• •An increase in attempts often seen if a classmate attempts??
• •Assess everyone for risks (alll ages)

• •Change in grades, loss of interest
• •Rapid highs and lows
• •Not following rules- as previously
• •Secretive behavior
• •Withdraws from friends and family, Isolation
• •Change in personal hygiene
• •Gives away prized possessions

• •Lock windows
• •Shatter proof glass and mirrors
• •Plastic flatware if any
• •NO phone cords, extension cords, curtains, equipment that can harm, belts, matches cigarettes, sharps or razors
• •1 to 1 obs.
• •Staff communication is crucial
• •Restraints? Meds?
• •Monitor and restrict visitors

• •Plans and history of past attempts
• •Make a no-suicide 24 hour contract (or sooner)
• •Escort patient to activities
• •Encourage a diary of thoughts
• •Demonstrate concern and care
• •Discuss plans, thoughts, ideas
• •Support and educate family
• •When less depressed= attempt may succeed**
• •Psych care is a must

• 1. SYMPTOMS- when one becomes aware that something is not right
• •May be physical or emotional
• •The nature of the symptoms, knowledge of the person, availability of resources enter into determining if an actual illness exists
• •Emotional responses often govern behavior during this stage
• •One may treat self if the s/s are mild
• •One may seek treatment for more serious illnesses

• 2. Sick Role
• •One who is ill, seeks the advice from family, friends, co-workers.
• •The social group supports the presence of illness and the individual wither plays the “sick role” or continues to deny illness
• •If the “sick role” is chosen, one is excused from every day duties, others pitch in to help, permission is given for the person to rest and heal

• 3. Medical Care
• •If the person remains ill and self-remedies do not help, one may seek professional help
• •The professional can confirm the illness, offer assistance, and educate- or the person can continue to deny the illness

• 4. Dependency
• •During this stage, the individual accepts the attention of others
• •One who relies on the kindness and energy of others has chosen the dependency role
• •People in this stage need to be emotionally supported

• 5. Recovery & Rehabilitation
• •This can occur suddenly- response to drug therapy
• •Can occur slowly- recovery from CVA or mental disorder
• •If recovery is quick and complete- the individual continues the same role as before illness
• •For longer recovery- long term care arrangements are made (at home if at all possible)

• •NOT ISOLATED- affects the activities of the individual and those in contact with them
• •SERIOUS mental/physical problems may have emotional and behavioral changes
• •Some may react to illness with anxiety, anger, denial, shock, or withdrawal
• •If the illness involves a change in physical appearance it will have a strong impact on the individual’s BODY IMAGE.
• •Self-esteem issues are also impacted and this can take a toll on the family as the affected person starts lacking self-confidence
• •Prolonged illness can cause “situational stress’’ or stress due to the actual situation at hand that would not have existed if the family member would not have become
• sick
• •Often, new roles and habits must be established- this adds stress to the family unit

• •Some emotions serve to protect the individual from further stress
• •Others can be destructive if they block efforts toward resolving health problems
• •EXAMPLE- denial can be “paralyzing” or useful

• •Psychological defense mechanism used to ward off the painful feelings.
• –can be helpful when it allows time to collect and reorganize thoughts and plans
• –Can be deadly if it clouds judgment from taking steps to restore health

• Placement in an in-patient care facility for continuous nursing
• care and organized medical staff
• •Remember that people can be affected by other’s experiences
• •The person who is ill must rely on their coping skills that are being challenged by the anxieties of being ill
• •Most feel hospitalization is a crisis- some have difficulty coping

• •In emergency situations, one is admitted to the hospital in a time of crisis-
• •There is NO time to prepare emotionally to the fact that hospitalization is eminent
• •Lives are suddenly interrupted
• •If illness is long-term, lifestyle adjustments must be made QUICKLY
• •ALL hospitalized patient’s must deal with issues of feeling out of control and dependency
• •**Those who are hospitalized due to a pre-existing condition, usually have some time to prepare for hospitalization both physically and emotionally

• •Causes high anxiety
• •One goes from being an individual to a “client or patient”
• •Think of the paperwork = one becomes a medical record #
• •The armband = the persons identity
• •The hospital gown = strips the persona of part of their identity
• •One is touched and asked personal questions by strangers
• •Remember that when focusing on the physical problem, that the personal has emotions and feelings attached

• 1. OVERWHELM- separated from loved ones
• •left alone in a strange environment
• •People who are ill are often exhausted – we all know you CAN NOT rest in the hospital!
• •High anxiety secondary to medical procedures, some painful
• 2. STABILIZATION- patient gains some strength to re-establish some identity
• •Individuals become self centered in this stage
• 3. ADAPTATION- The individual has regained enough of their personal identity to adapt

• •Often becomes interested/willing to learn about health
• problems
• •Uses coping techniques and interested in preventative measures
• •Energy is replenished- body feels better
• •Emotional responses are stable
• •IF… transferred to another institution, the crisis begins again!!

• •Individuals and family members must deal with the stigma of being admitted into a psychiatric facility
• •Friends may not want to discuss the illness with the client and may not know how to offer support
• •Insurance companies may refuse payment
• •Employers may ask questions
• •The diagnostic label will follow people for years if not forever
• •Admission may make the person feel that they are “crazy”
• •The client may fear other client’s behavior
• •Fear what will happen after release

• •First- assess coping abilities
• •Try to identify problems before a crisis begins, plan preventative interventions
• •Use active listening skills
• •Encourage discussion of anxieties and fears
• •Clarify the clients perception of the problems
• •DO NOT pass judgment
• •Create an accepting environment
• •Establish a trust in the therapeutic relationship
• •Assist the client in coping with the fight or flight response brought on by crisis if illness and hospitalization
• •Encourage relaxation and teach relaxation techniques
• •Be alert for any cultural practices that may assist in the healing process
• •Assess any possible risk factors
• •Remember risk factors may be very evident, sometimes not- so SAFETY!

• •Families are what the client perceives them as – may not be “traditional”
• •Some men who are the support of the family, may feel inadequate when illness strikes
• •Family should be kept informed of progress
• •Family members are also in crisis- if the family feels the client is being cared for well, there will be decreased anxiety

• •The same nursing for the mental health care patient – but…
• •Pain may be perceived differently, exaggerated, or ignored
• •Some may drug seek
• •Some may attempt to od
• •Some will refuse meds to exert control

• How one copes with losses is based upon how they have coped with loss, stress in the past
• }Responses can be calm, quiet withdrawal
• }Responses can be anger and violence
• }Losses are INTERNAL and EXTERNAL
• }EXTERNAL losses relate to objects, possessions, environment, loved ones
• }INTERNAL losses are more personal- loss of emotional, physical, sociocultural or spiritual self

• }Can be an actual or potential state (a threat or based on reality)
• }Losses can be imagined (what if…)
• }How a loss is defined is based on the importance and value the person places on the object
• }Remember to assess the importance of the loss for each person as the loss will be different for each
• }With loss comes change
• }Losses may be temporary or permanent, expected or unexpected
• }Losses can be sudden or gradual
• }Illness can be considered a loss if there is a loss of roles or obligation
• }Loss of a limb is permanent and life changing
• }Losses can cause gain of maturity- giving something up in order to gain a higher form of development
• }“Situational losses”- occur in response to external events (divorce, loss of a loved one)
• }Here there is no control over the loss
• }Different developmental stages cope with loss differently-

• Children’s perception and understanding and reaction is based on the level of development, past experiences, and current support systems
• }We must be aware of the person’s stage of mental development to understand coping with loss
• }Infants- loss of caregiver with little emotional reaction as long as basic needs are met
• }Toddlers- concerned with themselves. There may be little understanding if the parent is “gone”
• }Preschoolers- have inability to understand the permanence of loss as in with death
• ◦they believe that thoughts can control events- this may lead to shame, guilt and doubt
• ◦Children have developed fewer coping mechanisms
• }School-age children- have some idea about cause and effect, but they still associate misdeeds with loss
• }Children 6 or 7 years of age- will often give responsibility for loss to the devil or God
• }By 9 or 10 years of age- they realize that some losses are permanent, and some are temporary. Attitudes and reactions and responses to loss are now FIRMLY ESTABLISHED
• }Adolescents-can react to losses with adult thinking and childlike emotions
• ◦Least likely to accept their situations
• ◦They grieve acutely and fear rejection from their peers
• ◦They are still establishing identity- death of a loved one may make them stand out differently from their peers
• ◦Many adolescents ignore or minimize the loss of deny their own mortality
• }Adults- know the difference b/t temporary and permanent losses
• }- Most are able to accept their losses and grow from the experience
• - As we encounter and cope with various losses we develop a sense of self-confidence and motivation about life and death
• - By the time we reach OLD AGE, we have developed the ability to cope with loss because of the many life’s losses we have probably endured

• }GRIEF- set of emotional reactions that accompany loss
• }MOURNING- process of working through or resolving grief
• }BEREAVEMENT- emotional and behavioral thoughts, feelings and activities that follow loss
• }Grief may be short or long term, very personal
• }There is no right or wrong way to grieve

• }This is the method for resolving losses and a way to heal or recover
• }Grieving, mourning and bereavement are normal, healthy responses to loss
• }Allows time to get things back together on the road to normalcy pre-loss
• }The nurses role- provide atmosphere for clients, support them in accomplishing the painful process

• }Say “NO”- refusal to give up the object so loved and accept the loss
• ◦One may refuse to acknowledge the loss
• ◦One may pretend the object is still present
• ◦“DENIAL” at this stage provides an emotional buffer that gives grieving people time to gather their resources for the work to come

• }When we realize the loss and it can no longer be ignored, denial turns to “yearning”:
• ◦The reality of the loss sinks in and the griever becomes overwhelmed
• ◦Crying, anger and self-blame is common
• ◦One can become disorganized and “fall apart”- depression may become apparent
• ◦Suicide may be an option considered
• ◦Emotional support of friends and family is a must

• }As the impact of the loss is felt in day to day living- DEPRESSION &IDENTIFICATION with the lost object begins to settle
• ◦MOURNING begins as the full impact of the loss is realized
• ◦Guilt /remorse are frequently felt feelings as attempts are made to cope with the loss
• ◦The one grieving may withdraw from social activities, feel lonely, and may use maladaptive, coping mechanisms

• }ACCEPTANCE AND RECOVERY- begins when the grieving individual begins to focus energies toward living
• ◦One starts to refocus on the relationships of those living
• ◦Life begins to slowly stabilize

• }One may backslide and regress in the stages or make multiple adjustments at one time
• }Experts say that grieving gradually decreases within 6-12 months
• }Mourning may continue for 5 years +
• }When the grieving process and mourning is done successfully and adaptively- one can recognize and accept the loss – one becomes healed and is able to continue

• }Grieving before the actual event takes place
• }Example: - one diagnosed with CA
• - or one who knows about an impending amputation

• }Mental health problems can occur if the grieving process is prolonged or impairment of function is an issue
• }There can be many different unhealthy, ineffective grieving reactions
• }2 types:
• 1. Bereavement related depression
• 2. Complicated grief

• }Grieving is so intense one feels despair and worthlessness that overcomes daily life
• ◦Life becomes a burden
• ◦Changes are seen in eating, sleeping habits and activity levels
• ◦One may become angry, hostile
• ◦One may have an inability to concentrate or work
• ◦People become more socially isolated
• ◦This can lead to suicide
• ◦If recognized and treated early, this type of grief can be treated successfully
• ◦Psychotherapy and drug therapy has been effective, but emotional and social support are always important

• }Persistent
• yearning for the deceased person that often occurs
• without s/s of depression

• ◦S/S appear to
• be that of normal grieving, but there is impaired psychological functioning and mood, self-esteem and sleep disturbances
• ◦One may relive past experiences- because life in the present is not as desirable
• ◦One may become socially isolated
• ◦Grief is treated with emotional support, and sometimes with drugs if there are also signs of depression
• ◦Nurses need to be alert for s/s of adaptive as well as maladaptive coping and grieving
• ◦Therapeutic listening is a must!!

• }Even though the nurse and the client have a therapeutic relationship- there is often a close bond that forges b/t them, especially if the client is dying!
• }Caregivers can share the grief experience, but need to understand that the role of the nurse is to be there for family as a support, therapeutic listening and communication becomes necessary
• }Many healthcare facilities offer group therapy for nurses who work with dying clients
• }Understand the steps of the grieving process
• }Know that grieving is normal to some degree
• }Talk if you need to!
• }Take care of you

• }Dying is the last stage of growth and development
• }It is inevitable and is individually personal
• }For some it is a welcomed end to suffering
• }For others it is the ultimate fear
• }Remember to keep in mind the cultural aspects for death and dying- allow grieving time and respect healthy traditions
• }Death may be sudden or gradual- sometimes it is expected
• }Some die with loved ones in comfortable
• surroundings
• }Some die alone and in a strange place- like a hospital, nursing homes

• }Before age 8- most children do not understand the permanency of death, but they do acknowledge the fear of death
• }By age 12- children know death is irreversible
• }Adolescents and young adults often do not relate to death unless forced to
• }As we grow old we loose family and friends and begin to face our own mortality

• }This is a condition where the outcome is DEATH
• }Dx. is very difficult for anyone in any age group
• }There are often periods of hope and then devastation and grieving is constantly ongoing through the process
• }How do people respond and prepare for death?
• }What does death mean to the individual?
• }What coping mechanisms have been used throughout their lives?
• }If the person is comfortable/satisfied with his life- death is usually accepted without fear
• }One who has had his share of struggling in life- may have the same in the dying process
• }True crisis-
• when one is dx. with a terminal illness, there is shock and disbelief

• }Crisis
• involves the family as well as the client- CRISIS INTERVENTION may be effective

• }Denial
• and hope may soon begin with condition progression

• }This
• allows time for adjustment for the reality of the situation

• }HOPE- allows the individual /family to endure the present
• suffering; offers possibility that things may get better
• }DENIAL- offers a way of coping with little losses until the
• situation is finally accepted
• }During this time- one is encouraged to initiate self-care and “life as usual” for a s long as possible
• }As time goes on- the client and family will gradually begin to accept the inevitable or continue to deny until it is no longer possible…
• ◦For those who are diagnosed with a terminal illness and are young and feel healthy- denial is very much a part of the beginning process
• ◦For others- this may be seen as a “wake-up call” and major lifestyle changes begin
• ◦Caregivers should accept and support clients’ decisions about terminal illness and structure the goals of care to provide the best interventions within the REALITIES of each situation!

• }Please review what we covered last semester..
• }Culture, religion, spirituality will all come into play
• }Burial, funeral and mourning practices will be different
• }Nurses must respect and advocate
• }This is part or Transcultural Nursing!

• }Review Elizabeth Kubler – Ross
• }5 stages include- denial, anger, bargaining, depression, acceptance
• }Later theorists changed this up some:
• 1- Resistance- fights the issue through denial, avoidance, anger and bargaining
• 2- Working-life review, dealing with unfinished business
• 3- Open awareness-death is accepted, talk becomes present, allows grief with the patient instead of FOR the patient!
• So these stages are similar, but arranged differently
• Please be aware of them all!

• }Define- Good death (full participation)
• }May refuse treatments, meds, etc.
• }Peace and acceptance replace denial, anger and depression
• }Each day is cherished
• }No fear of death
• }Focus on all needs-
• not just the physical ones

• }Humane care for the dying patient
• }24 hour care in-patient or in the home
• }Allows some control by the patient
• }Allows for dignity and choices
• }Family is usually very involved
• }Patient often chooses the comfort of own home
• }Family support

• }Terminal
• }Death within about 6 months
• }Does not have to be CA
• }End-stage, treatment finished
• }Patient must be aware of diagnosis and prognosis
• }If possible- patient should request hospice

• }Free of pain!
• }Addiction is not an issue
• }Able to voice fears and concerns
• }Patient advocation by the nurse
• }Preserve self-esteem and personal identity
• }Nutrition- what they want
• }COMFORT
• }Respect and dignity for patient and family

• }If stuck in grieving- can cause mental health issues
• }DSM-IV- Bereavement and Bereavement Depression = significant impairment > 2 months
• }Mentally ill- loss can be devastating
• }If inadequate coping- increased mental issues

• Difficult in identifying and defining problems when dealing with mental illness
• REMEMBER: Physiologic effects often accompany physical/mental illness and vice versa!

• §Full assessment- interviews by multidisciplinary team members
• §Physical and physiological testing is done
• §Team members then meet to compare data
• §Treatment plan is devised with the input of the client and goals are stated
• §Behavioral therapies as well as the possibility of medications are started
• §Progress toward the goal will be evaluated often and changes may be made in the treatment plan
• §The mental health treatment plan changes often and is revised as new information is gathered

• §AXIS I = Clinical disorders (Mood, substance abuse, schizo d/o)
• §AXIS II = Personality d/o and mental retardation (Dependent, antisocial d/o, and mild, moderate, severe retardation)
• §AXIS III = General medical conditions (Physical d/o as in heart problems, etc)
• §AXIS IV = Psychosocial/environmental problems (Education, housing, legal, economic)
• §AXIS V = Global assessment of functioning (GAF) –(
• Overall level of psychological, social and occupational functioning)

• §Supports goal-directed care for the client
• §Nurses perform holistic assessments
• §Develop Nursing Diagnoses
• §Work with mentally troubled client’s to set and achieve realistic goals
• §Clients are involved in the treatment planning, at least some part
• §Clients responses to the treatment is evaluated and documented, and adjusted as needed to aid in reaching the goals set and necessary for the client

• §Gathering and verifying information relative to the client
• §This is ON-GOING
• §Assessment data includes:
• - physical info
• - social info
• - cultural info
• - Spiritual info
• §A more complete assessment aids in more effective treatment for the client

• §OBJECTIVE
• §What is measured and shared
• §Gathered thru smell, taste, touch, sight
• §ex: Bp, P,T, labs, testing results compared with the normals
• §Done via physical exam, repeated observations of behavior
• §SUBJECTIVE:
• §Relates to the clients perceptions
• - Remember that often the perceptions are distorted!
• §ex: pain, nausea, anxiety- are not measurable by anyone except the person experiencing them
• §Feelings, emotions

• §You are meeting people with the purpose of exchanging or obtaining information
• §Can be formal and structured, or casual
• §Usually documented
• §Serves as a starting point for the therapeutic relationship-
• §Done during the WORKING phase

• §purposeful looking
• § or “observation”
• §Be careful not to show bias or personal opinion/attitude
• §Do NOT pass judgment
• §We are not the judge and jury

• §Observation or “INSPECTION” – purposeful exam of the body
• §AUSCULTATION/PERCUSSION – use hearing to detect sounds within the body
• §PALPATION- sense of touch to feel (temp, texture, pulsations)
• §Used to evaluate changes and to evaluate effectiveness of the therapeutic intervention

• Done using a holistic approach- always!
• §HOWEVER: emphasis is on mental/emotional functioning vs. physical functioning
• §USE THE PSYCHIATRIC ASSESSMENT TOOL to collect data about the problems, coping behaviors, and
• resources of clients
• §If the client is a risk to themselves or others- risk factor assessment should be done first!

• §Helps formulate a nursing diagnosis by identifying risk factors that potentially present an immediate threat to the client.
• §Eight areas for potential risk are identified
• §POSITIVE FINDINGS- lead to more specific assessment s or appropriate safety precautions
• §Usually done by a RN, but other healthcare workers gather data and make objective observations

• §Interviewed upon admission
• §Introduction and purpose are stated
• §Serves as the starting point of the therapeutic relationship!
• §Insight into the clients concerns and expectations are gained
• §Offers clues to areas that may be of more concern and need for further investigation

• §Focuses on cultural, social, spiritual aspects of the individual
• §Obtaining information of the client’s background
• §Gives the healthcare provider to observe behaviors, appearance and attitude
• §6 general areas include:
• Gender,Education,Age,Ethnicity,Income,Belief System

• §Risk factors and stressors are defined also
• §This helps develop accurate and appropriate plans of care
• §Helps caregivers identify risks and potential risks for the patient
• §Helps guide the services to be provided

• §Physical exam on admission to psychiatric services
• §Are there physical problems that need medical treatment?
• §Alterations in behavior can often be traced to a physical cause
• §Complete physical exam by DR. , Routine assessment of the clients status done by the nurses and must be alert to changes
• §Diagnostic studies-
• §Serum and urine testing
• §Electrolyte studies
• §Hormone function
• §Many clients may be screened for HIV, TB, STD’s
• §X-rays, ECG’s, EEG’s, CT, MRI

• §Explores- general state
• §Emotional state
• §Experiences
• §Thinking
• §Sensorium and Cognition

• §General appearance, speech, motor activity, behavior
• §Physical characteristics, dress, facial expressions, motor activity, speech, reactions.
• §Describing body build, coloring, cleanliness, manner of dress
• §Are they neat and tidy or unkempt, body odor?
• §Does the appearance match the dress, age, gender, situation
• §Facial expressions:
• §Eye contact?, dilated pupils = drug intoxication, and small pupils = narcotic use
• §Speech:
• §Volume, rapid or slow, abnormal patterns
• §Motor activity:
• §Gestures/posture, movement during activity, type of activity, unusual movements
• §Is the client irritated, agitated, lethargic (depression), anxious, excessive movement (anxiety/mania), are these characteristics drug induced?
• §Repeated movements (OCD)
• §Picking at clothing (delirium, toxic reaction)
• §What is the client’s behavior:
• §Hostile, overly friendly, cooperative, trusting?, did their verbal messages match the behavior?

• §MOOD- overall feelings
• §Mood is subjective! Can only be explained by the person in that “mood”
• §Can change throughout the day based on specific situations
• §AFFECT-emotional display of the mood being experienced
• §Labile- rapid, dramatic mood changes
• §Inconsistent- Affect and mood do not agree
• §Flat- Unresponsive emotions

• §Pleasurable response-
• Euphoria- feeling “too good”
• Exaltation- Intense happiness, feelings of grandeur
• §Unpleasurable Response (Dysphoric)
• Aggression- anger, hostility, rage that is out of the situation
• Agitation- Motor restlessness, seen often with anxiety
• Ambivilence- Positive and negative feelings
• Anxiety- Vague, uneasy feeling, often from an unknown cause

• úDepression- Sadness,
• hopelessness

• úFear- reaction to a
• recognized danger

• §PERCPTIONS- ways in which one experiences the world.
• §AKA “Frame of reference”- helps determine the clients sense of reality
• §Many with mental health problems have difficulty perceiving reality
• §What positive and negative experiences have they had?

• §Is thinking clear or distorted
• §Is speech clear
• §Is the conversation appropriate to the subject
• §Is the conversation fluid or is the “flight of ideas” or “word salad”
• §Is the patient making up their own language
• §Is thinking threatened or threatening (OCD, Suicide, Homicidal thought)

• §Insight
• §Judgment
• §Reliability

• }The stress response mechanism is to designed to protect us during times of stress and illness
• }Think fight or flight response- biochemical response in the body
• }Provides one with the energy needed for fighting or running for survival
• }“General Adaptation Syndrome”- biochemical reactions of the stress response and their effects on various body systems
• }Hans Selye
• }The
• hypothalamus communicates to the pit. gland and it notifies the adrenal glands
• (biochemical cascade of events!)

• }The adrenal glands manufacture and release the stress hormones- DOPAMINE,
• }EPI, NOREPI and CORTISOL
• }Body functions are very easily controlled and changed in response to changes in the levels of these chemicals
• }The continuum of psychophysical responses- from maladaptive to adaptive responses and effects everything in between (see page 225) when the body is under biochemical changes as in times of crisis/illness
• }The immune system is affected by stress
• }BP increases, HR, RR all increase during stress or anger-
• }Stress and anger have a definite effect on the immune system
• }POSITIVE attitude and lifestyle also effects the immune system
• }If one is able to deal with stress effectively and before it becomes a true crisis- physically, the effects on the body are few
• }Physical problems can arise from psychological sources when one focuses stress into body activities and functions

• }SOMATOFORM DO- feeling physical symptoms without evidence of disease or out of proportion to an ailment
• }PSYCHOSOMATIC DO- emotionally related physical disorders
• }PSYCHOPHYSICAL DO- more recent terminology for psychosomatic DO- stress related physical problems

• GI Tract-
• }Problems with indigestion
• }vomiting
• }constipation
• }diarrhea
• }ulcerative colitis
• }gastric/peptic/duodenal ulcers
• Respiratory tract-
• }Hyperventilation
• }Asthma
• Cardiac-
• } Tachycardia
• }Increased blood pressure

• }Stress Response Theory- humans are biochemically patterned to react to stress - ANS- fight or flight
• }Symbolism vs- Symptoms- developing a medical illness due to no outlet for stress responses due to being inappropriate, etc… (causes hypertension, ulcers, etc)
• }Personality Types- Higher risk for illness due to stress for those who are independent, hard working, overly ambitious- may develop heart attacks, etc

• }The quiet, non-complainer can still suffer ill effect- ulcers, headaches, etc…
• }Organic Weakness- one body system is weaker than the others, therefore each individual will suffer in that particular system- individual to each person
• }The symptoms of illness is r/t the body’s attempt to lower stress
• }Remember- the illness is very real to that person- don’t treat the symptoms as casual complaints- they can be life threatening!

• Primary Gains- anxiety reducing benefit
• Secondary Gains- the “sick role”- relief of responsibilities
• }One can easily become dependent on this behavior
• }Encourages this behavior if secondary gains benefits are great

• SOMATIZATION- feeling physical symptoms withoThis is a common stress reducing mechanism
• }No OBJECTIVE cause for the symptoms of illness
• }No physical dysfunctions either
• }The symptoms DO however suggest a medical illness
• }All physical dysfunctions are ruled out before a somataform DO dx. can be made
• }Approx. 80% of healthy people have a somataform disorder within each week
• }Under stress the body’s immune system IS at risk…
• }Somatization DO- “Briquet’s Syndrome” or hysteria
• }Begins before age 30 (typically)
• }More frequent in women
• }Tends to be familial
• }Males in the family tend to show an increase in some anti-social personality and increased substance abuse
• }Genetics as well as environment contribute to he risk of developing this disorder
• }Complaints are often exaggerated
• }May seek treatment from many physicians- watch for polypharmacy!
• }Most common c/o= sexual complaints and GI complaints, PAIN, false neuro problems
• }Anxiety and depression complaints are common
• }May be impulsive and possible suicidal
• }There is often marital problems and life in general seems
• chaotic
• }What is assessed in order to make a dx. of Somataform DO vs- medical problems:

• }Multiple system organ involvement
• }Early onset and chronicity with no physical changes over time
• }The absence of any abnormalities in lab values
• }So you see- there is little to no change in the physical assessment, but the patient has many, many complaints…

• }This is typically not the case in the elderly-
• }Assess carefully if they complain of increased problems with multiple organ systems!
• }They may actually have a problem- so assess and rule out…

• Conversion Disorder
• }Relatively uncommon disorder
• }Somataform disorder- complaints are related to SENSORY and MOTOR functions
• }More common in those in lower socioeconomic status and in those with little knowledge of healthcare
• }More common in women
• }In men- often associated with the military, industrial accidents and antisocial personalities
• }Onset usually during late childhood through early adulthood (after 10, before 35)
• }Children usually present with gait problems and seizures
• }In adults- symptoms are usually sudden
• }Symptoms usually only last a short time
• }In the hospitalized client- symptoms often disappear within 2 weeks
• }Re-occurence is common
• }Conversion disorders are thought to be the result of emotional conflict
• }Seizures and paralysis may be common complaints- but the symptoms are not compliant with the actual symptoms (seizures are not typical- paralyzed limd moves on its own, etc..)
• }“La Belle Indifference”- feature = lack of concern about the s/s
• }Symptoms are more exaggerated during increased stress
• }S/s can be modified or intensified by the reaction of others
• }Labs often show NO abnormalities- this helps to make a DX!
• }Treatment focuses on eliminating any possibility of physical problems- then focuses on the conflicts that may be causing the s/s
• }Psychotherapy, behavior modification
• }Counseling
• }Pharmacotherapeutic treatment

• }Intense fear or preoccupation with having a serious disease based on a misinterpretation of s/s
• }Watch for polypharmacy and Dr. shopping
• }These clients feel that Dr.’s are ignoring their complaints, etc…
• }Can begin at any age- more commonly in early adulthood
• }Strains interpersonal relationships because of self focus
• }Employment can be strained
• }Anxiety
• }Depression
• }Compulsive personality traits
• }Be patient, listen, use therapeutic communication, OBSERVE carefully
• }Show emotional support
• }Anti-anxieties and antidepressants can help- long-term psychotherapy
• }Preoccupation must be present for at least 6 months to dx.

• SOMATAFORM PAIN DO-
• }pain and discomfort is the focus of distress AND no other causes of pain is identified
• BODY DYSMORPHIC DO-
• }preoccupation with a physical difference or defect in
• one’s own body
• }Face/head is the main focus
• }Defect is described as painful, devastating
• }Feel “ugly” and avoid social situations
• }Affects interpersonal relationships and work
• }Watch for severe depression and suicide/self mutilation ideations
• }It is all in the way the person “sees” himself
• }Can often lead to self mutilation
• }Can lead to eating disorders and more

• }S/s are intentionally produced to assume the “sick role”
• }Done for some form of gain
• }Illnesses and injuries are self inflicted
• }(discuss abcesses)
• }Psychological as well as physical s/s are expressed by the client
• }These client’s definitely shop for doctors
• }They often seek repeated hospitalizations
• }“Munchausens by proxy”- deliberate production of s/s in another person
• }Often a child of the parent or caregiver- inducing illness to seek medical care
• }Dx. can be difficult
• }In client’s with Facticiuos DO- will often explain a very colorful medical history but are very vague about any details
• when questioned or assessed
• }If the cause of the original s/s are ruled out- they often come up with new s/s
• }If confronted, can become belligerent and will often check out AMA
• }The client with malingering- usually with a specific goal- students who fake illness to get out of a test…
• }Also those who seek compensation from government and social programs

• }R/o anything medically wrong
• }Develop trust in the therapeutic relationship if possible with the client
• }Attempt to understand the client’s purposes served by the clients
• }Teach anxiety lowering skills
• }Convey an attitude of acceptance for the client
• }Encourage autonomy

• —Expected to be helpful in problem solving
• —Serve as role models for good mental and physical health
• —Work to instill confidence
• —Work to help encourage change within the security of the therapeutic relationship

• —Self-awareness is a
• consciousness of one’s personality

* This is the ability to objectively look at one’s self

• —Allows us to be in
• control of our own growth and development

• —Caregivers encourage
• self-awareness in our clients

• —CARING: Allows us to interact and establish a connection with EACH client!
• —What happens to an infant without care and love? FAILURE TO THRIVE
• —What happens to adults without care and love?
• *ISOLATION/DEPRESSION/LONELINESS

—COMMITMENT- to the patient and to caring and helping

• —COMPASSION – FEELING THE SORROW AND SUFFERING OF OTHERS, TOLERANCE FOR THE DIFFERENCE IN OTHERS - EMPATHY
• —COMPETENCE- You know what you are doing and you are up to date on all the newest ideas
• —CONSCIENCE – FEELING OF WHAT IS RIGHT AND WRONG AND CORRECTING WHAT MAY BE WRONG
• —CONFIDENCE – FOSTERS TRUSTING RELATIONSHIPS. ASSITING CLIENT’S IN COPING WITH HEALTH PROBLEMS. ALSO TRUST AND BELIEF IN OWNS OWN ABILITY

• —We gain insight and wisdom through experience
• —The ability to see things clearly
• —Relies on common sense and good jugement
• —For care providers- includes sensitivity to people, willingness to seek new knowledge

• —INTROSPECTION- looking into ones own mind/analysis of ones-self
• —Also the process of observing our own behavior in various situations
• —Allows care givers to identify personal and professional learning needs

• —In order to grow, we must take risks
• —Risk taking behaviors are practiced when the rewards of success are larger than the consequences of failure
• —What about the possibility of failure? – Can be filled with defeat or can be filled with positive growth promoting experiences.
• —Can be the next step toward success if we use failure to grow

• —DO NOT limit clients with your own values
• —Set some high expectations and encourage!
• Allow clients the same ability to grow and fail and LEARN from this.

• —The receiving of the whole person and the world in which they function
• —THE DOES NOT mean to accept all behaviors!
• —DON”T correct the person, DO correct the unacceptable behavior

• —Care for yourself in order to care for others
• —Personal boundaries- provide order and security b/c they help to establish the limits of one’s behavior (based on values and beliefs)- focus on self
• —Professional boundaries- define the needs of the caregiver vs. the different needs of the client- focus on the client
• —DO NOT become “controlling”
• —Do assist in helping and encouraging success, but do NOT ignore the client’s true needs based on our need to succeed

—Personal and professional lives are to remain VERY separate

—Re-evaluate the relationship with the client often

—If the caregiver feel they are the ONLY one’s who can help and understand the client- CO-DEPENDENCY can occur.

—This can shadow the professional relationship. It can be easy to become emotionally attached

—When the client-caregiver relationship begins to fulfill the needs of the caregiver- “CODEPENDENCY” can occur. This will lead to unmet goals for the client!

—Do NOT show a significantly greater concern for one client over another to avoid the risk of co-dependency

• —MOST IMPORTANT- to yourself
• —The promise to do your best in every situation

—Commitment to your personal growth- allows you to learn from errors and to gain insight in them, this in turn allows you to assist others to grow.

—Also commit to your patient

—Positive attitude will assist others in the same

—Negative attitudes discourage others from interacting with them

—THINK ABOUT IT… Does a positive outlook and attitude affect one’s health?

• —A positive attitude can serve as a role model for those client’s who have not learn to cope with the world effectively
• —Those client’s who are mentally and emotionally troubled deal with a lot of negative misfortune and unhappiness-

• —There is often a need for a positive attitude to give hope for these clients
• —If the personnel has a positive outlook- then you are modeling for the patients!

• —Listen to your “self-talk”- pay attention to the words you use.
• —Words can become emotional- is this negative or positive?
• —Change recurrent negative themes- replace negative, self-defeating needs with positive one’s- this leads to greater self-esteem and a highly effective immune system
• —Present yourself with positive thoughts
• —Visualize future success- picture yourself achieving your goals
• —Act the part- a positive mental attitude helps to develop self-esteem, self-respect and self-acceptance.

• Frustration and failure can come easily when we are unable to alleviate pain and suffering
• —We become easily worn
• out or BURNED OUT!!
• —Find a balance
• —KNOW YOUR STUFF!
• —Value each individual
• —Be responsible and accountable for your own actions
• —Be open to new ideas
• —Connect with others- support your peers
• —Like what you do and take pride
• —Recognize moments of joy (live for the moment)
• —Recognize and accept your own limitations, but strive to improve. Focus on your accomplishments
• —Rest each day and start over!