Communication interview

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You will conduct a professional interview with a staff nurse and a staff nurse leader to discover their intra/inter-professional communications styles.  It will be important to incorporate learning objectives regarding therapeutic communication styles including their method of caring, assertive, and responsible communication in your discussion/analysis of the interview.

N402 Communication Interview Assignment and Rubric

You will conduct a professional interview with a staff nurse and a staff manager to discover their intra/inter-professional communications styles. It will be important to incorporate learning objectives regarding therapeutic communication styles including their method of caring, assertive, and responsible communication in your discussion/analysis of the interview.

The paper should utilize APA 7th format using Times New Roman 12pt font and include a title page. There should be less than 10% of direct quotations used in your paper, sources should be paraphrased and cited appropriately. The use of headings should be incorporated in the paper design. Additionally, provide citation for the personal communication with the interviewees (use initials only). Support from at least 3 peer reviewed journal articles in addition to your textbooks must be used. Use initials and avoid the use of patient names, staff names, and facility names for HIPPA compliance. Complete the Contact Information Form for Experiential Learning for all individuals interviewed and submit with your completed assignment to the drop box Sunday by 11:59pm.

You should use headings and subheadings from the Instructions to set up your paper

The following information should be included in your interview:

Description the facility i.e.: a large metropolitan hospital, rural nursing home or urban clinic

Staff Nurse Interview

Interview a staff nurse regarding:

· What (s)he perceives are the main communication issues/barriers

· how they communicate with patients,

· how they communicate with colleagues

· how they communicate with leadership/administration.

Describe your findings in no more than 2 pages using terms and vocabulary from course learning. Relates each interview question to content learned in the class by providing analysis and synthesis of question and response and includes minimum of one citation per question- you may cite the texts & or other peer reviewed journal articles.

Nurse Manager Interview

Interview a nurse in a leadership/administrative position regarding:

· What the manager perceives as the main communication issues/barriers

· how they communicate with patients,

· how they communicate with colleagues, and

· how they communicate with leadership/administration.

Describe your findings in no more than 2 pages using terms and vocabulary from course learning. Relates each interview question to content learned in the class by providing analysis and synthesis of question and response and includes minimum of one citation per question- you may cite the texts & or other peer reviewed journal articles.

Analysis of Interviews

· Cohesive analysis of part I & II. Clearly describe your main findings/ communication styles

· List at least 3 actions that would improve communication/ remove barriers. supported with 3 citations- you may cite the texts & or other peer reviewed journal articles.

Conclusion- Write a one-two paragraph conclusion summarizing importance of Intra/interpersonal communication

References- Create an APA reference page including all paraphrased and quoted sources.

N402 Rubric for Communication Interview Assignment





Element Partially Addressed

Element In-sufficiently Addressed

Points possible



Part I: Staff Nurse Interview (this should be approximately 1 page of the paper length) and follows APA 7th ed. Format.

· Introduction : includes importance of Interprofessional communication and description of facility


· Asks the 4 assigned questions during interview that relate to course content/learning objectives: 2 points

· Appropriately and adequately summarizes interview responses (not verbatim) 4 points


Relates each interview question to content learned in the class by providing analysis and synthesis of question and response and includes:

Minimum : one citation per question- you may cite the text &/or other source(s) 8 pts


Part II: Staff Nurse Manager Interview: (this should be approximately 1 page of the paper length) and follows APA 7th ed. Format.

· Asks the 4 assigned questions during interview that relate to course content/learning objectives: 2pts

· Appropriately and adequately summarizes interview responses (not verbatim) 4 pts


· Relates each interview question to content learned in the class by providing analysis and synthesis of question and response and includes:

Minimum : one citation per question- you may cite the text &/or other source(s) 8 pts


Analysis of Interviews

· Cohesive analysis of part I & II. Clearly describe your main findings of the interviews. 4pts

· List at least 3 actions that would improve communication/ remove barriers supported by 3 citations 6 pts


· Conclusion: summarizes importance of Intra/Interpersonal communication 4 pts


Spelling, Grammar, 7th ed. APA Format

· Free of spelling, typographical, & grammatical errors, cites interviewee . Uses headings and subheadings from the Instructions 4 pts

· Reference Page Complete and follows APA format 2 pts





Staff and Nurse Manager Interview/Communication Assignment

Student Name

Minnesota State University, Mankato

N402-8 Psychosocial/Interprofessional Communication

Dr. Ellen Vorbeck, DNP, ANP-BC, ARNP


Professional Communication

I interviewed a staff nurse and a staff nurse manager about inter/intra-professional communication styles for this assignment. Understanding communication styles is essential for healthcare workers. Knowing how one communicates can help improve communication clarity with both colleagues and patients. Both nurses who were interviewed work at a large hospital in a busy emergency department.

Staff Nurse Interview

Perceived Barriers

The staff nurse, AR, identified a few barriers to communication within the work environment. The main obstacle that AR discussed was between physicians and nurses. Often, physicians do not clearly communicate with nurses or communicate in a very aggressive manner. AR talked about how this kind of communication is very frustrating, especially in an intense environment, like the emergency department. Those who communicate in an aggressive manner are often not good listeners and interrupt regularly (Baraldi, 2020). They adopt a commanding stance, speak loudly, and strive to control people (Baraldi, 2020). This makes it difficult for AR to care for patients properly, especially in a setting as intense as an emergency department.

Communication with Patients

AR talked about how important it is to read the situation and adjust your communication approach as needed when communicating with patients. AR tries to use patience, open-ended questions, active listening, and explains as much as possible while working with patients. By using an assertive style of communication, AR finds that she can communicate with patients best. Being assertive is vital to building successful relationships with coworkers, family members, and patients (Blazer, 2020). This style of communication helps minimize personal stress, improve patient safety, and improve nursing care (Blazer, 2020).

Communication with Colleagues

AR discussed how building relationships with your colleagues is critical. Using assertive communication has helped AR build better and more trusting relationships with coworkers. This style of communication helps this nurse work better with colleagues and find resolutions to problems faster. In a fast-paced work environment, positive working relationships are critical to success (Spence Laschinger, 2010). A group of healthcare workers that respect each other’s efforts to the patient care process and work well together is required for high-quality patient care (Spence Laschinger, 2010). AR states that there are a few coworkers who use an aggressive style of communication. These coworkers are often tricky and draining to work with.

Communication with Leadership

AR feels that she and her coworkers can have good communication with those in leadership positions. They have opportunities each morning to ask questions and give any updates to leadership. Those in leadership make an effort to keep the lines of communication open and are highly respected on the unit because of this. Effective relationships between leadership and healthcare employees may lead to better strategic planning, more efficient use of limited resources, a shared sense of purpose, increased job satisfaction, higher staff retention rates, and improved patient outcomes (Center for Rural Health Policies Analysis, 2013). AR feels that because there is good communication between her and management, she feels supported and more comfortable doing her job.

Staff Nurse Manager Interview

Perceived Barriers

The nurse manager, NW, discussed that the most significant barrier for communication seems to be between floor nurses and doctors. Some of the physicians use a more aggressive style of communication which frustrates a lot of the nursing staff. Aggressive styles of communication can lead to feelings of distrust, increased stress and conflict, not feeling respected, and poor goal achievement (Scott, 2020). NW, at times, speaks with those physicians to try and discuss using a more assertive communication style rather than an aggressive style. NW feels that there is still work to be done to help improve the communication between the nurses and doctors.

Communication with Patients

NW said that communication with each patient is a little different depending on the situation. Explaining what is happening, being empathetic, using a calm and assertive tone, and utilizing therapeutic communication techniques is how NW usually communicates with patients. According to Balzer (2020), utilizing empathy helps a person feel more connected with another person. Empathy also helps decrease a patient’s feelings of isolation and loneliness (Balzer, 2020). NW discussed how, at times, a firmer approach is needed when interacting with patients to help maintain order during a chaotic or traumatic event but still tries to use a warm tone during these situations.

Communication with Colleagues

NW tries to communicate with coworkers in a respectful as assertive manner. Communicating in this way helps maintain order when things get chaotic in the emergency department. Assertive communication can help you express your point of view while simultaneously showing respect for others’ beliefs and rights (Mayo Clinic, 2020). NW discussed how it took some time to learn how to communicate assertively. As a new nurse, NW recalled how her communication style was probably seen as timid and unsure. Assessing your current communication style, practicing, and rehearsing what you want to say, and using “I” statements are ways that nurses can learn to be more assertive (Mayo Clinic, 2020). Learning how to be assertive is a lifelong process in which one continually learns (Balzer, 2020).
Communication with Leadership

NW emphasized how important it is to keep an open line of communication with leadership, especially in the emergency department. NW tries to make sure all the nursing staff’s concerns are addressed, and any questions are answered as promptly as possible. NW feels that this is very important given the intense critical care that is provided in this environment. Strong communication from leadership in an emergency department is essential to promote and strengthen teamwork (Lateef, 2018). When leadership allows for staff to express their thoughts and ideas, communication can be improved, which helps make sure that staff’s concerns are heard and can help improve morale (Lang et al., 2020).

Analysis of Interviews

After interviewing AR and NW, I feel like they both have a good sense of the importance of communication within healthcare. It seems like the problems with communication that they identified are fixable with time and continued communication. It appears that the assertive communication style is the preference for both nurses interviewed. It seems to assist them the most in their work and allow for a better relationship with both patients and coworkers. Both nurses have a solid understanding of their styles of communication. This understanding will enable them to build healthy and trusting relationships with colleagues and patients. This understanding also allows the nurses to be able to reflect and improve upon their communication skills.

Communication Improvements

           Communication is a skill that can be learned and improved upon. By understanding this, one can continue to strengthen relationships with colleagues and patients. One area for improvement could be learning how to better communicate with those who use an aggressive communication style. Aggressive communication can put patients’ safety at risk when it is used (Balzer, 2020). Before dealing with an aggressive colleague, taking a deep breath, remembering not to take their behavior personally, and distinguishing between the problem and person is important (Balzer, 2020). By asking questions to gather more information, one can create a conversation to help understand the source of the aggression (Balzer, 2020). To determine whether the aggressor is aware of their behavior and its effects, ask questions to better understand this (Balzer, 2020). Using the CARE (clarify, articulate, request, encourage) confrontation technique, one can clearly state how the aggressor’s behavior has affected them and what changes you would like to see in their behavior (Balzer, 2020). By utilizing these techniques AR and NW could minimize the amount of aggressive communication they experience while working. 

Assertive communication is a skill that requires time to practice (Balzer, 2020). Participating in assertive communication training has been associated with improved assertiveness, enhanced self-esteem, and creating balanced connections with others (Omura et al., 2016). Training can take numerous forms, including demonstration, discussion groups, lecture, and role-playing using virtual or face-to-face scenarios (Omura et al., 2016). This training has also been shown to enhance the well-being of healthcare personnel by improving happiness, self-esteem, and reducing anxiety (Omura et al., 2016). Furthermore, it has been shown to help with conflict management and as a coping method for aggressive behavior (Omura et al., 2016). Both AR and NW could participate in this training to improve upon a skill they frequently use in their practice. By doing this, they can form better relationships with coworkers, patients, families, and improve and promote patient safety (Balzer, 2020).

Both interviewed nurses seemed to feel that there was some breakdown in communication between physicians and nurses. Poor intra-professional communication can be associated with delayed diagnosis, adverse medication events, and inadequate patient monitoring (CMPA, n.d.). Poor intra-professional communication can also increase a patient’s length of hospital stay and increase the cost of healthcare (Wang et al., 2018). By understanding the detrimental effects poor intra-professional have on patients, one can take steps to improve communication. Communication can be enhanced by healthcare providers communicating effectively and being knowledgeable about their scope of practice, duties and responsibilities, and relevant policies and procedures (CMPA, n.d.). Similar mental models, shared objectives, and proper accountability also assist in effective communication and trust-building within care teams (CMPA, n.d.). The SBAR communication technique can assist in clarifying important information during patient transitions and handoffs (CMPA, n.d.). Structured communication tools, like SBAR, can aid in the simplification and organization of inter/intra-professional patient care planning and increase communication clarity and patient safety (CMPA, n.d.). The use of communication tools such as bedside whiteboards, daily goal sheet/form, and door communication cards are other ways that can improve communication between physicians and nurses (Wang et al., 2018). It was found that after the implementation and explaining of the use of daily goal forms, the percentage of nurses and doctors who understood the daily goals for patients increased (Wang et al., 2018). Additionally, patient length of stay decreased (Wang et al., 2018).


Understanding how intra/interpersonal communication influences all aspects of healthcare is essential. Interpersonal communication is critical not just for understanding the patient but also for treating them as a person with their own wants and challenges, instead of just a set of symptoms (Practo, 2015). Furthermore, it aids in the patient’s understanding of their health condition and promotes active participation in self-care (Practo, 2015). Good communication can also help improve and strengthen the relationships between staff members (PCC Institute for Health Professionals, 2016). Good interpersonal communication in healthcare has been shown to reduce stress and burnout (Kognito, 2020). High turnover rates and low morale have been explicitly correlated with poor communication between team members (Kognito, 2020).


Balzer-Riley, J. W. (2020). 
Communication in nursing (9th ed.). Elsevier. 

Baraldi , A. M. (2020, February 11). 
Principles of communication in Healthcare. Retrieved November 2, 2021, from 

Center for Rural Health Policies Analysis . (2013, July 15). 
How Hospital Leaders Can Build Good Working Relationships with Physicians. Rural Health Value. Retrieved November 3, 2021, from 

Kognito. (2020, December 8). 
The importance of interpersonal communication in Healthcare. Kognito. Retrieved November 5, 2021, from 

Lang, E., Ovens, H., Schull, M. J., Rosenberg, H., & Snider, C. (2020). Authentic Emergency Department leadership during a pandemic. 
22(4), 400–403. 

Lateef, F. (2018). Grace under pressure: Leadership in emergency medicine. 
Journal of Emergencies, Trauma, and Shock
11(2), 73. 

Mayo Clinic. (2020, May 29). 
Stressed out? be assertive. Mayo Clinic. Retrieved November 3, 2021, from 

Mayo Clinic. (2020, May 29). 
Stressed out? be assertive. Mayo Clinic. Retrieved November 6, 2021, from 

Omura, M., Maguire, J., Levett-Jones, T., & Stone, T. E. (2016). Effectiveness of assertive communication training programs for health professionals and students: a systematic review protocol. 
JBI Evidence Synthesis
14(10), 64–71. 

Practo. (2015, February 27). 
The importance of interpersonal communication in medical practices. The Practo Blog for Doctors. Retrieved November 5, 2021, from 

Scott, E. (2020, October 14). 
How to deal with relationship aggression. Verywell Mind. Retrieved November 3, 2021, from 

Spence Laschinger, H. K. (2010). Positive working relationships matter for better nurse and patient outcomes. 
Journal of Nursing Management
18(8), 875–877. 

Wang, Y.-Y., Wan, Q.-Q., Lin, F., Zhou, W.-J., & Shang, S.-M. (2018). Interventions to improve communication between nurses and physicians in the intensive care unit: An integrative literature review. 
International Journal of Nursing Sciences
5(1), 81–88. 


3rd Edition

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

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

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

00Gorman(F)-FM 11/8/07 10:54 AM Page i

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

3rd ed.
p. ; cm.

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

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

Handbooks. 3. Nursing Assessment—Handbooks. WY 49 G671p 2008]
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00Gorman(F)-FM 11/8/07 10:54 AM Page ii



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

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

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

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

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

00Gorman(F)-FM 11/8/07 10:54 AM Page iii

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

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

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

Linda M. Gorman
Donna F. Sultan

iv Preface

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

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

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

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

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

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

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

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

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

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

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

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

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

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00Gorman(F)-FM 11/8/07 10:54 AM Page viii



SECTION I— Aspects of Psychosocial

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

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

Psychosocial Nursing Care………………………………………………49

SECTION II— Commonly Encountered

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

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

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

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

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

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

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

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

00Gorman(F)-FM 11/8/07 10:54 AM Page ix

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

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

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

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

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

The Patient Abusing Other Substances ………………………………250

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

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

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

The Morbidly Obese Patient …………………………………………………330

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

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

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

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

SECTION III— Special Topics

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

The Chronically Ill Patient………………………………………………………400

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

William R. Whetstone, RN, CNS, PhD

The Dying Patient……………………………………………………………………421

x Contents

00Gorman(F)-FM 11/8/07 10:54 AM Page x

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

The Disaster Responder/Nurse ……………………………………………435

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

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



Contents xi

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SECTION I Aspects of
Psychosocial Nursing

1Introduction to Psychosocial
Nursing for General
Patient Care

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

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

care settings.

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

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

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


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

01 Gorman(F)-01 11/5/07 4:53 PM Page 1

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

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

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


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

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

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

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

planning, and effective interventions

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


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

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

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

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


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


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

Chapter 1 ■ Introduction to Psychosocial Nursing 3

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


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

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


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

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


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

4 Chapter 1 ■ Introduction to Psychosocial Nursing

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

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


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

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


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

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

Chapter 1 ■ Introduction to Psychosocial Nursing 5

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

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


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


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


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

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

6 Chapter 1 ■ Introduction to Psychosocial Nursing

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Response to Illness

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

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

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

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

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

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

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

02 Gorman(F)-02 11/5/07 4:55 PM Page 7

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


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

8 Chapter 2 ■ Psychosocial Response to Illness

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

02 Gorman(F)-02 11/5/07 4:55 PM Page 8

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

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

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

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

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

Chapter 2 ■ Psychosocial Response to Illness 9

02 Gorman(F)-02 11/5/07 4:55 PM Page 9

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

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

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

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

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

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

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

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


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

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


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

Chapter 2 ■ Psychosocial Response to Illness 11

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12 Chapter 2 ■ Psychosocial Response to Illness

Common Defense Mechanisms

Mechanism Definition Example






Attempt to remove an
experience or a feeling
from consciousness

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

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

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

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

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

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

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

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

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

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Chapter 2 ■ Psychosocial Response to Illness 13

Mechanism Definition Example







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

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

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

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

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

Expressing repressed urges
or desires in socially
acceptable ways

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

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

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

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

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

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

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

Some common coping mechanisms include:

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

• Expressing intense emotion by crying, yelling, or laughing

02 Gorman(F)-02 11/5/07 4:55 PM Page 13

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

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

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

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



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

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

14 Chapter 2 ■ Psychosocial Response to Illness

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Psychosocial Skills

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

playing, and acceptance.

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

using therapeutic communication.


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

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

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

03 Gorman(F)-03 11/5/07 4:57 PM Page 15

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

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

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

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

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

16 Chapter 3 ■ Psychosocial Skills

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

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

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

• Keep the focus on the patient.

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

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

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

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

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


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

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

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

Chapter 3 ■ Psychosocial Skills 17

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18 Chapter 3 ■ Psychosocial Skills

Mental Status Examination and Related Definitions

Category Description Related Definitions




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

Describe behavior, motor
activity, mannerisms.

Describe how patient
speaks; list barriers
to communication.

Catatonic: Remaining
totally immobile

Posturing: Assuming inap-
propriate or bizarre posi-

Compulsions: Insistent,
repetitive unwanted

Perseveration: Mechanical
repetition or words,

Pressured: Highly acceler-
ated rapid speech

Loose associations: Absence
of logical connections
between thoughts

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

Tangential: Talking around
main point

Word salad: Unconnected
words and phrases without
meaning or logic

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

Neologism: Making up new
words only speaker under-

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Chapter 3 ■ Psychosocial Skills 19

Category Description Related Definitions




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

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

Labile: Emotions that change
quickly and unpredictably

Flat affect: No demonstra-
tion of any feeling

Blunted affect: Constricted
display of emotions

Anhedonia: Absence of any

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

Ambivalence: Contradictory
feelings experienced simul-

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

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

Delusions: False, fixed beliefs
not alterable by logical

Obsessions: Unwanted, dis-
tressing recurring thoughts

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

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

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

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20 Chapter 3 ■ Psychosocial Skills

Mental Status Examination and Related Definitions—cont’d

Category Description Related Definitions

Ability to




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

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

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

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

Grandiosity: Exaggerated
beliefs in own worth
and/or abilities

Paranoia: Unwarranted
belief that others have
harmful intentions to

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

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

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

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Chapter 3 ■ Psychosocial Skills 21

Category Description Related Definitions




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

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

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

Orientation to person: Knows
his or her name

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

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

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

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

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


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

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22 Chapter 3 ■ Psychosocial Skills

Mental Status Examination Answer Sheet

Circle the correct words or fill in the blanks.

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

Calm appropriate restless agitated compulsions
unusual actions

Appropriate pressured loose association loud
soft mute

Appropriate labile flat depressed worried
anxious angry hopeless

Appropriate low self-esteem suicidal ideations hallucinations
delusions phobias

Ability to abstract
Impaired Yes No

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

Estmated intelligence
Below average average above average

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

Person Time
Place Situation

Realistic decision-making Yes No

Good fair poor

Summary of Impressions:

FIGURE 3–1. Mental Status Examination Answer Sheet.

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

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Chapter 3 ■ Psychosocial Skills 23

Mental Status Changes Caused By Electrolyte Imbalance

Electrolyte Imbalance Possible Cause Mental Status Changes

Calcium (Blood Level: 8.5–10.5 mg/dL)



Sodium (Blood Level: 135–145 mEq/L)




Bone metastasis
(breast, lung cancer)

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

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

Restricted fluid

Diabetes insipidus

Severe dietary
sodium restriction

Addison’s disease
Excessive water

SIADH (syndrome
inappropriate anti-
diuretic hormone)

Loss of energy

Reduced concentra-
tion and intellectual

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


Hyperactive intellectual



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24 Chapter 3 ■ Psychosocial Skills

Mental Status Changes Caused By Electrolyte Imbalance—cont’d

Electrolyte Imbalance Possible Cause Mental Status Changes

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


Potassium (Blood Level: 3.5–5 mEq/L)



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


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

Gram-negative septicemia
Alcohol withdrawal
Intravenous hyperalimentation
Low dietary intake

Renal disease
Potassium-sparing diuretics
Increased IV intake

Renal disease
Cushing’s syndrome
Potassium-wasting diuretics

Prolonged vomiting
Status asthmaticus
Renal failure
Diabetes mellitus with ketosis



Mood and personal-
ity change


Decreased intellectual


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

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Chapter 3 ■ Psychosocial Skills 25

Therapeutic Communication Techniques

Technique Definition Example




Active listening





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

Questions structured to
encourage the patient to
share information and

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

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

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

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

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

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

“How did you feel
when the doctor
told you of your

“Where does it hurt?”

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

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

“You sound very wor-
ried about the test

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26 Chapter 3 ■ Psychosocial Skills

Therapeutic Communication Techniques—cont’d

Technique Definition Example



Overt behavior that indi-
cates listening and atten-

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

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

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

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


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

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

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

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Chapter 3 ■ Psychosocial Skills 27

Barriers to Therapeutic Communication

Technique Possible Result Example

Giving advice

False reassurances


Leading statements

Multiple questions

Why question


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

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

Patient will sense your

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

Patient may not know
what to answer first.

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

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

“You should go back
to school.”

“I’m sure you’ll do
just fine.”

“How can you still
smoke when your
husband has lung

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

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

“Why do you feel that

Patient: “I’m worried
about the test

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

03 Gorman(F)-03 11/5/07 4:57 PM Page 27

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

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

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

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

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

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

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

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

28 Chapter 3 ■ Psychosocial Skills

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Chapter 3 ■ Psychosocial Skills 29

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

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

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

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

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

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


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

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30 Chapter 3 ■ Psychosocial Skills

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

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

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

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

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

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

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

ation information

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

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

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

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Chapter 3 ■ Psychosocial Skills 31

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

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

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

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

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

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

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

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

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

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

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

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

Massage—Manipulation of tissues and muscles to promote relaxation and

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

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

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

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

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

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

03 Gorman(F)-03 11/5/07 4:57 PM Page 31

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

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

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

32 Chapter 3 ■ Psychosocial Skills

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Nurses’ Responses to
Difficult Patient Behaviors

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

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

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

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


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

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

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

04 Gorman(F)-04 11/5/07 5:02 PM Page 33

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


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

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

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


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

34 Chapter 4 ■ Nurses’ Responses to Difficult Patient Behaviors

04 Gorman(F)-04 11/5/07 5:02 PM Page 34

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

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

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

Chapter 4 ■ Nurses’ Responses to Difficult Patient Behaviors 35

The Nursing Process with Difficult Patient Behaviors

Assessment Step Positive Cycle Negative Cycle



Patient outcome

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

Nurse evaluates if he or she
is stereotyping or reacting

Nurse gets assistance and

Nurse responds accurately
and with empathy to

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

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

Patient does not explore

Patient responds only
to surface level of

Patient reacts personally.
Nurse complains to staff
about patient.

Nurse avoids or rejects

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

Patient feels alienated
with escalation of
undesirable behaviors.

Potential exists for nega-
tive health outcome.

04 Gorman(F)-04 11/5/07 5:02 PM Page 35

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

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

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

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

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

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


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

36 Chapter 4 ■ Nurses’ Responses to Difficult Patient Behaviors

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

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

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

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

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

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

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

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

cial privileges.
• Do not personalize any hostility.


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

Chapter 4 ■ Nurses’ Responses to Difficult Patient Behaviors 37

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

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

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

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

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

38 Chapter 4 ■ Nurses’ Responses to Difficult Patient Behaviors

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

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

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

Chapter 4 ■ Nurses’ Responses to Difficult Patient Behaviors 39

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

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

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

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

04 Gorman(F)-04 11/5/07 5:02 PM Page 39

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

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


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


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

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

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

with the patient and his or her problem and previous treatment

40 Chapter 4 ■ Nurses’ Responses to Difficult Patient Behaviors

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

Chapter 4 ■ Nurses’ Responses to Difficult Patient Behaviors 41

Staff Responses to Difficult-to-Care-for Patients

Staff Responses Intervention

Feeling inadequate to respond effectively
to patient’s symptoms

Feeling angry when patient gets angry

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

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

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

Concern over being manipulated by
patient’s demands

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

Uncomfortable with certain personal topics
related to family dynamics or personal

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

Lower emotional reactivity.

Maintain objectivity.

Provide staff education on
identifying and handling

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

Share workload evenly.

Schedule consistent staffing.

Foster staff value system that
precludes patients labeling.

Support staff through discus-
sion and education.

04 Gorman(F)-04 11/5/07 5:02 PM Page 41

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

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

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

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

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

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

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

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

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

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

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

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Crisis Intervention

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

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

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

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

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

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

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

05 Gorman(F)-05 11/5/07 4:57 PM Page 43


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

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

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

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


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

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

44 Chapter 5 ■ Crisis Intervention

Types of Crises

Types of Crises Examples

Maturational—Crisis in response
to facing a new developmental

Situational—An unanticipated,
external event triggers a strong

Adventitious—Crisis of disaster

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

Loss of a job, death of a loved one

Natural disaster, terrorism

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

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

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

• Identify the precipitating event and determine its meaning.

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

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

• Evaluate the patient’s support system.

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

member or a counselor?

• Evaluate previously used effective coping mechanisms.

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


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

Chapter 5 ■ Crisis Intervention 45

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

When facing a crisis, consider the following interventions:

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

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

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

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

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

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

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

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

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

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

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

46 Chapter 5 ■ Crisis Intervention

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

• Assess the need for medications to reduce anxiety.

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

Chapter 5 ■ Crisis Intervention 47

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Cultural Considerations:
Implications for Psychosocial
Nursing Care

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

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

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

preter is not available.

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

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


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

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

06 Gorman(F)-06 11/5/07 4:58 PM Page 49

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

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

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

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

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

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

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

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

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

50 Chapter 6 ■ Cultural Considerations

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

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

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


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


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

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

Chapter 6 ■ Cultural Considerations 51

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

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

52 Chapter 6 ■ Cultural Considerations

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

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

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

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


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

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

cultural background all hold the same beliefs.

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

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

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

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


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

Chapter 6 ■ Cultural Considerations 53

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

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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

Chapter 6 ■ Cultural Considerations 55

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56 Chapter 6 ■ Cultural Considerations

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

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


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

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

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

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

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

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

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

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

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

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Encountered Problems

7Problems with Anxiety

The Anxious Patient

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Chapter 7 ■ Problems with Anxiety 59

Characteristics of Anxiety Levels

Level Characteristics




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

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

• Hesitation and procrastination, blocking loss of train of

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

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60 Chapter 7 ■ Problems with Anxiety

Characteristics of Anxiety Levels—cont’d

Level Characteristics



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

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

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

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

• Inability to speak, unintelligible communication, inco-

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

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

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

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

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

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

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

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

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

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

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

Chapter 7 ■ Problems with Anxiety 61

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


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

• Guilt or discrepancies between self-perception and actual behavior

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

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

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

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

Paralysis or retreating: Withdrawing or being immobilized by anxiety

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

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

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

Syndromes of abnormal anxiety frequently observed in patients include the

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

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

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

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

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

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

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

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

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

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


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


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

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

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

Mood and Emotions
• Dread, fear, apprehension

• Lack of control or self-confidence

• Guilt

• Anger

• Grief

• Sense of imminent catastrophe

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

Chapter 7 ■ Problems with Anxiety 65

• May be apprehensive and even fearful about caring for patients experienc-

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

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

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

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

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

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

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

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

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

anxiety and maladaptive coping

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

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

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

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


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

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

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

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


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

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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

• For patients with panic-level anxiety:

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

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

will stay with you”).

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

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

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


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

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

• Promote communication that reinforces rational thinking and decreases

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

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

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

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

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

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

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

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

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

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

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

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


Comfort, Impaired
Gas Exchange, Impaired
Perception, Disturbed

70 Chapter 7 ■ Problems with Anxiety


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


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

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Chapter 7 ■ Problems with Anxiety 71

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


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

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

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

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

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


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

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

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


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

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

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

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

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

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

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

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Problems with Anger

The Angry Patient

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


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

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

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

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

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

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

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

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

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

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


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

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

74 Chapter 8 ■ Problems with Anger

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

of control

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


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

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

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


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

Chapter 8 ■ Problems with Anger 75

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

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


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

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

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

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

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

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

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

• Possible physical violence

Chapter 8 ■ Problems with Anger 77

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

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

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

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

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

Comparing Behavioral Responses to Anger

Traits Passive Assertive Aggressive



Eye contact

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

Whiny, weak

Looks down

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

Firm, clear

Erect, relaxed

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



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

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

denying any concerns, or inappropriate cheerfulness for the situation

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

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

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

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

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

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


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

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

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


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

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

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

• Use therapeutic communication techniques including open-ended ques-

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

tives outcomes.


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

Chapter 8 ■ Problems with Anger 81


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

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

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

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

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

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


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

response to them.


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

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

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

of anger escalating to violence.

82 Chapter 8 ■ Problems with Anger


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

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The Aggressive and Potentially
Violent Patient

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

and long waits

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

• Impersonal care, which may stress already frustrated patients

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

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


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

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

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

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

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

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


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

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

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

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

Exposure to toxic chemicals, pesticides, lead


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

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

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

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

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

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

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

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

88 Chapter 8 ■ Problems with Anger

• May fear being hurt by the violent or aggressive patient or one who uses

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

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

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

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

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

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• Thoughts or plans to harm someone

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

• Hallucinations, paranoid delusions

• Views others as out to hurt him or her

• Sense of being out of control

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


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

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

Physical Responses
• Increased muscle tension

• Increased heart rate and blood pressure

• Altered level of consciousness, confusion, lethargy

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

• Increased use of medications

Pertinent History
• History of violent behavior, particularly assault

• Psychiatric diagnosis

• Substance and/or alcohol abuse

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


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

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

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

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

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

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

90 Chapter 8 ■ Problems with Anger

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

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

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

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

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

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

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tility and/or aggression to others, threatening others, possession of potential
weapon, assaulting others related to impaired judgment, feelings of power-
lessness, impulsive behavior, inability to evaluate reality secondary to neuro-
logic problems, psychotic thoughts, and/or drug/alcohol use.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

92 Chapter 8 ■ Problems with Anger

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

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

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

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

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

the consequences.

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

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

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

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

Chapter 8 ■ Problems with Anger 93

Summary of Staff Interventions to Avoid
Escalation to Aggression

Patient Staff



Acting out

Tension reduction

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

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


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

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

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

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

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

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

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

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

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

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

94 Chapter 8 ■ Problems with Anger

BOX 8–4
Preventing Workplace Violence
• Be particularly vigilant during change of shifts and on night shift. Events

often occur between 8:30 p.m. and 10:30 a.m.
• Minimize stress factors such as long waits, crowded, confined spaces, and

inflexible policies for patients where possible.
• Avoid wearing jewelry or neckties that can be grabbed or tugged.
• Recognize and report any signs of inappropriate angry responses in co-

workers, patients and families
• Encourage coworkers to report incidents
• Immediately report all assaults to your supervisor and security.
• Be aware that many agency security staffs have minimal training.
• Receive education on local gangs and gang violence.
• Participate in agency safety committees to ensure that adequate security

measures are in place.

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• Once the decision is made to restrain patient, act quickly and decisively.
Determine what appropriate type of restraint is to be applied before
approaching patient. Restraints include cloth chest and limb restraints or
leather (hard) locked restraints. (Note: When using hard restraints, make
sure you have the key, and double-check that they are locked after apply-
ing them to patient.) Have equipment ready before approaching patient.

• Never attempt to restrain a patient by yourself. Have adequate staff
members available (usually three to five persons) and a plan of action
before attempting to physically control a patient. Recruit reliable help
from all possible sources, such as security. Assess their experience in
managing a violent patient and review the plan. Decide in advance who
will grab which arm or leg if patient must be restrained. The presence of
a number of staff members (show of force) alone may subdue a patient.
Identify a leader before taking any action.

• Designate one person to talk with the patient and another to direct the
other staff. Only one staff member should talk with patient, preferably
someone who knows him or her. It is important to communicate in a firm
manner, speaking slowly. Lack of leadership can cause confusing and
contradictory messages and result in someone being hurt or the patient
escaping. Remove other patients from the area.

• Maintain a firm base of support for balance if you are suddenly pushed.
Remove name badge, eyeglasses, jewelry, and so on to avoid injury.

• If patient is resisting, he or she may need to be distracted. Each staff
member should grab one of the patient’s limbs when given the command
by the coordinating person and take the patient down to the floor or bed
quickly. Attempt to cradle patient’s head to prevent injury.

• Once restraints are applied to bed frame, take the time to talk with the
patient in a calm, concerned manner to try to humanize situation. Call
patient by his or her name.

• Make sure patient has no potential weapons within reach. Patient needs
to be searched for sharp objects, matches, and so on.

• Administer medications as ordered.
• Be aware of agency policy regarding application of restraints. Require-

ments for monitoring patients while in restraints, reasons for restraints,
doctor’s orders, and the length of time each order remains valid should
be clearly spelled out in agency policies. If you are not sure about using
restraints on someone, discuss with your supervisor to weigh your obli-
gations to protect the patient versus going against the patient’s wishes.

• Monitor the patient closely and document findings according to agency
policy including vital signs, circulation extremities, and intake/output.

• Remove restraints and observe patient closely when the situation is under
control. Consider removing restraints from one limb at a time so that the
patient has time to adjust. For the high-risk patient, keep one arm and
one leg in restraints at all times until it is clear that patient can be

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released. Inform other staff members that patient has been released.
Establish clear criteria for reapplying restraints with patient and staff.
Prepare family for patient’s condition, as appropriate.

• Once the patient has regained control, discuss with him or her why that
intervention was used, and allow opportunity to express feelings. This
increases his or her sense of control and decreases dehumanization.

• If the patient has a gun or other weapon, never attempt to disarm him or
her. Contact security and/or law enforcement agency as soon as possible.
Focus on getting assistance and protecting patients and staff. Patients and
staff should remain in a safe area until help arrives.

• Consider taking a specialized class on use of defensive techniques such as
management of assaultive behavior. Proper training is essential to prevent
injury to patients and staff. Staff members can practice with each other
to demonstrate how they would handle a violent patient.

• Identify jobs at higher risk of exposure to violence and ensure that
employees in these jobs have adequate training. Agency management
should be providing adequate support and possibly critical incident
debriefing to assist staff recovery after a violent event.


Coping, Ineffective
Self-Esteem, Disturbed
Thought Processes, Disturbed

96 Chapter 8 ■ Problems with Anger


• Escalation of behavior from aggressive to violent
• Patient in possession of a weapon
• Inadequate staff members available to control behavior
• Increased staff anxiety over caring for the patient
• Staff members at risk for violence without adequate training/security
• Staff potential for injury or emotional trauma


• Other colleagues in area of incident
• Security/law enforcement
• Psychiatric Team

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• Review early warning signs of escalation of aggressive behavior with patient
and his or her family.

• Instruct patient on role of alcohol and drugs in contributing to aggressive

• Instruct on use of prescribed medications to control tension. Instruct on
when to ask for PRN medications.

• If patient is in restraints, review with him or her criteria for removal and


• Document all actions taken to prevent violent behavior.
• Document application of restraints including type, length of time in

restraints, reasons for application, patient response, release of limbs, and
care given while in restraints. Document vital sign monitoring.

• Document need for and response to medication given.
• Document any threats made by patient
• Document alternatives tried to avoid restraints
• Document all interventions and responses to them.


• Provide information to patient’s family and/or caregivers about emergency
psychiatric services, if needed. Discuss potential for violence with family to
share possible strategies from nursing care plan.

• Provide information on shelters and/or domestic violence services, if appro-

• If patient is being transferred to another facility, share concerns about
patient’s behavior and interventions and share any history of violent

• Provide information to family and caregivers on what to do if behavior is
out of control. Encourage them to call for help immediately.

• Provide information and referrals on drug treatment if appropriate.
• Provide family/caregivers with information on resources for support, how

to get emergency assistance

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Problems with
Affect and Mood

The Depressed Patient

Learning Objectives
• Differentiate feeling depressed from a depressive disorder.
• Describe common physical symptoms seen in depressive disorders.
• Describe interventions for the patient with low self-esteem.
• Describe possible nurses’ reactions to the depressed patient

Anhedonia – Loss of pleasure in activities or interests that were previously

Dysthymic disorder – Mild to moderate chronic depression lasting at least

2 years.
Major Depressive Disorder – Primary psychiatric illness manifested by char-

acteristic symptom clusters such as depressed mood, lowered self-esteem,
pessimistic thoughts, and loss of pleasure or interest in former activities.

Masked depression – Concealed depression in which patient is not aware of
depressed mood or does not display obvious sadness. The depression is
expressed through other means, such as physical complaints or diverse psy-
chiatric symptoms such as phobias or compulsions.

Psychomotor agitation – Classic symptom cluster of depression including
restlessness with rapid, agitated, purposeless movements like pacing or
wringing hands .

Psychomotor retardation – Classic symptom cluster of depression including
slow movements and speech.

Seasonal affective disorder (SAD) – Depression associated with shortened
daylight in winter and fall. It disappears during spring and summer.

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Feeling down, discouraged, and depressed is something all people experience at
different times in their lives. Periods of emotional highs and lows are normal.

Depressive illness, also known as major depressive disorder, however, is very dif-
ferent from simply feeling depressed. Major depressive disorder is a psychiatric
illness characterized by a cluster of symptoms including prolonged depressed
mood, lowered self-esteem, pessimistic thoughts, and loss of pleasure or interest
in former activities for at least 2 weeks. It is a painful, debilitating illness. It needs
to be differentiated from short-term depressed moods or grief reactions, which
are normal. Although grief displays many of the signs and symptoms of depres-
sion, it is a time-limited condition in response to an obvious loss and does not
cause lowered self-esteem. The Diagnostic and Statistical Manual of Mental Dis-
orders, 4th edition text revision, 2000, also known as DSM-IV-TR, describes dys-
thymic disorder as a chronic depressed mood most of the day for more days than
not during a period of 2 years. Seasonal affective disorder is another form of
depression. Adjustment disorders with depressed mood can also occur in
response to situations like illness and loss. This disorder is of shorter duration but
may progress to major depressive disorder in some cases.

Depression is the most common reason for seeking out mental health
professionals. A major source of diagnosis is primary care providers who
diagnose one-third to one-half of people identified as having depression (Agency
for Healthcare Quality and Research, 2000). It is the leading cause of disability
in the United States (Montano, 2003). About 5% to 8% of the population suf-
fers from some form of depression at any one time (NAMI, 2007). There is
a 16.6% chance of developing a major depressive disorder in one’s lifetime
(Kessler et al., 2005). Because the symptoms of depression can be hidden and
vague, and may present as physical symptoms instead of a mood disturbance,
primary care physicians may be the first to see the patient. However, the symp-
toms of depression can often go unrecognized and are often misdiagnosed.
Undiagnosed and untreated depression is considered a major national health con-
cern, contributing to poor work performance, family disruption, substance
abuse, and premature death as a result of suicide or lack of self-care. Family
history, stressful life events, and a previous history of depression are major pre-
dictors. Women are twice as likely to suffer from depression as men. Although
men have a greater tendency to suffer a masked depression that can be concealed
with drug use, alcohol abuse, and long work hours. Without treatment, these
episodes can increase over time. It crosses all ethnic lines. In addition, depression
can be part of a bipolar disorder psychosis, eating disorders, or dementia.
Depression can also be secondary to a primary problem such as substance abuse
or schizophrenia.

Once a person experiences a depressive episode, there is a high risk for recur-
rence. After one depressive episode, an individual has a 50% chance of another;
after two episodes, there is a 70% to 80% risk of another; and after three
episodes, the individual is at very high risk for chronic disability from depression
(DSM-IV-TR, 2000).

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No single theory of depression is accepted by all theorists and clinicians. Differ-
ent theories may apply to the divergent pathways that patients travel to arrive at
the various types of depression.

Biological theories have focused on an insufficiency of neurotransmitters,
especially norepinephrine and serotonin. These insufficiencies may be the result
of inherited or environmental factors. The effectiveness of antidepressants may
result from enhanced levels of these neurotransmitters. The most severe depres-
sions are predominantly biologically determined. Hormonal factors, including
abnormal melatonin metabolism, are associated with seasonal affective disorder
(also called major depression with seasonal pattern).

Genetics may be a factor in more severe depressions. Relatives of people
with depression have a higher incidence of this illness than those in the general

Psychological theories about a predisposition to depression have focused on a
personal history of deprivation, trauma, or significant loss during childhood.
These patients may be more susceptible to depression because current losses
revive memories of former losses. They are more likely to experience low self-
esteem and powerlessness.

Depression can be viewed as forbidden anger that has been turned inward.
Classic psychoanalytic theory identified depression as the reaction to the loss
of a significant person who has been both hated and loved. The patient handles
this ambivalence by turning the hatred inward, resulting in depression and
low self-esteem, whereas the memory of the departed person remains beloved and

Certain predominant issues of low self-esteem and helplessness are major con-
tributors. For instance, low self-esteem may be based on the faulty development
of an adequate, competent sense of self during childhood. As a child, the patient
may have received attention and approval only when meeting parental needs and
expectations. In adulthood, the absence of external support and praise and espe-
cially the loss of a supportive person may make the patient vulnerable to loss of
self-esteem, which triggers depression.

Learned helplessness is displayed by a lack of adequate effort based on the
belief that a person cannot be effective in getting needs met or making an impact.
This person grew up in an environment that did not respond to any actions or
initiative that he or she took (Seligman, 1975).

Distorted thinking can generate depression. Typically, the patient has negative
expectations about himself or herself, the world, and the future. If he or she con-
sistently overgeneralizes any mistake into the conclusion “I can’t do anything
right” and judges himself or herself as deficient, these negative beliefs can build
toward depression. Negative expectations of the world, such as receiving no help
from others or expecting only criticism, reinforce helplessness and lead to hope-
lessness (Beck, 1979).

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Clinically significant depressive symptoms are detectable in about 12% to
36% of the medically ill population (DHHS, 1993). The risk for depression
greatly increases among people with a medical disorder (Varcarolis, 2006).
Valente and Saunders (1997) reported that 20% to 25% of people with cancer
experience depression that often goes untreated. Untreated depression in the
medically ill can contribute to longer hospital stays, poor compliance,
poorer quality of life, and increased doctor visits. It may also impact morbidity
and mortality (Rouchell, Pounds, & Tierney, 2002). Major depressive
disorder associated with a myocardial infarction has been shown to contribute
to a higher mortality rate. This may be caused by changes in the endocrine
and immune systems as well as reduced motivation and compliance (Rouchell
et al., 2002). Stewart, Janicki, Muldoon, Slatton-Tyrell, & Kamarck (2007)
reported that physical symptoms of depression may play an important role in
the earlier stages of the development of cardiovascular disease. The patient’s
response to a medical illness could cause depression, and in some cases might
precede it as can been seen in hypo- or hyperthyroidism, Addison’s disease,
and Huntington’s disease. Symptoms of some illnesses such as fatigue or changes
in appetite or bowel habits, can also mask depressive symptoms, making it diffi-
cult to diagnose. See Box 9–1 for a list of medical disorders associated with

In addition, some medications can trigger depression (Box 9–2).

102 Chapter 9 ■ Problems with Affect and Mood

BOX 9–1
Medical Conditions Associated with Depression
• Stroke (especially frontal lesions)

• Myocardial infarction

• Adrenal disorders

• Dementia

• Diabetes

• Cancer

• Hypothyroidism

• Brain tumors

• Parkinson’s disease

• Multiple sclerosis

• Chronic pain

• End stage renal disease

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Experts do not agree on the prevalence of depression in children; however, there
is consensus that it does occur, even in young children. Children as young as
3 years of age have been diagnosed with depression (Varcarolis, 2006). Depression
could be the aftermath of emotional deprivation, abuse, or separation. Children
who were abused or neglected are known to be at a higher risk for major depres-
sive disorder in childhood and adulthood (Widom, Dumong, & Czaja, 2007).

Because the child may be unable to express feelings or worries, other signs
need to be analyzed, including acting-out behaviors, conduct disorders, inappro-
priate aggression, refusal to go to school, negativity, irritability, not meeting

Chapter 9 ■ Problems with Affect and Mood 103

BOX 9–2
Drugs That Cause Depression
• Antihypertensive agents

• Reserpine
• Beta blockers
• Methyldopa
• Oral contraceptives

• Steroids
• Benzodiazepines
• Anabolic steroids
• Amphotericin-B
• Cancer chemotherapeutic agents

• Vincristine
• Vinblastine
• Interferon
• Procarbazine
• L-asparaginase

• Psychoactive agents
• Alcohol
• Amphetamine or cocaine withdrawal
• Opioids

Source: Rouchell, A. M., Pounds R., & Tierney, J. G. (2002). Depression. In J. R. Rundell & M. G.
Wise (Eds.), Textbook of consultation-liaison psychiatry (pp. 307–338). Washington DC: Ameri-
can Psychiatric Press; Dubovsky, S. L., Davies, R., & Doboxsky, A. N. (2003). Mood disorders.
In R. E. Hales & S. C. Yodofsky (Eds.), Textbook of clinical psychiatry (4th ed) (pp. 439–542).
Washington, DC: American Psychiatric Press.

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developmental tasks, sleep disorders, inability to experience joy (anhedonia), and
self-destructive behaviors. There is a higher risk of depression in children when
one or both parents suffer from major depression. Depression can also be a sec-
ondary reaction to other problems such as learning disorders and substance
abuse. Children have been treated successfully with antidepressants in conjunc-
tion with psychotherapeutic interventions. However, precautions must be taken
because of the potential increased suicide risk for children and adolescents. The
Food and Drug Administration label on anti-depressants recommends close mon-
itoring for increased suicide risk (Fochtmann & Gelenberg, 2005) leading to a
dramatic reduction in prescriptions for SSRIs for young people (Leckman &
King, 2007). Maternal depression while a child is young puts him or her at par-
ticularly high risk. Because the recurrence rate of depression is so high in children
and adolescents, treatment is essential to prevent a lifetime of disability from it
(NIMH, 2007a).

National Institute of Mental Health (NIMH) (2007b) estimates that 5% of ado-
lescents suffer from major depressive disorder. Adolescents often do not express
feelings of depression verbally because they may fear exhibiting feelings of vul-
nerability and dependency. Rather, their feelings of depression are often
expressed in self-destructive or antisocial behaviors including sexual promiscuity,
school truancy, threats, or petty crime. Some experts believe that substance
abuse, antisocial behavior, and eating disorders in adolescence may be masking
or related to depression. A depression-prone adolescent with low self-esteem will
have greater difficulty achieving a positive sense of self as an adult. Adolescent
victims of abuse and a history of parental depression contribute to a particular
vulnerability to depression.

Debate continues as to whether the cause of postpartum depression is solely hor-
monal or represents an intermingling of psychological and physiological stres-
sors. Although postpartum “blues” (a few days of labile mood after the birth of
a baby) are extremely common, more severe reactions are relatively rare. Post-
partum depression can include psychotic symptoms including delusions that
often concern the newborn infant. Bonding with the infant is disrupted. Women
with a history of prenatal depression and bipolar disorder are at higher risk.
Once a woman experiences a major postpartum depression with psychotic fea-
tures, the risk of recurrence in subsequent deliveries is between 30% and 50%
(DSM-IV-TR, 2000).

Older Adults
Depression is the most common emotional disorder of later life. Elderly people
are at higher risk because they experience multiple losses and more medical

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illnesses than the rest of the population. However, in geriatric patients, depres-
sion is more likely to be masked rather than exhibited by typical depression
symptoms such as sadness, so it is often not diagnosed. Using the Geriatric
Depression Scale is a useful way to capture this diagnosis. Even though these
individuals may see a doctor more frequently than younger adults, it remains
undertreated (Varcarolis, 2006). Symptoms are often more physical or expressed
as personality changes, including irritability. Depression can also be superim-
posed on dementia or confused with pseudodementia because common depres-
sive symptoms in elderly persons include confusion, distractibility, and memory
loss. In addition, some of the physical symptoms of depression such as fatigue,
anorexia, constipation, and psychomotor retardation can be confused with phys-
ical illness, medication interactions, substance abuse, or “signs of old age.” Treat-
ment with antidepressants must be very closely supervised because of the
possibility of severe side effects, but it can be very helpful. Electroshock treat-
ments may also be tried in an elderly patient who is unresponsive to antidepres-
sants. Risk factors for depression in older adults include alcohol and substance
abuse, dementia, cancer, stroke, myocardial infarction, functional disability,
being widowed or a caregiver, and social isolation (Kurlowicz, 2003).

Chapter 9 ■ Problems with Affect and Mood 105

• May feel depressed when working with these patients. A patient’s despair

and unhappiness can be very painful to be around and could lead to the
nurse’s avoidance of the patient.

• May reject the patient because of own perception of the patient’s depend-
ency. Or may become over-involved because of patient’s needs and inadver-
tently create more dependency.

• May resent patient because of the longer time it takes to provide care.

• May feel angry or frustrated with depressed patient who isn’t “helping him-
self or herself” or can’t just “snap out of it.”

• May feel inadequate when unable to make a quick impact on a patient’s
depression. Nurse may create unrealistic expectations of patient’s recovery.

• Staff members may have inaccurate beliefs about the cause of depression,
which may lead to their minimizing the degree of the patient’s suffering.

• Because of the high prevalence of depression in our society, the nurse may
have personally experienced it or may have witnessed a family member’s
struggle with depression. This can cause the nurse to identify with the
depressed patient and reexperience these feelings.

• Reaction may depend on whether the nurse believes that the expression of
sadness is an acceptable behavior; for example, the nurse may believe sad-
ness is acceptable in women but not in men.

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Behavior and Appearance
• Persistently sad, anguished, or apathetic facial expression
• Dejected appearance: Head down, poor eye contact, posture slumped as if

bearing a heavy weight
• Psychomotor agitation and/or retardation
• Decreased interest in grooming and self-care
• Decreased sexual interest
• Makes statements like “I don’t care any more”
• May have difficulty with even simple tasks
• Anhedonia

Mood and Emotions
• Dysphoric mood: Verbalizes feelings of sadness and depression
• Inability to enjoy activities that were enjoyed previously
• Low self-esteem with feelings of worthlessness and inadequacy
• Feeling ineffective, powerless, and helpless
• Pessimistic: May appear brooding and express feelings of futility and despair
• Feelings of great heaviness
• Mild to high levels of anxiety, possibly including panic attacks and irritability
• Unexpressed anger, turned inward against self
• May express generalized anger
• Ambivalence: may feel two opposing ways at the same time

Thoughts, Beliefs, and Perceptions
• Thoughts slowed
• Poor concentration with possible temporary impairment of recent memory
• Self-doubt with relentless rumination and obsessions
• Lack of self-worth: Believes self undeserving of good experiences
• Indecisiveness
• Preoccupation with body changes
• Loss of perspective: May reject positive comments from others; gives self no

credit for achievements
• Excessive guilt: condemns self; feels deserving of punishment
• Narrowing of interest to self
• Possible suicidal thoughts
• Confusion

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• In severe depression: delusions; hallucinations that express feelings of
worthlessness; guilt

• Believes life has no meaning and that there is no future

Relationships and Interactions
• Withdrawal from social interactions
• Deterioration of relationships because of preoccupation with self, anger,

and anxiety
• Increasing dependence on others because of inability to make decisions or

care for self

Physical Responses
• Slowed physiologic functioning evidenced by:

• Lethargy and fatigue, especially in the morning
• Constipation
• Decreased appetite with weight loss or increased appetite with weight

• Sleep problems including early morning awakening, frequent awaken-

ings, waking up feeling tired, sleeping all the time
• Body aches; pains such as headaches; indigestion; dizziness

• Thyroid function tests may be ordered to rule out hypothyroidism

Pertinent History
• Past history of depression, bipolar disorder, panic attacks, suicide attempts
• Family history of depression
• History of substance abuse
• History of stroke or myocardial infarction (particularly high rate of


See Box 9–3 for List of Commonly Used Depression Scales.


The advent of so many new antidepressants has provided many more opportuni-
ties for successful treatment. The American Psychiatric Association Practice
Guidelines for Major Depressive Disorders (Karasu, Gelengerg, Merriam, &
Wang, 2000; Fochtman & Gelenberg, 2005) recommend antidepressants be pre-
scribed for moderate to severe depression and can be used with mild depressive
symptoms if the patient wishes. Components of firstline treatment today are the
Selective Serotonin Reuptake Inhibitors (SSRIs) and newer atypical antidepres-

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sants. Because there are so many on the market that have the same effectiveness
but side effects differ (AHRQ, 2007). Other variables are patient profile, history
of previous response, type of depression, rate of onset, concurrent medical or psy-
chiatric illnesses, and other medications the patient is taking. See Chapter 21 for
a detailed discussion of antidepressants, their side effects, and nursing implica-
tions. Most antidepressants require at least 3 to 4 weeks of use before full bene-
fits are obtained. Often, relief of other symptoms occurs before a change in the
patient’s subjective sense of feeling better. Side effects must be monitored closely.
The patient may need to remain on a maintenance dose of antidepressant for
many years.

Monoamine oxidase inhibitors (MAOIs) are used less today but may be a
second- or third-line treatment for depressions that do not respond to the more
commonly used antidepressants. If the patient is experiencing anxiety, panic
attacks, hallucinations, or delusions, other medications may need to be added. A
trial of stimulants such as methylphenidate hydrochloride (Ritalin) or modafinil
(Provigil) may be tried in adults with severe psychomotor retardation.

Herbal products that are used for depression include stimulants such as ma
huang, which contains ephedra, Gingko biloba, and SAM-e. The most common
herbal product for this use is St. John’s wort. As with most herbal products, there
are potential side effects and drug interactions. St. John’s wort is known to inter-
act with some HIV medications and can inhibit effectiveness. However, con-
trolled trials on St. John’s wort have been inconclusive (Fochtmann & Gelenberg,
2005). An alternative, nonpharmacological approach is light therapy, particularly
useful in seasonal affective disorders. Exposure to natural light is shown to
reduce depression and improve alertness (Nelson, 2006).

Psychotherapy and other psychosocial treatments continue to be an important
component of depression treatment. A combination of psychotherapy and phar-
macotherapy is more effective than pharmacotherapy alone. Combination ther-
apy is particularly helpful in improving treatment adherence (Fochtmann &
Gelenberg, 2005). One short-term psychotherapy approach is cognitive therapy.
This method is brief, structured, directive treatment designed to alter the negative
thoughts so common in depression. Group therapy can also be helpful to enhance
the patient’s socialization.

108 Chapter 9 ■ Problems with Affect and Mood

BOX 9–3
Commonly used Depression Assessment Scales
• Beck Depression Inventory
• Zung Self-rating Depression Scale
• Geriatric Depression Scale
• Hamilton Depression Scale

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Electroconvulsive Therapy
Electroconvulsive therapy (ECT) is a first-line treatment option only for patients
with more severe or psychotic forms of depression. It may also be used for those
who have failed to respond to other therapies or those with medical conditions
that preclude the use of antidepressants.


SELF-CARE DEFICIT evidenced by decreased ability to manage own hygiene,
grooming, feeding, and daily activities related to loss of energy, inhibition of
motivation, anxiety, and/or dependency.

Patient Outcomes
• Increased participation in self-care, daily activities
• Improved grooming and hygiene

• Determine patient’s level of self-care before onset of depressive symptoms

to set realistic goals.
• Assess whether the patient is expressing certain psychological needs such

as dependency or rebellion by not performing self-care. Observe whether
patient acts more independently when unaware of being watched.

• Encourage as much independence as possible. Take the time to allow
patient to do things for himself or herself. Assign care to staff member
who may have more time or is especially patient. Make sure all staff
members reinforce patient’s participation. Encourage patient’s participa-
tion in decisions about timing, sequence, and approaches to self-care.

• Create a positive attitude that patient can learn and progress with prac-
tice. Avoid taking over for the patient if he or she has trouble.

• If patient is not eating, encourage small meals that are high in protein and
nutrition dense.

• Break down tasks into small steps so patient can experience some suc-
cess. For instance, have the patient focus on washing his or her face
rather than completing the whole bath. Recognize that patient’s thinking
processes are slowed.

• Create an environment to ease patient’s participation, such as having
proper utensils available at mealtime or having the walker available in
room if patient is ambulating to bathroom.

• Provide reassurance and encouragement. Avoid minimizing patient’s
problems or infantilizing him or her.

• At times, a nurse may need to make all decisions for a very depressed
patient such as when to eat. Then, as the patient begins to improve,

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limited options can be presented. With further improvement, the patient
should take on increasing decision making.

SELF-ESTEEM DISTURBANCE evidenced by statements of low self-esteem,
misinterpreting positive or pleasurable experiences, expressions of shame and
guilt related to feelings, thoughts of worthlessness, failures, and negative rein-

Patient Outcomes
• Identifies positive aspects of self
• Modifies unrealistic expectations for self
• Demonstrates reduced symptoms of depression

• Provide emotional nurturing through empathetic listening and support-

ive encouragement. Treating the patient as a valued individual will
enhance his or her self-esteem.

• Avoid blanket reassurances like “things will get better soon.” These tend
to alienate the patient, who may feel that you don’t understand his or her

• Encourage patient to share feelings, especially negative ones. If this is too
difficult, consider alternative means of expression such as writing about
feelings or drawing pictures.

• Point out any specific improvement, no matter how small. Depressed
people often do not see improvement because they are so focused on the
negative. Consider keeping a progress chart at the bedside to record con-
crete accomplishments such as the number of times the patient ambulates
or the percentage of food he or she eats.

• Encourage patient to speak up if he or she disagrees or feels his or her
rights are being violated. Reinforce assertive response.

• Recognize and point out manifestations of self-destructive or self-
undermining thinking or behavior:

• Requiring self to be perfect or setting unattainable goals
• Assuming responsibility for and feeling guilt about failures and events

that are outside the patient’s control
• Basing entire feeling of self-worth on one achievement or attribute, a

single relationship, or obtaining approval from others
• Projecting own feelings of self-hate onto family, staff, or friends, such

as “All the nurses hate me.” “My family blames me for my illness.”
• Expressing self-hate directly through suicidal thoughts and behavior
• Expressing self-hate indirectly with repeated accidents, noncompli-

ance, provoking or being antagonistic to others, thereby unwittingly
creating rejection

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• Covering poor self-esteem with anger, blaming, or other maneuvers
that displace responsibility onto others

• Suggest that the patient identify a few achievements from the past.
• Discuss and practice with patient alternative ways to respond to stress

and to ask for what he or she wants.

POWERLESSNESS evidenced by lack of initiative, nonachievement of realis-
tic goals, passivity; nonparticipation in decision making related to decreased
motivation, decreased energy, hopelessness, perfectionistic expectations or

Patient Outcomes
• Identifies factors that he or she can control
• Participates in decisions about his or her care

• Encourage the patient to describe feelings or the experience of power-

lessness. Let the patient know that you are interested and that you under-
stand his or her pain. For instance, you may state, “You believe there is
no hope for you to ever feel better.”

• Once the patient indicates that he or she feels understood, suggest alter-
native viewpoints. Work with patient to identify times in life when he or
she felt better or felt more in control.

• Work with the patient to identify realistic goals to work toward. Encour-
age having patience and accepting current limitations. Break down goals
into small steps and recognize progress as each is achieved.

• Allow the patient to maintain reasonable control over some of the daily
routine if able.

• Have the patient list specific situations in which he or she felt powerless.
Correct distorted assumptions, discuss alternative ways to handle situa-
tions, and identify helpful resources.

• Direct the patient to other topics if he or she obsesses on unrealistic goals
or things that cannot be changed.


Coping, Ineffective
Grieving, Dysfunctional
Injury, Risk for
Nutrition, Altered
Sleep Pattern, Disturbed

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Social Interaction, Impaired
Thought Processes, Disturbed

112 Chapter 9 ■ Problems with Affect and Mood


• Extreme self-care deficit to point of not being able to care for basic

• Suicidal thoughts, threats, or attempts
• Hallucinations or delusions
• Severe side effects from antidepressants, including severe urinary

retention, dramatic fluctuations in blood pressure, cardiac complica-
tions, seizures


• Psychiatric Team
• Social Worker
• Attending Physician


• Teach the patient that depression can generate feelings of helplessness, pow-
erlessness, and pessimism. Encourage the patient to delay major decisions
and actions based on those feelings, and reinforce the idea that the severe
symptoms will abate with treatment and time.

• Reinforce the idea that depression is a treatable illness. Even though the
patient may feel hopeless, the illness is not.

• For patients on antidepressants, review potential side effects and impor-
tance of taking the medication even when they start feeling better. Patient
should know which side effects to report to physician. Reinforce that these
medications should not be stopped abruptly.

• Inform the patient that other medications are available if the side effects
from the current one are too uncomfortable.

• Encourage the patient to maintain a schedule of activity.
• Explain to the family the symptoms of depression, medication management,

and interventions and what the family can do to assist and encourage the

• Teach the patient and family to report signs of increasing depression or sui-
cidal thoughts.

• Teach the patient that long-term, enduring self-esteem comes from beliefs
about self as a valuable human being and is expressed through achieve-
ments, relationships, and healthful living.

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• Inform the patient that the negative assumptions about himself or herself
are not necessarily true.

• Direct patient to American Psychiatric Association Website for “Patient and
Family Guide to Major Depressive Disorders” ( and
National Mental Health Association website for a confidential screening
test on depression (


• Document patient activity, intake, sleep patterns, and bowel patterns.
• Document any expressed suicide thoughts, plans, or attempts.
• Document side effects of medication.
• Document patient response to encouragement or support.


• Strongly encourage patient to seek counseling. Give appropriate referrals. If
patient is too depressed to have the energy to follow through, involve fam-
ily or friends in seeking help.

• If patient is unable to care for himself or herself or is potentially suicidal,
work with other members of the team as well as family to determine dis-
charge options. Patient may need psychiatric hospitalization or temporary
placement in a board and care or convalescent facility.

• Refer patient for psychiatric home health care for follow-up on medication
compliance and self-care activities.

• Encourage patient to maintain follow-up with physician and compliance
with treatment plan.

The Suicidal Patient

Learning Objectives
• Identify risk factors for suicide.
• Differentiate between a suicide attempt and a suicide gesture.
• Describe effective interventions to protect the high risk patient in the

• Describe common nurses’ reactions to the suicidal patient.

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Completed suicide – Suicide attempt resulting in death.
Deliberate self-harm – Willful self-inflicting of painful, injurious acts without

intent to die.
Lethality – The level of risk in suicide method chosen to cause death. The

more lethal methods include guns, jumping, and hanging. Lower lethality
methods include superficially slashing wrists, inhaling house gas, and
ingesting pills because death is not immediate and there is more of a
chance of being found and treated.

Psychological autopsy – Retrospective review of deceased person’s life to
establish likely diagnosis at time of death.

Suicidal ideation – Thoughts about harming one’s self.
Suicide – Self-inflicted death with evidence that person intended to die.
Suicide attempt – Any act intended to end in suicide.
Suicide gesture – Any action that appears to be a suicide attempt but that is

actually contrived or manipulative and that results in only minimal harm,
such as superficial cuts on the wrist or a small overdose of sleeping pills.

Suicide threat – Verbal threat to commit suicide.

Some nurses mistakenly believe suicidal patients are found only in psychiatric
settings. However, patients with suicidal tendencies are not always easily iden-

tified, and they can be the same patients you care for in an intensive care unit,
medical unit, nursing home, or in their own homes.

Many people have experienced momentary self-destructive thoughts. But
obsessive preoccupation with these thoughts and acting on them is another mat-
ter. Thinking about suicide does not mean that the individual will act on those
thoughts; however, anyone who talks about, threatens, or attempts suicide must
be taken seriously. There are individuals who may perform deliberate self-harm
when they inflict injury on themselves without intent of death. These individuals
often are not suicidal, but a psychiatric evaluation would need to be done to
determine this. In approximately 70% of suicides, the individual has one or more
active or chronic medical illnesses at the time of death (DHHS, 1993). See Table
9–1 for key risk factors. 90% of suicide victims suffer from at least one psychi-
atric disorder. Major depressive disorder is most common. Others include bipo-
lar disorder, schizophrenia, substance abuse, panic disorder, borderline and
antisocial personality.

There are approximately seven suicide attempts for every completed suicide.
All cultural groups are vulnerable although American Indians have a higher rate.
Women make more attempts than men, but men are more likely to complete the
suicide because they tend to use more lethal methods, particularly firearms
(CDC/National Center for Health Statistics, 2004). Firearms are the leading form
of suicide followed by suffocation and poisoning (CDC, 2004). Three factors that
need to be present for a completed suicide include:

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• Specific plan,
• Lethality, and
• Access to lethal method.

Suicide is the 11th leading cause of death in the United States and there are
about 89 suicides per day (American Association of Suicidology, 2004). However,
it may be higher because hidden suicides such as “accidental” overdoses, auto
accidents, noncompliance with medical regimens, or not seeking medical care for
symptoms are not reported as suicides. Most suicide attempts are expressions of
extreme distress, not bids for attention (Captain, 2006).

Because suicide is basically not accepted by our culture, it generates anxiety
that has led to a number of myths (Box 9–4).

Chapter 9 ■ Problems with Affect and Mood 115

BOX 9–4
Clearing up the Myths About Suicide
Asking people about their
suicidal thoughts will make
them more likely to act on
All people who attempt sui-
cide have a psychiatric dis-
A person who talks about
suicide won’t do it.

A person who attempts sui-
cide won’t try again.

People who attempt suicide
are always determined to die.
People who attempt suicide
just want attention.
As the person becomes less
depressed, the risk of suicide

Most patients are not afraid to talk about their
thoughts of committing suicide and are usually
grateful that someone is available and cares.
Talking can reduce the sense of isolation.
People can become overwhelmed with life
circumstances without having a psychiatric
Approximately 80% of individuals who
attempt or complete suicide give some definite
verbal or indirect clues. As many as 50% have
seen their physician within the previous
month, often with vague somatic complaints.
Almost 75% of those individuals who com-
plete suicide have attempted it at least once
Many individuals are ambivalent and are
using the suicide as a cry for help.
Even if the suicide attempt is manipulative, the
individual may go on to complete the suicide.
As the depression lifts, the individual’s energy
level can increase before feelings of hopeless-
ness are relieved. Once the individual makes
the decision that suicide is an effective solu-
tion to the problems, his or her mood may
even elevate.

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It is estimated that each person who commits suicide leaves behind at least six
survivors who suffer many emotional complications. The American Association
of Suicidology (2007) notes that survivors have a higher risk of suicide them-
selves. Surviving family and friends of the suicide victim often experience com-
plicated grief reactions that may affect them for the rest of their lives. They are
faced with the stigma of this form of death as well as many unresolved feelings
of anger and guilt. Unfortunately, they may receive less support from others
because of the discomfort surrounding the cause of death. In addition, many life
insurance policies do not cover self-inflicted death, so the surviving family may
be economically devastated.


Suicide is not a disease in itself but a symptom of some underlying problem. Bio-
logical and genetic theories are closely tied to those causing depression. It is
believed that low levels of the neurotransmitters, serotonin and norepinephrine,
are a factor in the decision to commit suicide. There is also a strong link to alco-
hol and substance abuse. Suicidal behavior also runs in families. This may be
related to genetics or to psychological factors in which suicide is viewed as an
acceptable way to cope. The risk of suicide in family members of individuals who
have committed suicide is 15 times greater than in the general population. Cap-
tain (2006) reports that psychological autopsies reveal that in 90% of completed
suicides, the person had one or more mental disorders with the most common
being major depression and substance abuse.

Psychological theory focuses on a number of motivating forces. Suicide can be
a way to escape deep psychological pain or atone for past sins. Intense feelings of
hopelessness and helplessness are key factors. It can be related to unacceptable
feelings of aggression, which the individual turns inward. The individual could
believe that he or she is reuniting with a loved one. The wish to instill guilt in a
significant person who is perceived as abandoning or rejecting could motivate the
suicidal person. Individuals with limited coping reserves who become over-
whelmed with stress may seek self-destructive acts as a way to escape these feel-
ings. Because the suicidal person may be severely depressed, the theories on
etiology of depression and substance abuse may also relate to suicide.

Suicidal behavior can also be a symptom of psychosis as the person acts out
hallucinations or delusions. Command hallucinations, in which voices tell the
patient to kill himself or herself, create a very high risk. Severe anxiety and dis-
tress regarding psychotic symptoms as well as lack of judgment or reality testing
may lead to suicide as a way to escape overwhelming anxiety or disturbed

Suicidal gestures with nonlethal self-mutilation may occur in individuals who
have poor impulse control or a high need for the attention or control of others.
An individual with a history of multiple threats and gestures may have a border-
line or other personality disorder.

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Sociological views look at a person who may feel alienated from others. A sus-
ceptible individual who no longer feels part of his or her culture or social group
could be at an increased risk, especially if cultural or religious taboos against sui-
cide are not very strong. For some, suicide is a way of expressing political beliefs.
Economic losses or unemployment could also play a role as a person feels trapped
and powerless to change. Suicide is an increasing problem in minority and eco-
nomically deprived groups. It can also be associated with substance abuse. A psy-
chological autopsy can be used by the psychiatry team and survivors after a
completed suicide to try to understand the etiology. See Box 9–5 for Risk Factors
and Protective Factors that may help to estimate suicide risk.


Physical illness is a frequent contributor to suicidal behavior. Illnesses associated
with suffering and dependency, such as advanced cancer and AIDS, are more apt
to be associated with higher suicide rates. Uncontrolled pain and delirium are the
key variables with these illnesses. The terminally ill patient’s “right” to commit
suicide has been debated for many years. Right-to-die groups have supported

Chapter 9 ■ Problems with Affect and Mood 117

BOX 9–5
Risk and Protective Factors
Risk Factors for Increased

Risk of Suicide
Psychiatric diagnosis
Physical illness
Psychosocial factors including
recent lack of social support, unem-
ployment, recent stressful event
Childhood traumas such as sexual
Family history of suicide, mental
Psychological characteristics includ-
ing hopelessness, anxiety, impul-
siveness, aggression
Demographics including male,
widowed/divorced/single, elderly

Factors Associated with Protective
Effects for Suicide

Children at home
Sense of responsibility to family


Life Satisfaction

Positive coping skills

Positive social support

Positive problem solving skills

Source: Jacobs, D. G., Baldessarini, R. J., Conwell, Y., Fawcett, J. A., Horton, L., Meltzer, H., et al.
(2003). Practice guideline for the assessment and treatment of patients with suicidal behaviors.
Washington, DC: American Psychiatric Association.

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initiatives in several states seeking physician-assisted suicide for terminal patients.
The patient’s ability to remain in control until death is a key motivation for this
action. Other illnesses, such as multiple sclerosis and Huntington’s disease, that
may not be terminal but are chronic and debilitating may also be associated with
increased suicide risk. Suicidal patients with physical illnesses should be carefully
evaluated and treated for depression. In addition, every effort to identify and con-
trol any uncomfortable symptoms will enhance quality of life.

Medications that contribute to depressive or psychotic symptoms could also
precipitate a suicide attempt. See Box 9–2 and Box 11–4 for lists of medications
that contribute to these symptoms. Patients with suicidal tendencies who are tak-
ing prescribed analgesics, tranquilizers, or sleeping pills may be at risk for saving
up medications to use later for a possible suicide attempt.


Although the rate of suicide in children is low, it is rising and is cause for great
concern and analysis. Young children have tried to kill themselves by jumping out
of windows, hanging themselves, or running in front of moving cars. Firearms
and suffocation are also common methods in the 10- to 14-year-old age group.
These actions are generally impulsive and in response to intense emotion. A
suicidal act may be an attempt to gain power, punish a parent, or escape
stressful situations. It could also be a response to parental neglect, rejection, or
abuse. A young child who does not understand the finality of death may not
understand the consequences of his or her action. Children could also be imitat-
ing parental behaviors. Suicidal behavior can also be related to substance abuse
and school problems. Suicide is the 3rd leading cause of death in 10- to 19-year-
olds (CDC, 2004).

Suicidal behavior in adolescents is considered a serious health problem. It is the
second leading cause of death in teens, accidents being the first. And some acci-
dents could be concealed suicide attempts. Teens who are depressed, socially iso-
lated, or using drugs and alcohol are at highest risk. Low self-esteem, history of
abuse, not fitting in with peers, and school pressures may be other risk factors.
As with adults, girls make more attempts but boys are more likely to use more
lethal methods such as firearms. The availability of firearms in our society is
believed to contribute to the increase in teenage suicides. Carbon monoxide poi-
soning and ingestion of pills are other common methods used by adolescents.
High-risk behaviors like drug use, drag racing, and gang activity could be mask-
ing suicidal thoughts. Substance abuse, psychiatric disorders, and conduct disor-
ders are risk factors in this age group. Suicide assessment should be performed on
any high-risk teen.

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“Cluster” or copycat suicides, in which adolescents copy an episode of suicide
of an acquaintance or celebrity, is a recent and alarming trend. To some teens the
suicide of an idol can be romanticized.

Older Adults
Elderly people commit suicide more often than any other age group in the United
States (Jacobs et al., 2003). Elderly white men older than 80 years of age are
at highest risk (Moscicki, 1999). Guns remain the most frequent method. Suicide
statistics in elderly persons are probably even higher because of the prevalence
of passive suicides. Elderly people are more likely to use noncompliance with
medical regimens or refusal to eat as a way to hasten their death. Risk factors
include living alone, widowhood, lack of financial resources, poor health, and
social isolation. In addition, misuse of alcohol and antianxiety medications may

Chapter 9 ■ Problems with Affect and Mood 119


See Boxes 9–6 and 9–7 for suicide assessment of lethality and assessing a suicide

• May see a suicidal patient as weak or bad because of personal religious or

moral beliefs.
• May experience feelings of anxiety with these patients, which prevent

recognition of warning signs.
• May avoid dealing with suicidal patients for fear of saying the wrong thing

or contributing to their suicide because of lack of adequate training. May
believe talking to patient about suicide would increase risk.

• May believe he or she is rescuing patient and then experience intense guilt
if patient does attempt or complete suicide. May take patient’s behavior as
a personal rejection.

• May feel angry with patient for creating chaos, especially if the nurse per-
ceives that the patient has much to live for, such as children and a good job.
The nurse’s anger may conflict with his or her mission of promoting health
and saving lives.

• May deny or minimize suicidal behavior as a defense against anxiety and

• Patient’s behavior could stir up personal feelings of depression. Nurses have
six times the suicide rate of the general population and much higher lethal-
ity because of their knowledge and access to drugs.

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120 Chapter 9 ■ Problems with Affect and Mood

BOX 9–6
Assessing Current Suicide Lethality
1. Do you think about hurting or killing yourself? If yes:
2. Do you have a plan? How have you considered doing it? If yes:
3. Do you think you may or will do something to act on your thoughts?

If yes, where and when? Do you feel you have control over your own

4. Do you have the means available (such as rope, rolled-up sheet, gun, saved-
up pills [note lethality of plan])?

5. Have you ever tried to harm yourself in the past? If yes, how? Did you
expect to survive?

6. Are you willing to contract or notify staff whenever you feel you may act
on these thoughts? Our side of the contract is to be available and actively
help you during these times.

If patient denies having a suicide plan, ask about other plans for the future
and support systems.

1. What do you see yourself doing in a week, in a month, and in a year from

2. Do you feel optimistic or pessimistic about the future?
3. Do you have family members or friends with whom you can freely discuss

your problems?

BOX 9–7
Assessing the Suicide Attempt
1. Did the patient expect to die? (yes, no, uncertain). Did the patient think his

or her chance of dying was high, medium, or low? Did he or she underes-

2. How does the patient feel about surviving? If the patient regrets surviving,
question him or her about any current plan to attempt suicide.

3. If the patient’s objective in suicide attempt or gesture was to manipulate a
significant other to behave differently, have the sought-after changes
occurred? Does the patient have alternative, more adaptive methods for

4. Is the support system present (helpful, unhelpful)?
5. Does the patient have any hope for the future? How optimistic or pes-

simistic is he or she?
6. Is the patient willing to make a no-suicide contract?

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Behavior and Appearance
• Direct verbal statements (e.g., “I wish I were dead”)
• Indirect verbal statements (e.g., “You won’t see me when you come back to

work” or asking about specific suicide methods)
• Giving away possessions
• Agitation
• Sudden changes in eating, sleeping, or usual activities
• Neglecting appearance or hygiene
• Drawing up a will
• Refusing medications

Mood and Emotions
• Depression or despair
• Sudden lifting of depression, sudden elevation in mood
• Apathy
• Hopelessness
• Helplessness
• Anxiety
• Bitter anger

Thoughts, Beliefs, and Perceptions
• Disorganized, chaotic, irrational thinking
• Tunnel vision—unable to see options other than death
• Poor judgment
• Persecutory delusions and hallucinations, especially commands
• Excessive guilt or self-blame
• Low self-esteem

Relationships and Interactions
• Social isolation; withdrawn; feels alone and abandoned
• Recent loss of significant person through death or separation
• Recent tumultuous termination or interruption of psychiatric treatment

Physical Responses
• Chronic debilitating illness
• Unrelieved pain
• Terminal illness
• Recent, catastrophic loss of physical abilities

Chapter 9 ■ Problems with Affect and Mood 121

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Pertinent History
• History of suicide attempts
• Self-destructive behavior, such as drug abuse, reckless acts, or self-mutilation
• Family history of suicide attempts or depression
• Psychiatric illness
• Recent significant loss


Suicidal patients may benefit from taking antianxiety medication, such as
lorazepam, to reduce feelings of intense anxiety or distress. In addition, antipsy-
chotic and antimanic medication may be prescribed as needed. If antidepressants
are being started, it is important to remember that it will take a number of weeks
to lift depression, so other interventions must be used in the interim to prevent
suicide. Antidepressants could actually increase suicide risk if the patient gets a
sudden burst of energy to act out the plan before the depression lifts. Overdos-
ing on antidepressants is an increasingly frequent method of suicide. However,
untreated depression puts the patient at greater risk so antidepressants are seen
as protection against suicidality (APA, 2006).

Adequate symptom management for pain and other distressing symptoms
must be provided to the patient with a serious or terminal illness. A patient’s
belief that his or her symptoms cannot be controlled could be a contributing fac-
tor in hopelessness and suicide.

Patients at high risk for suicide may need to have medications administered in
liquid or parenteral form to avoid “cheeking” and hoarding pills. Outpatients
should be given only a few days’ supply of any medication that could potentially
be used in a suicide attempt.


RISK FOR VIOLENCE TO SELF evidenced by suicide attempts. self-mutila-
tion, suicide plan related to suicide ideation, poor impulse control, depression.

Patient Outcomes
• Remains free from injury
• Verbalizes intent not to harm self
• Expresses more optimistic view of future in specific terms

• Determine if patient has a plan and how potentially lethal and available

that plan is (see Box 9–3). A patient in the hospital who talks about using

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a gun to kill himself or herself would be at lower risk (until discharge) as
long as he or she does not have a gun available. A patient who has a stash
of medication would be at higher risk. Seek input from other profession-
als to participate in this assessment. If your agency has mental health pro-
fessionals on staff, it is essential to involve them in the assessment. See
high risk interventions in subsequent text.

• Make a thorough assessment of patient’s risk of suicide (see Table 9–1).
Note: research is being conducted to develop assessment rating scales to
better predict suicide potential.

Chapter 9 ■ Problems with Affect and Mood 123

Suicide: Intensity of Risk

Intensity of Risk

Behaviors or
Symptoms Low Moderate High



Isolation or

Daily functioning


Coping strategies
being used

Significant others

Previous psy-
chiatric help


Alcohol or
drug use



Some feelings of
isolation; no

Fairly good in
most activities


Generally con-

Several available

None, or positive
attitude toward


Infrequently to



Some feelings of
hopelessness, or

Moderately good
in some activities


Some are construc-

Few or only one

Yes, and moder-
ately satisfied
with the help

Moderately stable

Frequently to

High or panic


helpless, with-
drawn, self-

Not good in
any activities

Few or none


Only one or
none available

Negative view
of help


Continual use


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• Talk openly with patient about your concern that he or she is suicidal.
Let the patient know you are concerned and available to help and that
confidentiality is shared among the entire health-care team for optimum
care. Encouraging the patient to talk about this does not increase risk for
suicide. Do not promise to keep secrets from the team. Notify all mem-
bers of the health-care team of the patient’s risk of suicide. Staff members
must be supportive, empathetic, and familiar with treatment plan.

• If the patient has attempted suicide, see Box 9–7.
• Talk to patient about making a no-suicide contract with you. Ask him or

her to wait or postpone action so that you and other professionals have
time to help. Point out that depression is not permanent (with time, med-
ication, and therapy there is hope for a change) but that death is perma-
nent and cuts off other options. Renew the contract each shift and as
needed between patient and main caregiver.

• Never attempt to work with a suicidal patient by yourself. Involve all
members of the team. Seek additional resources such as social workers;
notify supervisory staff.

124 Chapter 9 ■ Problems with Affect and Mood

Suicide: Intensity of Risk—cont’d

Intensity of Risk

Behaviors or
Symptoms Low Moderate High

Previous suicide

Disorientation or



Suicide plan

Source: Adapted with permission from Hatton C. & Valente S. (1984). Suicide: assessment and interventions.
Norwalk, CT: Appleton-Century-Crofts.

None or low


Some feelings

Little or none

Vague fleeting
thoughts but no

One or more; mod-
erate lethality


Some feelings


Frequent thoughts;
occasional ideas
about a plan

attempts; high


Negative view
of self


Frequent or
thought with
a specific plan

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For patients assessed to be at high risk for suicide:
• Follow agency policy for need for continuous supervision. Discourage

use of family for this purpose.
• If patient is in the hospital, arrange for a room close to the nurses’ sta-

tion or in an ICU for closer monitoring.
• Avoid checking on patient at predictable intervals; check more frequently

during danger times (changes of shift) when patient may think staff will
be preoccupied.

• Remove objects with self-harm potential (such as glasses, razors, belts, or
lighters) from the room. Be aware of agency policy regarding need to
search personal belongings or do a body search.

• Make sure windows cannot be opened.
• If all other interventions have been ineffective, use physical restraints for

brief periods to prevent patient self-harm.
• Make sure family and friends are not bringing in potentially dangerous

items such as medications, alcohol, or razors.
• When patient is sleeping, ensure both hands in view.
• Meal trays should have no glass or metal silverware
• Obtain Recommendations from American Association of Suicidology for

Inpatient and Residential Patients Known to be at Elevated Risk for Sui-
cide for inpatient settings.

• Arrange (per physician) to transfer the suicidal patient to a psychiatric
unit as soon as medically stable.

• If patient is not hospitalized, make sure family and friends are aware of
the possible suicide risk. The patient probably should not be left alone.
Give him or her a list of resources such as hotlines, therapists’ phone
numbers, or support people he or she can call. Call MD/Psychiatric
Assessment Team if you believe the patient is still at risk of suicide.

HOPELESSNESS evidenced by expectations that there will be no improve-
ment in situation related to depression: overwhelmed by life circumstances.

Patient Outcomes
• Verbalizes more optimistic expectations for the future
• Initiates realistic plans for the immediate future
• Demonstrates initiative in decision making

• Recognize that extreme hopelessness is a strong indicator of suicide;

assess thoroughly.
• Listen to patient’s concerns and issues. Convey empathy to promote ver-

balizing about doubts and fears. Reflect back patient’s despair without

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agreeing with it. For instance, you might say “You describe a world that
seems empty to you.”

• Encourage patient to discuss recent events or stresses that have con-
tributed to the hopeless view. Offer alternative analysis viewing the event
without arguing or minimizing patient’s concerns. Minimizing or joking
about the patient’s feelings will increase the patient’s sense of isolation
and lack of trust.

• Emphasize the patient’s strengths and problem-solving abilities. Describe
a recent situation in which you observed the patient being successful.
Have him or her describe a past success. Point out obstacles or negative
thinking that get in the way of effective problem solving.

• Provide a balanced point of view to counteract patient’s tendency to judge
himself or herself harshly. Point out unrealistic, perfectionistic thinking.
Offer more constructive interpretations to open real options for the future.

• Acknowledge that you understand that the patient feels that everything
is useless and nothing will help, but also that you believe something help-
ful can be done.

INEFFECTIVE COPING evidenced by repeated suicide threats/gestures,
related to stunted areas of personality development with intermittent self-
destructive impulses.

Patient Outcomes
• Decrease in self-destructive behaviors
• Demonstrates more adaptive means of communicating thoughts, feelings,

and needs

• Determine if self-destructive behavior is a pattern.
• Remain calm and neutral; treat patient’s suicide threats and gestures in

matter-of-fact manner. Treat any physical injury without excessive emo-
tion. Avoid creating a sense of alarm about the patient’s behavior. Cau-
tion: Do not dismiss any threat or gesture as manipulative or not serious.
Any self-destructive threat or gesture should be taken seriously and not

• Ask the patient to identify any disturbing thoughts or feelings that
occurred just before the threat or action. Encourage him or her to put
thoughts and feelings into words rather than acting them out impulsively
and destructively. Teach that anger can hide more painful feelings such as
sadness and rejection.

• Teach alternate coping: talking, relaxation, distraction, exercise, music,
and so forth.

• Confront the patient who wants to commit suicide for revenge and retal-
iation. These patients may state, “They’ll be sorry when I’m dead.”

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Remind patient this is not a solution because he or she won’t be there to
see the results.

• Encourage the patient to alert staff members if feeling out of control or
when having thoughts of self-harm. Consider discussing a no-suicide con-
tract and including guidelines for behavior.

• Establish limits with patient on amount of time staff will spend listening
to patient’s concerns. Set limits on the patient’s use of verbal abuse and

• Review with the patient possible causes for self-destructive behavior that
could include an attempt to get others to assume responsibility for
patient’s life. The patient needs to be encouraged to take more self-
responsibility. See Chapter 12, The Manipulative Patient, for additional


Grieving, Dysfunctional
Self-Concept, Disturbed
Self-Mutilation, Risk for
Spiritual Distress (Distress of the Human Spirit)
Thought Processes, Disturbed

Chapter 9 ■ Problems with Affect and Mood 127


• Self-mutilation
• Suicide threats or attempts
• Access to highly lethal methods such as firearms, car in an enclosed

space, or sleeping pills in a high-risk patient
• Hallucinations or delusions
• Lack of staff members available to manage suicidal patient
• Increasing staff anxiety and fear over patient’s behavior


• Security
• Psychiatric Team
• Law Enforcement
• Manager
• Critical Incident Team

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• Teach patient that his or her view of the options available becomes nar-
rowed when he or she is depressed or suicidal. Review alternative ways of
viewing problems. Incorporate family into this education.

• Encourage patient and family to obtain educational material including
Understanding and Helping Suicidal Persons and Surviving after Suicide

• Review with the patient the idea that he or she needs to reach out to others
for support and assistance. Teach the patient to reach out immediately when
feeling the urge for self-harm.

• Encourage the patient to report and seek out adequate treatment for uncom-
fortable symptoms of physical illness, possibly including analgesics, to
reduce suffering.

• Teach alternative outlets for anger rather than self-destructive ones. (See
Coping Interventions.)

• Make sure that patient and family understand the purpose of close obser-
vation by staff members if patient is actively suicidal.

• Make sure that the family knows signs of increasing suicide risk and inter-

• If a patient does commit suicide, prepare the family for the complex grief
reaction that may follow (Box 9–8).


• Document all behaviors that could be considered a suicide thought, threat,
or action, and who was notified about them.

• Note patient’s response to suicide assessment.
• Document all measures in place to prevent suicide.

128 Chapter 9 ■ Problems with Affect and Mood

BOX 9–8
Information for Survivors of Suicide
• Recognize that their grief may have an added burden of guilt, shame, and

• Sharing their grief with others about the cause of death will put the tragedy

out in the open and provide added support.
• Recognize that factors contributing to the suicide may be out of the family’s

• Provide information on dynamics of suicide.
• Encourage attendance at bereavement support groups specific for survivors

of suicide.

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• Document patient’s response to a no-suicide contract and teaching.
• Document any information from others on availability of potential methods

for suicide available to the patient and interventions to protect patient.


• Make sure that patient and family have information on referrals for follow-
up counseling. They should also have emergency numbers such as suicide
hotlines. Provide written information and education.

• Determine if psychiatric evaluation needs to be made before the patient
leaves the agency/institution.

• Determine the appropriate quantities of prescribed medications to send
home with the patient.

• Refer for home health follow-up and make sure that the agency is aware of
the patient’s suicide risk. Refer for psychiatric home care if available.

• If patient is a high suicide risk, transfer to a psychiatric hospital as soon as

The Grieving Patient

Learning Objectives
• Describe the variables that contribute to the intensity of the grief

• Describe some common behavioral responses to grief in children.
• Identify dysfunctional grief reactions.
• Describe effective nursing interventions to assist the grieving family.
• Describe common nursing staff reactions to the grieving patient.

Absent grief – In an effort to avoid aspects of the loss and avoid relinquish-

ing the lost object, no grief is experienced.
Anticipatory grief – Grief response before and in preparation for a significant

actual or potential loss.
Bereavement – State of having suffered a loss.
Delayed grief – The absence of grief behavior when it would be normally


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Disenfranchised grief – Loss that cannot be acknowledged or publicly

Distorted grief – Abnormal extension or overelaboration of grief behavior.
Dysfunctional or complicated grief – Grief reaction that does not follow the

usual pattern and may include delayed and/or distorted grief.
Grief – Subjective, emotional response to a loss.
Loss – Situation, real or potential, in which a valued object is rendered inac-

cessible or is altered in such a way that it no longer has the valued qualities.
Mourning – The process by which grief is resolved.
Prolonged grief – Continued grief behavior lasting much longer than would

be expected.

Experiencing loss is a normal part of life. Friends moving away, loss of a job,
loss of functional abilities or physical health, or the death of a loved one are

something we all experience.
Grief is the normal human response that usually follows these experiences. As

things change in our lives, we must adapt. This process of adaptation is called
grieving. The purpose of grief is to begin to face the loss, work through the emo-
tions, and eventually let go or adapt with renewed energy to focus on new rela-
tionships and goals. Because all individuals respond to loss differently, the
process of adapting varies widely and can take days, months, or years depending
on many variables. Grief does not decline in a linear, predictable fashion over
time. Rather, it can fluctuate over time and be affected by many factors. Variables
that can influence the sense of loss include:

• The meaning of the lost object to the person (Generally, the more important
the loss is to the person, the more intense the reaction.)

• The degree of preparation and past unresolved losses
• Physical health
• The degree of conflict or dependency in the relationship
• Support system
• Concurrent stressors

Culture also influences the way an individual responds to loss. Most cultures
have specific rituals and traditions that provide support and reassurance during
the grieving process. Grief caused by a death can be influenced by the cause of
death. Unexpected deaths, deaths viewed as preventable, and the death of a child
all create additional distress. Death resulting from a cause with a social stigma,
such as suicide or AIDS, can be particularly difficult. With suicide, death is unex-
pected, violent, and possibly preventable. Survivors may experience intense anger,
guilt, and self-blame. Those who lose a loved one from AIDS may have had time
to prepare for the death, but many complicated feelings may still need to be
resolved before grieving can be accomplished. Society’s reactions to deaths caused
by problems such as these may affect the type of support the mourners receive.

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There is no one comprehensive theory that explains normal grief. Research has
shown that grief occurs in a sequence of phases or stages with predictable symp-
toms that change over time, and that these stages do not necessarily progress in
an orderly, set fashion.

Acute grief symptoms were first described in Lindemann’s classic study of 1944
after the Coconut Grove Night Club fire in Boston. Symptoms include sighing,
sobbing, hyperventilating, and a sense of unreality or shock as the first reactions
to facing a major loss. Elisabeth Kübler-Ross (1969) and Theresa Rando (1993)
both describe stages through which individuals advance in their progression
toward resolution (Table 9–2). These stages give us guides for expected behaviors,
but each individual goes through the process in his or her own way and time.

During the initial period of shock, the mourner may experience denial or avoid-
ance as a protective mechanism from the overwhelming stress to block out the
pain. As denial and shock fade, the mourner begins to face the sadness of the loss.
In addition to depression, there may be periods of anger and guilt. Anger can be
directed at the lost person for leaving or the person responsible for the situation
(if applicable), or it can be displaced onto others. Guilt feelings, possibly evidenced
by self-reproach for real or imagined acts of negligence or omissions, can be espe-
cially painful. All of these behaviors force the individual to confront the pain over
and over again. However, not all reactions cause the individual to feel discomfort.
Some can provide comfort, such as a sense of being watched over by the lost per-
son. Maciejewski, Zhang, Block, & Prigerson’s (2007) research has validated the
model of stages of grief and noted that depression peaked at six months post loss.

The ability to tolerate intense emotions, increasing periods of stability, taking
on new roles and relationships, having the energy to invest oneself in new endeav-
ors and ability to bring meaning to one’s life (Niemeyer, 1997) are signs that the
individual is recovering. Remembering both the positives and negatives of the lost
person or object can also indicate successful completion of grieving. However,
brief periods of intense feelings may still occur at significant times, such as anniver-
saries and holidays. Because each individual is unique, the extent of a grief reac-
tion may vary. People may grieve as deeply over the loss of a pet or a longed-for
goal as over the death of a family member. Disenfranchised grief can prevent out-
ward expression of grief. This may be seen after an abortion or when the depth of
relationship of deceased person is not known publicly. In addition, the length of
time to resolution is individual, not necessarily fitting the 1-year tradition. How
long grief should go on is less related to the calendar and more to the depth of the
loss and the individual’s reaction. Also, grief may be delayed because of extreme
situations, such as multiple losses, and the mourner must deal with many respon-
sibilities before taking time to experience the loss. Grief can take a more compli-
cated or maladaptive form that interferes with the adaptation to the loss. Examples
of these include absent, delayed and distorted grief. These forms of complicated
grief often require professional intervention (Ott, 2003). These complicated forms
of grief may be related to the circumstances that do not allow the person to

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132 Chapter 9 ■ Problems with Affect and Mood

Adapting to Loss

Stage Purpose Behavior

Rando’s Stages of Adapting to Loss

Avoidance phase



Kübler-Ross’s Stages: Adapting to a Loss of Self




• Recognize the loss

• React to separation

• Recollect and re-
experience the deceased

• Relinquish old attach-
ments to deceased and old
assumptive world

• Readjust to move adap-
tively into new world
without forgetting old

• Reinvest

• Unconscious avoidance to
protect self from painful

• Attempt to take control
when feeling out of con-
trol by attacking, blaming

• Attempting to change real-
ity by making agreement,
bargains for more time

• Indicates beginning

• Acknowledge loss (intel-
lectually first, then emo-

• Experience pain of
loss—it will impact all
areas of functioning

• Make changes in one’s
life to adapt to life
without person

• Change old habits, find
new support systems

• New relationship with

• Form new identity
• Emotional energy into

new things

• “No, not me.”

• Lack of expected reac-
tion; using unproved
treatment methods; doc-
tor shopping to avoid
confronting diagnosis

• “Why me?”

• Irrational demands; crit-
icizing staff; hostile

09 Gorman(F)-09 11/5/07 4:59 PM Page 132

complete the grieving process for some reason. With a long illness, anticipatory (or
preventative) grief may prepare the person for the future loss (Rando, 2000).


The physical stress of grief can place the mourner at risk for health problems
(Stroehe & Schut, 2001). Lack of sleep, poor eating, and changes in routine can
predispose the individual to illness. Loss of a spouse in elderly people is associ-
ated with higher morbidity and mortality rates. Two months after a death,
bereaved elderly persons report more illness, greater use of medications, and poor
health ratings. Major depressive disorder associated with complicated grief can
contribute to higher mortality rate, poor wound healing and immune system dys-
function (Duffy, 2005).


Often adults try to protect children by not including them in the crisis or expres-
sions of grief for other family members. However, they need to be included in the
process, based on their level of development, so that they do not feel abandoned

Chapter 9 ■ Problems with Affect and Mood 133

Stage Purpose Behavior



Source: Adapted from Rando T. (1993). Treatment of complicated mourning. Champaign, IL: Research Press;
and Kübler-Ross, E. (1969). On death and dying. New York: MacMillan.

• Work of grief as realiza-
tion hits

• Involves despair, the pain
of experiencing loss

• Resolution of feelings
about death

• Neither happy nor sad
• Acceptance of reality, sense

of peace and letting go

• “It’s me, but …”

• “I want to live til my son’s
wedding, then I’ll accept

• Making bargains with
God to change if can have
more time, change reality

• “It’s me.”
• Sad, tearful, life review

• Comforting others to
accept impending death;
remembering the past
with fondness but without
fighting to hang on to life

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and left to face their fear and loss alone. Children generally display grief differ-
ently from adults, and it is important not to misinterpret their behaviors to mean
that they are not grieving or that they are unaware of what is happening. Chil-
dren often use symbolic or nonverbal language to communicate their awareness
of loss and may even feel ashamed of their loss because they feel differently from
their peers. Because they may also need more time to really assimilate what has
happened, grief reactions may be delayed (Table 9–3).

Children’s initial reaction to death is often shock and sadness but can quickly
return to seemingly inappropriate laughter or activity. But their suffering may
continue under a different guise (Brown-Saltzman, 2006).

134 Chapter 9 ■ Problems with Affect and Mood

Children’s Understanding of Death

Common Behaviors in
Age Understanding of Death Response to Death

Infant to

3–5 years

School age


• Unable to comprehend death
• Fears separation and aban-


• Views illness as punishment
for real or imagined wrong-

• May view death as sleep;
cannot comprehend death

• Magical thinking; may think
they caused the event by
their thoughts or actions

• Associates death with pun-
ishment multilation, violence

• May feel responsible for

• By age 9, understands that
death is final

• Understands own

• May seem to have adult
view of death but not emo-
tional view

• Frightened, difficulty sep-

• Sadness
• Clinging to parent

• Nightmares, sleep disrup-

• Regression in toilet habits
• Complaints of stom-

achache and headaches
• Temper tantrums

• School phobia, dimin-
ished school performance

• Aggressive behavior

• Preoccupation with par-
ent’s health

• Loss of appetite
• Change in relationship

with friends

• Acting out; substance

• Increased time with peers
• Withdrawal from family
• Depression

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As they struggle with dependency issues, the adolescent may feel vulnerable to
express feelings of grief. They may appear to deny or avoid the dying patient, act
out their frustration in such ways as school truancy, substance abuse. This may
be very distressing to other family members who may view the teen as uncaring.

Older Adults
Elderly people face multiple changes, often including the loss of a spouse, friends,
job, financial status, health, and mobility. In spite of the extent of these losses,
most elderly persons seem able to adapt, probably because of their past experi-
ence. However, the death of a spouse or partner still remains one of the major
losses in life. This loss requires multiple life changes that become more difficult
with increasing age. Grief can be masked by symptoms of dementia, depression,
suicidal ideation, and substance abuse. Brown-Saltzman (2006) notes that the
older adults may suffer disenfranchised grief as they experience multiple losses
which others may consider normal for this age.

Chapter 9 ■ Problems with Affect and Mood 135

• May feel helpless and uncomfortable, not knowing what to say. This could

lead to avoidance or inappropriate hopefulness.
• May fear saying the wrong thing that will cause the patient or family to feel

more pain.
• May fear losing control of emotions, crying.
• May make judgments regarding the degree of intensity of grief behavior,

such as thinking that a family is “not upset enough” or too upset for a dying
95-year-old parent.

• May feel guilty for “causing” client to cry when discussing the loss.
• May become detached from the situation and attempt to minimize the loss

to the patient with phrases like “This was for the best” or “At least you can
have more children.”

• May expect all people to experience the stages of grief in the same way.
• May relive past and unresolved personal losses, causing intense emotions.


Behavior and Appearance

• Crying, agitation
• Extreme change from usual behavior patterns
• Unable to concentrate, distractible
• Taking on behavior traits of lost person
• No apparent reaction when one would be expected
• Unkempt, not caring for self

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Mood and Emotions
• Shock, numbness
• Depression (Table 9–4)
• Anxiety, panic

136 Chapter 9 ■ Problems with Affect and Mood

Differentiating Grief From Depression

Uncomplicated Grief Major Depression



Sleep patterns







Source: Adapted from Ferszt, G. G. (2006). How to distinguish between grief and depression? Nursing, 36,
60–61; Brown-Saltzman, K. (2006). Transforming the grief experience. In R. M. Carroll-Johnson, L. M. Gor-
man, N. J. Bush (Eds.), Psychosocial nursing care along the cancer continuum (2nd ed) (pp. 293–314). Pitts-
burgh, PA: Oncology Nursing Press.

• Labile
• Heightened when thinking

of loss

• Variable, shifts from shar-
ing pain to being alone

• Variable restriction of

• Periodic episodes of
inability to sleep

• Often expressed

• Varying periods

• Preoccupied with loss
• Self-esteem not as affected

• Generally no history of

• Responds to warmth and

• Recognizable, current

• Mood consistently low
• Prolonged, severe symp-

toms lasting more than
2 months

• Completely withdrawn
or fear of being alone

• Persistent restriction of

• Wakes early morning

• Turned inward

• Consistently sad

• Focused on self
• Feels worthless; has

negative self-image

• History of depression or
other psychiatric illness

• Hopelessness
• Limited response to

• Avoids socializing

• Often not related to an
identified loss

09 Gorman(F)-09 11/5/07 4:59 PM Page 136

• Mood swings
• No obvious emotional reaction or one that is inappropriate to situation
• Anger
• Guilt, remorse
• Relief that ordeal is over

Thoughts, Beliefs, and Perceptions
• Self-blame
• Idealizing lost person
• Remembering only positive aspects of lost person
• Ruminating over events leading to the loss
• Obsession with lost person
• Illusory phenomena in which mourner thinks lost person is present
• Preoccupied with thoughts that can bring only pain
• Imagining that lost person is watching over mourner
• Difficulty making decisions

Relationships and Interactions
• Seeking support from others, may become more dependent
• Fear of being alone
• Unable to participate in conversation because of preoccupation with loss
• Feeling that others do not understand the pain (“How can they have a good

time when I hurt so much?”)
• Projection of anger onto others

Physical Responses
• Initial symptoms that may include hyperventilating, sighing, sobbing, mus-

cle tension, chest pain, fainting
• Gastrointestinal distress
• Loss of appetite
• Change in bowel habits
• Insomnia, constant fatigue
• Dehydration

Pertinent History
• Unresolved or multiple past losses
• Ambivalent relationship with lost person
• History of psychiatric disorder or substance abuse
• Tendency to isolate self

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Sedatives and tranquilizers are often used in the early stages of grief to reduce the
impact of the intense emotions and promote rest and sleep. However, these med-
ications suppress the intense emotions and interfere with the purpose of the grief
process. Antidepressants may be useful, along with psychotherapy, when depres-
sive symptoms are prolonged.

As people face loss and grief, they may be more likely to reach out for spiritual
support. They may question their beliefs, talk about an afterlife, and face past
wrongdoing. Allow the patient to express feelings and, as needed, seek out clergy
available within the agency or ask the patient’s or family’s own clergy to assist.
Churches and temples may also offer special support programs. If the patient
requests, provide information on important religious rituals such as the Sacra-
ment of the Sick and prayer, and provide religious articles such as Bibles, prayer
books, medals, rosaries, candles, and special clothing. Clergy may also provide
important support for staff members who may be struggling with helping patient
or family with spiritual issues.


GRIEVING evidenced by denial, anger, depression, sorrow related to signifi-
cant personal loss (actual or potential) including change in relationship, unex-
pected outcome, illness, death.

Patient Outcomes
• Acknowledges loss
• Expresses concerns, feelings of grief
• Verbalizes feeling of being supported in the grieving process
• Identifies potential coping mechanisms, support systems

• Accept all grieving behavior. Recognize that responses to grief are highly

• Provide private environment for person to acknowledge loss and express

• Recognize your role as listener. Providing an accepting, supportive envi-

ronment to share feelings is extremely important. Recognize that words
are often less important than just being present at these times.

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• Support grief rituals used by individual from his or her culture. These can
provide reassurance and comfort to the bereaved.

• Accept feelings, tolerate mourner’s expressions of extreme emotions such
as sobbing, wailing.

• Provide privacy for the mourner.

• Recognize that it is not only acceptable but preferable to talk about the
loss and express feelings. Not talking or not expressing feelings is a
greater concern.

• If you are helping someone who just heard about the death or other loss,
provide needed information such as mortuary, support groups in small
amounts. Information may need to be repeated several times. Focus assis-
tant on helping to get other family members or friends to assist so that
mourner will not be alone. Assist with making phone calls. Provide con-
crete written information whenever possible.

• Seek assistance from colleagues if possible. Dealing with acute grief can
be very draining.

• Use touch; holding the mourner can be very supportive. Recognize that
waves of emotions will come and go. Be prepared for more intensity as
the person relives events leading to the death or other loss.

GRIEVING, DYSFUNCTIONAL evidenced by inhibition, suppression,
absence, prolongation, or distorted grief reactions related to significant loss,
multiple losses, unresolved guilt, lack of support system, difficulty expressing

Patient Outcomes
• Acknowledges the loss
• Demonstrates absence of abnormal, prolonged, excessive reactions to

• Resumes or develops social relationship.
• Expresses feelings expected with the loss

• Recognize that the individual needs to confront the loss slowly and

accept it into his or her reality at the individual’s own pace. Part of this
process will include talking about the loss, reliving memories, talking
about events leading to the loss, and expressing feelings.

• Use supportive phrases such as “It must be hard for you now” or “I’m so
sorry to hear of your loss.” These phrases acknowledge the loss and
encourage the person to tell his or her story. Avoid phrases such as “At
least you had him for 20 years.” These statements diminish the loss to the
mourner and can lead to feeling isolated and misunderstood.

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• Monitor for signs of dysfunctional grieving, including prolonged denial,
lack of emotional response, living in the past, or self-destructive behav-
ior. If the mourner exhibits these behaviors, monitor closely and talk with
him or her about your concerns. Point out feelings or reactions that the
individual might be experiencing, for example, “You might be feeling like
you’re in a dream right now” to encourage expressing feelings.

• Encourage involvement in new activities and meeting new people. Help
the person to set small goals to begin these activities very slowly, and
identify realistic expectations.

• Assist the mourner to redefine the relationship with the lost person or
object. This includes remembering the positives and negatives and
acknowledging possible angry feelings.

• If the mourner does not acknowledge the loss, bring up the subject. You
might say “I notice you never mention your deceased husband. How has
it been for you?”

• Provide spiritual support as requested. Encourage involvement of clergy.
• Recognize that patients with histories of psychiatric disorders or sub-

stance abuse may need additional support to maintain their past improve-
ments during these times.


Coping, Family: Compromised
Coping, Ineffective
Knowledge, Deficient
Self-Esteem, Disturbed
Sleep Pattern, Disturbed
Social Isolation
Spiritual Distress (Distress of the Human Spirit)


• Prepare patient and family for the normal stages of grieving.
• Inform them that anticipatory grief does not necessarily reduce the emo-

tional impact of the loss. Mourners still may expect an intense reaction.
• Tell the family the signs of dysfunctional grief and encourage them to seek

help if they begin to experience them.
• Tell the patient that feelings of anger and guilt may be normal. Encourage

seeking professional help if he or she is having difficulty resolving these

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• Encourage mourner to be very patient through this process. Time is needed
to slowly face the grief. Discourage making major decisions early on in

• Discourage use of tranquilizers as a way to avoid intense emotions.
• Let the mourner know that his or her feelings may be intensified at key times

such as holidays and anniversaries and that they may last for a few days.
• Encourage good nutrition and good health habits, especially for elderly peo-

ple. Encourage seeking medical attention, as needed, during the bereave-
ment period because the mourner is at an increased risk of illness.

• Prepare mourner and family for delayed grief reaction when intense feelings
may occur in response to future loss.

• Provide written information on grief for family members.


• Document grieving behaviors.
• Document use of medications such as tranquilizers and analgesics.

Chapter 9 ■ Problems with Affect and Mood 141


• Disturbing behavior including hallucinating, delusions, obsessions
• Evidence of intense prolonged preoccupation with the loss
• Recurrence of psychiatric symptoms, substance abuse
• Dwelling on detailed events leading to loss or death long after the event
• Long periods of depression, possibly including suicidal thoughts or

• Living in the past many months or years after loss occurred
• No emotional reaction to loss for a prolonged period of time
• Or if the staff exhibits: Intense emotional reaction to death of patient;

Difficulty in dealing with personal grief to the extent that it impacts
on patient care


• Social Worker
• Chaplain
• Psychiatric Support
• Bereavement Counselor
• Critical Incident Team/Employee Assistance

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• Avoid documenting judgments about patient behavior.
• Document available resources identified to support grieving individual.


• Provide information on bereavement counseling and support groups. Pro-
vide the information in writing because mourners may be unable to con-

• Inform referring agencies and home health agencies about patients’ recent
losses and grief reactions.

• Identify opportunities for socialization. Encourage involvement in activities
when appropriate.

• Encourage involvement of family and friends to expand mourner’s support

• Provide follow-up phone calls to mourner to reinforce information given.

The Hyperactive or
Manic Patient

Learning Objectives
• List the outstanding characteristics of mania.
• List possible contributing factors to manic episodes.
• Describe effective nursing interventions for a manic episode.
• Describe possible nurses’ reactions to manic behavior.

Cyclothymic disorder – A chronic mood disturbance lasting at least 2 years

that can be thought of as a muted version of bipolar disorder
Bipolar Disorder – Psychiatric disorder marked by shifts in mood, energy and

ability to function. Alternating moods are characterized by mania, hypoma-
nia, depression. There are two types: Bipolar I disorder: Characterized by
the occurrence of one or more manic episodes or mixed episodes. Often,
but not always, individuals with this disorder also have one or more major

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depressive episodes. Bipolar II disorder: Characterized by the occurrence of
one or more major depressive episodes with the presence (or history) of at
least one hypomanic episode.

Hypomania – A distinct period that is similar to a manic episode but with less
severe symptoms. There is impairment of social or occupational function-
ing, mood is clearly different from usual nondepressed mood, but psychotic
features may not be present.

Mania – A distinct period during which there is an abnormally and persist-
ently elated, expansive, or irritable mood possibly accompanied by inflated
self-esteem or grandiosity, decreased need for sleep, pressured speech,
flight of ideas, or subjective experience that thoughts are racing, dis-
tractibility, increased involvement in goal-directed activities or psychomotor
agitation, and excessive involvement in pleasurable activities with a high
potential for painful consequences. Marked changes in social or occupa-
tional functioning or need for hospitalization or psychotic features must be

Mixed episode – A period during which the criteria for both a manic and a
major depressive episode are met nearly every day.

Rapid cycling – At least four episodes of a mood disturbance in the previous
12 months that meet criteria for a major depressive episode or a manic,
mixed, or hypomanic episode.

Schizoaffective disorder – An uninterrupted period of illness during which, at
some time, there is a major depressive, manic, or mixed episode concurrent
with the characteristic symptoms of schizophrenia.

Bipolar disorder, formerly called “manic depression,” is best viewed as a
recurrent, life-long illness. Episodes of mania or depression can last from

days, to weeks, to months. 1.2% to 1.6% of the population suffer from some
form of bipolar disorder (DSM-TR-IV, 2000). There is a 3.9% lifetime risk of
developing this disorder (Kessler et al., 2005). First episodes are more likely
in a younger population especially if there is a family history. More than
90% of patients who experience a first manic episode go on to have future
episodes. The majority of individuals with bipolar disorders eventually return
to a fully functional level between episodes. Many patients with bipolar I
disorder return to work when properly medicated. Manic and hypomanic
episodes often precede or follow major depressive episodes in a characteristic
pattern for a particular person. The frequency of manic episodes varies. Some
have periodic episodes separated by years, and some have close repetition. Long-
term, even life-long medication may be necessary. (Medication-free trials should
be tried only under physician supervision.) Cyclothymic disorder may also
require medication.

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In the early phase of a manic episode an individual can become engaging,
outgoing, and charming, presenting as one who is achieving and successful with
excessive energy and optimism. During the hypomanic episode, the person
accelerates to an “abnormally and persistently elevated, expansive or irritable
mood lasting at least 4 days.” (APA: DSM-IV-TR, 2000, p 365). Mania can
continue to accelerate to a continuously frenzied, out-of-control pace, leading
to seriously impaired decision making and potentially very hazardous activity.
An increasing manic episode can be viewed as a series of stages during which
the symptoms become more intense and severe. For example, an initial
overestimation of abilities (“I can earn more money than any other salesman
in the United States”) can balloon to grandiose delusions (“I am Jesus Christ”)
and hallucinations. What begins as pressured, rapid, but still organized speaking
can escalate to constant, loose, flitting verbalizations from topic to topic with
little or no connections and, eventually, incoherence. Irritability, especially
when demands are not met, can escalate into belligerent explosiveness and
combativeness. Restlessness can peak into a state of continuous motion. A
patient in an escalated manic phase frequently denies the seriousness or even
the existence of illness, both medical and psychiatric. This individual could
walk endless miles for days, expecting cars to clear a path for him or her, ignores
the need for any food and sleep, and disregards any physical impairment.
Without medication, a manic episode can last months. Individuals may be
prone to abuse substances like tranquilizers to sleep or control some aspect of the
manic episode.

Interestingly, descriptions of manic episodes reflect a mirror image of depres-
sion. Depression is characterized by an insidious slowing down of movement,
thought, self-esteem, and initiative, accompanied by dejected, constricting, pes-
simistic, and even despairing mood. Internally focused guilt abounds, and anger
is usually self-directed. In mania, everything seems to speed up, including
thought, speech, decisions, activity, mood, self-esteem and a belief that all desires
and dreams can be fulfilled. Externally focused anger and blame are directed out-
ward: Guilt is noticeably absent. In the extreme forms of both depression and
mania, there is a psychotic break with reality, including delusions and/or halluci-

During the acute manic phase, the primary goal is maintaining patient safety
and hospitalization may be required in severe cases. When the manic episode has
resolved, the patient may need to deal with substance abuse issues and need help
to reduce the risk of relapse. Long term the goal is to try to prevent or at least
reduce the severity and duration of future episodes. People often emerge from a
manic episode in a confused and startled state with minimal memory of what
happened. They may be shocked to see what has happened to their lives—bills,
destroyed relationships, legal problems (Varcarolis, 2006).

Depressive episodes in bipolar patients tend to have a greater impact for the
patient but there is less research on this phase of the illness (Hirshfeld, 2005).
Schizo-affective disorder may also be present in a patient with schizophrenia.

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Bipolar disorder is a complex phenomenon in which a variety of factors

Biological theory predominates. Studies indicate that this disorder is caused by
an imbalance in neurotransmitters, particularly norepinephrine, dopamine,
and serotonin. Increased levels are believed to be present in manic episodes
and decreased in depressive ones. Impaired interrelationships of the hormonal
and endocrine systems are currently being explored. Investigation of brain
electrical activity is also being studied because valproate, carbamazepine,
and other anticonvulsants have been successfully used with lithium-resistant
manic episodes. Electroencephalographic changes have been linked to mood dis-
turbances as well. Disruptions in circadian rhythms and exposure to light, as in
light therapy for depression with seasonal pattern, can contribute to manic

A genetic link has also been demonstrated through family studies. Bipolar
patients have a significantly greater percentage of relatives with bipolar and
depressive disorders than the general population. Studies done on twins and
adopted individuals provide strong evidence of a genetic influence for bipolar I
disorder. When a family history is present, the first episode tends to be at a
younger age.

Sociologically, there are no reports of differential incidence of bipolar I disor-
der based on race, ethnicity, or sex. Mania is more often the initial episode in men
and depression in women. Bipolar II disorder may be somewhat more common
in women.

Psychological theory views mania as a defensive flight from an underlying
extreme depression with its attendant painful feelings of hopelessness, worthless-
ness, and emptiness. It is suggested that the individual uses denial as a defense
mechanism. Hypotheses requiring further investigation are that the patient uses
manic symptoms to covertly get dependency needs met; approval from others
maintains self-esteem, whereas manic symptoms prevent others from setting lim-
its and containing out-of-control behavior. Psychological factors may be a larger
factor in precipitating relapse.


Hyperactive symptoms caused by substance abuse, medication use, or a general
medical condition are not considered to be a bipolar disease. Under these cir-
cumstances, the diagnoses would be substance-induced mood disorder or mood
disorder caused by a general medical condition but not be considered bipolar dis-
order (Box 9–9).

Manic episodes can be induced in susceptible individuals by other somatic
treatments for depression, such as ECT or light therapy for depression with sea-

Chapter 9 ■ Problems with Affect and Mood 145

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sonal pattern (exposure to increased amount of bright visible-spectrum light dur-
ing seasons of the year with diminished daylight).

Sleep disturbance is both a symptom of manic episodes and an irritant that can
exacerbate manic episodes and worsen the overall condition.

Patients with extreme manic episodes may be at risk for illness owing to phys-
ical exhaustion and immune system compromise.


Studies indicate that frequently bipolar disorders have their onset before the age
of 20. This disorder is now being diagnosed in younger people. Children may
manifest bipolar disorder as an ongoing, continuous mood disturbance that
includes both depression and mania rather than distinct phases (Child and Ado-
lescent Bipolar Foundation-CABF, 2007). Children may be misdiagnosed as hav-
ing a conduct disorder such as attention deficit hyperactivity disorder (ADHD).
Before putting a child on a stimulant for ADHD, an evaluation for history of
bipolar disorder should be done. A stimulant could precipitate a manic episode
in an at-risk child. If one parent has bipolar disorder, a child has a 15% to 30%
chance of having this disorder (CABF, 2007).

Manic episodes in adolescents are more likely to include psychotic features and
can be misdiagnosed as schizophrenia. As with younger children, behavioral

146 Chapter 9 ■ Problems with Affect and Mood

BOX 9–9
Drugs and Physical Illnesses That can Cause Manic States
Drug Related Infections
Steroids Influenza
Levodopa Q fever
Amphetamines St. Louis encephalitis
Tricyclic antidepressants Other Illnesses
Monoamine oxidase inhibitors Hyperthyroidism
Methylphenidate Multiple sclerosis
Cocaine Systemic lupus erythematosus
Thyroid hormone Brain tumors


Source: Dubovsky S. L., Davies, R., & Doboxsky, A. N. (2003). Mood disorders. In R. E. Hales, S.
C. Yodofsky (Eds.), Textbook of clinical psychiatry (4th ed.) (pp. 439–542). Washington, DC:
American Psychiatric Press; McDaniels J. S., & Sharma S. M. (2002). Mania. In M. G. Wise & J.
R. Rundell (Eds.), Textbook of consultation liaison psychiatry (2nd ed.) (pp. 339–359). Washing-
ton, DC: American Psychiatric Press.

09 Gorman(F)-09 11/5/07 5:00 PM Page 146

problems can lead to the misdiagnosis of conduct disorder. Approximately 10%
to 15% of adolescents with recurrent major depressive episodes will go on to
develop bipolar I disorder (DSM-IV-TR, 2000). Assessments should include a
family history of mood disorders.

In adolescents, manic and hypomanic episodes may be associated with
school truancy, antisocial behavior, suicide attempts, school failure, or substance
abuse. A significant minority of adolescents appear to have a history of long-
standing behavior problems preceding a frank manic episode. It is unclear whether
these problems represent a prolonged prodrome to bipolar disorder or an inde-
pendent disorder. The Child and Adolescent Bipolar Foundation has developed
consensus guidelines for diagnosis and treatment for this age group (Kowatch et
al, 2005). Screening for substance abuse should be done with any teen with bipo-
lar disorder.

Antimanic medications can be used in adjusted doses along with psychothera-
peutic interventions in this age group.

The majority of first manic episodes in bipolar disorder occur between 20 and 30
years of age with preponderance in the early 20s. If the onset of a first manic
episode occurs in a patient 40 years of age or older who has no previous psychi-
atric illness, medical conditions and drug-inducing manic symptoms should be
ruled out.

In the adult years, uncontrolled symptoms can result in job losses, marital and
other relationship breakups, grave financial problems, or serious legal repercus-
sions from violating laws. During manic episodes parents may be unable to care
for and provide safety for a child. Child abuse, spousal abuse, or other violent
behaviors may occur during severe manic episodes or during those with psychotic

“Postpartum onset” is applied to manic, depressive, or mixed episodes that occur
within 4 weeks after delivery of a child. The symptoms remain the same. If delu-
sions are present, they often concern the newborn child. If a manic episode devel-
ops in the postpartum period, risk for recurrence in subsequent postpartum
periods may be increased.

Older Adults
The intervals between episodes tend to decrease in bipolar I disorder and to
increase in bipolar II disorder as an individual ages. Medical conditions and drug
reactions as causative factors in manic episodes need to be carefully evaluated
particularly when initial episodes occur in elderly people. Managing patients with
bipolar disorder in long-term care settings can create major challenges for staff

Chapter 9 ■ Problems with Affect and Mood 147

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Behavior and Appearance
• Excessive in all areas: bizarre, garish, flamboyant, eccentric
• Pressured speech (profuse, rapid, as if generated by an engine)
• Poor personal grooming and excessive and bizarre clothing or make-up

• Restlessness, hyperactivity with constant moving and pacing
• Flitting attempts to participate in multiple activities, unable to complete

things, impulsive
• Poor judgment in decision making; undertakes risky or dangerous endeav-

ors without awareness of consequences, including buying sprees, foolish
business investments, reckless driving, hypersexuality

• Behavior inappropriate to situation
• Complaints, hostile comments, and angry tirades; may be violent

Mood and Emotions
• Elation; heightened sense of pleasure; unrealistic optimism
• Lack of shame or guilt
• Anger escalating to rage, especially when wishes are thwarted
• Labile mood swings including depression, irritability, and anger

Thoughts, Beliefs, and Perceptions
• Distracted; unable to concentrate on task at hand; overly attuned and

responsive to stimulation from people and events
• Grandiose overestimation of own abilities, talents; exaggeration of past

achievements; inflated self-esteem; impaired judgment

148 Chapter 9 ■ Problems with Affect and Mood

• May be entertained or amused by the initial exuberance and acting out and

not set limits
• May become irritable, anxious, or angry when patient is noncompliant with

healthcare regimen or routine
• May be embarrassed or sense lowered self-esteem if the nurse believes that

a “good” nurse should be able to control patients or prevent them from
behaving strangely

• May feel verbally abused and unrecognized by the patient
• May feel manipulated, outsmarted, and defensive, needing to justify actions

and motives
• May feel frightened if patient becomes violent

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• Complicated plans to acquire unlimited fame, fortune, and/or power
• Poor insight; unaware of his or her distortion and negative effect on others
• Makes puns, plays on words, and jokes
• Flight of ideas (continuously jumps rapidly from one topic to another)
• Suspicious; escalates to delusions or hallucinations of grandiosity or perse-


Relationships and Interactions
• Excessively gregarious; can be charming; lacks true concern for others
• Forms superficial relationships quickly but becomes manipulative, demand-

ing, intrusive, taunting
• Attempts to engage everyone into his or her plans and activities; constantly

demands attention
• Manipulates self-esteem of others by flattery
• Irresponsible; gives quick, deceptively plausible excuses for own actions;

puts responsibility on others
• Intimidating

Physical Responses
• Sometimes initial overeating; weight gain, even food hoarding
• As mania escalates, inadequate nutritional intake leading to weight loss and

even dehydration
• Physical exhaustion with insomnia, reduced need for sleep, changes in sleep

• May exhibit side effects of drug abuse and symptoms of general medical

conditions that can cause mania
• Patients on lithium must have blood levels monitored for therapeutic level

Pertinent History
• Earlier episodes or family history of depressive and/or manic episodes
• Dramatic changes in personality during manic phases
• Psychiatric diagnosis and treatment of schizophrenia or schizoaffective dis-

order may occur; differential diagnosis is often confused because extremes
of manic episodes have similar symptoms

• History of substance abuse


Patients may need to take antimanic (mood stabilizer) medications for the rest of
their lives; therefore education and compliance are very important.

Chapter 9 ■ Problems with Affect and Mood 149

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Lithium carbonate remains first-line treatment for a severe manic episode
(Hirschfeld et al, 2002). An antipsychotic medication may be added as well.
Lower maintenance doses are often continued in the intervals between episodes.
Blood levels and side effects need to be monitored because lithium can reach a
toxic range, possibly causing seizures, coma, and even death. Therapeutic lithium
levels are between 0.5 and 1.2 mEq/L for most patients. Blood lithium levels can
be elevated when there is significant lowering of body fluids as in such conditions
as limited fluid intake, dehydration, profuse sweating, or chronic diarrhea. It is
essential to constantly monitor for adverse drug reactions because some individ-
uals can become toxic at blood levels considered normal for most people. Onset
of sedation, nausea, and vomiting are early warning signs of lithium toxicity. As
toxicity increases, tremors and muscle twitching may occur as well as renal fail-
ure when blood levels approach 2.0 mEq/L.

Lithium can take 7 to 10 days to reach the desired effect. If psychotic symp-
toms are present, antipsychotics can be used on a regular or as-needed basis. The
need should diminish as lithium or other antimanic medications reach therapeu-
tic levels. The antipsychotic drug aripiprozole (Abilify) has been used to treat
severe agitation in bipolar disorder.

Antimanic drugs are available only in oral forms. If the patient is unable to
take oral medications, other medications may be used, such as antipsychotics or
antianxiety drugs, which can be given parenterally.

Anticonvulsants, such as carbamazepine and divalproex, are also used. Carba-
mazepine can cause agranulocytosis with lethal implications. The incidence of this
adverse effect is low; however, it is important to monitor the patient continually
for changes in white blood cell and granulocyte count and any signs of infection.
Agranulocytosis subsides promptly when the drug is discontinued. Antidepres-
sants that are normally used to treat depression unrelated to bipolar disorder may
be used but they need to be combined with a mood stabilizer (Hirschfeld, 2005).

Herbal products such as valerian root and chamomile may be used to calm the
person. During depressive periods, the individual may use stimulants to recreate
some of the feelings of the hypomanic period.

A patient in an escalated manic phase may be too restless to sit down and eat.
Patients may need “finger foods” that can be carried, such as sandwiches and
milkshakes. A high-calorie diet should be provided if patient is in constant move-

Maintaining a psychotherapeutic relationship is an important part of the total
treatment program to prevent or reduce the severity of relapses and promote
compliance with the lifelong medication regimen. The patient has to take the time
to work through the denial and, later, anger over having an incurable condition.
Medications can control the frequency and intensity of manic episodes, but exac-

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erbations can still happen. The patient may need assistance in dealing with shame
over behavior during manic episodes. He or she may also need to learn how to
discriminate normal from abnormal moods and will probably need help in learn-
ing to tolerate more dysphoric feelings and moods.

As life becomes flatter and less colorful without mania, the patient may need
to grieve for the losses associated with giving up mania, such as fantasies, high or
euphoric states, increased level of energy and sexuality, decreased need for sleep,
and possibly decreased degree of productivity and creativity.

Developmental tasks may have been overshadowed by the illness. For exam-
ple, the adolescent tasks of establishing a separate identity and learning about
relationships may have been disrupted. Once the patient is stabilized, these issues
will need to be addressed. If the patient has an alcohol or drug abuse dependency,
this needs to be acknowledged as a problem, especially because the patient usu-
ally denies the problem. Mood disorders can mask substance abuse just as sub-
stance abuse often masks mood disorders. Effective substance abuse treatment
should be used concurrently with approaches for bipolar disorder (Goodwin &
Jamison, 1990). In extreme depressive phases when the patient exhibits suicidal
ideation or psychosis, electroshock therapy may be needed.


ANXIETY evidenced by hyperactivity, distractibility, disorganized and unre-
alistic thoughts related to manic phase of bipolar disorder.

Patient Outcomes
• Slower and more controlled speech and behavior
• No evidence of delusions or hallucinations
• Demonstrates an increased ability to concentrate
• Demonstrates more realistic decision making
• Complies with medication regimen

• Determine psychiatric care provider for treatment of mania. If none,

strongly encourage immediate referral and assessment. Make sure that
physician and other staff members are aware of the patient’s history.

• Provide firm, clear limits. Describe exactly what is expected and what is
not allowed. Be realistic. For instance, patient may need to have a desig-
nated area in which to pace without being disruptive.

• Administer ordered antimanic medications; monitor blood levels, adverse
effects, and signs of possible toxicity.

• Assess for psychotic symptoms; evaluate for need to administer PRN
antipsychotic medications.

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• Do not reinforce patient’s delusional beliefs. Present reality without argu-
ing with the patient.

• Be consistent even if the patient produces seemingly plausible reasons
and excuses. Do not participate in verbal battles—just repeat the rules.
Avoid power struggles. Keep directions simple and specific.

• Use a calm, relaxed approach.
• Provide a focus to conversation if patient jumps from one topic to another.

Interrupt to slow him/her down. Refocus on the chosen topic. Phrase
questions so that they require a brief answer. If the patient’s thoughts are
speeding to the point of confusion, do not encourage continued speaking,
and, if possible, arrange for someone to sit quietly with patient. Supervise
other caregivers who are unfamiliar with manic patients.

• Explain to staff, patients, and visitors who complain about patient’s con-
stant need for attention that the patient will feel better in a quiet atmos-
phere. Encourage them to limit interactions with the patient without
abandoning him or her.

• Remove patient from external stimulation. If possible, place patient in a
room in a quiet area and use dim lighting. A private room is preferable.
Calming music may help.

• Assess whether patient should be allowed to verbalize anger or fear. If
patient becomes overly agitated, change or redirect the topic of conver-
sation. As the mania decreases, the patient may be better able to tolerate
more processing of emotion.

• Limit the patient’s choices. Attempt to limit the number of objects patient
has in the room. Encourage family and/or friends to take home unneces-
sary possessions.

• Remove hazardous objects from patient’s room.

• Provide brief activities because of short attention span. Tasks can be
more complex as mania decreases.

• If the patient’s behavior is unacceptable, distract with more productive
activities. Do not reinforce inappropriate behaviors by giving them a lot
of attention.

• Assess for activities patient can do in his or her room, such as writing or

• Provide an outlet for excessive energy. Assess whether a stationary bike
or other equipment can safely be placed in the patient’s room. Supervise
any physical activity. Consider physical and/or occupational therapy

• Support and encourage the patient’s ideas that are realistic and consistent
with the healthcare regimen.

• Assess for any injuries, bruises, and signs of infection.

152 Chapter 9 ■ Problems with Affect and Mood

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• Assess for substance abuse.
• Assist the family in dealing with any negative feelings they may have

toward the patient so that they can interact more constructively with him
or her.

• Obtain support from peers and other resources if patient’s manipulations
begin to erode the nurses’ abilities to maintain an effective approach.

SLEEP PATTERN, DISTURBED evidenced by inability to lie down at night,
sleeping only brief periods, and erratic sleep patterns related to manic/uncon-
trolled activity.

Patient Outcomes
• Remains alert and awake during the day without daytime fatigue
• Sleeps at least 5 hours per night
• Does not require naps during the day

• Monitor sleep patterns and assess for signs of fatigue.
• Use calming techniques just before bedtime: warm milk, soothing music,

or warm bath. Avoid stimulants such as caffeine.
• Decrease stimulation at bedtime: lights out, curtains drawn, phone

unplugged. Avoid loud noises nearby and loud talking. Some patients
may respond well to having someone sit quietly just outside the room
until he or she is asleep. Encourage the patient to remain in bed long
enough to fall asleep.

• Provide ordered sleep medication if patient is unable to sleep.
• Encourage the patient to go to bed at the same time each night.
• If naps are needed during the day, encourage taking them at the same

time each day.


Coping, Ineffective
Fluid Volume, Deficient
Injury, Risk for
Nutrition, Imbalanced: Less Than or More Than Body Requirements
Social Interaction, Impaired
Therapeutic Regimen Management: Ineffective
Thought Processes, Disturbed
Violence, Risk for

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• Avoid health teaching until patient displays significant reduction in psychi-
atric symptoms and demonstrates good awareness of reality.

• Teach the family the symptoms of a manic episode so they can recognize
what is occurring and not personalize the patient’s interactions with them.

• Teach the patient and family the importance of continuing psychiatric med-
ications and treatment, monitoring signs of medication adverse effects and
toxicity, and noting early signs and symptoms of recurrent episodes.

• Teach patients, especially those on lithium, to maintain normal diet, fluid,
and salt intake.

• Teach patients on lithium to check with their physician about withholding
drug if excessive diarrhea, vomiting, or diaphoresis occurs.

• Provide educational resources such as for Bipolar Disorder

• Teach the patient to make a contract with a family member or a trusted sig-
nificant other to encourage and assist the patient to make contact with psy-
chiatrist or counselor if there is a resurgence of symptoms. Often family
members are the first to notice behavioral changes.

• Help the family to make plans for hospitalization so they will be able to act
quickly if an emergency situation arises.

154 Chapter 9 ■ Problems with Affect and Mood


• Out-of-control verbalizations and behavior
• Psychotic symptoms
• Patient refusing health care or refusing to take medications
• Gross interference in other patients’ care
• Symptoms of lithium toxicity
• Laboratory values indicating agranulocytosis in patients taking carba-



• Attending Physician
• Social Worker
• Psychiatric Team
• Security

09 Gorman(F)-09 11/5/07 5:00 PM Page 154

• Teach patient about the process of realistic decision-making and the effect
of one’s decisions on others.

• Teach patient that life includes accepting periods of sadness, disappoint-
ment, and uncomfortable feelings.

• Teach patient about his or her effect on others.
• Explain to the patient and family that alcohol or drug abuse can undermine

bipolar treatment.
• Encourage continuing in psychotherapy even when symptoms have stabi-



• Note the presence or absence of adverse effects of lithium.
• Document the amount of PRN antipsychotics given and the results if used.
• Document any factors that could lead to dehydration.
• Document percentage of food eaten and weight changes.
• Note changes in patient’s behavior and thoughts expressed.
• Document patient’s compliance or lack of compliance with health-care



• Reinforce the idea that it is essential that the patient continue in medical and
psychiatric treatment and take prescribed medications after discharge.

• Make sure that patient has appointments for required blood level tests and
follow-up referrals.

• Social service referrals may be helpful for patients who may have alienated
friends, family, or associates before hospitalization. Financial and legal
issues may be pending because of unwise actions such as excessive spending

• Recommend assessing the need for transfer to psychiatric facility if patient’s
behavior and thought processes are not sufficiently stabilized.

• Recommend that the patient attend community support groups for bipolar
disorder such as the Manic Depressive and Depressive Association; refer for
alcohol or drug problems if indicated.

• Recommend that the family attend support groups such as those sponsored
by the National Alliance for the Mentally III (NAMI).

Chapter 9 ■ Problems with Affect and Mood 155

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Problems with Confusion

The Confused Patient

Learning Objectives
• Differentiate between dementia and delirium.
• List the most common types of dementia.
• Describe common nurses’ reactions to the confused patient.
• Describe effective nursing interventions for the confused patient with the

following: memory deficits, unable to verbalize his or her needs, and at
risk for falling.

Agnosia – Loss of ability to recognize objects
Apraxia – Inability to carry out motor activities despite intact motor function
Agraphia – Difficulty writing and drawing
Alzheimer’s disease – Progressive deterioration of memory, and intellectual

functioning, often leading to complete loss of functioning and personality.
Autopsy reveals brain atrophy, senile plaques, and neurofibrillary tangles.

Delirium – Rapid fluctuations in mental status, memory deficits, disorienta-
tion, and perceptual disturbances over a short period of time.

Dementia – Multiple cognitive deficits: aphasia, apraxia, agnosia, or distur-
bance in executive function such as organizing or abstracting.

Mild cognitive impairment – Subtle but measurable memory disorder when
memory problems are greater than what are normally expected with aging
but no other dementia symptoms.

Mixed dementia – Vascular dementia and Alzheimer’s disease simultane-

10 Gorman(F)-10 11/5/07 4:55 PM Page 157

Nocturnal delirium (sundowning syndrome) – Increased confusion and agi-
tation at dusk.

Prompts – Staff actions used to help dementia patient initiate self-care or
other desired behaviors after loss of verbal comprehension.

Pseudodementia – Depression in elderly people that appears similar to

Substance-induced persisting dementia – Dementia caused by intoxication
or withdrawal from a substance such as alcohol or drugs.

Vascular dementia – Dementia caused by multiple strokes that have usually
occurred at different times and involve the cortex and underlying white

Confusion is not just a state of the mind seen in elderly people. It has many
causes and can occur at any age. It significantly influences a patient’s dignity,

independence, personality, and support system, and can complicate the diagnosis
and treatment of an illness. Confused patients are experiencing an alteration in
higher level brain functioning such as comprehension or abstract thinking caused
by delirium or dementia (Boxes 10–1 and 10–2). These patients have difficulty
remembering, learning, following directions, and communicating needs and pains.

158 Chapter 10 ■ Problems with Confusion

BOX 10–1
Factors That Contribute to Misdiagnosis
in Dementia and Delirium
• The symptoms of dementia and delirium are similar.
• Several causes may occur simultaneously to bring about dementia.
• Delirium occurring in a patient with a dementia can exacerbate already

existing symptoms.
• Health-care personnel may harbor unfounded beliefs that serious memory

deficits, confusion, and other progressive intellectual deficits are a normal
part of the aging process.

• Health-care personnel may harbor unfounded beliefs that confusion always
indicates Alzheimer’s disease in an older patient.

• Confusion and behavioral changes may be the first sign of medical illness in
the elderly.

• Head injuries and other conditions causing brain tissue trauma may present
with symptoms similar to those of dementia.

• Confusion is an adverse reaction to many medications.

Source: Gorman, L., Raines, M., & Sultan, D. (2002). Psychosocial nursing for general patient care
(2nd ed). Philadelphia: FA Davis.

10 Gorman(F)-10 11/5/07 4:55 PM Page 158

Nursing care must be modified to help these patients to retain and regain the
mental abilities that can be recovered and to compensate for those that cannot.

Delirium is a reaction to underlying physiologic (illness, drug reaction, or
exposure to a toxin) or psychologic stress. Nurses in the intensive care unit often
see delirium induced by the disorienting and confusing environment, sensory dep-
rivation, or sensory overload. It may also occur postoperatively related to anes-
thetic or electrolyte changes. It is also very common in advanced cancers and in
the terminally ill (Kuebler, Heidrich, Vena, & English, 2006). Delirium is caused
by a temporary malfunction of the brain. When the underlying causative condi-
tion is resolved, the delirium generally resolves. It is a medical emergency. If
left untreated, it could progress to dementia, coma, or death depending on
the underlying cause. It is often under-recognized until the symptoms become
more flagrant. Delirium can take 3 forms: hyperalert-hyperactive, hypoalert-
hypoactive, and mixed (Irving, Fick, & Foreman, 2006). See Table 10-1 for Types
of Delirium.

Dementia is generally a permanent condition caused by a variety of factors
that lead to cellular brain changes or malformations. It is characterized by slow,
insidious onset affecting memory (impaired ability to learn new information or
to recall previously learned information), intellectual functioning, and the ability
to problem solve. Types of dementia include Alzheimer’s disease, vascular demen-
tia, substance-induced dementia, and dementia caused by other medical condi-
tions including HIV, Parkinson’s disease, and Creutzfeldt-Jakob disease.

Alzheimer’s disease is the most frequently seen type of dementia, affecting
between 4 to 5 million Americans (Alzheimer’s Association, 2006). The number

Chapter 10 ■ Problems with Confusion 159

BOX 10–2
Characteristics of Delirium and Dementia
• Fluctuating levels of

awareness and symptoms
• Sudden onset
• Clouding of consciousness

• Perceptual disturbances
(hallucinations, illusions)

• Memory disturbance, more
often for recent events

• Highly distractible

• Reversibility possible with

• Slow, insidious onset with less fluctua-

tion of symptoms
• Deterioration of cognitive abilities
• Impaired long-and short-term memory

(memory impairment always present)

• Personality changes

• May focus on one thing for a long

• Often irreversible

10 Gorman(F)-10 11/5/07 4:55 PM Page 159

affected has doubled since the 1980s because people are living longer. The cur-
rent rate of dementia is expected to triple by 2050 (Davis, 2003; Hebert, Scherr,
Bienias, Bennett, & Evans, 2003). It strikes at least 50% of people older than 85
years because the risk to develop it increases with age. Initial changes occur so
slowly that they may not be recognized. The person may be regarded as absent
minded. Changes in communication, personality, and social skills occur gradu-
ally. Because the decline is usually so slow, patients and families may deny its
existence until a crisis occurs. The person with Alzheimer’s disease loses the abil-
ity to relate to the environment and recognize loved ones. This contributes to

160 Chapter 10 ■ Problems with Confusion

TABLE 10–1
Types of Delirium

Hypoactive- Hyperactive-
Assessments Hypoalert Hyperaltert Mixed

Level of alertness

Motor activity

Ability to follow

Thinking Ability

Source: Adapted from Forrest, J., Willis, L., Holm, K., Kwan, M. S., Anderson, M. A., & Foreman, M. D.
(2007). Recognizing quiet delirium. American Journal of Nursing, 107(4), 35–39.

Lethargic, falls
asleep between
questions, diffi-
cult to arouse

Decreased activ-

Follows a simple
command, e.g.,
lift your foot

Is passively

Difficulty in
focusing atten-
tion, disorgan-

between hyper-
alert and
states within
hours or days

within one
episode of

hypoactive and
states, may be

hypoactive and
states in an

Overly atten-
tive to cues

Moves quickly

May be com-
bative, pulls
at tubes, tries
to climb out
of bed

Easily dis-
tracted, ram-

May mumble,
swear, or yell

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families experiencing a prolonged grief process as they slowly lose who their
loved one was. Because of the long trajectory, this disease has many financial
impacts because the patient will require care for many years. In later stages, the
individual may develop gait and motor disturbances and eventually become
mute, bedridden, and incontinent. Death often occurs from severe debilitation,
aspiration pneumonia, and recurrent infections. The average duration of the ill-
ness from onset of symptoms to death is 8 to 20 years.

Vascular dementia, the second most common form, is caused by multiple
strokes. Symptoms are variable depending on the extent, location, and timing
of the strokes. Decline tends to occur in steps rather than a gradual decline.
There is usually more fluctuation in functioning. Impairment is limited and
distinct depending on the area of the brain affected. This contrasts with more
global intellectual impairment in Alzheimer’s disease. Evidence of strokes, such as
one-sided weakness, sudden onset of loss of speech, and focal neurological signs,
such as hyperactive deep tendon reflexes, occur with vascular dementia. Treat-
ment of underlying hypertension and vascular disease may prevent further

In 2001, guidelines for Mild Cognitive Impairment were developed by the
American Academy of Neurology. This condition may be a predictor of demen-
tia in about 50% of patients (Gauthier et al, 2006).


Delirium can have biological and psychological causes. Biological causes include
a variety of medical conditions, exposure to toxins, and drugs. The onset of
symptoms is related to exacerbation of a medical condition or introduction of a
new medication for example, and contributes to the diagnosis. Psychological
causes include sensory deprivation or overload, relocation or sudden changes,
sleep deprivation, and immobilization.

Dementia can be caused by a variety of biological factors including the direct
physiological effects of a medical condition, the persisting effects of a substance
(drug of abuse, medication, or toxin), or multiple etiologies such as the combined
effects of a stroke and Alzheimer’s disease. Alzheimer’s disease destroys brain
cells and nerves leading to shrinkage as gaps develop in the temporal lobe and
hippocampus where storing and retrieval of new information occurs. Diagnosis
can now be made by magnetic resonance imaging (MRI) and positron emission
tomography (PET) scan to document the brain atrophy.

The etiology of Alzheimer’s disease remains the focus of much research. Cur-
rent theories under investigation include decrease in the activity of the neuro-
transmitter acetylcholine and presence in the brain of the protein beta-amyloid.
Thus far, theories of environmental toxins, poisons, or a slow-acting virus are
unsupported. Genetic factors may also be present. There is a greater incidence of
Alzheimer’s disease in the family members of patients who acquire the disease
before the age of 60 (Schutte, 2006).

Chapter 10 ■ Problems with Confusion 161

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Medical conditions that can generate delirium include systemic infections,
hypoxia, hypercapnia, hypoglycemia, fluid or electrolyte imbalances, hepatic or
renal disease, thiamine deficiency, sequelae of head trauma, postictal states, post-
operative states, and complications of cancer. Some of the risk factors for delir-
ium include vision impairment, cognitive impairment, restraints, malnutrition,
and addition of more than three new medications (Samuels & Neugraschl, 2005).
Elderly patients and cancer patients with pain are particularly vulnerable (Kue-
bler et al., 2006). Delirium is the most common cognitive disorder seen in pallia-
tive care and in as many as 80% of patients with advanced cancer (Elsayem,
Driver, & Bruera, 2003). The presence of delirium increases the risk of compli-
cations associated with a medical illness and increases the risk of mortality.

Substance intoxication delirium can occur from ingestion of alcohol, amphet-
amines, cannabis, cocaine, hallucinogens, phencyclidine (PCP), opioids, hyp-
notics, and sedatives. Substance withdrawal delirium can occur from abruptly
stopping significant abuse of alcohol (formerly called “delirium tremens”), hyp-
notics, antianxiety medications, and corticosteroids.

Many prescribed medications can contribute to delirium, including analgesics,
anesthetics, anticonvulsants, antihistamines, antiparkinson drugs, corticos-
teroids, gastrointestinal medications, and psychotropic medications with anti-
cholinergic side effects.

Medical conditions that contribute to development of dementia include stroke,
Parkinson’s disease, Huntington’s disease, AIDS, Creutzfeldt-Jakob disease,
hypothyroidism, multiple sclerosis, traumatic brain injury, brain tumors, anoxia,
lupus, and hepatic failure. Substance-induced persisting dementia can also occur
with a long history of alcohol or substance abuse.

The dementia patient is at risk for many complications including unrelieved
pain due to inability to express it. In addition this patient is at risk for skin break-
down, aspiration pneumonia, weight loss, and sepsis.


Children to Adolescents
Children may be more susceptible to delirium than adults, particularly in the pres-
ence of febrile episodes and in response to some medications such as anticholiner-
gics. Assessment may be complicated by difficulty in eliciting the signs of problems
in thinking, memory, and orientation. In fact, delirium can be mistaken for unco-
operative behavior. One indication of delirium may be the inability of familiar fig-
ures to soothe the child. Children and teens may be at risk for delirium when they
abuse club drugs, PCP, inhalants, or combinations of several illicit drugs.

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Dementia is rare in children and adolescents but can occur as a result of med-
ical conditions including AIDS, brain tumors, and head injury. As with delirium,
dementia can be difficult to identify in young children. It may present as a dete-
rioration in function, as in adults, or as a significant delay or deviation in normal
development. Deterioration in school performance may be an early sign.

Older Adults
Delirium is extremely common in medically ill elderly people. It is a complex
process that is caused by many age-related physiologic changes in the brain and
other organs (Bond, Neelon, & Belyea, 2006). Ten percent to fifteen percent of
hospitalized elderly persons exhibit delirium on admission (DSM-IV-TR, 2000);
15% to 30% of hospitalized medically ill older people may develop it at some
time while they are in the hospital. Multiple medications, multiple chronic ill-
nesses, use of over-the-counter medications, and impaired kidney and liver func-
tion contribute to the development of delirium. Specific conditions that put the
elderly patient at greater risk include urinary tract infections, sepsis, stroke,
bypass surgery, myocardial infarctions, and dehydration (Liptzen & Jacobson,
2006). A masked depression can appear as confusion (pseudodementia). Acutely
confused elderly persons are often inappropriately labelled “demented,” when
potentially reversible conditions go undiagnosed and untreated.

Dementia in general is most common after the age of 85 and is often seen in
residents of nursing homes. It occurs with increasing frequency after the age of
65 but is not a normal or expected part of the aging process. Mixed dementias
are also more common as people continue to live longer.

Chapter 10 ■ Problems with Confusion 163

• May have a more positive attitude and take more active measures in care of

patients if they believe the confusion is reversible.
• May feel very frustrated and helpless because of lack of improvement, con-

stant need to repeat instructions or break tasks down step by step, repeti-
tion of the same question, and time requirements for care of patients with
irreversible dementia.

• To avoid feeling hopeless and helpless, may become emotionally detached
and give only impersonal care.

• May find themselves bored, unfocused, or confused if patients have consid-
erable problems in communicating verbally.

• May be angry with patient’s pathology; may believe patient can control
own behavior.

• May become impatient with negative, hostile, impulsive patients who are
very slow to respond.

• May feel repulsed by poor hygiene, messy eating behaviors, incontinence,
or inappropriate behaviors.

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Behavior and Appearance
• Disheveled, inappropriate clothing; poor grooming
• Restless, agitated, impulsive, aggressive
• Wandering

• Perseveration (involuntary repetitive movements, speech [most common]
or activity)

• Apraxia
• Agraphia
• Loss of coordination; stiff awkward movements; impairment of learned

skilled movements
• Unsteady, shuffling gait; stooped, leaning posture
• Loss of ability to perform activities of daily living (ADLs)

• Types of aphasia including

• Echolalia (repetition of word, phrase, or syllable just said by someone else)
• Repetitive questions
• Palilalia (repeating sounds or words over and over)
• Anomia (difficulty finding wanted words) leading to paraphasia (using

similar-sounding words) and circumlocution (using many words in place
of the one word that is wanted)

• Slurred speech
• In late stages, may remember only a few key words used inappropriately

in all situations (such as no)
• May become mute
• Hoarding
• Regression

• Hypersexual behavior such as obsessive masturbation
• Hyperoral symptoms including increased appetite
• Inappropriate eating and toileting behavior
• Sleep disturbance including nocturnal delirium (sundown syndrome)
• Overreaction to neutral stimuli (catastrophic reactions)
• Inability to tolerate stress and change

Mood and Emotions
• Emotional lability
• Depression

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• Suspicion, paranoia, hostility
• Anxiety

Thoughts, Beliefs, and Perceptions
• Loss of recent or remote memory or both
• Disorientation, first to time, then place, then person
• Impaired concentration
• Loss of abstract thinking ability
• Loss of ability to calculate
• Inability to learn and use new information
• Loss of ability to plan, initiate, sequence, monitor, and stop complex

• Agnosia
• Ability to read words without knowing what they mean
• Loss of ability to read
• Confabulation
• Loss of awareness of spatial relationships; loss of awareness of own body

parts and how they are organized in relation to each other
• Illusions
• Delusions, hallucinations
• Impaired insight and judgment

Relationships and Interactions
• Personality changes: accentuation or alteration of premorbid traits that

affects previous relationships (e.g., caretaker role reversals); family unsure
how to interact with patient

• Loss of social skills; social withdrawal
• Clinging, demanding
• Inability to sustain real relationships as memory gaps eliminate continuity;

in later phases, may not recognize family or friends
• Negative, belligerent, briefly combative at times; hostility caused by brain

damage or by misinterpreting events; not necessarily by the behavior of

Physical Responses
• The patient may not verbalize or demonstrate common physical signs of

pain or other symptoms such as bladder distention, constipation, dehydra-
tion, injuries, or urinary tract infections.

• Laboratory data, medication history, and possibly drug screening should be
performed to evaluate patient at the onset of confusion.

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Pertinent History
• Complex medical history
• Chronic illness
• Substance abuse
• Head trauma


A great many medications cause confusion. Confused patients who are taking
multiple medications may need to have the medications withdrawn one at a time
to determine their impact on the symptoms and the underlying illness. Any med-
ications used to treat confusion should be started at lower dosages. Drugs that
commonly cause delirium include anticholinergics, benzodiazepines, steroids,
antiemetics, and opioids.

Confused patients often become disruptive and may need to be controlled to
protect the patient and environment. Haloperidol (Haldol) is frequently used to
treat agitation and aggression. Atypical antipsychotics like resperidone are also
useful. Side effects such as orthostatic hypotension must be closely monitored
because the patient may not be able to verbalize how he or she is feeling. Other
medications used with this population include short acting benzodiazepines like
lorazepam and selective serotonin reuptake inhibitors (SSRIs).

Buspirone (Buspar) has been used successfully in patient’s with Alzheimer’s
disease, although it may take several weeks to take effect fully. Hypnotics, anti-
depressants (particularly SSRIs used for irritability), and anticonvulsants (used
for rage) are also useful. However, using medications to control agitation should
not replace other interventions. There can be a tendency to use medications to
sedate the patient rather than pursue behavioral techniques.

Medications to slow down the decline of Alzheimer’s disease include
cholinesterase inhibitors such as donepezil hydrochloride (Aricept), rivastignine
(Exelon) and Galantamine (Rozadyne) have been used to temporarily improve
cognitive function. Memantine (Namenda) is used to treat moderate to advanced
Alzheimer’s disease. It is a NMDA antagonist that protects brain cells against the
influx of calcium into the nerve cells. It does not stop the disease but may help
increase independence in activities of daily living and slow the progression.

A multidisciplinary approach for the patient with dementia is essential. Physical
and occupational therapy, nutritional support, speech therapy, psychiatry, social
work, nursing, and medicine all need to be part of the long-term management of
this patient. It is important that families use all available resources to reduce
their isolation and stress. A variety of nonpharmacological approaches have been

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helpful to reduce agitation. Some include pet therapy, massage, therapeutic
touch, and aromatherapy.


IMPAIRED VERBAL COMMUNICATION evidenced by inability to name
objects or sensations such as pain; inability to comprehend verbal instructions;
inability to communicate needs; inappropriate, dramatic reactions or accusa-
tions, catastrophic reactions related to confusion, disorientation, memory loss.

Patient Outcomes
• Demonstrates understanding of nurses and communication
• Able to communicate thoughts and needs
• Responds appropriately

• Look directly at patient when speaking. Call patient by name frequently.

Identify yourself by name before each conversation and refer to others by
their names rather than “he” or “she.”

• Keep interactions simple. Use short words and simple sentences that
express one thought or question at a time.

• Ask specific questions such as “Does your stomach hurt?” rather than
general ones like “How are you?”

• Reinforce speech with nonverbal techniques. For example, point, touch,
or demonstrate an action while talking about it. For instance, if the
patient is trying to tell you about his or her body, point as well as ask “Is
this where it hurts?”

• Note in the chart or on the care plan the phrases, key words, and tech-
niques that the patient responds to so that others can use them as well.

• If patient keeps repeating a question, try distraction and give reassurance
that he or she will be cared for. Repetitive questions may indicate anxi-
ety, and you want to be reassuring.

• If patient is searching for a particular word or trying to communicate
something, guess at what it is, and ask if your guess is correct. If you are
unable to determine what he or she is trying to say, focus on the feelings
possibly being communicated. Always ask patient to confirm whether
your determination is correct.

• If patient is reacting inappropriately, remain calm and reassure him or
her that you are there to help. Avoid arguing or trying to convince patient
that he or she is overreacting. Clarify any information or instructions.
Assist patient with the next step of a task that is the source of frustration.
Try to distract patient by removing him or her from disturbing situation.

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• If patient makes inappropriate accusations, such as accusing the staff of
stealing his or her glasses, help look for the missing item. Remember that
the patient may accuse you of stealing because of memory loss. Also, rou-
tinely check wastebaskets for missing items.

• Family/caregiver support to deal with difficult behaviors. Resources for
support should be provided to avoid reactions to behavior with frustra-
tion and aggression.

IMPAIRED MEMORY evidenced by confusion, decreased ability to perform
activities of daily living (ADLs), or inability to follow therapeutic regimen;
inappropriate emotional or behavioral responses related to delirium, demen-
tia, or other cognitive deficits.

Patient Outcomes
• Demonstrates improved orientation to person, place, and time
• Demonstrates improved ability to perform ADLs
• Displays less emotional or behavioral agitation

• Establish a baseline assessment of patient’s mental status and functioning:

• Observe ability to perform ADLs.
• Use a standardized method of mental status assessment such as that

found in Table 3–1.
• Ask the patient orientation questions. For example, ask patient per-

sonal questions such as names of his or her children or home address.
Make sure that you can verify the answers from the chart or family.

• Assess if patient is willing to discuss memory lapses. Determine emo-
tional responses to these lapses. Do not push the discussion if the patient
becomes agitated or defensive.

• Be aware that patient may try to disguise memory loss by confabulation,
avoiding responding, or by speaking in a rambling style to hide the fact
that no thought or information is being expressed.

• Be aware that when social skills and personality are still intact, patient
may mistakenly appear stubborn and resistant rather than unable to

• Do not argue with patient about what he or she remembers. Rather, focus
on immediate and specific tasks to be completed. Give patient step-by-
step instructions on what needs to be done. Be directive without being

• Do not make demands that the patient cannot handle or focus on topics
that clearly cause distress. Such demands will only add to the confusion
and/or agitation.

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• Break down complex tasks into individual steps. The seemingly simple
act of brushing one’s teeth can take over 10 steps. Be aware of the steps
the patient can handle himself or herself and those requiring assistance.
Use prompts to cue each step of the task.

• Establish a regular and predictable routine. Try to do things at the same
time and in the same order each day, such as shave, bathe, and then eat
breakfast. Communicate routines to the staff to coordinate patient’s care
and ensure that the same techniques are used. Obtain input from the fam-
ily on patient’s usual routine. Use prompts such as consistent cue words
or signs to remind patient of the routine.

• Attempt to arrange for consistent staff to care for patient.
• Keep surroundings simple. Reduce clutter. Do not leave equipment in the

patient’s room if possible.
• Personalize the patient’s room. Have the family bring in photos and

favorite objects. Encourage the family to create a memory box with mean-
ingful items from the patient’s past (wedding photos, special momentos).

• Place a large, visible clock and calendar in the patient’s room. Cross each
day off the calendar daily. Place large signs on the wall noting where
patient is and special events such as when the family is coming and the
next upcoming holiday.

• Write lists of daily activities or tasks patient needs to do if still able to
read and comprehend. Put labels on possessions and patient’s name on
his or her door in large letters.

• Avoid an overstimulating environment. In the hospital, the patient’s room
should be close enough to nurses’ station to monitor safety yet far enough
away to avoid noise. Restrict the number of people visiting at one time.

• If the patient tends to wander, make sure all staff are aware of this prob-
lem and can bring him or her back to the unit. Consider using alarms, if
available, for a patient at high risk of leaving the area. Monitor all exits.
Draw a large red octagon-shaped stop sign and hang it by the exit. At
home, make sure exits are monitored. Have the family notify neighbors
of the problem and elicit their assistance to monitor for wandering. Make
sure the patient always has some form of identification stating that he or
she is confused, such as an identification bracelet. Maintain photos of the
patient to be shown if he or she is missing.

• Provide some form of night light. If the bathroom is connected to
patient’s room, leave the bathroom light on. Otherwise, use reflective
tape in the shape of arrows to direct the patient to the bathroom door.
Encourage the use of a bedside commode.

RISK FOR INJURY evidenced by falls and bumping into objects. related to
problems in gait, vision, hearing, lack of coordination, confusion, or lack of
understanding of environmental hazards.

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Patient Outcomes

• Remains free of injury
• Demonstrates appropriate actions to avoid injury
• Reduce use of restraints


• Be aware of factors that increase risk for falls (Box 10–3).
• If patient is a fall risk, keep side rails up and bed in lowest position. At

home consider taking the mattress off the bed frame and putting it on the
floor to avoid injuries from falls. In the inpatient setting, bed alarms and
hip protectors can be used to prevent injury.

• Even with side rails up, be aware that patient may get out of bed. Keep
area around bed free from clutter. Make sure that there is always a clear
path to the bathroom because that is the place where the patient will
most often attempt to go. Make sure that patient uses the bathroom
before going to bed at night. Plan administration of medications such as
laxatives and diuretics so that they are not given in the evening. Recog-
nize that the patient with dementia may have sleep pattern disturbances
and become more confused at night.

• Make rounds frequently for patients at high risk for falling. Keep the
patient’s door open, and make sure all staff members know that this
patient is at risk.

• Use restraints only after all other methods are ineffective. In some
instances, restraints can increase confusion in elderly patients.

• If the patient has an unsteady gait, have him or her take your arm instead
of the reverse while walking. Make sure the patient has access to any
needed equipment such as walkers or wheelchairs. Provide instruction
as appropriate within the patient’s ability to understand. Ensure that
any furniture or objects the patient leans on for support are sturdy
and well balanced. Railings in hallways and bathrooms are very help-
ful. The patient may need prompts to perform simple actions, such
as walking.

• Make sure the patient receives adequate exercise within the limitations of
his or her abilities and condition.

• If the patient wears glasses or a hearing aid, make sure that these are
in place before any activity. Be sure to check that the hearing aid battery
is good.

• Ensure that the room is adequately lighted for any activity and that the
call light is within reach when patient is in bed, in bathroom, or sitting
in chair.

• Check the patient routinely for bruises, cuts, or burns.

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• Use colored waterproof tape along the area of the bathtub where patient
is to stop filling with water. Decorative markers that stick to the bottom
of the shower or tub can compensate for spatial disorientation.

• Use brightly colored materials in the room, if possible.
• Be aware that the patient may try to pull out catheters or intravenous

tubing. Try to reduce risk of the patient’s pulling out the tubes by reduc-
ing the discomfort associated with tubes. For instance, use the smallest-

Chapter 10 ■ Problems with Confusion 171

BOX 10–3
Causes of Increased Risk of Falls and Injury
• Stiff, awkward movements caused by damage to areas of brain that control

muscle movement:
• Difficulty getting out of bed
• Stooped or leaning posture and shuffling gait as disease progresses
• Apraxia, with inability to make or coordinate movements

• Overmedication: Changes in drowsiness, walking, posture, stiffness, agita-
tion, falling, increased postural hypertension

• Visual problems:
• Cataracts
• Increased near- or farsightedness
• Inability to distinguish between similar color intensities (may have diffi-

culty identifying railings that are same color as walls; may stumble into
walls of color intensity similar to that of floor)

• Poor depth perception
• Blurred vision (may be side effect of medication, anticholinergic action)

• Hearing problems: May not hear approaching machinery or people
• Agnosia: May bump into furniture, not recognizing what it is
• Diminished or absent pain perception:

• Inability to recognize or communicate injury (for example, patient may
try to walk on broken leg)

• Only manifestation may be change in behavior
• May burn self while smoking

• Sundowning syndrome (increased confusion at night) with night restless-
ness, wandering

• Any factor, including concurrent delirium, that increases confusion and dis-

Source: Gorman, L., Raines, M., & Sultan, D. (2002). Psychosocial nursing for general patient care
(2nd ed). Philadelphia: FA Davis.

10 Gorman(F)-10 11/5/07 4:55 PM Page 171

size nasogastric tube or cover the IV site with a large bandage to avoid
the patient’s pulling on the tubes. Wrist restraints, freedom splints, or
monitoring by a family member may be required to avoid injury.

• Be aware of medication interactions that could add to confusion and the
risk for falls.

AND FLUID VOLUME DEFICIT evidenced by weight loss, electrolyte imbal-
ance, increased confusion, or other signs of dehydration, related to impaired
recognition of hunger and thirst, memory loss, impaired movements.

Patient Outcomes
• Receives adequate nutritional and fluid intake

• Displays ability to recognize signs of hunger and thirst

• Demonstrates ability to feed self

• Assess the patient’s ability to feed and care for self (Fig. 10–1).

• Provide assistance, as needed, for dressing, personal hygiene, and eating.

• Determine how much patient can safely do independently. Perhaps just
opening containers or cutting meat is all that is needed to promote inde-
pendence. Provide verbal cues to keep patient on track.

• Determine patient’s food preferences and provide these foods, if possible.
Encourage the family to bring familiar foods from home if appropriate.

• Make sure that dentures are in place and that they fit correctly before
serving a meal.

• Allow hot foods to cool to prevent burn injury.

• Simplify the meal routine. The patient may be able to cope with only one
food or one utensil at a time. Provide finger foods if utensils are difficult
to use.

• Reduce distraction during mealtimes. For instance, turn off the television
or radio.

• Assess regularly for signs of dehydration and aspiration (coughing after
eating/drinking). Use thickened liquids or pureed diet.

• Make sure that patient can see his or her food and hear your instructions.

• Consider liquid supplements if eating solid food is too difficult.

• Assess for constipation.

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Chapter 10 ■ Problems with Confusion 173

FIGURE 10–1. Self-care checklist.

10 Gorman(F)-10 11/5/07 4:55 PM Page 173

• For patient with end-stage dementia, family may face decision on
whether to pursue aggressive nutrition intervention if patient refuses to
eat or is unable to swallow. Provide support for the family in attempting
to weigh these difficult options. Consider offering ethics consultation or
palliative care/hospice assistance, if appropriate.


Confusion, Acute
Confusion, Chronic
Family Processes, Interrupted
Sensory Perception, Disturbed
Sleep Pattern, Disturbed
Therapeutic Regimen Management: Ineffective
Thought Processes, Disturbed


• Provide simple instructions based on patient’s current ability to compre-

• Teach the family techniques to control uncooperative and aggressive

• Give the family information about the disease so that they can better under-
stand that the patient has no control over his or her behavior.

• Teach the family or caregivers about the need to avoid stress and fatigue for
the patient because this can increase behavior problems.

• Encourage family to obtain material and newsletters from the Alzheimer’s
Association ( Also encourage them to obtain a copy of The
36-Hour Day by Mace and Rabins.

• Alert family to signs of caregiver abuse.

• Teach the family or caregivers to build support systems to maintain a bal-
ance in their lives. Give information on obtaining caregivers.

• Encourage family to consider options for the future such as nursing homes,
in-patient dementia programs.

• If the patient is in the early stages of dementia, encourage discussion of
wishes for resuscitation and feeding tubes when the disease advances.
Encourage completion of an advance directive.

• Review realistic expectations from Alzheimer’s drugs and symptom man-
agement medications.

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• For patients with delirium, help the patient/family identify possible sources
of the delirium so the risk can be minimized in the future.

• Teach the family about the emotional strain created by caring for the con-
fused patient. Educate them that, with Alzheimer’s disease in particular, the
family may go through a mourning process for the person who their loved
one used to be. This process is complicated because the patient looks the
same but no longer has the same personality. Adult children must be pre-
pared to reverse roles and become caretakers.


• Document any changes in levels of confusion, memory, behavioral routines,
or consciousness.

• Document which activities the patient cannot do.

• Document if patient is able to start an activity but requires a prompt to con-
tinue. Document words or physical directions that work as a prompt.

• Document stimulus that causes the patient to have catastrophic reactions,
such as too much noise or too many demands at the same time.

• Document the patient’s response to medications.

• Document any techniques that have been effective in calming patient.

Chapter 10 ■ Problems with Confusion 175


• Social Worker

• Security

• Psychiatric Team

• Geriatrician


• Sudden onset of confusion

• Episodes of patient’s becoming physically combative

• Patient who becomes a danger to self or others because of poor judg-
ment (driving, cooking, etc.)

• Severe agitation unresponsive to medication or other interventions

• Delirium that does not remit or gets worse

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• Be sure that the family has the needed information on financial resources
and legal information for power of attorney.

• Report all indications of caregiver abuse.
• Assist the family or caregivers to set a plan to provide them with needed rest

and recreation. Encourage family and caregivers to seek out support of
friends or clergy. Encourage attendance at local support groups.

• If the care demands become too great, families need to consider placing the
patient in a nursing home, specialized Alzheimer’s program, or day care.
Provide information on any specialized programs in the community and
suggestions for what to look for in a facility. Provide families with support
to make this difficult decision.

• Give specific information on this patient’s management to home health
agencies and skilled nursing facilities.

• Give information from local Alzheimer’s Association chapters on treatment
programs, research, and facilities.

• Patients with end-stage dementia may be appropriate for referral for pallia-
tive care or hospice care when they are bedbound, experiencing repeated
infections, and are having difficulty with eating and drinking.

• Refer to home health agency if patient to be discharged home with a feed-
ing tube or needs further instructions on prevention of aspiration, skin

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Problems with Psychotic
Thought Processes

The Psychotic Patient

Learning Objectives
• Differentiate between schizophrenia and other psychoses.
• Describe effective interventions for the hallucinating and delusional

• Describe possible nurses’ reactions to the psychotic patient.
• Discuss specific interventions for the patient experiencing intensive care

unit psychosis.

Delusional disorder – Persistent suspicions, persecutory ideation, and delu-

sions or delusional jealousies with resentment, anger, and sometimes
grandiosity without other signs of psychotic thoughts or mood disorders.
Patients are usually able to maintain daily functioning. (Previously known
as paranoid disorder).

Brief psychotic disorder – Sudden onset of psychosis precipitated by severe
stress with patient returning to premorbid state within 30 days.

Delusions – False, fixed beliefs that cannot be corrected by feedback and are
not accepted as true by others in the same culture.

Good reality testing – The ability to accurately identify and evaluate events.
Absence of delusions, hallucinations, and other distorted perceptions.

Hallucinations – Sensory experiences that are very real to the patient but that
do not exist in external reality, occurring while the patient is awake and
when no one else has a similar experience.

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Poor reality testing – Defects in a person’s ability to accurately assess exter-
nal events and interactions with others.

Psychosis – Severe distortion of and withdrawal from reality accompanied by
severe disorganization of the personality.

Schizoaffective disorder – Symptoms of major depressive disorder or the
manic phase of bipolar disorder as well as some of the symptoms of schiz-

Schizoid personality – Individual who is indifferent to social relationships and
with a very limited range of emotional experiences and expressions

Schizophrenia – A severe thought disturbance characterized by impaired
reality testing, hallucinations, delusions, limited socialization; diagnosis
requires the symptoms to last at least 6 months.

Caring for a patient who is hearing voices, believes that the staff is trying to
kill him or her, or exhibits other bizarre behavior can be confusing, disori-

enting, frightening, and disarming for the nurse. Although nurses in the psychi-
atric setting may frequently see psychotic patients (more than 50% of psychiatric
beds are occupied by patients with schizophrenia [Berkow, 1992]), nurses in
other settings may be unprepared for managing the psychotic patient. These
patients are often feared and shunned by healthcare workers.

Hallucinations and delusions can be frightening for both the patient to expe-
rience and the nurse to observe. Even hallucinations that begin as fairly innocu-
ous experiences can become frightening or accusatory to the patient (Box 11–1).
Subjects of delusions vary. Common delusions are described in Box 11–2.

Hallucinations, delusions, or other psychotic thought disorders occur in
patients with a primary psychiatric disorder such as schizophrenia, delusional
disorder, brief psychotic disorder, or severe depressive disorder. Physiological

178 Chapter 11 ■ Problems with Psychotic Thought Processes

BOX 11–1
Recognizing Hallucinations
Affected Sense Example

Auditory (most common)


Kinesthetic (bodily or
movement sense)

“I watch gypsies bring different babies to my
apartment, each night.”
“The voices are calling me a prostitute.”
“When I touched my arm, I could tell my arm
is made of stone.”
“I don’t want to stay in that room. I can smell
the odors of the people who died there.”
“I taste milk in my mouth all the time.”
“It feels as if the rats in my head are eating up
my brain.”

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changes or drug and alcohol use or withdrawal can also cause these thought dis-
orders. Whether or not the etiology of the symptoms is known, the basic inter-
ventions are similar.

Psychotic thought disorders lead to severe distortion of and withdrawal from
reality, accompanied by major personality disorganization. This disorganization
leads to hallucinations, delusions, and bizarre behavior such as catatonia (assum-
ing inappropriate postures or becoming completely immobile) or echolalia (repe-
tition of words heard).

Schizophrenia, a psychiatric diagnosis characterized by changes in cognitive,
perceptual, affective, motor, and social domains, is one of the most common
forms of psychosis. Schizophrenics have psychotic episodes, but not all psychotic
episodes are caused by schizophrenia. The word schizophrenia refers to splits
between different components of the personality; for example, what the patient
says does not match the emotion shown. The onset of schizophrenia occurs
between the ages of 17 and 25 for 75% of cases (Moller and Murphy, 2001). Ear-
lier onset is associated with poorer outcome. The lifetime prevalence of schizo-
phrenia is 1% worldwide, with no differences related to race, social status,
culture or environment (Mariani, 2004). All socioeconomic and cultural groups
are affected, but schizophrenics tend to cluster in the lower socioeconomic levels
because of their difficulty maintaining employment and functioning in society.
Schizophrenia is a chronic, disabling condition, although symptoms can usually
be controlled with appropriate medication. Schizophrenic patients can also have
features of depression, manic behaviors, or both (schizoaffective disorder). Pre-
dictors for schizophrenia include social maladjustment and schizoid personality.
See Box 11-3 for the various forms of schizophrenia.

Other types of psychoses include delusional disorder, brief psychotic disorder
and psychosis due to general medical condition.

Patients without a psychiatric illness who experience sensory deprivation or
overstimulation can become psychotic. A common example is referred to as
intensive care unit (ICU) psychosis. However, the patient does not need to be
physically located in the intensive care unit to experience this problem. Psycho-
logical stress, sleep deprivation, sensory overload, and immobilization all con-

Chapter 11 ■ Problems with Psychotic Thought Processes 179

BOX 11–2
Common Delusions
Delusion Example
Grandeur (belief of exaggerated importance)
Paranoia (belief of deliberate harassment and
Reference (belief that the thoughts and
behavior of others is directed toward self)
Physical sensations (belief that parts of body
are diseased, distorted, or missing)

“I am Napoleon Bonaparte.”
“The FBI is following me
and wants to kill me.”
“Those people on the TV
show are talking to me.”
“I have no blood in me.”

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tribute to the critically ill person’s developing personality changes, hallucinations,
and delusions. A delirium from a medical condition or drug reaction can also
contribute to psychotic behavior. Physiological changes such as hypoxia, renal
failure, and response to medications also contribute.


No single cause of schizophrenia has been identified. Genetic theories recognize
possible hereditary tendencies because there is a higher incidence in families with
one schizophrenic parent or sibling. Biological theories have received increasing
attention. Some causes may be brain dysfunction in the limbic system and pre-
frontal cortex or biochemical disruption in neurotransmitters such as dopamine.
Antipsychotic medications work by blocking dopamine activity. Psychological
theory focuses on deficits caused by severely inadequate parenting throughout
development, with special recognition of the devastating impact of deprivation
during the first years of life. The more research validates the genetic and biologic
theories, the less psychological theories appear to be causal. Clearly, though, per-
sonality is affected by psychological development and in turn affects outcomes in
patients with schizophrenia. Cognitive theories indicate that the patient with
schizophrenia has problems with attention or information processing. The per-
son is unable to filter stimuli, leading to disorganization of mental functioning.
Family theory has examined communication patterns that present unrealistic and
unworkable expectations for the susceptible individual.

Other types of psychotic disorders may develop in individuals with fragile egos
who become flooded with anxiety under severe stress.


Certain physical conditions and medications, drug and alcohol withdrawal, and
sleep and sensory deprivation cause some type of brain dysfunction that may
result in psychosis. Examples of physical conditions include brain tumors, head
injuries, high fever, septicemia, AIDS, encephalitis, epilepsy, and hepatic
encephalopathy. Box 11–4 lists the types of psychotic reactions caused by med-

180 Chapter 11 ■ Problems with Psychotic Thought Processes

BOX 11–3
Types of Schizophrenia
Type Characteristics
Paranoid Schizophrenic

Regressive and primitive behaviors
Marked abnormalities in motor function
Delusions of persecution or grandeur
Does not meet criteria for other types

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ications. Withdrawal from alcohol as well as effects of drugs such as LSD, PCP,
stimulants and cocaine can also produce psychosis.

Disorders, medications, and environmental factors can alter cerebral perfusion
and chemistry to create biological states that mimic some psychiatric disorders,
including exhibiting psychosis and thought disorders. The combination of med-
ications, sensory and sleep deprivation, fear and anxiety, and illness put the patient
in an intensive care unit at risk of experiencing psychotic episodes. If this occurs,
a thorough assessment is essential to accurately determine the underlying cause.

A patient with a psychotic disorder may also misuse drugs or alcohol as a way
to self-medicate for uncomfortable symptoms. These medications could intensify
psychotic symptoms and confuse the diagnosis and treatment. Dual or co-
occurring diagnosis is the term used to describe someone with a substance
dependency and a major psychiatric disorder.

Chapter 11 ■ Problems with Psychotic Thought Processes 181

BOX 11–4
Drugs Associated with Psychotic Reactions
• Amphetamines
• Antidepressants (particularly tricyclics)
• Anticholinergics (e.g., atropine)
• Anticonvulsants (e.g., carbamazepine, valproic acid)
• Antihistimines (e.g., diphenhydramine)
• Antiparkinsonians (e.g., L-dopa)
• Antituberculosis (e.g., isoniazid)
• Antivirals (e.g., acyclovir, amantadine)
• Antiarrythmics (e.g., Lidocaine)
• Alcohol
• Beta blockers (e.g., propranalol)
• Corticosteroids
• H2-receptor blockers (e.g., cimetidine)
• Cyclosporine
• Digitalis
• Dilsulfiram (antabase)
• Anesthetics (e.g., ketamine)
• Antibiotics (e.g., cephalosporins, ciprofloxacin, sulfonamides)
• Opioids (e.g., morphine, hydromorphone)

Source: Adapted from Goff D.C., Freudenreich, O., & Henderson, D. C. (2004). Psychotic patients.
In T. Stern, G. L. Friccione, N. H. Cassem, M. S. Jellinek, &. J. F. Rosenbaum (Eds.), Massachu-
setts General Hospital handbook of general hospital psychiatry (5th ed.) (pp. 155–173). St Louis:

11 Gorman(F)-11 11/5/07 4:58 PM Page 181


Although schizophrenia is rare in children, it has been identified. Symptoms
include inappropriate affect, hallucinations, and mutism. It is often confused with
autism, which is the most severe developmental disability of childhood, but it is
not the same disorder. Children with psychotic disorders can be treated with
antipsychotic medications, but side effects such as sedation and weight gain are
a concern.

Children of parents with schizophrenia are at high risk for developing the dis-
order. As children of the mentally ill, they are at risk for being victims of abuse
because they may be inadequately protected as a result of parental illness. They
are likely to take on more responsibility to care for the household and less likely
to have developmentally appropriate social skills because of the poor skills of
their parents. Because so many people with schizophrenia are homeless, their
children may be living on the streets.

The diagnosis of schizophrenia is more common in adolescence. Teens may be
more likely to experiment with drugs in an effort to self-medicate to deal with
distressing symptoms of anxiety and hallucinations. The move to college can trig-
ger a psychotic episode in an at-risk teen or an exacerbation of long standing
mental disorder. Being away from home, increased pressure to make independent
decisions, and exposure to drugs and alcohol can all contribute to a psychiatric
crisis in an adolescent at risk for psychosis.

Postpartum psychosis is a relatively rare disorder. Psychotic behavior tends to be
evident within 4 weeks of delivery. Women with a past history of this are at higher
risk for recurrence with succeeding pregnancies. If the symptoms last longer than
4 weeks, other diagnoses need to be considered. For patients at risk for this con-
dition, precautions need to be in place to prevent child abuse and/or neglect.

Older Adults
Elderly schizophrenics often have fewer and less severe symptoms, especially hal-
lucinations and delusions, although symptoms of emotional flattening and loss of
motivation often continue. These patients often do not verbalize pain or discom-
fort, which leads to under-treatment of medical conditions. The first signs of
physical illness in these patients may be changes in ability to perform activities of
daily living. They are also more prone to the nonreversible drug side effect of tar-
dive dyskinesia (constant involuntary movements). See Chapter 21 for further
discussion. With elderly persons living longer and mentally ill people less likely

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to be institutionalized, it is believed that there will be an increase in the number
of these patients in nursing homes and retirement settings.

A new onset of psychotic behavior in elderly people must be closely assessed
to rule out physical illness, delirium, or medication toxicity. Because elderly per-
sons may already have some sensory deprivation, illness, and use a variety of
medications, the simple fact of their being hospitalized can increase anxiety and
can make them at risk for confusion and psychosis. Symptoms can easily be con-
fused with those of dementia, which could lead to inappropriate treatment.

Chapter 11 ■ Problems with Psychotic Thought Processes 183

• May avoid psychotic patients because the nurse feels that he or she lacks

knowledge or experience with them.
• May feel strangely uncomfortable or detached because of patient’s lack of

emotional connectedness.
• May feel frustrated and angry and have unrealistic expectations regarding

the patient’s self-care.
• May feel afraid because of patient’s bizarre behavior. May fear violence and

personal harm.
• May feel confused when patient responds unpredictably.
• May ignore patient’s complaints because “he’s crazy.”
• May feel rejected if patient’s extreme mistrust or fear of others is not under-

• May feel that he or she has to control patient’s bizarre behavior to be

• May feel unable to intervene, leading to the nurse’s giving up on the patient.


Behavior and Appearance
• Strange or bizarre appearance, poor grooming, disheveled, eccentric clothing
• Unusual gestures, mannerisms, facial grimaces, posturing
• Neglect or difficulty performing activities of daily living
• Incoherent, repetitive speech; mumbling; talking to self
• May not answer questions or responds only partly; frequently asks that

questions be repeated.
• May be watchful or withdrawn: head positioned, eyes moving, watching

something that is not there.
• Socially unacceptable behavior and speech; may make up words
• Marginal functioning, such as being unable to maintain employment

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Mood and Emotions
• Displays emotions inappropriate to situation such as crying when others are

• Displays contradictory emotions at same time; unpredictable mood changes
• Flat affect
• Highly anxious, panic
• Difficulty controlling emotions: outbursts of rage, crying, laughing

Thoughts, Beliefs, and Perceptions
• Poor concentration
• Impaired ability for abstract and/or logical thinking
• Loose associations (ideas shift rapidly from one unrelated subject to another)
• Hallucinations; sensory distortions such as seeing objects or people change

in size and shape
• Delusions
• Extreme sense of worthlessness; overwhelming, inappropriate guilt
• Decreased recognition of own body sensations, such as hunger, pain, and

urge to urinate
• Depersonalization (sense of feeling separated from body)
• Suspicious; paranoid
• Extreme ambivalence; impaired decision-making ability; inability to prob-

lem solve
• Altered sense of self; uncertain where own body stops and external objects

and people begin

Relationships and Interactions
• Dependent on others for basic needs
• Fear and distrust of others
• Unable to maintain close relationships
• Lack of social skills
• Interactions seem cold and detached
• Poor eye contact; withdrawn

Physical Responses
• Complaints of unusual or bizarre symptoms
• Blunting of pain

Pertinent History
• Psychiatric hospitalizations
• Ongoing or periodic outpatient psychotherapy
• Substance abuse

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• Childhood behavior problems such as being isolated or described as “odd”
• Minor infractions of law
• History of suicide attempts


Although they are not cures, antipsychotic (or neuroleptic) medications can reduce
and control many of the symptoms of psychosis. See Chapter 21 for a detailed dis-
cussion of these medications. Antipsychotics are especially effective in managing
agitation, combativeness, and belligerence. Newer antipsychotics, often called
atypical, such as risperidone (Risperdal), quetiapine (Seroquel), and olanzapine
(Zyprexa) are particularly effective in treating social withdrawal, flat affect, hal-
lucinations, and delusions. These are now being used for patients with schizo-
phrenia that is refractory to other antipsychotics. They have fewer extrapyramidal
side effects than the older antipsychotics. One of the original atypical medications,
clozapine, can cause agranulocytosis. Though more effective, these drugs are con-
siderably more expensive than traditional antipsychotics. Patients with schizo-
phrenia may need to remain on these medications for the rest of their lives, and
symptoms can recur if they stop taking them. Approximately 25% of patients
with schizophrenia do not respond adequately to traditional antipsychotics
(Moller & Murphy, 2001). For patients with chronic psychotic processes, finding
the right antipsychotic with minimal side effect profiles can take months or even
years of trial and error. Traditional antipsychotic drugs like haloperidol are used
less today due to the extrapyramidal side effects which impact functioning.

Antipsychotics can be given on an occasional basis to manage acute agitation,
such as might be seen in ICU psychosis or drug reaction. They control the symp-
toms until the problem resolves or the cause can be treated.


RISK FOR VIOLENCE evidenced by agitation, aggressive behavior related to
delusions and hallucinations.

Patient Outcomes
• Able to maintain control of own behavior
• Demonstrates less anxiety
• Does not cause harm to self or others

• Reassure patient that he or she is safe and that the staff will provide pro-

tection. Be aware that the psychotic patient is more timid and frightened
than dangerous.

Chapter 11 ■ Problems with Psychotic Thought Processes 185

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• Avoid putting patient on the defensive. Avoid ultimatums.
• Maintain nonstimulating environment. Use a calm voice with relaxed,

nonthreatening body language.
• Ask if patient is hearing voices and if he or she can tell you what they are

• Ask the patient if he or she is hearing “command” hallucinations, such

as voices commanding him or her to act a certain way. If these commands
are for dangerous behavior, monitor the patient closely.

• Reinforce the patient’s ability to remain in control of his or her behavior.
• Be aware of signs that indicate tension level is increasing.
• Monitor patient’s behavior closely. If having hallucinations or delusions

that are very frightening, patient could inadvertently harm self or others
(e.g., the patient has to protect himself or herself from a monster in the
room or voices saying to kill himself or herself). Observe closely if this
occurs and seek out additional assistance.

• The patient may interpret even the most innocent behavior as threatening
(turning up the thermostat could be interpreted as turning on poison gas).

• Administer ordered antipsychotic medications. Consider injectable ones
for faster onset of action. Patient may need these medications admin-
istered frequently (rapid tranquilization) until behavior is controlled.
Monitor closely for side effects including postural hypotension and extra-
pyramidal symptoms.

• Determine if use of touch calms patient or adds to his or her distress. Ask
the patient’s permission to be touched.

• Set limits on destructive behavior. Let the patient know what behavior is
and is not allowed. Reinforce to staff members that everyone must sup-
port the same approach.

• If patient is out of control, use restraints only as last resort. See Chapter
8 on managing violent behavior and restraint application. For the psy-
chotic patient, restraints can represent a relief from the tremendous anx-
iety and loss of control being experienced, or they can significantly
increase anxiety and persecution delusions. Have adequate, trained staff
available to manage potential violence.

DISTURBED THOUGHT PROCESSES evidenced by inability to evaluate
reality; hallucinations, delusions related to schizophrenia or other psychoses.

Patient Outcomes
• Demonstrates clear communication to others
• Maintains reality orientation (person, place, time, situation) and demon-

strates good reality testing
• Demonstrates improved ability to participate in treatment plan

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• Determine if patient’s behavior is a chronic problem or if this is a new

onset. If chronic, determine baseline behavior, medications taken, psy-
chiatric care received, and provider. If new, determine possible causes.

• Make short, frequent contacts to help build trust by helping the patient
feel secure.

• Focus on the present reality rather than future or past. Speak simply.
Focus on concrete subjects. Keep directions simple. Give only one step at
a time. Avoid theoretic or philosophical topics.

• Provide a quiet, nonstimulating environment.

• Use one form of communication at a time; avoid using a lot of hand
motions while speaking.

• Although psychotic speech is unclear, listen for unconsciously symbolic

• Avoid giving choices to severely disorganized patients to avoid provoking

• If possible, problem solve with the patient about ways to cope with

• Provide frequent reality orientation: review location, date, and so on.

• Arrange for the same staff members to care for patient, if possible.

• Find ways to provide structure in patient’s day; provide a written sched-
ule to follow.

• Make sure patient is taking and swallowing prescribed antipsychotic
medications. Recognize that hallucinations and especially delusions may
take weeks to months to diminish fully once the medication is started.

• Patient can easily misinterpret what you are saying or doing. Obtain fre-
quent feedback from patient.

• Monitor patient’s decisions. Poor judgment may indicate an exacerbation.

• Ask the physician to arrange for a psychiatric consultation.

• For the patient who may be reacting psychotically to the stressful hospi-
tal environment:

• Ensure that patient is able to get adequate rest and sleep.

• Make sure patient is oriented to the time of day.

• Explain equipment and noises and their significance to patient.

• Call patient by name and personalize his or her care.

• Encourage family to bring in personal belongings such as photographs.

• Vary stimuli around the patient; for example, turn on music or TV at

Chapter 11 ■ Problems with Psychotic Thought Processes 187

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• If the patient is hallucinating:

• Ask patient directly about his or her hallucinations. For instance, you
may say, “Are you hearing voices? What are they saying to you?” “Are
they telling you to do anything or not to tell?”

• Watch patient for cues that he or she is hallucinating: eyes darting to
one side, muttering, or watching a vacant area of the room. Patient
may deny hallucinations per imagined commands to do so.

• Avoid reacting to hallucinations as if they are real. Do not argue back
to the “voices.”

• Do not negate patient’s experience, but offer your own perceptions.
For instance, you may say, “I don’t see the devil standing over you, but
I do understand how upsetting that must be for you to be seeing that.”

• Focus on reality-based diversions and topics such as conversations or
simple projects. Tell patient, “Try to not listen to the voices right now.
I have to talk with you.”

• Be alert to signs of anxiety in the patient, which may indicate that hal-
lucinations are increasing.

• If the patient is having delusions:

• Be open, honest, and reliable in interactions to reduce suspiciousness.
Respond to suspicions in a matter-of-fact and calm manner. Ask patient
to describe the delusions: for example, “Who is trying to hurt you?”

• Avoid arguing about the content of the delusions, but interject doubt
where appropriate: for example, “I don’t think it would be possible for
that petite girl to hurt you.”

• Focus on the feelings that the delusions generate, such as “It must feel
frightening to think there is a conspiracy against you.”

• Once patient describes delusion, do not dwell on it. Rather, focus con-
versation on more reality-based topics. If patient obsesses on delusions,
set firm limits on amount of time you will devote to talking about them.

• Observe for events that trigger delusions. If possible, discuss these with

• Validate if part of the delusion is real, for instance, “Yes, there was a
man at the nurse’s station, but I did not hear him talk about you.”


Coping, Ineffective
Injury, Risk for
Self-Care Deficit
Sleep Pattern, Disturbed
Social Isolation

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• Teach patient signs of escalating symptoms.
• Teach patient effective interventions to control anxiety and fears, such as

distraction, listening to music.
• The patient needs to have strategies for coping with hallucinations. Some

suggestions include reading aloud, telling voices to go away, physical aciv-
ity, calling someone for help.

• Review with patient ways to validate whether what is being experienced is
real, such as asking others if they see or hear the same things.

• Make sure family or caregivers are aware of signs of escalating symptoms
and provide suggestions for managing them. For chronic psychotic disorders,
give the family written information on the diagnosis or suggest appropriate
reading, such as Surviving Schizophrenia: A Family Manual by E. F. Torrey.

• Teach the importance of taking prescribed medications and ways to manage
side effects.

• Teach the importance of informing the physician of new symptoms, delu-
sions, physical symptoms, and pains.


• Document patient’s behavior and content of delusions and hallucinations.
• Document the administration of medications, side effects, and patient’s

response to the medication.

Chapter 11 ■ Problems with Psychotic Thought Processes 189


• Self-mutilation
• Suicide threats or attempts
• Aggressive behavior escalating to violence
• Hallucinations or delusions with increasingly violent, bizarre content
• Patient’s inability to care for self
• Increasing staff anxiety and fear over patient’s behavior


• Psychiatric Team
• Security
• Social Worker

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• Document efforts and effectiveness in controlling patient’s behavior.
• If restraints are needed, document the type used and appropriate monitor-

ing provided.
• Document the family response to patient and the education and discharge



• Determine psychiatric care and provider. Reinforce the need to continue in
treatment. Reinforce to the family or caregivers their responsibility for get-
ting the patient to follow-up appointments. Give patient and family written
referrals and specific appointments for psychiatric care.

• Emphasize to the family their need for emotional support. Refer to appro-
priate programs or support groups, such as local chapters of the National
Alliance for the Mentally Ill.

• If the patient has a chronic psychiatric disorder, determine patient’s func-
tional ability. Referrals may be needed to programs to assist with employ-
ment skills and living arrangements.

• If the patient has difficulty functioning in society, he or she may need to be
transferred to a psychiatric hospital or more protected living arrangements,
such as a halfway house, group living home, or day treatment program.

• Reinforce need to continue follow-up medical care. Give written specific

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Problems Relating
to Others

The Manipulative Patient

Learning Objectives
• Identify types of manipulative behaviors.
• Identify some possible nurses’ reactions toward manipulative patients.
• Describe “staff splitting” and characteristic manifestations.
• Define confrontation and limit setting as therapeutic responses.
• List effective nursing interventions to deal with manipulative patients.

Adaptive manipulation – Skillful management or use of one’s self to affect or

change a situation to one’s best advantage. It is goal oriented, used only
when appropriate, considers others’ needs and welfare, and is only one of
several coping mechanisms used.

Antisocial personality disorder – A psychiatric disorder in which there is a
pervasive pattern of disregard for and violation of the rights of others. Indi-
viduals with this disorder rarely feel motivated to change.

Borderline personality disorder – A psychiatric disorder in which there is a chro-
nic state of instability with changes in relationships, self-image, and mood.

Cognitive behavior therapy – Form of psychotherapy that focuses on chal-
lenging core beliefs that adversely affect self-perception

Dialectical behavior therapy – Form of cognitive behavioral therapy for the
borderline client that focuses on gradual behavior change, teaching skills
to regulate emotions, group social skills training, and psychotherapy.

12 Gorman(F)-12 11/5/07 5:03 PM Page 191

Maladaptive manipulation – Similar to an addiction and not goal directed, it
is the predominant, continuous controlling of others whether or not it is
appropriate, effective, or attains specific goals.

Personality disorder – A group of psychiatric disorders in which specific, per-
vasive patterns of inflexible, enduring maladaptive thinking about one’s self
and the environment cause difficulties in interpersonal relationships and
the ability to do work.

Splitting – An unconscious defense mechanism found in certain manipula-
tive people that causes them to experience others only in the extremes of
love or hate, or good or bad.

Staff splitting – An unfortunate staff response to a patient that leaves the staff
members arguing and not coordinating with each other. The staff members
whom the patient treats well think highly of the patient and the others
do not.

The word manipulation usually conjures up negative images of pushy, untrust-
worthy individuals who are concerned only with getting what they want with

no regard for other people’s feelings, priorities, or needs. However, manipulation
can be viewed more accurately as a tool that is not inherently bad
and that can be used in either constructive or maladaptive ways. For instance,
adaptive or constructive manipulation is an effective technique for a charge nurse
making assignments to ensure the best use of nursing personnel to meet patients’
needs while considering the nurses’ preferences and learning needs. Some people
use maladaptive manipulation strategies during periods of stress to avoid uncom-
fortable, anxiety-arousing feelings and to gain a sense of security. The patient
may use manipulation to compensate for feeling overwhelmed, out of control,
and frightened by illness, hospitalization, or personal or occupational concerns.

People who consistently use maladaptive manipulation regardless of the cir-
cumstances may have a personality disorder. Personality disorders are frequent in
the general population and may coexist with other psychiatric diagnoses. Bor-
derline personality is the most common personality disorder seen in the clinical
setting (Oldham et al, 2001). People with this disorder make up about 1% to 2%
of the population and 20% of psychiatric inpatients (Gunderson, 2001). These
individuals operate using ingrained behavior patterns that have been effective for
them, and they may not be aware of their manipulative behavior, the cause-and-
effect relationship between their actions and resulting consequences, or the pos-
sibility of alternative, effective approaches. This behavior can be very difficult to
change because the person is repeatedly rewarded by achieving his or her goal
when the manipulation is successful. People with borderline personality disorder
manipulate to gain nurturance. They are so fearful of separation that they use
manipulation to try to achieve a goal of maintaining closeness. They may exhibit
both clinging and distancing behavior as they struggle with these issues
(Townsend, 2006). The family of borderline patients may have a long history of

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frustration and exhaustion with having to deal with multiple impulsive acts.
Another common disorder is antisocial personality disorder. Individuals with this
disorder manipulate to gain power, possessions, or some other material gratifica-
tion. Antisocial personality disorder is also associated with social irresponsibility
and reckless or criminal behavior. Manipulative behavior stemming from per-
sonality disorders can be either blatant or insidiously covert. The manipulative
person may appear superficially pleasant. However, the person being manipu-
lated often recognizes the impact or results even if he or she is unable to describe
clearly how they occurred.

Manipulative behavior can also take the form of sexually inappropriate behav-
ior such as provocative language or inappropriate touching or threats of violence
as a way to maintain control over others (Manos & Braun, 2006).

The first sign of a patient’s use of maladaptive manipulative behavior may be
the staff’s growing frustration and anger. Manipulative patients may uncon-
sciously project their own thoughts and feelings onto staff members and see one
or some of them as a mirror image of themselves. As a result, the patient per-
ceives the staff members as manipulative, unreliable, and even verbally abusive.
When the patient feels threatened, he or she tries to control the situation by
manipulating, attacking, or avoiding the staff members.

Two effective techniques for working with manipulative patients are con-
frontation and limit setting. Both of these techniques need to be used consistently
with concern for the patient. Although the word confrontation is usually associ-
ated with hostile, antagonistic battles, it is used effectively as an intervention to
dispassionately point out to the patient a discrepancy among words, actions, or
feelings. For instance, “You said you have not seen a doctor before coming to the
ER, but you have a bottle of prescription drugs dated last week. Where did you
get that?” Setting limits is teaching and maintaining boundaries of the nurses’
and the patient’s roles and acceptable behaviors. This may mean telling a patient
what he or she may or may not do under certain conditions or in certain situa-
tions (see Box 8–3).

Despite protests, manipulative patients feel more secure and less out of control
when their behavior is contained. Using these techniques, nurses can alleviate
much of the patient’s insecurity and help to create the appropriate boundaries of
acceptable behavior. Before being successful at using these techniques, however,
you need to feel comfortable being assertive and being in the role of an author-
ity figure. The nurse’s past experiences with authority figures and individual per-
sonalities influence his or her ability to master these techniques. It is important to
realize that no one can completely control another person’s behavior.

Manipulative patients who unconsciously block painful feelings by splitting
their perceptions of people into the extremes of all good or all bad can have a
very disruptive, divisive effect on the staff. Staff splitting is a possible response to
splitting when the patient idealizes certain staff members, treating them as all
worthy and good while viewing others as all bad and criticizing and devaluing
them. The staff may respond similarly, each one either intensely liking or dislik-
ing the patient and eventually becoming alienated from each other (Box 12–1).

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According to psychological theory, manipulative patients do not trust other peo-
ple to like or accept them, to be responsive to them, or to be responsible toward
them. Consciously or unconsciously, they rely on manipulative behavior to de-
mand that others supply what they need and want.

Manipulative behavior in health-care settings may reflect the patient’s ongo-
ing, habitual mode of interaction, or it may be an escalation of milder, more com-
mon control mechanisms. In the hospital setting, the patient may regress and
have unrealistic expectations that his or her every need will be instantly gratified.
Disappointment results in fury and an increase in manipulative behavior.

194 Chapter 12 ■ Problems Relating to Others

BOX 12–1
Warning Signs of Staff Splitting
A manipulative patient can have a devastating effect on the staff and func-
tioning of the unit. Staff group behavior that can indicate that staff splitting
has occurred includes:

• The staff viewed as “all bad” by the patient demonstrates resentment toward
the other staff members who are liked by the patient.

• Lunch hour and coffee breaks are dominated by discussion of the specific

• The nucleus of an in-group believes that only they can help the patient.

• Loss of morale and confusion in the out-group.

• Criticizing each other for how they handle patient issues

• Blurring of staff-client role boundaries (for instance, patient and staff dis-
cuss another staff member, staff share personal information with patient,
give personal phone number to patient, spend off time worrying about the

• Split in- and out-groups make accusations: “ins” accuse “outs” of being
cold and insensitive; “outs” accuse “ins” of being too permissive and
gullible and of spoiling patient.

• Splits between departments in a hospital agency structure.

• Staff keeping secrets about the patient.

• Staff members use poor judgment in decisions about this patient.

Source: Adapted from Lego, S. (1990). Borderline personality disorders. In E. Varcarolis (Ed.), Foun-
dations in mental health nursing (pp. 408–420). Philadelphia: WB Saunders; Groves, J. E. (2004).
Difficult patients. In T. A. Stern, G. I. Friccione, N. H. Cassem, M. S. Jellinek, & J. F. Rosenbaum
(Eds.), Massachusetts General Hospital handbook of general hospital psychiatry (5th ed.) (pp.
293–312). St. Louis: Mosby; Manos, P. J., & Braun J. (2006). Care of the difficult patient. New
York: Routledge.

12 Gorman(F)-12 11/5/07 5:03 PM Page 194

Chronic manipulative behavior may result from childhood dilemmas if parents
undermined attempts toward independence and autonomy. Manipulative indi-
viduals have come to suspect that any person or institution may try to control
them, rendering them powerless and vulnerable to attack. Even being cooperative
can be viewed as giving in or being weak, negatively affecting self-esteem.
Authority figures are seen as being stronger and having too much control over the
patient’s life. The patient may seek ways to equalize the power by controlling
staff, not complying with medical regimen, and making excess demands. Suicidal
gestures may be a frantic attempt to regain control or block painful feelings of
helplessness or dependence. Fear of rejection and abandonment or expectation of
increased responsibility are also triggers for self-destructive acts.

The learning theory of manipulative behavior focuses on the concept that the
behavior may have been learned in childhood based on adult role models, peers,
and even the media. The family theory suggests that manipulative behavior may
have been developed, especially in younger years, as the only way to cope with a
severely dysfunctional family.

Antisocial personality disorder frequently arises from a chaotic home environ-
ment with early parental deprivation. There may be some genetic link. Borderline
disorder is associated with separation issues concerning parental figures. Brain
dysfunction causing poor impulse control and mood instability have also been
implicated in the etiology of borderline personality (NIMH, 2001). Personality
disorders are generally associated with depression.


These patients may rely on sedatives, analgesics, or other substances to reduce
feelings of anxiety. These substances may trigger reduced inhibitions and increased
aggressive responses. These patients are high users of inpatient services because of
multiple crises (Shoemaker & Varcarolis, 2006). Borderline patients may use the
hospital for multiple medical problems and results of self-destructive behaviors.


Children and Adolescents
Manipulative behavior begins in the earliest years, partly as a way to test the
responses of parents and other caretakers. Toddlers have temper tantrums and
quickly learn whether or not they can get their way. Children of all ages mimic
the manipulative behavior of parents and siblings, such as making promises that
are not kept. Or they may try getting permission from one parent after receiving
a “no” from the other. They also learn from their peers. They may try to obtain
privileges or possessions by saying that all their friends have these already.

Disturbed, maladaptive manipulative behaviors manifested in conduct disor-
ders are seen in childhood and adolescence. Those who rely on deceitfulness can

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also display cruelty to animals or other children, destructiveness of property, and
serious violations of rules. This can evolve into antisocial personality disorder in
adulthood. These children may have experienced more severe deprivations such
as multiple rejections, neglect, or abuse.

People who have successfully used manipulative behavior as children tend to
become more proficient at this behavior as they grow older. They tend to flour-
ish in systems where they are able to manipulate. People who are extremely
manipulative and exploitative may violate laws and end up in the criminal justice
system. Those who exhibit strong manipulative tendencies but are able to stay
within legal confines may become successful in using people, personally and pro-
fessionally, for their own goals.

196 Chapter 12 ■ Problems Relating to Others

• May feel angry, frustrated, or resentful for being tricked; may have lowered

self-esteem if unable to stop the manipulation; or may feel embarrassed or

• May feel helpless in relieving patient’s apparent distress or when attempting
to get patient to conform to nurse’s expectations of reasonable conduct.

• May feel vulnerable and afraid of patient’s attacks.

• May take manipulations personally and react defensively, especially when
challenged in authority or position.

• May reject patient because the experience of coping with personal reactions
is too draining and demoralizing.

• May avoid patient, spend minimal time needed to provide physical nursing
care, or assign a different nurse to the patient each day.

• May compensate by becoming overcontrolling or engage in power struggles
with patient.

• May experience desire for revenge, retaliation; may become punitive, want
to counterattack by insulting, hurting, or embarrassing patient. May
secretly hope things go wrong for patient.

• May experience guilt about negative feelings toward patient.

• May become overinvolved or overattached and wish to rescue patient.

• May feel total responsibility for patient’s improvement or lack of improve-

• May be punitive in setting limits or confronting the patient or may be
inconsistent or hesitant in enforcing rules for fear of patient’s reaction.

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Older Adults
As people age and become more dependent on others for assistance in activities
or socialization, they may resort more frequently or aggressively to manipulative
behaviors to get their needs met. If inducing guilt has been a personal trait, dec-
larations such as “I don’t want to be a burden” may be intended to stir guilt and
get attention.


Behavior and Appearance
• Frequent disregard of rules
• Argumentative
• Can be superficially charming and entertaining
• Demanding; the more staff try to cater to demands, the more they escalate
• Impulsive and unpredictable; lacks ability to tolerate frustration; can easily

become out of control
• Uses threats to get demands met
• May use intimidation to control or feel superior
• Frustration causes more intense manipulative behavior
• Destructive toward self, others, property without taking responsibility
• Suicide threats and/or attempts
• Lies, cheats, steals
• Intense manipulation around medication; overuse of medication
• Noncompliant with health-care treatment
• Undermines treatment of other patients, such as encouraging them to ignore

doctor’s recommendations or suggesting alternate treatments

Mood and Emotions
• Anger predominates. Behavior can be cutting, sarcastic, and vicious.

• Anxiety rises rapidly to panic, which precipitates impulsive actions. May
not experience anxiety unless facing a threat to self-image or self-esteem.

• Views self as very vulnerable and frightened, even when being intimidating,
or as totally invulnerable to harm or negative consequences, resulting in
reckless behavior.

• Has labile moods and emotions. The more patient is in crisis, the more fre-
quently moods and emotions may fluctuate over the course of a day. May
appear resistant to depression or may have periodic depressive reactions.

• May have inflated or diminished self-esteem. If inflated, denies or distorts
information that would lower self-esteem.

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Thoughts, Beliefs, and Perceptions
• Thinking can contain gross distortions of some specific events or people and

yet maintain accurate perception and good reality of others.
• Projects own thoughts and feelings onto others, resulting in feelings of fear

and manipulation by others.

Relationships and Interactions
• May seek or avoid attention
• Exploitative with little real concern for others; limited capacity for empathy;

demonstrates caring only to get own needs met
• Quick to recognize vulnerable areas in others
• Limited ability to see others for who they really are; distorted perceptions

of how others experience self
• Needs to feel either in control or helpless and vulnerable (Life is seen as a

seesaw competition. If someone else is up, then patient feels down)
• Does not feel a sense of obligation to reciprocate favors or helpful acts
• Devalues others to feel good about self
• Sees others as attacking or dangerous
• Feels and acts as if he or she were entitled to having needs met without com-

parable effort or cost
• Becomes a “special patient” to the staff
• Blames others for mistakes and problems without taking personal responsi-

bility; confuses taking responsibility with being blamed, worthless, and vul-
nerable to attack

• Belief of being superior; cannot admit lack of knowledge and has great dif-
ficulty asking for assistance and information; obtains information by using
indirect manipulation; unable to accept suggestions or criticism

Physical Responses
• Physical complaints that cannot be substantiated with testing
• Magnifies any subjective symptoms that cannot be measured
• With documented disability, usually requires more frequent medication and

higher dosages; recovery takes longer than usual

Pertinent History
• Erratic, impulsive behavior with marked instability; frequent changes in jobs,

relationships, and physicians
• Drug or alcohol abuse
• Long history of many physical complaints

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• Suicide threats and attempts
• Psychiatric diagnoses including major depression, borderline or antisocial

personality disorder


If the patient is given tranquilizers to reduce anxiety, there is a risk for drug
dependence and power struggles (e.g., patient may try to manipulate the nurse to
get extra doses). Individuals with personality disorders may benefit from antide-
pressants to address depression and reduce impulsive behaviors. Fluoxetine and
olanzapine have been helpful in controlling rapid mood shifts. The anticonvul-
sant carbamezepine has been used to improve mood stability. Avoiding PRN
medications can reduce power struggles with the nurse. Regular dosing schedules
of analgesics if needed can be useful. Herbal products may be used as a way to
self-medicate uncomfortable symptoms.

Multidisciplinary Team Communication
When staff members have extremely different experiences with the same patient,
infighting among each other can occur when discussing care for the patient.
These variations in experiences can occur between or among individuals in the
nursing staff, different shifts, nurses and physicians, or all staff members and
administrators. To overcome this staff splitting, the group needs to recognize the
patient’s dynamics and cooperatively share their different perceptions to gain a
more complete picture of the patient. They need to identify whom the patient sees
as “all good” or “all bad” and how this affects interactions.

Once the team has identified the problem behaviors, it is essential to formu-
late a united, consistent care plan. Each staff member should monitor the inten-
sity of his or her individual reactions to the manipulative behavior. This will help
to avoid becoming entrapped into feeling the need to be special or the only one
who can help or avoid getting caught in power struggles. A supportive and coor-
dinated multidisciplinary team approach helps neutralize the manipulative
patient’s ability to identify vulnerability in team members and discord in the
health-care organization.

Psychotherapy represents the core treatment for borderline personality (Gunder-
son, 2001; Oldman, 2005). Dialectal behavior therapy (DLT) has been shown to
have the best results for borderline patient with substance abuse (Oldman, 2005).
Dialectal behavior therapy uses a multimodal approach of individual and group
therapy as well as education. Other useful therapeutic approaches include family
therapy, cognitive behavior therapy, and traditional psychotherapy.

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INEFFECTIVE COPING evidenced by noncompliance with rules and treat-
ments related to impulsive, manipulative behavior.

Patient Outcomes
• Decreased use of maladaptive, manipulative behaviors
• Complies with treatment regimen and hospital rules
• Demonstrates use of effective coping patterns
• Demonstrates more adaptive methods of dealing with stress, such as

using problem-solving skills

• Carefully assess patient’s mode of interaction and frequency over time

before labeling behavior as “manipulative.”
• Determine if the patient is using manipulation to indirectly express a

need, anxiety, or distressful emotion. Active listening and empathetic
responses to underlying issues can help diminish the patient’s anxiety and
need to control others.

• Approach patient in a calm and matter-of-fact manner, using a neutral
tone of voice.

• Provide feedback to patient, who may not be aware that manipulative
behaviors are being used. State specific observations about his or her style
of interactions without arguing. If patient argues or denies, calmly repeat
your observation without becoming defensive. Describe options and con-
sequences. Follow through consistently with consequences.

• Don’t state consequences that you do not have the authority to exercise.
• State which behaviors are not acceptable without personally rejecting the

• Help patient identify when using manipulative behavior becomes an

attempt to control anxiety. Encourage patient to identify triggers for
anger and frustration.

• Encourage patient to verbalize feelings instead of acting them out. Ask
the patient to identify what he or she is experiencing and what feelings
and thoughts preceded the behavior.

• Evaluate whether patient’s manipulative behavior increases or decreases
when not reinforced by nurse’s attention. Be aware that even when ignor-
ing provocation is effective over time, there may be an initial escalation
to test responses.

• Avoid power struggles and attempts to outmanipulate the patient. Point
out that the patient is undermining his or her own care. State explicitly
that the patient will not be forced to accept treatment and that each indi-
vidual is responsible for the outcome of the treatment.

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• Explain as early as possible rules and regulations and the reasons for
them. If allowable limits are not stated, patient may push and test until
they are clarified. If he or she attempts to break the rules, review firmly
the stated expectations.

• Include the patient in decisions about limits and provide opportunities
for personal decision making to enhance sense of control. When all rules
are rigid, the patient may feel a greater need to rebel. Be careful not to
allow patient to dictate nursing decisions.

• Written contracts defining both staff and patient expectations can be
most effective. Specifically define any consequences of patient’s continued
manipulation and lack of cooperation. Nurse and patient can sign con-

• Describe in detail on the care plan the limits set and the consequences of
breaking them. In periodic staff meetings and multidisciplinary case con-
ferences, give current information and promote agreement about the
patient, which will enable staff members to work more consistently and

• Make sure all staff members are aware of limits and consequences. Con-
front colleagues who are observed not following the treatment plan.

• Consult with physician when patient seems to exaggerate complaints of
pain or becomes preoccupied with timing of medications. The physician
may decide to convert a PRN order to low doses of regularly adminis-
tered medications to avoid power struggles.

• Assess for signs of substance abuse or withdrawal if patient has such a
history or shows symptoms.

IMPAIRED SOCIAL INTERACTION evidenced by attempts to undermine,
control and influence, and cause conflict related to splitting, distorted percep-
tions of others, impulsivity, and anxiety.

Patient Outcomes
• Uses acceptable methods to interact with others to communicate and

obtain needs
• Positively responds to confrontation and limit setting
• Demonstrates tolerance of frustration and waiting
• Does not reject or denigrate the staff as “bad” when they are unable to

respond in desired manner
• Demonstrates more trust in relationship with at least one staff member

by sharing personal thoughts and feelings

• Maintain assertive, centered, firm but fair, and even-toned stance when

patient tries to manipulate or undermine you.

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• Tell the patient that he or she may understand events and interactions dif-
ferently than the staff does.

• Direct patient who complains about staff member to discuss the problem
with implicated staff person. Do not allow yourself to be used as an inter-
mediary; do not take sides.

• Use “I” statements indicating how patient made you feel. Avoid becom-
ing defensive, which can escalate manipulative behavior.

• Confront the patient with your perception that he or she is trying to put
you down. This can have an impact even if patient denies it.

• Take time to think about effective responses and to diminish the intensity
of your reactions if patient is trying to manipulate. Use stress reduction

• Role play or discuss situation with other staff, if necessary.
• Return to original topic if patient tries to divert topic to a personal attack.
• Be aware of patient interactions that can increase staff divisiveness by

blaming, accusations, or comparisons. Monitor your own responses.
• Provide praise and reinforcement when patient communicates directly

and openly about needs and concerns.
• Use kind but firm approach. Clarify that setting limits is constructive and

caring rather than punitive.
• Establish from the beginning that you take all of the limits very seriously.

More flexibility can be introduced later as the patient takes more respon-

• Find neutral actions and topics for conversation. This will help to pres-
ent you as a person interested in the patient and not just a rule keeper.

• Be aware that patient may need to test limits repeatedly to see whether
there are repercussions and to be reassured that the staff will follow
through on the consequences.

• Let patient know immediately that threats or verbal abuse is unaccept-
able, that you expect these will never be repeated, and state the conse-
quences of repeated abuses.

• Confront patient when he or she attempts to undermine other patients’

• Do not allow patient to manipulate, flatter, seduce, bargain, or intimidate
staff into granting him or her special status. Do not accept gifts or favors
or share personal information, especially about any current difficulties.

• Never agree to keep a secret with a patient. Remind patient that the
entire health team needs to be aware of patient’s concerns in order to
offer the best care.

• Assess interactions with family. If patient uses same approaches with
them, family members may need information on changing their response.

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Coping, Defensive
Self-Esteem, Disturbed

Chapter 12 ■ Problems Relating to Others 203


• Threats or actions of physical harm to others or self, including suici-
dal threats or gestures

• Undermining own or other’s health care and unresponsive to nursing

• Repeated violation of agency rules
• Evidence of staff splitting
• Noncompliance, which jeopardizes patient’s health status, such as

refusing to take medications


• Psychiatric Team
• Social Worker
• Manager
• Attending Physician
• Advanced Practice Nurse
• Critical Incident Team/Employee Assistance


• Teach patient to ask directly for what he or she wants and needs in words,
not actions. Teach problem-solving skills.

• Help patient recognize that his or her desires may not require immediate
action and that he or she may not always get desired responses.

• Explain the consequences of manipulative behavior.
• If a patient will not take responsibility for own actions, explain how his or

her behavior contributed to the unwanted response or consequences and
that taking responsibility is not the same as being blamed.

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• Teach patient that understanding of one’s own behavior and developing
improved interactions are the avenues for developing stable support net-

• Involve family in patient education. The same skills used in working with
the patient may be helpful for the family.

• Provide information for family members of individuals with personality dis-
orders. Several websites provide information including www.mental-health- and for patient information on
borderline personality


• Describe specific manipulative behaviors objectively rather than just label-
ing the patient as manipulative.

• Develop a detailed treatment plan with interventions so that the team can
respond consistently. Chart patient’s responses to interventions. Update
team care plan as needed.

• Document usage of PRN medication, reason for use, and patient’s response.


• Begin discharge planning as early as possible to decrease last-minute impul-
sive and inappropriate decisions the patient might make without considera-
tion for consequences. When last-minute disruptions to the plan occur,
maintain a consistent, clear approach on the plan that has been developed.

• Inform the family and patient together of patient’s healthcare needs to
reduce manipulative behavior with family.

• Inform referring agencies of patient’s behavior, team care plan, and short-
term treatment planning goals.

• If appropriate, make referrals for individual and group psychotherapy as
well as substance abuse treatment if needed.

The Noncompliant Patient

Learning Objectives
• Identify factors that contribute to a patient’s noncompliance with treat-

ment plans.
• List the principles of adult education that contribute to effective patient


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• Identify nursing interventions to reduce noncompliance in the patient
whose cultural beliefs impede compliance.

• List some nursing staff reactions to the noncompliant patient.

Compliance – Patient’s accurately following a prescribed regimen of treat-

ment. Sometimes referred to as adherence.
Ineffective management of therapeutic regimen – A pattern of regulating

and integrating into daily living a program for treatment of illness and the
sequelae of illness that is unsatisfactory for meeting specific health goals.

Noncompliance – State in which an individual desires to comply but factors
are present that deter adherence to health-related advice given by health-
care professionals. Sometimes referred to as nonadherence.

Compliance and noncompliance are terms that are used to describe patient
behaviors in response to information they are given about their health care.

Compliance usually requires some form of motivation, perception of vulnerabil-
ity, and the belief that the recommendation will control or prevent an illness
(Carpenito-Moyet, 2006). What makes a patient follow, change, or ignore health
teaching is complex and may not always be related to the amount and quality of
information provided. Nurses need to be aware that noncompliance is a symp-
tom of an underlying problem and not the actual problem, and that labeling
behavior as “noncompliant” can have negative connotations, such as blaming or
criticizing a patient who is not following instructions. Once you have identified
that the patient is not following the medical regimen, you need to investigate
what barriers prevented the patient from following the recommendations.
Carpenito-Moyet (2006) describes noncompliance as occurring when the patient
is prevented from compliance due to factors like overly complex instructions,
lack of understanding of instructions, and lack of funds to follow through with
recommendations. If the patient makes an autonomous, educated decision not to
follow recommendations, that behavior is not noncompliance as long as the indi-
vidual understands the risks and benefits of not following the recommendations.
Some educators prefer the term adherence rather than compliance.

The cost of noncompliance is greater than can actually be documented. Besides
factors such as the cost of medications purchased but not taken or taken incor-
rectly, poor results of diagnostic tests caused by poor preparation, and more
severe illness from not following recommended treatments, both patients and
health-care providers can experience a great deal of frustration. Although not the
only reason for noncompliance, inadequate or inappropriate patient education is
among the most common.

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When teaching adults, the nurse needs to incorporate principles of adult learn-
ing (Box 12–2). Adults have different learning needs than children do. Adults are
goal oriented. The goals need to be clearly identified and attainable, and adult
patients need to consistently be made aware of their progress toward their goal.
Adults need to understand how the education will benefit them. Adults tend to
learn better when they understand the rationale for what they are learning, apply
what they learn immediately, and can compare what they are learning to knowl-
edge from past experiences. Learning is inhibited when authoritarian teaching
methods are used. Interpersonal relationships with teachers are important.


Many factors can interfere with the patient not being receptive or not be able to
receive or follow health information:

• Denial: This may be a conscious or unconscious method of believing that he
or she is not sick. For example, by not checking blood sugars, the patient
can block the diagnosis of diabetes from his or her mind.

• Power struggles: At times, the patient who feels a lack of control over his or
her body uses noncompliance as a way to maintain some control over a
sense of destiny or over health-care providers.

• Counterdependence: The patient could be concerned that following recom-
mendations would increase dependency on others. Because dependency can
enhance feelings of loss of identity, noncompliance becomes a statement of
independence and individualism.

• Loss of coping mechanisms: Often, health teaching involves asking the
patient to give up habits that are part of the person’s usual coping strategies.

206 Chapter 12 ■ Problems Relating to Others

BOX 12–2
Adult Learning Principles
• Adults need to participate in the learning process. Avoid directive approach.

Give them some control.
• Adults need to understand the purpose behind any information they receive.
• Adults learn more effectively if past experiences are integrated into the

• Put new information to immediate use.
• Give specific feedback to learner of progress made in learning process.
• Match medication format with learning style
• Barriers to learning are addressed

Source: Knowles, M. A. (1970). The modern practice of adult education. Englewood Cliffs, NJ:
Prentice-Hall; Russell, S. S. (2006). An overview of adult-learning processes. Urologic Nursing,
26(5), 349–352.

12 Gorman(F)-12 11/5/07 5:03 PM Page 206

For example, smoking, diet changes, or exercise may need to be altered or
avoided. If the patient has not yet developed alternative coping mechanisms,
the anxiety created by the loss of these habits may be overwhelming.

• Conflict with self-image: Noncompliance may be a method of self-protection
against the threat of an altered body image, particularly in individuals whose
health and activity are a source of pride. Taking medication or imposing lim-
itations on activity may represent a threat to the individual’s self-image.

• Fatalistic viewpoint: A patient may believe there is no point to following
instructions because of the belief that nothing will change the outcome.

• Hidden benefits of illness: Some people may consciously or unconsciously
perceive benefits from the sick role, such as attention, avoidance of respon-
sibility, controlling the destiny of another, or maintaining stability in a rocky

• Self-destructive behavior: A patient could be consciously or unconsciously
participating in a wish to die or hurt himself or herself, possibly reflecting
depression or suicidal tendencies. It could represent behaviors associated
with a serious personality disorder.

• Psychiatric disorder: Psychiatric illness or altered thought processes may
make consistent compliance with a health routine impossible.

• Family influence: Family members may discourage or undermine compli-
ance because they are using denial, lack the understanding of the treatment,
or unconsciously need to maintain the patient in the sick role.

• Lack of economic resources: If the patient has insufficient funds or no insur-
ance, he or she may need to decide between eating or feeding the family and
buying needed medications.

• Lack of social resources: Lack of funds, fear of being dependent on others,
or lack of social contacts may cause the patient to miss appointments
because there is no transportation.

• Unsatisfactory relationship with health-care team: If the patient perceives
the doctors or nurses as cold, uncaring, not knowledgeable, or authoritar-
ian, he or she may resent or ignore instructions. This may stir up in the
patient such issues as resentment of authority and feeling unrecognized as
an individual. This patient may minimize or distort information given
because of his or her emotional response. Long waits and uncomfortable
waiting areas may also contribute to the poor relationship.

• Lack of trust in information given: Patient may not believe health informa-
tion given because it has not proved useful in the past. Also, with the increase
in media reporting of conflicting reports of studies, patients may think the
information is not trustworthy enough to warrant a change in life-style.

• Cultural beliefs: Cultural or religious beliefs may influence the way the
patient views his or her illness and the treatments that are acceptable. For
instance, women in some cultures may not allow a male health-care
provider to examine their breasts or a Jehovah’s Witness may not accept a
blood transfusion.

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• Inability to read or understand instructions: Some patients may be too
embarrassed to acknowledge that they cannot read English. This may apply
to those who speak another language or even to those who do speak Eng-
lish. Literacy rates in the United States are dropping, so some patients who
function well in society may not be able to read. Also, be aware that some
patients will not admit that they do not understand language that is too
technical or that contains too much jargon. To be understood by the major-
ity, patient education materials should be written at the average reading
level, which for most adults is the fifth to eighth grade level. Low health lit-
eracy contributes to higher rates of hospitalization and use of emergency
services (Contillo, 2007). The Joint Commission for Accreditation of
Healthcare Organizations (JCAHO) has addressed the unsafe care that is
provided because patients do not understand medical jargon. They have
developed recommendations for health-care organizations to improve com-
munication and supported an educational campaign called Speak Up to
encourage patient engagement in their health care (JCAHO, 2007).

• Uncomfortable side effects: Patients may not follow instructions because of
real or perceived side effects, especially with medications. The patient may
be less likely to report them if they are embarrassing, such as impotence or
incontinence. In addition, incorrect beliefs such as fear of becoming depend-
ent on medications may cause some patients not to take medications. Non-
compliance can become part of a negative cycle because the patient feels
embarrassed or guilty for not following through and then begins cancelling
appointments to avoid health-care providers.


When patients are dealing with an acute crisis, most of their energy will be
focused on just coping with the situation at hand. They will not be able to con-
centrate on learning until the crisis has subsided or they have made adaptations
to deal with the situation. During this time, instruction should involve only what
is absolutely necessary. You will need to be prepared to repeat much of the infor-
mation provided as the patient may not remember what he or she was told.

Any physical or mental problem that impairs cognition will also interfere with
learning. Depression, hopelessness, social isolation, and cognitive difficulties may
contribute to compliance when a serious health problem such as myocardial
infarction is diagnosed (Rieckmann et al., 2006).


Following a particular treatment plan can be difficult for ill children and their
families. Medications may affect behavior, alertness, or school performance.

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Incorporating a child’s medical care into family life can create many stressors,
contributing to noncompliance because the child may not be able to be responsi-
ble. It can be time consuming and difficult to administer. Working parents and
single-parent families may not have the time to be able to supervise the child or
take him or her for follow-up care. Because the child may not be able to com-
municate his or her needs, medical care can be difficult to monitor.

The presence of attention deficit hyperactivity disorder (ADHD) can contribute
to discipline problems that make following recommendations very difficult. DSM-
IV-TR (2000) lists a diagnosis of Oppositional Defiant disorder in children and
teens. This diagnosis is found in 2% to 16% of children and is characterized by
a recurrent pattern of negative, defiant, disobedient behavior that can contribute
to noncompliance with health-care instructions.

Parents who refuse to give a child needed medical attention can have legal and
ethical ramifications that could be interpreted as negligence or even abuse.
Parental autonomy to make decisions for their child may be overridden in the
courts if it is determined the child is placed at some risk. In these extreme situa-
tions, legal intervention would be required. Further assessment of parental moti-
vation and religious and cultural beliefs that affect the care of the child needs to
done before any further actions are taken.

Adolescents are particularly vulnerable to problems with compliance. Their atti-
tude is often related to struggles with maintaining independence and rebelling
against adult authority. In addition, any medical regimen that affects body image
puts additional demands on the teenager. Also, because the adolescent does not
want to appear different from his or her peer group, complying with instructions
may be particularly difficult. For example, a diabetic adolescent who is eating
lunch with friends may be fearful of exposing his or her dietary restrictions.

Older Adults
Noncompliance is an extremely important issue for elderly people, who experi-
ence more chronic illness than the general population. Chronic illnesses often
require multiple medications and are often combined with over-the-counter drugs
as well as complementary and alternative therapies. Some elderly persons see
more than one specialist and have a variety of prescriptions from the physicians
they see or may be given contradictory treatment advice. They may become eas-
ily confused. Decreased muscle mass and increased fat stores may make individ-
uals more prone to drug side effects. The elderly patient may need more
assistance and time to explain instructions. If living alone, the elderly patient may
have limited support for encouragement or reminding. Hearing and vision
deficits as well as limited manual dexterity caused by arthritis can present other
problems. In addition, cognitive impairments including poor short-term memory
may inhibit the patient’s compliance by causing him or her to forget instructions
or how many pills have already been taken.

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Behavior and Appearance
• Does not follow rules or instructions, demonstrated by:

• Refusing to take or change medications
• Continuing unhealthy habits
• Missing medical appointments
• Altering medical regimen
• Challenging the necessity or helpfulness of treatments
• Leaving facility against medical advice
• Arguing without constructive resolution
• Indicating understanding or agreement with treatment plan and then not

following through
• Hiding inability to read or comprehend educational material

Mood and Emotions
• Anger
• Depression
• Resentment
• Irritability
• Anxiety

Thoughts, Beliefs, and Perceptions
• Religious or cultural beliefs in contradiction with compliance actions
• Believes health care should be obtained only when symptoms are blatant or

impairing needed activity

210 Chapter 12 ■ Problems Relating to Others

• May become angry or frustrated because the time spent with patient seemed

• May criticize or judge patient who does not follow instructions.
• May feel that situation is hopeless and makes less effort to communicate

with patient.
• May judge self as inadequate or incompetent when patient does not follow

• May feel responsible for patient’s noncompliance. Nurse may have diffi-

culty recognizing that ultimately the responsibility for health care belongs
to the patient.

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• Suspicions concerning motivations of health-care professionals

• Lack of confidence in own abilities

• Denial of health-care needs

• Psychotic thought process or suicidal thoughts

• Belief that one cannot question health-care provider

• Low self-esteem and fear of acknowledging lack of understanding of

Relationships and Interactions
• May avoid sharing information with others about medical regimen

• Tendency to manipulate or control others

• Family not providing needed support

• Inconsistent relationship with health-care team; at times may be very criti-
cal of them and other times more positive toward them

• Following instructions from only one particular nurse

Physical Responses
• Deterioration of health because of lack of compliance

• Blood or urine tests showing drug levels inconsistent with reported medica-
tion intake; discrepancies in other tests

Pertinent History
• Poor outcomes from previous medical treatment

• Poor relationships with past health-care providers

• Noncompliance in earlier health-care treatments

• Inability to read or write


Noncompliance for medication regimen is a major health problem. Not follow-
ing instructions for medications can contribute to safety problems including over-
doses. Many side effects of drugs are caused by misunderstandings about how to
take medication (Goldberg, 2006). Patients do not take medications for a variety
of reasons including fear of side effects, lack of knowledge about the purpose of
the drug, denial of the diagnosis, lack of money to pay for medications, and lack
of support or reinforcement (Box 12–3).

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Multidisciplinary Team Communication
To ensure the best chance for patient compliance, a team approach is essential.
All health-care providers should be consulted to ensure a cohesive treatment plan
and approach that the patient understands. This is a pivotal nursing responsibil-
ity because nurses coordinate most of the care provided, both in the hospital and
in the home. Discrepancies in instructions from physicians, physical or occupa-

212 Chapter 12 ■ Problems Relating to Others

BOX 12–3
Factors that Influence Medication Compliance
Factors that Increase Compliance:
• Client’s perception that illness is severe and medication is needed
• Client’s knowledge of illness and treatment
• Moderate level of anxiety (useful worrying)
• Continuity and length of relationship with caregiver
• Return of unpleasant symptoms immediately on stopping medication
• Caregiver optimism regarding use of medication
• Written instructions tailored to patient’s reading level provided
• Family support
• Side effect management is addressed
• Patient has easy access to obtaining medications (pharmacy close by)
• Longer acting tablets used where possible to reduce frequency of taking pills
• Client receives positive reinforcement for taking medicaitons
• Self-monitoring tools/diaries are easy to maintain
• Patient obtains health information over the Internet that reinforces need for

• Simpler way to take medication provided or fewer number of tablets pre-

Factors that Decrease Compliance:
• Numerous lifestyle changes required
• Uncomfortable side effects
• Lack of support for compliance
• Fear of independence and recovery
• Lack of immediate return of symptoms if medication is stopped
• Fear of drug dependence
• High-cost drugs or equipment required
• Long period when symptoms are controlled

Source: Adapted from Carpenito-Moyet, L. (2006). Nursing diagnosis: Application to clinical prac-
tice (11th ed). Philadelphia: Lippincott Williams & Wilkins; Falvo, D. R. (2004). Effective patient
education (3rd ed.). Sudbury, MA: Jones and Bartlett.

12 Gorman(F)-12 11/5/07 5:03 PM Page 212

tional therapists, pharmacists, or other health-care providers need to be discussed
so that the patient is not left to choose whose advice to follow. Understanding
factors that may contribute to poor compliance must be communicated to all
team members.


NONCOMPLIANCE evidenced by failure to adhere to medical regimen, fail-
ure to keep appointments related to health beliefs, cultural influences, lack of
understanding instructions.

Patient Outcomes
• Verbalizes beliefs that influence noncompliance
• Demonstrates adherence to treatment plan
• Expected therapeutic goals realized

• Develop a trusting relationship with patient. Communicate interest and

openness to patient’s needs and beliefs.
• Assess the degree of noncompliance and the underlying reason for it. One

common area of noncompliance is in using medications. Many prescrip-
tions are never filled, or they are filled and never used. When seeing a
patient in the hospital or in the home, always review the medications the
patient has, how they are being taken, and the patient’s understanding of
why the drug is necessary. Check expiration dates, the name of the physi-
cian who ordered the drugs, and the instructions on the labels. Analyze
whether the patient is taking more than one drug for the same reason,
especially if they were ordered by different physicians. If necessary,
encourage patient to bring in pill bottles to doctor appointments so pills
can actually be counted.

• Encourage the patient to share beliefs or traditions that affect health care.
Demonstrate to patient your interest in learning about these. Do not crit-
icize or belittle these beliefs; rather, communicate your respect for them.

• Ask the patient to share rationale for avoiding the prescribed treatment.
Resolve any misunderstanding the patient may have about the treatment,
its side effects, or its potential outcome. Avoid insisting that the patient
give up his or her beliefs. Never argue with the patient about the value of
the beliefs. Instead, explain any negative outcomes that these beliefs may
cause with his or her condition.

• In critical situations, the patient may need to be confronted more direc-
tly with life-threatening consequences of noncompliance (e.g., taking

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• Enlist assistance of family, friends, caregivers, or, if beliefs are based in a
particular culture, others with whom the patient may relate to, to explain
the consequences of these actions on the patient’s health status.

• Talk with family members about their beliefs about the patient’s illness to
determine their role in noncompliance.

• Obtain feedback from the patient to ensure that he or she understands
the instructions given. Use an interpreter if needed.

• If appropriate, negotiate the best compromise with the patient. Have him
or her commit to one or two areas in which he or she will comply rather
than expecting the patient to give up all his or her beliefs completely.

• Identify one staff member who has the best relationship with patient to
provide information.

• Recognize that it may be impossible to alter the patient’s strong cultural
or religious beliefs. Understand that in some cases, illness, or even death,
may be more acceptable and a higher priority than giving up one’s beliefs.

• Encourage patient to share factors that contribute to noncompliance. Ask
the patient to explain the rationale for actions taken or not taken.

• Avoid using medical jargon or abbreviations that may confuse or intimi-
date. Encourage open communication so that the patient will tell you
when he or she does not understand something.

• Have patient perform a return demonstration or verbalize his or her rou-
tine to determine patient’s understanding and determine areas of non-

• Break down complex regimens into small steps.
• Assess whether other methods of teaching would be more appropriate,

such as videos, Web sites, interactive tutorals on the computer, role-
playing, pamphlets with more pictures, or pamphlets written at a lower
reading level. Minimize any distractions during teaching sessions.

• Incorporate principles of adult learning in educating adult patients. For
example, explain rationale, avoid lecturing or belittling the patient,
involve patient in discussion, and allow patient to identify ways teaching
can be incorporated into his or her lifestyle.

VIDUALS) evidenced by acceleration of illness symptoms or verbalized diffi-
culty with regulating or integrating prescribed regimens related to complexity
of therapeutic regimen or health care system.

Patient Outcomes
• Identifies factors that contribute to not following medical regimen
• Demonstrates adherence to treatment plan
• Expected therapeutic goals realized

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• Ensure that the patient is in the best physical and emotional state for

learning to occur. Remember to repeat information that was previously
given when the patient was dealing with the acute crisis. Avoid teaching
if patient is in pain or has other discomforts.

• Take the time to talk with the patient about his or her understanding of
the problem, why he or she is receiving this information, and what is
expected to be the outcome.

• Demonstrate acceptance of the patient by use of eye contact and touch
where appropriate. Take care to avoid critical comments about the
patient’s situation.

• Set realistic expectation with the patient.
• Assess role of family in patient’s health-care regimen. Determine who

provides care for patient at home, and determine the caregiver’s role in
the noncompliance. Observe caregiver’s technique if appropriate, and
provide information as needed.

• Determine patient’s understanding of using the health-care system.
Review ways to get appointments, arrange additional care such as home
care, and how to contact health-care providers. As needed, check with
social service agencies to provide needed transportation, equipment, or
other services.

• Help identify ways in which patient can individualize information. For
example, if a patient works rotating shifts or travels extensively, you will
need to focus your teaching on how to adapt the treatment plan to best
fit into his or her lifestyle.

• Identify ways to reinforce patient’s self-esteem and sense of competency.
Provide positive reinforcement and recognition of patient improvement.

• Incorporate rewards as part of the teaching. For an adult, rewards may
include those activities that increase self-esteem and a sense of control.

• Be sensitive to signs that the patient is tired or is losing interest. Resched-
ule teaching for another time.

INEFFECTIVE COPING evidenced by not doing, partially doing, or revamp-
ing treatment plan related to anxiety about illness, inadequate coping mecha-

Patient Outcomes
• Verbalizes anxieties and concerns
• Verbalizes acceptance and commitment to the treatment plan
• Demonstrates adherence to health-care regimen
• Expected therapeutic goals realized

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• Encourage the patient to discuss worries and concerns regarding the ill-

ness. Determine patient’s understanding of the illness, prognosis, and
treatment plan. If patient’s understanding is not accurate, review the
appropriate information about the condition with him or her.

• Encourage the patient to express feelings verbally rather than act them
out through noncompliance.

• Repeat and reinforce teaching. The patient’s learning ability may be
impaired by anxiety or physical status.

• Give patient some control in treatment regimen. Seek his or her ideas for
adaptations that can be made. Identify other areas in patient’s life where
he or she can exert control. Consider negotiating a contract with the
patient to reinforce compliance.

• For the patient who is impatient and perfectionistic, point out the need
to develop realistic expectations of behavior changes. For example, he or
she may not be able to lose weight and give up smoking at the same time.

• Approach the suspicious patient with the expectation of compliance.
Keep directions clear and simple, and always be honest.

• Make an effort to reduce the patient’s anxiety before teaching session.

• Reinforce the idea that the patient is ultimately responsible for his or her
own health.

• If major life changes must be made, break down expected changes into
achievable steps that may be easier to accept and master. Develop a way
patient can chart own progress.

• If patient has relapsed, provide encouragement to start again and point
out positive steps that were achieved despite the setback.

• Continually assess emotional blocks.



Decisional Conflict

Knowledge Deficient


Self-Care Deficit

Therapeutic Regimen Management, Ineffective: Families

Thought Processes, Disturbed

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• Determine appropriate materials available to assist in patient education
including pamphlets, videos, closed-circuit health education channels in the
hospital, or flip charts.

• Determine if appropriate educational materials are available from pharma-
ceutical and medical equipment companies. Many times, they have excellent
materials available at no charge.

• Identify appropriate times to provide education to patient and family. Real-
ize that at times, the patient may not be ready for teaching when the nurse
is available. Other alternatives need to be identified.

• Provide information in patient’s primary language if possible.
• Before starting an education session, ensure that the patient and family have

needed tools to enhance comprehension including glasses, hearing aids, and
pain controlled. Patients may be too embarrassed or intimidated to tell you
that they need these items.

• Identify other resources, such as diabetes educators, ostomy nurses, phar-
macists, or dieticians, to assist in teaching. Be sure to coordinate teaching so
that no conflicting information is given.

• Use appropriate adult learning principles for all education (see Box 12–2).

Chapter 12 ■ Problems Relating to Others 217


• Patient refuses to comply with medical regimen, with life-threatening

• Family or caregiver abuses patient or interferes with patient’s compli-

• Patient uses folk remedies or alternative health practices that compli-
cate current medical condition.

• There is evidence of suicidal or psychotic thinking as reason for non-

• There is increased staff conflict over dealing with patient’s noncom-


• Attending physician
• Manager
• Psychiatric Team
• Social Worker
• Educators, Advanced Practice Nurses

12 Gorman(F)-12 11/5/07 5:03 PM Page 217

• To promote compliance with prescribed medications educate the patient
and family on: potential side effects, what to do if a dose of medication is
missed, where to call if concerned about a negative reaction to a drug, keep-
ing of diary of medications taken, and utilization of a pill box.

• If patient and family are using the Internet for health-care information, give
information on identifying reputable sites. Encourage patient and family to
bring information they are obtaining on the Internet to medical appoint-
ments so it can be evaluated. See Box 12–4 for Tips on Teaching Patients
About Health Internet Sites. Many sites offer information in several lan-
guages as well.


• Document all identified factors that contribute to noncompliance.
• Use objective, nonjudgmental terms to describe behavior.
• Document the teaching plan and patient goals to ensure that all health-care

team members are providing the same information.
• Document all teaching given and patient and family response to the

• Document patient’s verbalized reason for and effects of noncompliance.

218 Chapter 12 ■ Problems Relating to Others

BOX 12–4
Teaching Patients About Health Internet Sites
• Look for sites that are affiliated with a university or professional health-

care organization to have more credibility (may include web sites ending in
.edu or .org). Many professional and governmental Web sites have specific
information written for the layman in easy to understand language, such as (American Psychiatric Association), National Institutes of
Health. Websites ending in .com are generally supported by for profit com-
panies that may influence content.

• Looks for credentials, educational backgrounds, and board certification of
those providing the information

• View any site with skepticism where sweeping claims of health or cure are

• Check for the date of the posting
• Check for commercial sponsorship of the site–this may influence the infor-

• Bring copies of website materials to your health-care provider to review and

• Online chat rooms and blogs can provide support but can also expose a

person to misinformation

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• Refer the patient for home health follow-up to evaluate home situation and
its influence on compliance. Inform home health nurses of concerns regarding
patient’s compliance and any effective or ineffective strategies you have used.

• Identify practical issues that inhibit compliance such as lack of transporta-
tion, funds, or insurance. Then seek potential resources for assistance. Involve
social worker, case manager, or community resources advisor for assistance.

• Refer to support groups, community education programs, or volunteer sup-
port programs, such as Reach for Recovery, or ostomy visitors. These peo-
ple may provide needed reinforcement or role models for motivation and
support. Online chat rooms and blogs can also provide support.

• Ensure that the patient and caregivers have adequate information for fol-
low-up appointments and future treatment and that they have needed phone
numbers and resources to call for more assistance.

• Refer patient for follow-up counseling if persistent noncompliance is related
to inadequate coping skills or psychiatric disorder.

The Demanding,
Dependent Patient

Learning Objectives
• List the possible causes of underlying anxieties that could escalate a

patient’s demanding, dependent behavior.
• Select effective interventions for a patient who consistently needs to be

the center of attention.
• Identify possible nurses’ reactions toward demanding, dependent


Dependent personality disorder – Behavior characterized by a pervasive and

excessive need to be taken care of, leading to: submissive and clinging
behaviors; fears of separations; a severe lack of self-confidence; difficulty
making everyday decisions; difficulty expressing disagreement.

Entitlement – An unreasonable expectation that others will provide espe-
cially favorable treatment and automatic compliance.

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(Healthy) narcissism – An adequate amount of self-love, acquired during
early childhood, providing a healthy self-esteem without negating the
needs of others.

Hidden dependency – Dependent behavior that is not obvious. Person may
try to coerce others into behaving in ways that meet his or her needs.

Histrionic personality disorder – Behavior characterized by pervasive and
excessive expression of emotion and attention-seeking behavior.

Interdependence – Having the capability for a normal balance between
dependent and independent behaviors.

Narcissistic personality disorder – Behavior characterized by a pervasive pat-
tern of an inflated sense of self-importance, need for admiration, and lack
of empathy for others.

Regression – An individual’s response to overwhelming anxiety by moving
back to a much earlier, more comforting phase of childhood.

Both demanding and dependent patients can consume an enormous amount of
nursing resources. When patients exhibit these behaviors, it is essential to

identify the problems early so that efforts are not counterproductive and
resources are not drained (Manos & Braun, 2006). Very dependent patients can
stir up resentment in caregivers, and that inhibits the setting of limits (Groves,
2004). Setting baseline behavior goals help the patient contain or deal with his or
her needs to a tolerable degree for both the staff and the patient and prevent dys-
functional behavior from interfering with the planned healthcare regime. Demon-
strating a healthy narcissism is seen when an individual speaks up for him/herself
and displays self-care behaviors.

The demanding patient consistently wants more than the nurse can or should
give and asks for more than is reasonable. A request is usually expressed as an
emergency, with absolute insistence that it is a legitimate, rightful claim. The
dependent patient wants to be taken care of in more ways than is normal for an
adult. Unable to function independently or with self-reliance, this individual has
a sense of helplessness and powerlessness and either actively or passively expects
others to take responsibility to meet his or her needs, make personal decisions,
and provide support. Traits of dependency are found in many patients with psy-
chiatric disorders (Sadock & Sadock, 2007).

When a person is hospitalized, a dependent relationship occurs because basic
rules of living, such as when to eat, are set by others. An adult with healthy cop-
ing mechanisms can usually adjust to this dependency role appropriately. How-
ever, the response is not so predictable in individuals who have consistently
learned to use maladaptive coping mechanisms throughout their lives or in those
whose situational stress have exhausted their normal coping abilities. When the
patient deviates too much from commonly expected behaviors, misunderstand-
ings and battles can be generated between the patient and staff. Maladaptive
responses can include growing resentment at feeling so helpless, regression to a
clinging neediness more characteristic of earlier years in life, fighting and refus-

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ing to follow rules, covert expressions of the need to be cared for with an overem-
phasis on physical symptoms, or relentless demands for affection.

Patients with certain types of personality disorders, particularly dependent,
narcissistic, or histrionic types, normally exhibit a relentless demand for atten-
tion, and need to be dependent on others. Criteria for each of these personality
disorders are listed in DSM-IV-TR (2000). These individuals believe that their
views are correct and that others must adapt to them. Because these behaviors are
long-standing, they are very resistant to change. Additionally, the stress of illness
and hospitalization can cause other individuals who normally function without
the need to be demanding and dependent to exhibit these behaviors. This may
occur when there is a growing resentment at being helpless or when normal cop-
ing mechanisms have been exhausted. This behavior can also be a normal tem-
porary response in an individual faced with adjusting to a chronic condition, such
as quadriplegia. An individual may express his or her intolerance for the depend-
ent role by fighting, refusing to follow rules and meet expectations, or by overem-
phasizing physical symptoms. Patients with dependent personality disorder tend
to get others to assume responsibility for major areas of their lives and experience
intense anxiety when alone (Sadock & Sadock, 2007).


Psychological theories examine early developmental experiences that inhibit suc-
cessful independence contributing to demanding or dependent adult behavior and
may even result in a personality disorder. For instance, a child may learn that to
be heard and acknowledged, he or she must persist in making demands on
parental attention. Both inadequately met needs and overindulgence during the
first 18 months of life can discourage independence. If the child was not allowed
to ask directly for what is needed, he or she may learn to get needs met by hav-
ing physical symptoms, particularly if extra attention is received only during
early bouts of illness, when physical care provided the only expressions of sup-
port and nurturing. If the child assumed the caretaker role for an ill parent, he or
she may view illness as the main vehicle for obtaining care and assistance.

Patients who feel unloved and worthless or who are afraid to be alone may
make frequent requests for the nurse to do things in an attempt to get attention.
With attention given, the patient’s anxiety decreases, and he or she becomes less

In hidden dependency, the patient can be very controlling, intimidating, dom-
inating, or possibly even an overly caring caretaker. The patient does not seem
obviously dependent but attempts to coerce others to behave in ways designed to
meet his or her needs.

Patients with chronic personality disorders have a limited repertoire of coping
skills and can respond to anxiety by becoming more dependent and demanding,
regardless of whether such behavior is appropriate to the situation. These are also
associated with low self-esteem and depression. Contributing factors include

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demanding, perfectionistic parents and parents living vicariously through their


Independent decision making and initiative taking can be adversely affected by
dementia, depression, hearing and other sensory problems, and limited intellec-
tual abilities. Dependent individuals may use drugs as a method of coping with
intolerable feelings of anxiety and helplessness, which can lead to a pattern of
substance dependency.


Infants are expected to be totally dependent. Younger children are still expected
to be dependent in the areas in which they have not yet matured to the point of
being able to do things for themselves. As children grow older and physical, psy-
chological, cognitive, and social spheres develop, they are expected to do age-
appropriate tasks, make decisions, interact, and exhibit independent behaviors.
Children who must be more dependent because of illness or disabilities may have
more struggles with these issues.

The struggle with dependence and independence is the hallmark of adolescence. At
times teenagers are children and at other times they act like adults. They can have
an inflated sense of self and self-importance, with little empathy for others as a nat-
ural part of trying to form their own identities; however, this does not mean that
they will develop a personality disorder. People in this age group may be influenced
more by their peers, who are supports against the pressures of the adult world and
its expectations. They often become dependent on peers for recognition and grat-
ification. Parents can become confused by the frequent vacillation between respon-
sible behavior and childlike dependency, especially in earlier adolescent years.

Dependency can be manifested in fears of leaving the home of origin, difficulties
maintaining jobs, and remaining financially dependent on parents. Brief periods
of dependency during times of stress can be normal.

Older Adults
As individuals age, they may experience an accompanying increased dependence
based on losses in agility, speed, or strength. Some elderly people face illnesses
along with the loss of previous support systems. Old friends and relatives may die
or become preoccupied with their own growing limitations. Elderly persons who

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are treated as children incapable of making independent decisions and behavior
may eventually respond with dependent and demanding behaviors. However as
people age and experience increased frailty, they may need to begin accepting
more dependency and assistance from others.

For an older individual with a narcissistic personality disorder, adjusting to
physical and occupational limitations can be particularly difficult, often straining
family relationships.

Chapter 12 ■ Problems Relating to Others 223

• Nurses have different tolerance levels for demanding, dependent behaviors.

Patient may be considered difficult by one nurse but not by another. The
extremes of these behaviors are usually considered difficult by all.

• May experience frustration and anger with the constant demands.
• Resentful when patients appear to demonstrate sense of entitlement
• May expect thanks or reward for meeting patient’s needs.
• May feel guilty about not meeting all the patient’s stated needs and question

own competence. May try to avoid the patient.
• May not recognize that giving too much to patients who can do things for

themselves is detrimental to the patients’ emotional and physical health.
• May confuse appropriate limit setting with being overly harsh and with-

• May be punitive or hesitate to be firm with patients because of anger and

fear about being punitive. It may also seem easier just to give in to the
patient’s demands.

• Nurses with strong dependency needs or who are inexperienced may ini-
tially overidentify with patients and try to meet all of their demands. May
resent giving so much and not being appreciated.


Behavior and Appearance
• Intrudes into personal space and time of others
• Unkempt appearance, either actual inability to provide self-care or an

unconscious attempt to get others to provide care
• Demanding assistance although able to do things for self
• Manipulative behavior, such as:

• Arguing or begging
• Crying, clinging
• Calling nurse “mean,” “hardhearted,” “a bad person,” “incompetent”
• Dwelling on health problems and medical history

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• Complaining of feeling used and victimized by others
• Constantly seeking attention, suggestions from others

• Disregard of facility rules
• Regression; wanting to be totally taken care of, fed, repeatedly reassured, or

• Frequent use of call lights
• Repeated visits to nurses’ station
• Demands to have physician called several times each day
• Use of family visits to demonstrate helplessness; getting relatives to make

demands on staff
• Sense of entitlement

Mood and Emotions
• Frequently angry; may be expressed in passive-aggressive behavior
• Fears being alone or abandoned
• Anxiety

Thoughts, Beliefs, and Perceptions
• Believes that each request is an actual problem requiring instant attention
• Low self-esteem with chronic feeling of helplessness and inadequacy
• Resistant to interpretations that point out reason for behavior (may experi-

ence this as an attack)

Relationships and Interactions
• Self-absorbed, with little interest in others’ concerns or problems
• Frequently clings to others
• Sometimes nagging
• Fights or reverses roles and becomes a helper to others if unable to tolerate

or acknowledge own dependency needs
• Dependent relationships with significant others (SOs), in which other per-

son makes all decisions, answers for patient
• Others dislike caring for or being with patient for long periods

Physical Responses
• Overconcern about health and preoccupied with symptoms
• Frequent requests for and preoccupied with medications, especially for pain

or anxiety
• Adverse drug interactions if prescriptions taken from several different doc-

tors who are not aware of each other’s involvement

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Pertinent History
• Long history of medical problems, some of which linger atypically for an

unusually long time or do not quite match patterns of usually diagnosed dis-
eases; does not respond to usual treatments

• Goes from one doctor to another in search for diagnosis and treatment for
complaints that show no physical basis

• Multiple hospitalizations
• Unnecessary surgery
• Diagnosed in the past with histrionic, narcissistic or dependent personality



Multiple medications, perhaps from different prescribers, can generate a host of
problematic adverse effects. Psychiatric medicines may also be used. A tendency for
dependency may lead to increased risk for dependency on medications. Confusion
and lethargy in elderly patients, which can lead to more dependent behavior, can
be caused by overmedicating or too many types of medications. A pharmacologi-
cal review can be helpful in these instances. Antidepressants can be used for depres-
sive symptoms. Anxiolytics for anxiety and panic attacks may be used.


POWERLESSNESS evidenced by demanding, dependent behaviors related to
anxieties generated by illness, disability, and/or hospitalization.

Patient Outcomes
• Displays less demanding, dependent behavior and conveys needs more

directly and appropriately
• Provides increased amount of self-care as physical condition permits
• No longer exaggerates physical complaints to gain attention, support,

and concern

• Assess baseline:

• Consult with family or significant other to determine if behaviors are
normal for the person.

• Evaluate if the patient is demanding in all situations or only in specific
ones and if he or she exhibits this behavior only with certain people.

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• Identify the specific behaviors the patient uses to express dependency.
• Determine whether the patient’s helplessness is consistent with his or

her medical problem or if patient is more independent when not in
view of others.

• State limits and rules in advance. Discourage unnecessary or excessive
time spent at the nurses’ station. Discourage asking for nurses’ assistance
when the patient is aware that the nurse is on break, at lunch, or leaving
at the end of the shift.

• Assess the required amount of assistance the patient needs and provide
help when it is needed. Diplomatically point out unreasonable demands:
“We’re concerned about your overall well-being. In our experience,
patients feel more effective and better about themselves when they do as
much as they can. Let’s discuss what you’re realistically able to do right
now and what the nurses need to provide.”

• Make an extra effort to communicate concern:

• Demonstrate active listening. Sit down rather than stand up during the
talk. Repeat statements or reflect feeling being expressed, as necessary.

• Be consistent. If you have told the patient that you will speak with him
or her at a specific time and are unable to do so, explain reasons and

• Give feedback to demonstrate that you understand what patient is ask-
ing for, feels, or needs. Encourage patient to describe his or her fears
and anger over the loss of control.

• Explain that identifying each situation as an emergency makes it difficult
to determine what is an actual emergency.

• Determine if the patient has had previous bad experiences with health-
care providers or institutions. He or she may need reassurance that
proper treatment is being given.

• Give support and reassurance to allay fears when first attempting behav-
iors that will lead to more independence. Assure the patient that you will
be available if needed.

• Help patient to distinguish between feeling helpless and being helpless.
Provide a progress list of at least one new activity per day, however small,
that he or she can do independently.

• Encourage the patient to identify and verbalize real sources of anger. Ask
how he or she usually handles anger. Suggest ways to redirect anger into
positive activities.

• Encourage patient to make independent choices. Accept different prefer-
ences and opinions.

• Do not take an overly directive approach because it can reinforce

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• Identify and point out patient’s strengths; provide praise whenever used.
• Determine whether some of the patient’s expressed needs are better met

by other professionals.

INEFFECTIVE COPING evidenced by demanding, dependent behavior
related to continuous and ongoing personality disturbance that hinders ability
to do health-care tasks effectively and communicate concerns appropriately.

Patient Outcomes
• Uses less dependent behavior with fewer unnecessary demands for

nurses’ attention
• Uses appropriate methods to gain attention and support
• Verbalizes appropriate degree of health concerns
• Makes informed choices
• Initiates and carries through tasks

• Obtain history from patient and significant others to determine patient’s

baseline style of interaction before illness or hospitalization. Those who
have displayed demanding and dependent behaviors as a lifelong pattern
may present more complexities.

• Be aware that patients who have long-standing, ingrained, demanding,
dependent patterns will be resistant to change. Be patient and explain
limit setting as often as needed.

• Determine realistic expectations for behavioral changes and expect that
any changes will occur in small gradual steps.

• If the patient becomes upset because you are not presently able to spend
time with him or her, determine a convenient time and provide assur-
ances that patient will have your undivided attention.

• Assess whether the patient is inappropriately using other health-care
workers or volunteers or is interacting inappropriately with visitors or
other patients.

• Do not personalize remarks made by patients who need to feel superior.
If the patient wants to speak only with the charge nurse or doctor, let
those individuals explain the limits of their availability.

• Be aware when patients are using seductive behaviors to gain attention,
control, or unnecessary assistance. Mild behaviors can be ignored to dis-
courage future use. Persistent behaviors need firm confrontation.

• Assess for the use of manipulative behaviors to gain attention or depend-
ence. Encourage methods to increase self-esteem that can decrease the
patient’s need for approval from others.

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• Analyze behaviors to determine what needs the patient may be express-
ing when he or she asks the staff to perform tasks that could easily be
done independently.

• Point out to the patient ways in which he or she has control of some sit-

• Assess the cause of a problem with independent decision making. If it is
caused by a lack of information, provide all the information you can. If
the patient always has difficulty making decisions, teach effective prob-
lem-solving skills.

• Recognize your own tolerance for demanding, dependent behavior. Ask
for assistance or temporary reprieve if necessary. For extremely depend-
ent patients, strive for a balance between rotating staff to help decrease
dependency on one nurse and providing consistent nursing care.

• Be especially diplomatic in correcting patient’s behavior. Narcissistic
patients may react to criticism or defeat with rage, disdain, or counterat-
tack. If this occurs, help the patient regain a perspective on feedback and

• Maintain your own perspective when receiving praise from dependent or
histrionic patients as well as the devaluing or ignoring of your efforts and
contributions by more narcissistic patients, who tend to take all the credit.

• Praise independent and interdependent functioning. Reassure the patient
that he or she will not be forgotten nor abandoned by the staff when
more independent. Reward less demanding behavior by spending more
time with the patient.


Decisional Conflict
Self-Care Deficit
Self-Esteem Disturbed
Social Interaction, Impaired

228 Chapter 12 ■ Problems Relating to Others


• When the patient is “burning out” staff with insatiable, unreasonable

• When the patient’s demands or needs for assistance become so unre-
alistically prolonged that it impairs staff’s ability to adequately care
for other patients

• When the patient is not getting good medical care because of staff anger
• If the patient seems resistant to all interventions attempted

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Chapter 12 ■ Problems Relating to Others 229


• Teach decision-making skills, such as problem identification, listing possible
solutions, considering possible outcomes of each, and evaluating each out-
come. Teach the patient to draw upon past experience and intuition when
making decisions. Point out potential stumbling blocks such as choices that
lower self-esteem or violate values or goals. Caution the patient that there
may not be a perfect solution. Teach the concept of collaborative decision

• Teach the patient to recognize personal strengths.
• Explain to the patient that in delegating personal decision making to

another, one still must retain personal responsibility for one’s own life. He
or she will have to live with the consequences of the decision.

• Teach the patient to distinguish situations that require immediate attention
from those that do not. Explain that identifying each situation as an emer-
gency makes it difficult to determine what is an actual emergency.

• Teach the patient to identify which problems require assistance. Teach the
patient to use frustration as an opportunity for problem solving.

• Teach relaxation techniques.
• Teach the family members to identify when they are promoting dependent

behaviors and to examine alternatives. Teach approaches that the staff
members have found effective.

• Teach the patient the difference between providing good nursing care and
catering to excessive demands.


• Document specifics of demands and their frequency. Note if they occur at
similar times or in relation to similar events.

• Document actual patient responses to specific interventions listed in the
treatment plan. Avoid subjective opinions about the behaviors.

• Document frequency of requests for PRN medications.
• Document details of unusual physical complaints.


• Critical Incident/Employee Assistance
• Psychiatric Team
• Attending Physician
• Manager
• Social Worker

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230 Chapter 12 ■ Problems Relating to Others


• Anticipate increased dependency and demanding behavior as discharge
from one level of care becomes imminent; reduce anxiety by discussing con-
cerns as early as possible.

• Involve patient in discharge arrangements.
• Anticipate that discharge will probably be a difficult time if the patient will

be going to a facility with different caretakers and less staff.
• If patient is going home assess what services patient will need at home and

discuss arrangements with patient and family.
• Ensure that patient has specific plans for follow-up appointment with physi-

• Remind patient who is about to be transferred to another level of care to

continue to use the methods learned for expressing needs.
• Discuss with the next caregivers the interventions that have been effective.
• If the patient’s behavioral patterns continue to significantly impair health

care and the patient is distressed about this, discuss the possibility of seek-
ing psychotherapy.

• Communicate patient concerns and behaviors to referring agencies.

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Problems with
Substance Abuse

The Patient Abusing Alcohol

Learning Objectives
• Identify factors that contribute to the etiology of alcoholism.
• Formulate appropriate nursing interventions for patients experiencing

problems with alcohol abuse.
• Describe common nurse’s reactions to the patient abusing alcohol.
• Describe the characteristics of codependency.

Alcohol intoxication – Excessive alcohol use that leads to maladaptive

behavior and at least one of the following: slurred speech, incoordination,
unsteady gait, nystagmus, impairment in attention or memory, and stupor.

Alcoholism – A complex progressive disease characterized by significant
physical, social, or mental impairment directly related to alcohol depend-
ence and addiction.

Binge drinking – Pattern of periodic intervals of heavy use of alcohol (usually
defined as five or more drinks on one occasion) with intervals of no or little

Blackouts – Lapses of memory resulting from persistent heavy drinking. Dur-
ing blackouts the person may appear to function normally while drinking
but cannot recall events afterward.

Codependency – Maladaptive coping behaviors that prevent individuals
from taking care of their own needs because they are preoccupied with the
thoughts and feelings of another. Also known as “enabling behavior.”

13 Gorman(F)-13 11/5/07 4:51 PM Page 231

Detoxification – The process of withdrawal of alcohol from the body through
supervised medical interventions to prevent complications.

Dual diagnosis – Diagnosis of both a substance dependency and a major
psychiatric disorder. May also be called co-occurring or co-existing disorder.

Korsakoff’s syndrome – Severe memory impairment related to thiamine defi-
ciency from long-term alcohol use. Characterized by confabulation and
inappropriate cheerfulness.

Tolerance – The need for increasing amounts of a substance to achieve
desired effect.

Alcohol remains the most used and misused drug in America. Alcohol use is
socially accepted throughout our culture, is included as part of celebrations,

religious rituals, and social occasions, and is often used as a relaxant. Nearly
90% of all American adults have used alcohol at some time in their life (DSM-
IV-TR, 2000).

The move from social use of alcohol to alcoholism can occur very quickly in
some people and over many years in others. In the past, alcoholism was viewed
as a defective character trait, a weakness, or a moral flaw. Since the 1950s, it has
been realized that alcoholism is a complex disease that responds to proper treat-
ment. Today, the role of brain dysfunction is viewed as key to etiology.

Studies indicate that about 8% of Americans are dependent on alcohol at any
one time and 18% report an alcohol problem at some time in their lives (Kessler,
et al, 2005). This includes daily or binge drinking that negatively affects the way
one lives. Binge drinking is more common in young adults. Three times as many
men as women are reported to have a drinking problem; however, it is suggested
that women are more secretive in their drinking behaviors, and therefore, drink-
ing by women may be underreported. Alcohol is often used along with other sub-
stances, especially in younger individuals, often to alleviate or enhance the effects
of other drugs (e.g., to relax after using a stimulant). Heavy drinkers often have
periods of enforced abstinence to try to control the problem.

Alcohol is a central nervous system depressant that produces mind-altering
and mood-altering effects. Twenty percent of alcohol consumed is absorbed
directly into the bloodstream through the stomach. The remainder moves
through the digestive system and is absorbed more slowly. Drinking rapidly on
an empty stomach or consuming drinks with higher alcohol content will lead to
a more rapid rise in blood alcohol level. One ounce of distilled liquor, 5 ounces
of wine, and 12 ounces of beer have equivalent amounts of alcohol. It is known
that, given the same amount of alcohol, women have higher blood alcohol con-
centrations than men, even when size is taken into consideration. This is because
of differences in fat and body water content, making women more prone to long-
term effects of alcohol. Problem drinking is identified by the National Institute of
Alcohol Abuse and Alcoholism (2007) for men as having more than four

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drinks/day or greater than 14 drinks per week and in women and older men as
greater than three drinks per day or more than seven drinks per week.

Alcoholism has a tremendous impact on the individual, the family, and soci-
ety. Spouses and especially children are particularly vulnerable to become victims
of alcohol-related abuse. They may experience violence or emotional and physi-
cal neglect, and they may blame themselves for the alcoholic’s abusive state.
Amazingly, 43% of U.S. adults have been exposed to alcoholism through a
spouse or blood relative. Alcoholism is truly a family crisis (National Council on
Alcoholism and Drug Dependence, 2002). The impact of alcohol abuse on soci-
ety includes crime, traffic accidents and fatalities, suicide, industrial accidents,
fires, and decreased workplace productivity.

People with major psychiatric disorders may also have an abuse problem if
they use alcohol to self-medicate for the psychiatric symptoms. The co-occurrence
of a psychiatric diagnosis with alcohol or other substance abuse is very common
in the mentally ill population. These patients are referred to as having a dual diag-
nosis or co-occurring disorder. These patients may use alcohol and other sub-
stances to self-medicate the distressing psychiatric symptoms of agitation, anxiety,
or hallucinations. Alcohol or abuse of other substances may also trigger a psy-
chotic episode leading to a dual diagnosis. Nearly half of all people with severe
mental illness are affected by substance abuse, and 37% of alcoholics have at least
one mental illness (NAMI, 2003). Goldsmith and Garlapati (2004) report that
47% of schizophrenics, 56% of bipolar patients, and 27% of patients with major
depression have a dual diagnosis. The most common psychiatric diagnoses asso-
ciated with substance abuse are mood and anxiety disorders, attention deficit dis-
orders, and antisocial personality disorders (Miller & Grady, 2004). Patients with
co-occurring disorders tend to have poorer outcomes with treatment of both diag-
noses. Acute intoxication or withdrawal from alcohol and/or other substances can
complicate accurate diagnosis of a primary psychiatric disorder. These patients
require interventions specially geared to this population as they often do not fit in
standard substance abuse treatment as Alcoholics Anonymous. Collaboration
between the psychiatric treatment team and addiction specialists is essential.


Because alcoholism runs in families, there is current support for the genetic and
biological theories as the cause of alcoholism. Alcoholism runs in families with a
four-fold increase in close relatives of the alcoholic (Schuckit, 2006). The risk re-
mains even if the children are not raised in the same home as the alcoholic parent.

The current biological theory for abuse of alcohol and other substances is that
intrinsic reward pathways in the brain create a biological basis for craving the sub-
stance that induces a sense of well-being. The two main pathways are gluta-
matergic tracts in the prefrontal cortex and dopaminergic tracts. Each time a drink
is taken for persons with altered brain function, an intense state of craving for the

Chapter 13 ■ Problems with Substance Abuse 233

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substance develops. This theory is the basis for the two pharmacological treat-
ments of alcohol abuse: replacement therapy and neuromodulation. Replacement
therapy substitutes the abused chemical with a safer alternative as in detoxifica-
tion. Neuromodulators interact with the receptor system affected by the substance
and eventually decrease the craving (e.g., Naltrexone or Acamprosate for alcohol).

A number of psychological factors are recognized as contributing to alcohol
abuse. One of the most important looks at the link between depression and alco-
holism. Alcoholics may have a higher incidence of depression and low self-
esteem. Alcohol becomes a way to relieve those feelings. Each time a drink makes
the person feel better, it reinforces this behavior. Difficulty managing anxiety and
low self-esteem has led to identification of common coping styles (Table 13–1).
Denial is the major defense mechanism used when the person is unable to
acknowledge the role that alcohol plays in his or her life.

Alcohol use can severely affect the dynamics of the family relationship. Family
members use protective behaviors, sometimes called codependent or enabling
behaviors, to control or hide the alcoholic’s behavior so that a sense of
normalcy can be maintained. Affected family members care for and attempt to
control the behavior of the alcoholic at the expense of their own needs. The fam-
ily does not realize that this type of behavior reinforces the drinking patterns and
dysfunctional behavior. Examples of these behaviors include minimizing the
drinking, finding excuses for the drinker’s alcohol use, attempting to control the
drinking by diluting bottles or pouring out liquor, covering up for the drinker’s
unacceptable behavior, and self-blame for the drinking. Family members and
friends of the person abusing alcohol are also at an increased risk of emotional or
physical abuse.

Social and cultural factors may also contribute to the development of alco-
holism. Certain cultural groups have higher incidences of drinking problems,
which may represent genetic factors combined with an increased acceptance of
heavy alcohol use. It may be part of socially expected behavior. One’s social cir-
cle may play a role in how alcohol is used as one observes its use by friends or
family to avoid problems, become a risk taker, and so on.


Alcohol abuse plays a major role in a variety of health problems including gas-
tritis, liver failure, heart disease, and pancreatitis. Twenty-five percent of admis-
sions to general hospitals are related to an alcohol problem, including being
treated for consequences of drinking (National Institute of Alcohol Abuse and
Alcoholism, 2001). This statistic supports that need for all healthcare profes-
sionals incorporating some form of screening in their assessment. Assessing
patients for alcoholism abuse can be helpful to prevent complications from with-
drawal post-operatively (Sullivan, Sykora, Schneiderman, Narajo, & Sellers,
1989). Alcoholism is the third leading cause of preventable death in the United
States (Kessler et al, 2005).

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Chapter 13 ■ Problems with Substance Abuse 235

TABLE 13–1
Common Coping Styles Of Alcoholics

Coping Style Definition Behaviors







Person minimizes or does
not acknowledge the
problem or the results of
the problem even when
strong evidence is pre-

Blames others for their
drinking and behavior.

Justifies intolerable
behavior by giving plau-
sible excuses.

Avoids conflict by reduc-
ing the impact of the

Plays one person against
another in order to get
one’s way or cover up or
avoid a problem.

Maintains a sense of
superiority and irrespon-
sibility particularly evi-
dent when intoxicated.

• “I only have two drinks a
day, I could stop any time.”

• Refuses to admit drinking
problems that are obvious
to others.

• Family may participate in
denial by covering up the
problems created by the

• Avoids taking responsibility
for own unacceptable

• “My brother is the one with
the problem. He drinks
more than I do.”

• “I’d stop if everyone would
leave me alone.”

• Excuses reinforce denial.
• “My kids are always in trou-

ble. They make me drink.”
• “I only drink beer.”

• Places less value on the
behavior and the impact of
the problem.

• “You worry too much.”
• “I’m not hurting anyone.”

• Convinces one or two peo-
ple that he or she will
improve if they will help.

• If he or she fails it is the
fault of the helper.

• Lacks concern for others

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Alcohol is toxic to many major organs, especially the heart and liver. The
patient with heart disease who abuses alcohol is at increased risk of complica-
tions, including hypertension. Liver metabolism may be compromised, and there-
fore, drugs metabolized by the liver may need dosage adjustments. Alcohol
contributes to complications of diabetes.

Hingson (1993) noted that alcohol is a contributing factor in the following:
50% of trauma fatalities, 40% to 50% of falls, and 30% of motor vehicle acci-
dents. If alcohol problems persist throughout a lifetime, the person will die 15
years earlier on average, with major causes being heart disease, cancer, accidents,
and suicide (Rivara, Garrison, Ebel, McCarty, & Christakis 2004; Schuckit,
2006). Suicide assessment needs to be included in depressed patients abusing
alcohol. Alcohol abuse also contributes to unwanted pregnancies, workplace
accidents, and HIV exposure due to high-risk sexual activity.


Fetal alcohol syndrome is recognized as being caused by alcohol abuse during
pregnancy, when rapidly growing fetal brain cells are exposed to alcohol. The end
result can be an infant born with mild to moderate developmental disabilities,
hyperactivity, facial malformations, heart defects, and growth deficiencies.

Children and Adolescents
Alcohol use by children and adolescents has shown an alarming increase in recent
years. Access to alcohol from the home or from friends can make it readily avail-
able. Seventy-seven percent of high school seniors have used alcohol (National
Institute of Alcohol Abuse and Alcoholism, 2007). Teens who start drinking at
age 15 years are four times more likely to develop alcoholism than those who
start at age 21 (National Council of Alcoholism and Drug Dependence, 2001).

When teens are found to be drinking, they need to be evaluated for use of
other substances as well as high-risk sexual activity and criminal behaviors
(Schuckit & Tapert, 2004).

As with adults, children learn from parents, peers, or television and movie
images suggesting that alcohol can be a defense against feelings of depression,
low self-esteem, or anxiety. It may also represent an acting out against parental
authority or enhance a sense of closeness with peers. Children who grow up in a
home where one or both parents have an alcohol abuse problem may have an
increased risk of abusing alcohol. However, even those children who intensely
dislike their parents’ drinking behavior may use alcohol as a coping mechanism
because they have not learned more appropriate ones. Children and adolescents
who become intoxicated are at increased risk of injury related to motor vehicle
and bicycle accidents because they usually do not drink in the home. They are
also at increased risk of alterations in growth and development because of

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nutritional deficiencies and because they often do not learn to deal effectively
with normal anxiety and other uncomfortable emotions. Adolescents and young
adults are more prone to binge drinking, which has been associated with life
threatening effects from alcohol intoxication.

Older Adults
Alcohol abuse is often unrecognized and undertreated in the older-than-65 age
group. Our society generally does not view the older population as an at-risk
group. Because alcohol abuse is often a life-long pattern, elderly people may con-
tinue their earlier struggles with alcohol. Because of changes in metabolism with
age, it may take less alcohol to begin to cause intoxication or other problems.
Others may start drinking in later life because they face increasing problems, such
as isolation, loss of spouse, and changes in health status. Alcohol may produce
significant health problems in elderly persons, particularly if they have impaired
liver function. Mental changes from alcohol use may be confused with dementia.
It is a major factor in falls, burns, and suicide attempts. The brain in older adults
is more susceptible to the depressant effect of alcohol, and therefore, depression
may mask the signs of alcoholism. Other signs might be unexplained falls, poor
nutrition, and self-neglect. Use of multiple medications with alcohol can exacer-
bate alcohol’s effects. Withdrawal programs for this age group may require spe-
cialized care because of the increased health risks.

Chapter 13 ■ Problems with Substance Abuse 237

• May view alcohol abuse as a personality defect or weakness rather than a

health problem.
• May avoid, criticize, or reject the patient. This may trigger guilt feelings,

and the nurse may try to make up for these feelings by being overly sympa-

• May have feelings of disgust for the patient.
• May have unresolved feelings related to a past family or personal history of

substance abuse.
• May feel helpless to facilitate change, especially in a patient with a long his-

tory of alcohol problems.


Behavior and Appearance
• Signs of intoxication include odor of alcohol, slurred speech, loud talking,

loss of inhibition, loss of coordination, and poor judgment
• Sudden onset of signs of withdrawal

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• Frequently talks or brags about alcohol use
• Exhibits extremes of behavior from euphoria to irritability
• Justifies drinking or the need to drink
• Refuses to discuss drinking or lies about drinking
• Drinks large quantities of alcohol
• Needs to drink increasingly more to get same effect
• Unable to stop drinking once he or she starts
• Overreacts when questioned about drinking pattern
• Reports drinking a much smaller amount than is accurate
• Suicide attempts
• Two or more affirmative responses to the CAGE questionnaire (Box 13–1)

suggests dependence, further assessment required

Mood and Emotions
• Depression
• Remorse after a binge
• Low frustration tolerance
• Anxiety
• Low self-esteem

Thoughts, Beliefs, and Perceptions
• Evidence of defense mechanisms of denial, rationalization, projection, and

• Thinking about alcohol supply and plans to obtain it
• Blackouts
• Hallucinations

238 Chapter 13 ■ Problems with Substance Abuse

BOX 13–1
Cage Questionnaire
To determine the patient’s perception of his or her drinking problem, you may
ask the following questions. Two or more affirmative answers strongly suggest
dependence on alcohol.
1. Have you ever believed that you should Cut down your drinking?
2. Have people Annoyed you by criticizing your drinking?
3. Have you ever felt bad or Guilty about your drinking?
4. Have you ever had a drink first thing in the morning to steady your nerves

or get rid of a hangover (Eye Opener)?

Source: Mayfield, D., McLeod, G., & Hall, P. (1974). The CAGE Questionnaire: Validation of a
new alcoholism screening instrument. American Journal of Psychiatry, 131, 1121–1123, with

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Relationships and Interactions
• Dependent
• Resentful of authority
• Manipulates others to avoid confrontation, conflict
• Blames others for drinking
• Argues with family about drinking

Physical Responses
• Blood alcohol level (0.08 to 0.10 is legal limit to define intoxication in most

states) or positive polydrug panel (may be negative, depending on time since
last consumption). Blood level is less useful in elderly people because of
altered metabolism. Urine testing can be a less invasive approach.

• Amylase may be elevated if liver damage is present. Blood sugar measure-
ment may indicate hyper- or hypoglycemia. Serum magnesium may be low
from alcohol damage to the nervous system. Hemoglobin may be low if
bleeding is present

• History of falls, burns, accidents
• May have signs of gastrointestinal bleeding, ascites, or jaundice
• May be underweight and show signs of malnutrition and dehydration
• Korsakoff’s syndrome from prolonged thiamine deficiency creates a second-

ary dementia marked by ataxia, confabulation, and peripheral neuropathy
• Withdrawal symptoms may occur 8 to 24 hours after last alcohol use. Anal-

gesics and recovery from anesthesia can precipitate an acute withdrawal
reaction. This emphasizes the importance of quick diagnosis to institute
detoxification. Assessment of alcohol use in the hospital can be helpful to
reduce risk of complications. See Box 13–2 for Clinical Institute With-
drawal Assessment of Alcohol Scale (CIWA-AR). A score of greater than 15
predicts a severe alcohol withdrawal.

• Withdrawal grand mal seizures can occur in a small group of chronic alco-

• Alcoholic hallucinosis when hallucinations develop during the withdrawal
period. Most often these are visual hallucinations.

• Alcohol-related delirium (also known as delirium tremens) is a medical
emergency with a 20 percent mortality rate if left untreated. Complications
include pneumonia, dehydration, electrolyte imbalance, respiratory failure,
and status epilepticus (Box 13–3).

Pertinent History
• Previous history of alcohol or polydrug use
• History of heart disease, liver disease, gastrointestinal bleeding or varices
• Psychotic, depressed, or manic behavior

Chapter 13 ■ Problems with Substance Abuse 239

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240 Chapter 13 ■ Problems with Substance Abuse

BOX 13–2
Clinical Insitutue Withdrawal Assessment
of Alcohol Scale, Revised (CIWA-AR)
Patient:______ Date:_____ Time:______ (24 hour clock, midnight � 00.00)

Pulse or heart rate, taken for one minute: ______ Blood pressure: ______

Ask “Do you feel sick to your stom-
ach? Have you vomited?” Observa-

0. no nausea and no vomiting
1. mild nausea with no vomiting
4. intermittent nausea with dry

7. constant nausea, frequent dry

heaves and vomiting

TREMOR — Arms extended and
fingers spread apart. Observation.

0. no tremor
1. not visible, but can be felt finger-

tip to fingertip
4. moderate, with patient’s arms

7. severe, even with arms not



0. no sweat visible
1. barely perceptible sweating,

palms moist

4. beads of sweat obvious on fore-

7. drenching sweats

ANXIETY — Ask “Do you feel
nervous?” Observation.

0. no anxiety, at ease
1. mild anxious
4. moderately anxious, or guarded,

so anxiety is inferred
7. equivalent to acute panic states

as seen in severe delirium or
acute schizophrenic reactions

AGITATION — Observation

0. normal activity
1. somewhat more than normal

4. moderately fidgety and restless
7. paces back and forth during

most of the interview, or con-
stantly thrashes about

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Chapter 13 ■ Problems with Substance Abuse 241

“Have you any itching, pins and
needles sensations, any burning, any
numbness or do you feel bugs crawl-
ing on or under your skin?” Obser-

0. none
1. very mild itching, pins and nee-

dles, burning or numbness
2. mild itching, pins and needles,

burning or numbness
3. moderate itching, pins and nee-

dles, burning or numbness
4. moderately severe hallucinations
5. severe hallucinations
6. extremely severe hallucinations
7. continuous hallucinations

Ask “Are you more aware of sounds
around you? Are they harsh? Do
they frighten you? Are you hearing
anything that is disturbing to you?
Are you hearing things you know
are not there?” Observation.

0. not present
1. very mild harshness or ability to

2. mild harshness or ability to

3. moderate harshness or ability to

4. moderately severe hallucinations
5. severe hallucinations
6. extremely severe hallucinations
7. continuous hallucinations

“Does the light appear to be too
bright? Is its color different? Does it
hurt your eyes? Are you seeing any-

thing that is disturbing to you? Are
you seeing things you know are not
there?” Observation.

0. not present
1. very mild sensitivity
2. mild sensitivity
3. moderate sensitivity
4. moderately severe hallucinations
5. severe hallucinations
6. extremely severe hallucinations
7. continuous hallucinations

HEAD—Ask “Does your head feel
different? Does it feel like there is a
band around your head?” Do not
rate for dizziness or lightheaded-
ness. Otherwise, rate severity.

0. not present
1. very mild
2. mild
3. moderate
4. moderately severe
5. severe
6. very severe
7. extremely severe

“What day is this? Where are you?
Who am I?”

0. oriented and can do serial addi-

1. cannot do serial additions or is
uncertain about date

2. disoriented for date by no more
than 2 calender days

3. disoriented for date by more
than 2 calender days

4. disoriented for place/or person


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242 Chapter 13 ■ Problems with Substance Abuse

BOX 13–3.
DSM-IV Criteria for Diagnosis of
Alcohol-Related Syndrome
Alcohol abuse—Maladaptive pattern of alcohol use that is manifested by one
or more of the following within the same 12 months:

1. Inability to fulfill major role obligations at work, school, and home
2. Recurrent legal or interpersonal problems
3. Reduction or absence of important social, occupational, and recreational

4. Participation in physically hazardous situations while impaired, for exam-

ple, driving a car, exacerbation of a symptom

Alcohol dependence—Maladaptive pattern of alcohol use leading to impair-
ment by three or more of the following occurring at any time during the same
12 months:

1. All criteria for alcohol abuse
2. Presence of tolerance to drug
3. Presence of alcohol withdrawal syndrome
4. Ingestion of alcohol to relieve or prevent withdrawal
5. Taking more alcohol over longer period of time than intended
6. Unsuccessful or persistent desire to cut down or control use
7. Great deal of time spent in getting, taking, and recovering from alcohol

Alcohol withdrawal—Cessation of alcohol use which has been heavy and pro-
longed and has at least 2 of the following within several hours to a few days:

BOX 13–2
Clinical Insitutue Withdrawal Assessment
of Alcohol Scale, Revised (CIWA-AR) (continued)

The CIWA-Ar is not copyrighted and may be reproduced freely.
Patients scoring less than 10 do not usually need additional medication for

Total CIWA-Ar Score ______
Rater’s Initials ________

Maximum Possible Score 67

Source: Sullivan, J. T., Sykora K., Schneiderman, J., Naranjo, C. A., & Sellers E. M. (1989). Assess-
ment of alcohol withdrawal: the revised Clinical Institute withdrawal assessment for alcohol scale.
British Journal of Addiction, 84, 1353–1357.

13 Gorman(F)-13 11/5/07 4:51 PM Page 242

• Suicide attempts
• Blackouts, seizures, or delirium
• Alcohol-related police record, possibly including motor vehicle violations or

accidents, physical violence, or child or spouse abuse
• May have history of being abused as a child
• Erratic work record because of alcohol abuse
• One or both parents with history of alcohol problems


Symptoms from alcohol withdrawal generally start within 4 to 12 hours of ces-
sation of heavy drinking. Symptoms are the most intense on the second day. Pro-
tocols for detoxification from alcohol include pharmacologic treatment to
prevent or reduce the development of alcohol-related delirium. Sedation with
longer-acting central nervous system depressants is substituted for shorter-acting
alcohol. Benzodiazepines such as diazepam (Valium) and chlordiazepoxide (Lib-
rium) are the drugs of choice because they have anticonvulsant actions and are
relatively safe. The drugs are usually administered on a routine basis and then

Chapter 13 ■ Problems with Substance Abuse 243

1. Autonomic hyperactivity (high blood pressure, tachycardia, fever)
2. Hand tremor
3. Insomnia
4. Nausea and/or vomiting
5. Anxiety
6. Transient visual, tactile, or auditory hallucinations or illusions
7. Grand mal seizures

Alcohol-induced delirium—An organic mental disorder with symptoms in
excess of the usual withdrawal (formerly called “delirium tremens”) or intox-
ication symptoms that occurs after cessation or reduction of long-term heavy
drinking or during intoxication. In someone with a history of substance use,
symptoms include

1. Impaired consciousness
2. Changes in cognition including memory, language, disorientation, halluci-

nations (especially tactile such as feeling bugs crawling on one’s body)
3. Develops over short period of time (hours to days) and fluctuates over a day.

Source: American Psychiatric Association (APA). (2000). Diagnostic and statistical manual of mental
disorders—text revision (TR.) Washington, DC: American Psychiatric Association.

13 Gorman(F)-13 11/5/07 4:51 PM Page 243

tapered down by 20% to 25% per day until withdrawal is complete—usually
about 5 days. Shorter acting tranquilizers such as oxazepam and lorazepam (Ati-
van) may be used if patient has liver disease. Anticonvulsants may also be needed.
Detoxification may be done in an alcohol treatment unit or hospital or at home,
if adequate supervision is available. Fluid, vitamins, and electrolyte supplemen-
tation is also part of the treatment plan. The inpatient setting needs to be used if
the patient is at risk for alcohol related delirium, has multiple comorbidities, or
is elderly.

Disulfiram (Antabuse) has been used for chronic alcohol abuse. This drug
inhibits impulsive drinking because it produces an extremely uncomfortable
physical reaction when alcohol is ingested. The drug is taken daily and stays
in the system for 5 days after the last dose. If the patient is exposed to alcohol
while the drug remains active, he or she may experience headache, tachycardia,
nausea, vomiting, flushing, sweating, and changes in blood pressure, as well as
potentially serious reactions including shock and cardiac arrhythmias. Because of
the risks involved with using this drug, the patient must have the ability to under-
stand the reaction if alcohol is ingested and give informed consent. The patient
must be instructed to avoid inhaling substances that could contain alcohol, such
as paint or wood stains, and refrain from using any substances with alcohol,
including those with hidden sources such as some mouthwashes, elixirs, skin
preparations, or colognes. The drug metronidazole (Flagyl) may cause a disulfi-
ram-like reaction when alcohol is also ingested. Antabuse is best used for the
motivated patient who is less subject to impulsive behavior and does not have a
psychiatric history.

Acamprosate and naltrexone are also being used to treat alcohol cravings and
the physical signs associated with withdrawal. These work as neuromodulators
to treat the brain dysfunction causing the addiction. These should be used in con-
junction with psychological support. Other commonly used medications include
beta blockers, clonidine, and haloperidol (for hallucinations).

Dual-diagnosis patients present a challenge because they usually need to con-
tinue to take their psychiatric medications during the detoxification process.
These medications need to be closely monitored.

Alternative approaches for withdrawal may include herbs and plants such as
chamomile for insomnia, valerian for anxiety (should not be taken with sedatives),
and kava kava for anxiety (should not be used with sedatives or alcohol). Multi-
vitamins, thiamine, and magnesium therapy are indicated in chronic alcoholics to
prevent neurological complications. Patients must also maintain hydration.

Twelve-Step Program
The Twelve-Step Program of Alcoholics Anonymous (AA) is generally accepted
as part of every alcoholic’s treatment program. AA’s philosophy mandates that
the individual become sober and never drink or use mood-altering substances
again. The person acknowledges that he or she is powerless over alcohol, is
always considered recovering, and is never cured. One drink could cause a down-

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ward spiral to heavy drinking. The best outcomes occur when the AA group
members are of similar age and cultural background.

AA uses sponsors who have been sober for longer periods to support new
members. The alcoholic needs to attend regular, even daily group support meet-
ings and work on the Twelve-Step Program. AA chapters are found in virtually
every community in the United States. The only requirement for membership is
the desire to stop drinking. AA has been the model for other self-help groups,
including Gamblers Anonymous and Cocaine Anonymous. Family members of
alcoholics can participate in self-help groups following the same model, includ-
ing Al-Anon for spouses and friends, Al-a-Teen for adolescents, and Adult Chil-
dren of Alcoholics (ACoA).

Additional approaches may include behavioral, group, and marital therapies.


INEFFECTIVE DENIAL evidenced by lack of acknowledgment of alcohol
abuse related to impaired ability to accept consequences of own behavior.

Patient Outcomes
• Acknowledges own drinking problem
• Expresses feelings while under nurse’s care
• Demonstrates problem-solving skills
• Abstains from alcohol and drug use or significantly reduces intake
• Asks for assistance with drinking problem

• Help patient identify disturbing feelings by listening to concerns and

helping him or her put labels on possible emotions. Patient may have
used alcohol to deny feelings and needs assistance to identify them.

• Foster problem solving. Explore with the patient, the coping mechanisms
that are more appropriate than alcohol to deal with the specific causes of
stress and anxiety.

• Talk with patient about the normal range of personal emotions.
• Discuss behavioral inconsistencies.
• Maintain a positive attitude. Communicate the idea that patient can

overcome his or her problems.
• Work with patient to set realistic small goals for abstaining from alcohol

and managing his or her problems. This may require structured planning
for how to get through the next day without a drink. Encourage use of
readings and meditations.

• Reinforce the Alcoholics Anonymous philosophy of “one day at a time.”
This means setting a goal of not drinking today rather than thinking
about not drinking for the next year.

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• Develop a trusting relationship. When the patient feels safe with a staff
member, encourage examination of the negative consequences of his or
her behavior. Recognize that this relationship could become too threat-
ening to the patient and he or she may try to sabotage it or reject the
nurse. This is all part of the struggle to face one’s problems.

• If patient states, “I could stop drinking any time,” have him or her iden-
tify what could be done right now to stop. Look for windows in denial
that might indicate the slightest insight and focus.

• Set limits on manipulative behavior. Some patients may have learned to
be very charming. The goal of these behaviors is to avoid dealing with the
real problems.

RISK FOR INJURY evidenced by disorientation, lack of coordination, or
aggressive or disruptive behavior related to acute alcohol intoxication, with-
drawal, and/or delirium.

Patient Outcomes
• Remains free from injury while under care of the nurse.
• Sleeps at least 6 hours at night.
• Has reduced incidence of medical complications.
• Exhibits appropriate behavior.

• Monitor vital signs, seizures, and changes in mental status closely for 5

days after withdrawal from alcohol.
• Monitor closely for signs of withdrawal and report to physician to begin

early treatment. With appropriate management, severe complications can
be prevented. Recognize that the patient may be using several drugs, so
the signs of alcohol withdrawal may be masked or delayed.

• Follow agency policy or protocol for detoxification for high-risk patients.
• Maintain a quiet, calm environment. Use a soft voice and calm, support-

ive approach to reassure patient.
• Make sure there is a night light in the room. Institute fall precautions.

Encourage staff or family to stay with patient to ensure safety.
• Avoid restraints if at all possible by adequate use of medication.
• If the patient has pain from another medical condition, such as trauma

or surgery, be sure to treat the pain. Do not withhold analgesia out of
fear that it will reinforce addictive tendencies.

• Institute appropriate precautions if patient at risk for seizures, hallucina-
tions, violent behavior.

• Promote use of relaxation techniques and herbal teas to reduce tension
and help with possible insomnia.

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• Monitor for complications, including cardiac arrhythmias or diabetes.
• Monitor food intake. Encourage fluids and a high-carbohydrate diet. Dis-

courage use of dehydrating foods and fluids such as coffee, tea, and
chocolate. Administer vitamins as ordered.

• Provide emotional support for patient and family.

FAMILY COPING: COMPROMISED evidenced by over-responsible behavior
to control the alcoholism related to anxiety in the family system.

Patient Family Outcomes

• Demonstrates assertive response when faced with abusive behavior
• Expresses feelings about the impact of alcohol on the family
• Demonstrates reduced number of behaviors that take responsibility for

patient’s drinking
• Attends support group meetings

• Recognize that alcoholism is a health problem that affects all family

members. Monitor response of all family members to patient’s behavior.
• Give feedback to individuals about over-responsible behavior. Encourage

them to recognize the signs and feelings associated with it. Explain how
efforts to contain the patient’s drinking merely delay the needed con-

• Assist family members to set limits on the urge to “rescue” the patient.
Give suggestions on coping mechanisms to reduce the stress. They need
support to accept the idea that they are not responsible for patient’s
drinking or behavior.

• Educate family members about availability and purpose of group support
programs. Talk to them about meeting with a chemical dependency spe-
cialist for assistance. Participate in a planned intervention technique
under the supervision of the specialist when the patient is confronted by
family and friends about his or her drinking problem.

• Give person permission to take care of own needs first.
• Teach the family assertive responses to abuse or criticism from others,

especially the patient.
• Encourage them to express emotions, both positive and negative.
• Reinforce the idea that ultimately the individual with the drinking prob-

lem is the only one who can control his or her own behavior.
• Recognize the fact that family members may unconsciously sabotage

patient’s recovery in order to maintain the security of the status quo.
Remain as objective as possible and avoid becoming involved in family

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• Prepare patient for changes in relationships with family and friends that
may occur once he or she has stopped drinking. There may be some indi-
viduals who no longer like the patient when he or she is sober. Patient
needs to reexamine these relationships.


Nutrition, Imbalanced: Less Than Body Requirements
Sleep Pattern, Disturbed
Thought Processes, Disturbed
Violence, Risk for

248 Chapter 13 ■ Problems with Substance Abuse


• Escalation of aggressive, belligerent behavior to violence
• Need to apply restraints
• Intoxication
• Complications including seizures, cardiac arrhythmias, bleeding, high

• Inadequate staff available to manage behavior
• Presence of increase in psychotic behavior
• Sudden change in mental status


• Addiction specialists
• AA sponsor
• Social Worker
• Security
• Psychiatric Team


• Reinforce strategies to avoid exposure to alcohol. For example, caution
patient to avoid contact with drinking friends. Teach patient to avoid his or
her old habits that included drinking, and remove all alcohol from the home.
Teach patient and family to read labels of products purchased. Avoid prod-
ucts with alcohol in them such as mouthwashes and cough syrup. Avoid any
mood-altering substance that could be used as a substitute for alcohol.

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• Provide information about the addictive process and how it affects all
aspects of one’s life. Review “one-day-at-a-time” philosophy.

• Provide information on any medications being used to treat withdrawal
and/or alcoholism.

• Provide information on nutrition and how to address possible vitamin and
mineral deficiencies.

• Provide information on side effects of medications used to treat alcoholism

• Provide information to patient and family on managing potential seizures.

• Provide health teaching on the potential of gastrointestinal bleeding and
liver disease. Encourage patient to avoid using products containing aspirin.

• Educate patient and family on the hazards of drinking in pregnancy and the
effects of alcohol on driving and working.

• Teach strategies to replace alcohol with more healthy activities such as
sports, hobbies, and journal keeping.

• Reinforce relaxation measures.

• Prepare patient for need to develop social contacts who do not drink.

• Reinforce education to family on avoiding overresponsible responses.

• Prepare the patient for the fact that intense emotions may be more painful
without alcohol. He or she may need extra help at these times.

• Remind patient to tell every physician seen about his or her history to
ensure that doctor will prescribe medications appropriately.

• Useful Web sites for patients and families include (National
Council on Alcoholism and Drug Dependence) and (Substance
Abuse and Mental Health Services Administration).


• Document vital signs and any evidence of symptoms of withdrawal and

• Describe in detail the patient’s level of consciousness and mental status.

• Document the patient’s response to the medications being used for with-

• Document the family’s response to patient’s behavior.

• Document any observations of continued alcohol use.

• Document any actions taken to prevent violent behavior.

• If restraints are necessary, document the type, the time the patient was in
restraints, the reason why they were applied, the patient’s response to treat-
ment, when limbs were released, and the care given to the patient while in

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• Provide information to patient and family on location and phone numbers
for local chapters of AA, Al-Anon, and Al-a-Teen, as needed.

• Encourage the patient and family to begin or continue counseling or provide
referral to alcohol counseling programs.

• Communicate information on all medications prescribed for alcohol with-
drawal and alcoholism

• Encourage the patient to follow up with medical appointments

• Arrange for follow-up home health visits for patients being discharged from
detoxification treatment to home.

• Provide information to referring agencies, such as home health agencies or
nursing homes, on patient’s drinking patterns and the treatment program.

The Patient Abusing Other

Learning Objectives
• Differentiate between substance abuse and dependence.
• Identify common reactions of the nurse to the substance abuser.
• Describe important nursing considerations of abusing amphetamines,

cocaine, hallucinogens, nicotine, opioids, and sedatives.
• Identify nursing diagnoses and interventions in caring for the substance


Binge – Pattern of periodic intervals of heavy use of substances with intervals

of no or little usage.
Cross-tolerance – State in which the effect of a substance is reduced because

the individual has become tolerant to a similar drug.
Detoxification – Process of withdrawal of a drug from the body through

supervised medical intervention to prevent complications.
Drug tolerance – Need for higher and higher doses to achieve same desired


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Dual diagnosis – Individual with a mental disorder who is also a substance
abuser. The substance is often used to self-medicate to relieve psychiatric
symptoms. Also called co-occurring disorder.

Flashback – Transient recurrence of a disturbance in perceptions associated
with hallucinogens that are reminiscent of those experienced when taking
the drug. Sometimes referred to as a “hallucinogen persisting perceptual

Polypharmacy – Taking more than one substance at any given time.
Substance abuse – The maladaptive and consistent use of a drug accompa-

nied by recurrent and significant adverse consequences often related to
physical hazards, multiple legal problems, and recurrent social and inter-
personal problems.

Substance dependence – Cluster of cognitive, behavioral, and physiologic
symptoms indicating that the individual continues use of the substance
despite significant substance-related problems.

Withdrawal – Negative physiological and psychological reactions that occur
when the drug is reduced or no longer taken.

Using mind- and mood-altering substances is probably as old as the human
race. Today, many people use medications or other substances to relax, sleep,

and increase energy. Prescription and over-the-counter psychoactive substances
such as caffeine, tobacco, alcohol, pain killers, tranquilizers, and common cold
treatments are both socially acceptable and commonly used. It is interesting that
we accept these substances to help us feel better but loathe people who are
dependent on or abuse drugs. People who eventually become substance abusers
also take drugs to feel better, possibly as a way to avoid some problems and stres-
sors. Eventually, though, the need to obtain and use the drug negatively affects
all aspects of the person’s life, including family, job, friends, and other responsi-
bilities. Many people who use drugs retreat to the company of others who share
their lifestyle, beliefs, and drugs. Polydrug use is particularly common, as indi-
viduals use one drug to counteract or enhance the effects of the first drug.

There is a significant difference between substance dependence and substance
abuse. According to the DSM-IV-TR, substance dependence is characterized by a
pattern of repeated self-administration of a drug that usually results in tolerance,
withdrawal, and compulsive drug-taking behavior. Substance abuse is character-
ized by compulsive use in which the individual continues to use the drug even in
the face of problems, including inability to fulfill major role obligations at work,
school, or home; recurrent use in situations in which it is physically hazardous;
recurrent legal problems related to the substance use; and recurrent social or
interpersonal problems related to drug use.

Substance abuse is a major health problem for individuals in all ages and
socioeconomic groups; however, abuse rates are highest in the 18- to 20-year-old
age group (2004 National Survey on Drug Abuse and Health). At some time in
their lifetime, 14.6% of Americans have a substance abuse disorder (Kessler,

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et al, 2005). The National Survey on Drug Abuse and Health in 2004 found that
9.4% of the population has substance abuse or dependence at any one time, with
marijuana being the most frequently used illicit drug. Patterns of use vary in rela-
tion to cost and availability. The economic impact of drug abuse is tremendous,
including crime, medical costs, accidents, and loss of work days in addition to the
resulting family dysfunction.

Methamphetamine (known as crystal meth) has been increasingly abused by
young people in recent years. It is more often found in rural and suburban com-
munities. This drug is a long-acting amphetamine that contributes to many anti-
social behaviors including violent crime, child abuse, and prostitution. Originally
produced in this country in meth laboratories from over-the-counter deconges-
tant pseudoephedrine, it is now smuggled in from other countries.

Anabolic steroids are another relative recent drug of abuse. Used by athletes
to increase muscle mass, the pattern of addiction to this substance fits the defini-
tion of substance abuse when the individual continues to use the drug despite
negative effects.

Substances known as “club drugs” have been popular with young people.
These include ecstasy, ketamine, and rohypnal. Rohypnal has been associated
with “date rape.” When this short-acting benzodiazepine is slipped into an alco-
holic drink, the victim becomes incapacitated and unable to resist a sexual
assault. Ecstasy (also called MDMA) is a stimulant/hallucinogenic that can
destroy neurons in the brain leading to brain damage.

It is estimated that 10% to 15% of nurses suffer from some form of chemical
dependency (Raia, 2004). Alcohol is the most widely abused drug followed
closely by narcotics. Stressful jobs and a tendency to perfectionism, coupled with
a feeling of inadequacy; family history; and knowledge about and access to drugs
increase the risk of substance abuse in this population. Because they do not fit the
image of an addict, nurses often minimize or deny their problem. Many states
have now developed Diversion Programs to provide treatment and rehabilitation


The causes of drug abuse are similar to those of alcohol abuse; however, because
of the wide range of drugs abused, there are some differences.

Biological theories look at the role of specific brain dysfunction and view
addiction as a brain disease. Cravings for drugs are stimulated by two path-
ways—the glutamatergic tract from the prefrontal cortex and the dopaminergic
tract. After using a drug that induces an altered state, brain changes that lead to
increased craving for this drug again are created. Cocaine has been studied in
more depth than some of the other drugs, and it is believed that there may be a
deficiency of dopamine and norepinephrine that creates more of a craving for
that drug. With opioids, it is theorized that there may be some abnormality in
opioid receptors and endorphins.

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Psychological theories view drug dependence as an attempt to adapt to severe
emotional distress. Low self-esteem and anxiety become masked under the influ-
ence of the drug. Drugs relieve feelings of depression and dependency and may be
used to suppress anxiety, particularly after a traumatic event such as rape or vio-
lent crime. Individuals with tendencies toward antisocial behavior and difficulties
with impulse control and frustration tolerance may use substances as a way to
control anxiety that contributes to antisocial behavior. In addition, the role of the
family and tendency to codependent relationships (see the preceding subsection on
alcoholism for complete discussion) also exist with substance abuse. Drug abusers
use many of the same coping mechanisms that alcoholics do, including denial,
projection, and manipulation (see Table 13–1). Substance abuse can also be a way
to cope with overwhelming traumas such as physical and mental abuse.

Sociocultural views recognize that certain drugs may be more likely to be used,
depending on peer group, income, or culture. Acceptable behavior within a
group, access to specific drugs, and status related to specific drugs may all be
influencing factors. For example, crack cocaine has spread quickly within the
low-income groups because of its easy availability and low cost.

As with alcohol, patients with a co-occurring disorder of substance abuse and
a psychiatric disorder are very common and tend to complicate treatment for
both conditions. See previous section of this chapter on patients who abuse alco-
hol for more information. The National Alliance for the Mentally Ill (2006)
reports that 53% of substance abusers have at least one mental illness.


There is no evidence to suggest that an individual will become dependent on
drugs by taking analgesics for pain. In fact, McCaffery and Ferrell (1994) report
that less than 1% of individuals who take analgesics for a painful condition
become addicted to that substance. Individuals who have developed drug toler-
ance require larger amounts of medications to relieve pain. This should not be
confused with addiction.

Individuals with a substance abuse problem may experience withdrawal symp-
toms when hospital admission prevents them from taking the addictive sub-
stance. This is an important consideration when analyzing assessment findings.
For instance, when a patient who has been hospitalized and NPO for 2 days
experiences headaches and irritability, it may be related to caffeine withdrawal.
In certain instances, withdrawal symptoms for more potent substances can
increase the risk of complications. For example, the confusion resulting from
amphetamine withdrawal may cause a postoperative patient to attempt to get out
of bed, tear out tubes and intravenous lines, and possibly fall.

The effects of high-risk behaviors that contribute to HIV, hepatitis, and bacte-
rial endocarditis from infections and shared drug paraphernalia cause additional
clinical concerns. Individuals may be more prone to high-risk behavior when
under the influence of drugs because inhibitions are suppressed. Intravenous drug

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use remains a major cause of HIV. Many stimulants and inhalants contribute to
cardiac arrhythmias.

Polydrug use combined with alcohol is another common finding in the
substance abusing population. For example cocaine users commonly use alcohol
to get to sleep or calm down. Complications related to multiple drug use include
interactions between drugs and synergistic effect of some drug combinations.
Detoxification from multiple drugs requires close monitoring by addiction


Cocaine use during pregnancy presents severe problems for the exposed neonate.
Cocaine crosses the placenta and can induce premature labor. Complications
include lower birth weight, decreased head circumference, preterm delivery, and
placental abruption. Long-term problems can include aggressiveness and atten-
tion deficit. There is often a lack of prenatal care associated with the pregnancy
as well because the mother may be fearful of seeking medical care.

Children and Adolescents
Children and adolescents today are at high risk for exposure to substance use and
abuse because of the easy availability of drugs in the schools and community. Peer
pressure, experimentation, curiosity, and rebellion, as well as trying to
find ways to cope or escape from problems, may be part of the etiology. Alcohol,
tobacco, and marijuana are most frequently used. Drug use often begins while
experimenting with peers. When the child or teen experiences a sense of well-being
and power, drug use continues. He/she may then become drawn into the drug cul-
ture and possibly into a gang, which provides a support system for continued use.
Children and adolescents are more likely to have abuse problems than dependence
disorders. Adolescents who are victims of abuse and gay teens are particularly vul-
nerable to drugs as a way to cope with painful feelings (Tweed, 1998).

Some of the most common abused substances for children and teens include
easy-to-obtain over-the-counter substances like inhalants and cough/cold reme-
dies. Children as young as 7 years have been identified as using inhalants. These
are an easily available substance to children and younger teens when household
items such as hair spray and aerosol whipped cream can be used. Over-the-
counter cold and cough medicine abuse is now rising by 50% per year in teens
(Partnership for a Drug-Free America, 2006). Products with dextromethorphan
can contribute to hallucinations and out-of-body experiences. Use of anabolic
steroids often starts in adolescence when a teen becomes active in school sports
and also wants to enhance his appearance.

Signs of substance abuse in this group may be indicated by a change in func-
tioning at school, loss of interest in sports, change in sleep patterns, increased iso-
lation, or change in social network.

254 Chapter 13 ■ Problems with Substance Abuse

13 Gorman(F)-13 11/5/07 4:51 PM Page 254

Older Adults
Substance use and abuse in elderly people are complicated because they routinely
take a greater number of prescribed and over-the-counter drugs and have dimin-
ished tolerance to many medications. The individual, family, and health profes-
sionals often deny this problem in this age group. This may be because family
members and health-care professionals are reluctant to accuse an older person of
drug abuse. The signs of abuse may also be masked or mistakenly attributed to
the use of another drug the person is taking. The older adult is more likely to
abuse prescribed tranquilizers, sedatives (especially benzodiazepines), and some
analgesics. Falls, unexplained accidents, increased lethargy, loss of memory and
attention span, and unexplained confusion may be signs of a drug abuse prob-
lem. Use of illicit drugs is relatively uncommon in elderly people, but it may
increase in the future as young and middle-age addicts grow older.

Chapter 13 ■ Problems with Substance Abuse 255

• May have strong negative feelings, viewing the patient as weak, immoral,

or responsible for his or her own problems.
• May fear the patient’s manipulative, provocative behavior and potential for

criminal or violent behavior.
• May tend to minimize patient’s concerns or discomforts because of resent-

ment or fear of being manipulated.
• May distance self from patient because of own discomfort.
• May have a rescue fantasy of being the one to help this patient. The nurse

may then become repeatedly disappointed when the patient returns to drug

• May view patient’s cure as hopeless.
• May allow personal or family experience with substance abuse to influence

response to the patient.

ASSESSMENT (See Table 13–2)

Behavior and Appearance
• May talk frequently or brag about using drugs

• May have an in-depth knowledge of drugs and how they work

• Dramatic behavior changes, for instance, may be suddenly euphoric,
drowsy, more outgoing

• Wears sunglasses indoors because of photophobia or to hide dilated or pin-
point pupils

• Unpredictable behavior

• Grandiosity, overconfidence (text continued on page 264)

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256 Chapter 13 ■ Problems with Substance Abuse

TABLE 13–2
Comparing Commonly Abused Substances

Drug Intoxication Overdose Withdrawal Considerations



Signs: Eupho-
ria, high
panic disor-
ders, insomnia
and delusions
(often seen
with long-
term use)

Signs: Eupho-
ria; intensified
impaired judg-
ment and
motor ability;
weight gain,
sinusitis, and
with chronic
use; anxiety,
paranoia; red

Signs: Ataxia,
high temper-
distress, car-
coma, death


Signs: Extreme

sion, agita-
dreams fol-
lowed by

suicide pre-

Signs: With-
not recog-
nized in
TR though
report loss
of appetite,
sleep, rest-
and irri-

• Used in weight
reduction pro-
grams and to
treat benzodi-
azepine abuse.

• Tolerance can
develop fairly

• User often
also using
alcohol and
other sub-
stances to

• May cause a
reaction in

• Remains in
urine for up to
3 days.

• Most widely
used illicit

• Impaired judg-
ment may
contribute to

• Respiratory
damage from
inhaled sub-
stances can

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Chapter 13 ■ Problems with Substance Abuse 257

Drug Intoxication Overdose Withdrawal Considerations



Signs: Eupho-
ria, grandios-
ity, sexual
nasal perfo-
ration associ-
ated with
route; psy-
chosis associ-
ated with


Signs: High
causing MI
or CVA,
coma, death


• Remains in
urine for up
to 7 days.

• May exacer-
bate psychi-
symptoms in
mentally ill

• May nega-
tively affect

• May thera-
reduce nausea
and vomiting,
pressure, and

• Crack is
smoked or
injected IV;
has a rapid
onset and high

• Tolerance

• Cocaine
is inhaled,
snorted or
injected IV.


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258 Chapter 13 ■ Problems with Substance Abuse

TABLE 13–2
Comparing Commonly Abused Substances—cont’d

Drug Intoxication Overdose Withdrawal Considerations


LSD, psilo-
cybin, and

Signs: Dilated
of colors,


Signs: Panic,
with halluci-
nations, cere-
bral tissue
mia, death

Diazepam or
quiet envi-


Signs: None

• High risk of
acquiring HIV,
hepatitis, bac-
terial endo-
carditis, and
from shared
IV needles or
sexual rela-

• May be used
to control

• Flashbacks
can occur for
up to 5 years.

• Could precipi-
tate a psychi-
atric disorder
in susceptible

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Chapter 13 ■ Problems with Substance Abuse 259

Drug Intoxication Overdose Withdrawal Considerations

or hair
and paint

and nico-
tine gum
or patch

Signs: Eupho-
ria, impaired
unsteady gait

Signs: Pro-
duces a sense
of anxiety
relief from
and satisfac-

Signs: Psy-
chosis with
tions, cardiac
CNS depres-
sion, coma,
cerebral tis-
sue damage,


Signs: None

Signs: None

poor con-

• Most avail-
able substance
for younger

• Intoxication
period is brief
(15-45 min-

• Can cause
CNS damage

• May be diffi-
cult to detect
specific sub-
stance used.

• Particularly
and/or flam-
mable sub-
stances can
cause trauma
and burns in
nose, mouth,
and airways.

• Because most
medical facili-
ties do not
allow smok-
ing, inpatients
may experi-
ence with-


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260 Chapter 13 ■ Problems with Substance Abuse

TABLE 13–2
Comparing Commonly Abused Substances—cont’d

Drug Intoxication Overdose Withdrawal Considerations


dine, Oxy-
phene, and


pupils, res-

patches in
doses, nicotine
gum, nicotine
nasal spray,
and clonidine
for severe
Long term
smokers may
need to
remain on
nicotine ther-
apy for some

Signs: Yawning,
anorexia, irri-
tability, rhi-
cramps, chills,
nausea, vomit-
ing, feelings of
doom and

• Less than
25% of indi-
viduals are
with first
attempt to

• Self-help
strategies with
and nicotine
has greatest

• Monitor for
weight gain.

• Monitor for
with cloni-

• High risk of
acquiring HIV,
hepatitis, bac-
terial endo-
carditis, and
from shared
IV needles.

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Chapter 13 ■ Problems with Substance Abuse 261

Drug Intoxication Overdose Withdrawal Considerations


dine (PCP,
angel dust)

Signs: Impul-
sive behavior,
ataxia, mus-
cle rigidity,
numbness or
response to


Signs: Hal-

juice or
nium chlo-
ride to
urine (if
quiet envi-
dol or

possibly with
clonidine for
severe anxiety
and methadone,
and/or burenor-
phine to block

Signs: None

• May be
illegally or
through pre-

• Monitor for
with cloni-

• Have ade-
quate staff
is unpre-
dictable and
patient may
become vio-

• May con-
sider using


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262 Chapter 13 ■ Problems with Substance Abuse

TABLE 13–2
Comparing Commonly Abused Substances—cont’d

Drug Intoxication Overdose Withdrawal Considerations


and anxi-
rates and

Signs: Slurred
speech, labile
mood, inap-
behavior, loss
of inhibi-

sion, nystag-
mus, stupor,
renal failure,
ates), coma,

induce vom-
iting, if
awake; acti-
vated char-
ratory sup-

Signs: Insom-
nia, hand
tremor, agita-
tion, panic
disorder, nau-
sea and vom-
iting, anxiety,
tinnitus (with
seizures, and
cardiac arrest

tion using
dosages of a
similar drug,
sants, and
support and

• Drugs
remain in
urine for

• Avoid using
they can
the effects
of PCP.

• Abrupt bar-
can be life-

• Alcohol will
drug effects.

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Chapter 13 ■ Problems with Substance Abuse 263

Drug Intoxication Overdose Withdrawal Considerations


Club Drugs

Signs: Eupho-
ria, muscle
poor judg-

Signs: Confu-
sion, hallu-
severe anxi-
ety, hyper-
high temp


Signs: Not
cally addic-
tive, but
can cause

• Cross-
may develop
alcohol and
other CNS

• Detectable
in blood
and urine.

• Shorter-
acting ben-
have a
greater risk
of produc-
ing addic-
tion and
more severe
anxiety than
acting ones.

• Can cause
memory loss
and brain

• Physical
may be
by dehydra-


13 Gorman(F)-13 11/5/07 4:51 PM Page 263

• Disheveled appearance

• In children and adolescents, loss of interest in school, drop in grades

Mood and Emotions
• Mood swings

• Low frustration tolerance, angers easily

• Angry outbursts

• Anxiety, especially associated with discussion of drug use

• Emotional reactions related to change in medication regimen, particularly
changes in analgesics

• Depressed; verbalizes self-deprecating thoughts

Thoughts, Beliefs, and Perceptions
• Denies impact of drug use

• Rationalizes that he or she can stop using any time

• Persistent belief that drug is for medical use only

• Obsessive thoughts about drug use and access to drug supply

• Suicidal ideations

264 Chapter 13 ■ Problems with Substance Abuse

TABLE 13–2
Comparing Commonly Abused Substances—cont’d

Drug Intoxication Overdose Withdrawal Considerations


Signs: Dra-
increase in
muscle mass,
blood sugar,
acne, edema
from fluid
sex charac-

Signs: Liver
sion, para-
ity, manic


Signs: Depres-
sion, fatigue,

• Masculin-
ization of
women and
of men is

• May be self-

• Repeated
use can

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Chapter 13 ■ Problems with Substance Abuse 265

Relationships and Interactions
• Change in circle of friends and isolation from family
• Blames others for need to use substances and other problems
• May become more isolated as fears of exposing habit to others increases
• Charming, charismatic, or manipulative with others

Physical Responses
• Needle tracks (raised marks from repeated IV injections) may be seen in

antecubital space, wrist, feet, behind knees, or in tattoos.
• Recent injection sites may be red and swollen.
• Abscesses and ulcerations may be present.
• There is evidence of drug(s) in urine testing. Each drug varies as to how long

it remains in the body. Check with the laboratory for specifics.
• Pupil response varies from constricted to nonreactive with different drugs.

Pertinent History
• History of withdrawal symptoms, overdosage, complications from past

drug use
• Psychiatric disorders
• Family history of drug or alcohol abuse
• Criminal record and other legal problems
• Daily or binge drug abuse or dependence
• History of eating disorders


Treatment for substance abuse frequently requires a multidimensional approach
including pharmacological treatment for detoxification, individual and group
counseling, Twelve-Step Program, and education. Most treatment can be done on
an outpatient basis, except for high-risk detoxification.

Pharmacology can be used to replace the illicit substance as in Methadone.
Pharmacology can also be used to neuromodulate the drug cravings by interact-
ing with the receptor system in the brain affected by the substance. Examples of
neuromodulators include buprenorphine and naloxone for opioid addiction.
These substances also reduce the physical signs of withdrawal.

Medications are used in detoxification programs for many drugs, including
opioids, barbiturates, sedatives, and tranquilizers. They are used to control with-
drawal symptoms and discourage continued use of the abused substance. Most
are used for only short periods until withdrawal is complete; however, in some

13 Gorman(F)-13 11/5/07 4:51 PM Page 265

cases, they may be used for longer periods to control cravings for the drug.
Methadone, a synthetic narcotic that resembles morphine and heroin but does
not produce the euphoric effects, is used daily on a long-term basis to treat heroin
addiction. Both physical and psychological dependence are maintained on
methadone, but the euphoric effects of heroin are blocked. Patients usually make
daily trips to a methadone clinic to obtain the drug. Buprenorphine, an opioid
with agonist and antagonist action, has been used as an alternative to methadone.
Naltrexone also reduces the euphoric sensation from narcotics, and clonidine
decreases discomfort during narcotic withdrawal. The newest opioid withdrawal
treatment uses Suboxone (buprenorphine and naloxone). Addiction specialists
must be certified to prescribe this regimen. Patients on this medication must be
monitored closely if they have conditions that require use of analgesics. Admin-
istering analgesics could precipitate a withdrawal syndrome. So pharmacology
can be used to replace the illicit substance like methadone for heroin addiction.

Benzodiazepines and sedative withdrawal is more risky because of the risk for
seizures and delirium. Tapering the dose of the identified or similar drug, along
with anticonvulsants and antidepressants, is usually used.

Dual-diagnosis patients may require medications for treatment of their psy-
chiatric diagnosis, but efforts are made to avoid sedatives and tranquilizers.
Patients with anxiety or psychotic disorders may be using illicit drugs as a way
of controlling hallucinations or anxiety.

Nicotine withdrawal has been successfully treated with nicotine replacement
and also the addition of bupripion (Wellbutrin). No effective drugs are currently
available for stimulant addiction but research is suggesting modofinil (Provigil)
may be helpful.

Complementary approaches to treatment of substance abuse might include
acupuncture, biofeedback, and massage. Herb and plant products to treat dis-
tressing symptoms may be helpful and include chamomile, valerian, kava kava,
and St. John’s wort. The last is contraindicated if the patient is taking antide-
pressants, narcotics, or amphetamines.

Twelve-Step Program
The Twelve-Step Program has been used to treat substance abuse and includes
groups such as Narcotics Anonymous, Cocaine Anonymous, and Pills Anony-
mous. The philosophy mandates that the individual remains free from the sub-
stance and acknowledges that he or she is powerless over the chemical.
Individuals need to attend group meetings routinely. Sponsors who have been
drug free for longer periods provide support for new members. Family members
can also participate in self-help groups following the same model.

Drug rehabilitation also includes counseling to restore physical and emotional
stability, identify the person’s usual coping mechanism and work to adopt more
effective ones, and develop a sense of self-worth and self-esteem.

266 Chapter 13 ■ Problems with Substance Abuse

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INEFFECTIVE DENIAL evidenced by lack of acknowledgment of substance
abuse problem related to impaired ability to accept consequences of own

Patient Outcomes
• Acknowledges substance abuse problem
• Abstains from substance use
• Demonstrates participation in treatment plan

• Convey acceptance of patient. Avoid criticizing, preaching to, or attack-

ing the patient to get his or her attention.

• Promote trust by listening to concerns and treating patient as an

• Give patient specific feedback on any behavior that appears drug related.
Identify defense mechanisms such as blaming others or rationalizing
behavior. Encourage personal responsibility for own behavior.

• Provide information on treatment approaches, such as Cocaine Anony-
mous (CA) or Narcotics Anonymous (NA).

• Help patient identify and share the possible emotions he or she is feeling.

• Help patient see link between substance use and personal and medical
problems. Give the patient the opportunity to identify these, if possible.

• Assist patient to identify ways in which drug use affects daily life.
Encourage being specific and honest.

• Set limits on manipulative behavior and realistic consequences for this
behavior. Recognize that patient may exhibit charming, charismatic
behavior, making limit setting more difficult. Never cover up for the
patient or act entertained by drug use.

• Recognize that the drug effects may overwhelm the patient’s motivation
to stop. However, do not ignore signs of patient intoxication. Become
familiar with your institution’s policies for suspected drug use such as
conducting a room search or confiscating drugs.

• If the patient indicates that he or she wants to participate in a treatment
program, immediately contact appropriate resources, such as a social
worker, to facilitate admittance to a program.

INEFFECTIVE COPING evidenced by anxiety, withdrawal symptoms, inabil-
ity to function without drugs in recovery related to inadequate coping skills to
manage stressors without drugs

Chapter 13 ■ Problems with Substance Abuse 267

13 Gorman(F)-13 11/5/07 4:51 PM Page 267

Patient Outcomes
• Demonstrates participation in treatment plan
• Demonstrates alternate coping mechanisms to deal with stress that do

not involve drugs
• Verbalizes need to continue in treatment
• Abstains from substance use

• Help patient to focus on getting through each day without drugs rather

than the overwhelming thought of never using them again.
• Give reinforcement for ability to delay gratification and tolerate frustra-

tion. Provide information on possible coping mechanisms to reduce stress
and tolerate discomfort. Review alternative ways to cope with anger.
Role-play dealing with stressful situations.

• Explain the long-term physical effects of drug use, such as short attention
span, that affect daily life.

• Prepare patient for the possibility that family and friends may have diffi-
culty relating to him or her when he or she is not using drugs. For
instance, friends may seem to abandon the patient who no longer wants
to participate in their drug-related activities. The patient will need to pre-
pare to accept this and work on changing these relationships or develop-
ing new ones.

• Help the patient discuss realistic future plans and life changes to make
when no longer using drugs. Help to identify steps to achieve these goals.

• Encourage participation in support groups or visits or phone contacts
with sponsors.

• Monitor to see if visitors are bringing in drugs.
• Provide information on drug treatment for withdrawal. Emphasize need

to remain on medications as prescribed.

RISK FOR INJURY evidenced by disorientation, lack of coordination, or
aggressive or disruptive behavior related to substance intoxication, overdose,
or withdrawal

Patient Outcomes
• Remains free from injury
• Reduced incidence of medical complications related to substance abuse
• Sleeps at least 6 hours a night

• Recognize that many people who abuse drugs can function in society

fairly well. Early signs of withdrawal may occur during hospitalization

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13 Gorman(F)-13 11/5/07 4:51 PM Page 268

with no access to drug supply. Suspicious symptoms should be assessed
carefully so that treatment can be instituted as early as possible.

• Determine which substances the patient has been using. Take a careful
history from patient or family and friends (if applicable). Obtain ordered
urine and blood for drug screening, and carefully monitor the patient’s
clinical condition and behavior. Recognize that many patients are using
more than one substance, including alcohol.

• Institute fall and seizure precautions, as appropriate.

• Recognize that many substance abusers have poor nutritional habits
because of anorexia, emotional changes, or inadequate intake. Monitor
food and fluid intake. Encourage adequate fluids and nutrition.

• Administer ordered medications to ease symptoms and monitor for
adverse and therapeutic effects. Monitor for signs of aggressive, agitated
behavior. Avoid restraints, if at all possible.

• Promote rest and sleep by maintaining a quiet environment and encour-
aging use of relaxation techniques and herbal teas.

• Patients with painful medical conditions need to have analgesics. The
substance-abusing patient may need higher doses of analgesics and bene-
fit from a regular dosing with a long-acting analgesic rather than as-
needed administration. This avoids the euphoric effect from the analgesic.


Infection, Risk for
Knowledge, Deficient
Self-Care Deficit
Self-Concept, Disturbed
Social Interaction, Impaired
Thought Processes, Disturbed

Chapter 13 ■ Problems with Substance Abuse 269


• Escalation or onset of aggressive, belligerent behavior or violence
• Change in level of consciousness unrelated to underlying medical

• Need to apply restraints
• Inadequate staff available to manage behavior
• Patient demonstrating signs of impairment of substances
• Suspected criminal activity related to drug use, selling drugs

13 Gorman(F)-13 11/5/07 4:51 PM Page 269


• Encourage patient to inform health-care providers about past or present
drug use because this information will influence drug and dosage selections
for needed medical treatments.

• Use caution when using over-the-counter drugs, diet pills, sedatives, and
herbal products.

• Teach family members about need to adjust some aspects of their relation-
ship with patient. Help them to identify possible behaviors that could be
reinforcing substance use. Give them specific feedback if you observe any of
these behaviors.

• Encourage patient to establish new routines and activities that do not
involve drug use. This may include avoiding an old circle of friends and
developing hobbies or new interests.

• Provide information on risks of exposure to HIV, hepatitis, and other infec-
tions. Encourage patient who is at risk to obtain blood tests to determine
exposure, and teach health practices to reduce risk to self and others.

• Help patient recognize potential fears and changes that may occur when he
or she changes his or her life to live without drugs.

• Provide information on the health impact of specific substances patient is

• Provide information on treatment of substance abuse to patient and family.
• Provide information on pharmacological treatment of addiction.
• Educate patient and family on effects of drugs on pregnancy, on the job, or

operating mechanical equipment.
• Useful websites for patients and families include (Partnership

for a Drugfree America).


• Document behavior associated with intoxication, overdose, or withdrawal.
• Document any indications of inappropriate drug use.

270 Chapter 13 ■ Problems with Substance Abuse


• Addiction Specialist
• Psychiatric Team
• Security
• Social Worker
• Attending Physician
• Sponsor from Twelve Step Program

13 Gorman(F)-13 11/5/07 4:51 PM Page 270

• Describe patient behavior after visits from family or friends.
• Describe response to treatments.
• Describe pain or anxiety behaviors and need for analgesics or tranquilizers.


• Provide referral information on clinics, hotlines, halfway houses, drug treat-
ment programs, and counseling that assist drug abusers.

• Inform referring agencies of patient’s history.
• Arrange for follow-up psychiatric home health visit to reinforce drug treat-

ment program as needed.
• Encourage follow-up medical appointments.

Chapter 13 ■ Problems with Substance Abuse 271

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14Problems with
Sexual Dysfunction

The Patient with
Sexual Dysfunction

Learning Objectives
• Define sexuality and sexual health for adults.
• Differentiate the major sexual dysfunctions found in men and women.
• Identify therapeutic interventions for common sexual dysfunction
• Describe common nurses’ reactions to patients with issues about sexual


Dyspareunia – Persistent genital pain in either a man or woman before, dur-

ing, or after sex.
Female sexual dysfunction – Includes inhibited desire, orgasmic dysfunction,

and vaginismus.
Gender Identity Disorder – Strong and persistent cross-gender identification
Impotence – Erectile dysfunction or inability to attain or maintain an erection

sufficient to complete intercourse.
Male sexual dysfunction – Includes inhibited desire, erective incapacity, pre-

mature ejaculation, ejaculatory incompetence, and ejaculatory pain.
Premature ejaculation – Persistent and recurrent ejaculation with minimal

sexual stimulation and before the person wishes it.
Sexual dysfunction – A change in sexual health or function that the individ-

ual views as unrewarding or inadequate. Sexual dysfunction is usually
related to one or more of the following: lack of knowledge or incorrect infor-
mation; biological or physiological causes, such as diabetes, drug or alco-

14 Gorman(F)-14 11/5/07 4:59 PM Page 273

hol use, hormonal disorders; change in or loss of body part; ineffective cop-
ing or poor relationships; or organic problems (impotence, premature ejac-
ulation, vaginismus, and orgasmic dysfunction).

Sexual response cycle – Includes excitement, plateau, orgasm, and resolution.
Gender, age, culture, experience, and expectation affect each of these stages.

Sexually transmitted disease – Any disease that can be contracted by sexual
contact; also called venereal disease. Symptoms range from merely annoy-
ing to life threatening.

Vaginismus – Involuntary spastic constriction of the lower vaginal muscles.

Human sexuality is a complex phenomenon encompassing biological, psy-
chological, and sociocultural aspects. Biological aspects include the

anatomy and physiology of sexual development and sexual activities; psycholog-
ical aspects include gender identity, sexual self-concept, and valuing one’s self as
male or female; and sociocultural aspects include sexual orientation learned from
the value systems of family, peers, and community. All of these aspects are inter-
related, influencing the individual to experience and value the self as masculine
or feminine, seeking and giving affection, and striving to meet basic needs for
love and belonging

A sexually healthy person has the following characteristics:

• Behavior agreeing with gender identity (persistent feeling of one’s self as
male or female)

• Ability to participate in loving and committed relationships
• Physical ability to find erotic stimulation pleasurable
• Ability to make decisions about sexual behavior that are compatible with

values and beliefs, cultural norms, and social mores
• Ability to make adjustments in sexual functioning appropriate to limitations

and changes resulting from illness, injury, or other events such as unavail-
ability of a partner.

Human sexuality can be healthy, satisfying, and enriching, as defined by the
preceding characteristics; or it can be the source of physical and mental distress
(LeMone & Jones, 1997; Fergusson, 1999). Sexuality encompasses a person’s
feelings about himself or herself and how to interact with others. Sexuality and
sexual behaviors are influenced by age, knowledge, marital status; resources; val-
ues; social, spiritual, and cultural norms; and emotional and physical health
(Poorman, 2001).

Society today allows people to experience various types of adult relationships.
Once believed to be the legal and moral right only of married people, sexual
activity is now considered by many individuals to be acceptable for any consent-

274 Chapter 14 ■ Problems with Sexual Dysfunction

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ing adult. More people are involved in relationships that were not considered
acceptable just a decade or two ago, such as premarital sex, open marriages,
remarried or blended families, unions of never-married adults, single-parent
families, and homosexual relationships. Although homosexuality was once
considered a mental illness, sexual preferences are now considered a matter of
personal choice (King, 1999; Levine, 1999; Torkelson & Dobal, 1999).

All aspects of human sexuality may be affected by acute and, especially, chronic
illness. Ill health is one of the greatest detriments to sexual expression, not only
because it focuses energies toward recuperation but also because it often lowers
an individual’s sense of personal worth and attractiveness, and indirectly, sexual
desire. The most common dysfunctions in women are arousal and orgasmic dys-
function. Common dysfunctions in men are impotence and premature ejaculation.

A diagnosis of sexual dysfunction is made when an individual identifies a
problem with sexuality (not when the caregiver is uncomfortable with the
patient’s sexual preference) or when antisocial sexual behavior results in harm to
others. Individuals have the right to make choices regarding their sexual options
and should be offered education about them, such as information on appliances
and strengthening exercises for cord-injured patients. However, they do not have
the right to inflict discomfort or harm on others (Taylor, 1999). Changing social
norms for sexual behavior have recently made deviations from “traditional” sex-
uality more acceptable. Some individuals who adopt alternative modes of sexu-
ality (e.g., homosexuality) experience little or no conflict internally or externally
and thus may not be subject to problems of sexual dysfunction. However, some
members of society continue to experience extreme discomfort with less tradi-
tional sexual expression (Townsend, 2006).

Gender identity disorders can be manifested by repeated persistent desire to be
the opposite sex, cross-dressing, and cross-gender role in play as a child (DSM-
IV-TR, 2000). Although rare, this condition requires much sensitivity on the part
of health-care providers to accept the person as he or she sees himself or herself.
Gender identity disorders may be first observed in childhood as the child main-
tains persistent interest in being the opposite gender and may eventually lead to
surgery in adulthood.

Competence and success in handling problems with sexual dysfunction depend
on the nurse’s knowledge, experience, and comfort with his or her own sexuality.
It can be difficult for some nurses to assess a patient’s sexual problems or inter-
vene for inappropriate sexual behavior. It may be useful in these situations to
confer with a nurse colleague, especially a nurse specialist or a mental health
practitioner with training in sexual counseling (Poorman, 2001). Incorporating a
sexual history or assessment can be useful to promote an environment of accept-
ance for a patient and promote needed education (Smeltzer & Bare, 2004).
Nurses are in a key position to help patients cope with sexuality concerns related
to serious illness (Wilmoth, 2006).

Nurses should not feel that they need to be sex therapists. They can, however,
help resolve some sexual problems created by the patient’s illness and the

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limitations it creates. To be prepared to deal with this aspect of patient care, the
nurse should:

• Be knowledgeable about sexuality and sexual norms.

• Use this knowledge to understand others’ behavior and reactions to sexual-
ity in health and illness.

• Be aware of differences in cultural and individual attitudes and perspectives
regarding sexuality.

• Assist patients’ adaptation to an optimal level of health regarding their

• Make appropriate referrals for patients with more complex sexual dysfunc-


The human sexual response cycle stages describe the type of responses people
have during sexual activity. Sexual dysfunction can occur at any of these stages.
There is seldom any single cause of unsatisfying or inadequate sexual experi-

The National Health and Social Life Survey (2001) has identified that 39%
of men and 41% of women have had some type of sexual dysfunction in
their lives that has lead to some decrease in well-being. A wide range of
common sexual dysfunction including erectile dysfunction and decreased
desire can be traced to side effects of medications for common medical and psy-
chiatric illnesses (DSM-IV-TR, 2000). Virtually all antipsychotic and antidepres-
sant medications and a variety of other psychotropic medications can cause
disruptions in sexual function. Antihypertensives are also implicated in
disorders of sexual desire, arousal, and orgasm (Table 14–1). Illicit drugs and
alcohol should not be overlooked in evaluating sexual disorders. Many patients
believe that alcohol and other drugs decrease sexual inhibitions, whereas in real-
ity, they decrease sexuality and ability to perform sexually. Major tranquilizers,
cocaine, and even tobacco have been implicated in sexual disorders (Finger,
Lund, & Slagle, 1997).

Physiological causes of sexual dysfunction include disruption of neural path-
ways as seen in spinal cord injury or prostate surgery; impaired circulation
as seen in diabetes or peripheral vascular disease; and hormonal changes as
in testicular or ovarian dysfunction. Physiological factors are likely to be
consistent across time and situations, whereas disorders with psychogenic causes
are likely to be situation or mood specific. Psychological causes include
unresolved internal conflicts, low self-esteem, discordant relationships with cur-
rent or past partners, feelings of dependency or abandonment, and depression.
Sociocultural factors include cultural or religious myths or beliefs that inhibit
sexual activity.

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Chapter 14 ■ Problems with Sexual Dysfunction 277

TABLE 14–1
Drug Categories that Alter Sexual Behavior

Drug Type Probable Effects





Sedatives and

Oral contraceptives



Cancer chemotherapy



Source: Adapted from Finger, W. W., Lund, M., & Slagle, M. A. (1997). Medications that may contribute to
sexual disorders. Journal of Family Practice, 44, 33–34; Carpenito-Moyet, L. J. (2006). Nursing diagnosis:
Application to clinical practice (11th ed). Philadelphia: Lippincott Williams and Wilkins.

Produce vasodilation and decreased cardiac out-
put, depress CNS; cause impotence in men and
decrease vaginal lubrication in women

Peripheral blockage of nervous innervation of sex
glands; may have positive effect because they
decrease depression

Block parasympathetic nervous innervation of sex

Inhibit parasympathetic innervation of sex glands

Block autonomic innervation of sex glands; may
have positive effect as they produce tranquiliza-
tion and relaxation, may have negative effect
influencing libido

Remove fear of pregnancy

In small amounts, may increase libido, in large
amounts, impairs neural reflexes involved in erec-
tion and ejaculation, chronic use may
cause impotence

Central sedation causes impotence in chronic users

May produce temporary sterility or neurotoxicity
in men, causing impotence

Suppresses sexual function in men

Chronic use may cause impotence

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Sexual disorders are categorized by DSM-IV-TR (2000) into six major

1. Sexual desire disorders, including hypoactive sexual desire in men or
women, and extreme aversion to genital sexual contact

2. Sexual arousal disorders, including female sexual arousal disorder and
male erectile disorder

3. Orgasmic disorders in both men and women, also known as delayed or
premature ejaculation in men

4. Sexual pain disorders, including dyspareunia in men or women, vaginismus
in women

5. Sexual dysfunction caused by general medical condition and substance-
induced sexual dysfunction

6. Paraphilias, which are repetitive sexual fantasies or behaviors involving use
of a nonhuman object (fetishism), nonconsenting partners (voyeurism, and
exhibitionism), or activity that causes humiliation or harm (masochism,
sadism, and pedophilia)


In nonpsychiatric settings, most nurses see sexual dysfunction related to medical
problems, traumatic injuries, or surgical procedures. Sexual dysfunction may be
a temporary concomitant of an illness or treatment, or it may be a permanent
consequence of chronic illness or injury. Sexual problems associated with illness
or injury can be classified into four groups:

1. Lack of interest in or desire for sexual activity
2. Physical incapacity for or discomfort during sexual activity
3. Fear of precipitating or aggravating a physical illness through sexual

4. Use of illness as an excuse to avoid feared or undesired sexual activity

Serious, advanced illness can disrupt sexual functioning due to the presence of
fatigue, pain, dyspnea, neuropathies, and impaired range of motion (Lamb, 2006).
Surgical procedures resulting in changes in sexual functioning include urologic pro-
cedures for prostatic hypertrophy; intestinal surgery for colitis, ileitis, or Crohn’s
disease; and most other fecal or urinary diversion surgeries for neoplasms. Loss of
external or internal body parts or functions; relocation of orifices, such as hys-
terectomy, mastectomy, colectomy, and cystectomy; and amputations can all lead
to changes in both physical and mental components of sexual functioning. How a
surgical procedure influences postoperative sexual functioning depends on the:

• Reason for surgery, diagnosis, and prognosis related to sexual functioning
• Significance of loss of childbearing and fertility functions

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• Knowledge of anatomy and physiology of sexual structures and functions
• Meaning, assumptions, and values related to sexual identity
• Type and rationale for premorbid sexual activity

The main difference between a health disruption resulting from chronic illness
and surgical or accidental trauma is the irreversible effect on nerves, blood ves-
sels, and hormonal supply usually associated with surgery and trauma.

Most of the drugs reported to affect sexual functioning directly (see Table
14–1) act on specific neurotransmitters. There is evidence that the primary
neurohormone in mobilizing sexual behavior is dopamine, whereas serotonin is
the major inhibitor. Therefore medications that block dopamine receptor sites
and drugs that deplete dopamine interfere with central control of sexual function,
whereas drugs that depress serotonin concentrations in the brain are expected to
stimulate sexual function.

Many sexual responses are mediated through the parasympathetic nervous
system; therefore, parasympatholytic or cholinergic blocking drugs may cause
impotence in men and problems with vaginal lubrication in women. Orgasm and
ejaculation are primarily functions of the sympathetic, adrenergic, and nervous
system, and therefore, drugs such as anticholinergics may interfere with potency
and orgasm.

Ganglionic blocking drugs, such as antispasmodics, impair both sympathetic
and parasympathetic nervous system function. Drugs that stimulate or depress
the central nervous system can affect sexuality, particularly antianxiety agents
and narcotics and many of the substances used socially such as caffeine, alcohol,
cocaine, marijuana, and amphetamines. Many therapeutically useful drugs have
some adverse effect on sexual function.


Masculinity and femininity are defined culturally. Although chromosomes deter-
mine sexual identity before birth and by physical appearance of the genitals at
birth, postnatal factors greatly influence the way children perceive themselves and
others sexually. Gender identity is usually firmly established by the age of 18
months. In rare cases in which gender was misassigned at birth because of phys-
ical abnormality or accidental damage was suffered, it is considered almost
impossible to reassign a child to the opposite sex after age 2 years.

Research on infantile sexuality indicates that both male and female infants are
capable of sexual arousal and orgasm. By age 3 years, children are very aware of
how they are alike or different from their parents. Research supports that early
masturbation experiences are seen in 5- to 8-year-old children. By age 10 to 12
years, children are preoccupied with pubertal changes and beginnings of roman-
tic interest in the opposite sex.

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American culture has very ambivalent feelings about adolescent sexuality.
Although teachers and parents realize the importance of psychosocial develop-
ment, most want to avoid anything that will encourage teenage sex. Trends in
teen sex for the past 2 decades include more teens engaging in premarital inter-
course, and the average age of first intercourse is decreasing. Nationally, 16 years
is most common age for first sexual experience in boys and 17 years for girls
(Sadock, 2005). Recently the previously increasing trend in incidence of teen
pregnancy has decreased in most areas of the United States. A major concern at
this time is sex education regarding sexually transmitted diseases, birth control,
and the development of satisfying, long-term relationships with same-sex and
opposite-sex friends.

During this period of the life cycle, from about age 20 to 65 years, every adult
must deal with numerous issues that may lead to temporary or long-term sexual
dysfunction. Developing sexual relationships, choosing a marital partner, atti-
tudes about premarital or extramarital sex, infidelity, divorce, remaining single,
and raising children are just a few of the issues. After age 45 to 50 years, a
decrease in hormonal activity, menopause, and other physical changes in both
men and women may decrease biological drives. In general, health-care providers
should feel comfortable encouraging both sexes to continue healthy sexual activ-
ity during adulthood (Townsend, 2006).

Older Adults
There are many myths and stereotypes about sexuality and older people. The
most common barriers to sexual relationship in advancing age is health of the
partners and in many cases lack of a partner due to death or illness of a signifi-
cant other rather than lack of desire (Sadock, 2005). A 2004 study by AARP
(2005) found that although the amount of sexual activity generally decreases
with age, the amount of sexual interest and ability remains fairly constant. Sig-
nificant health issues affecting sexuality for older people include fear of heart
attack, poststroke dependency, fatigue related to chronic illness, erectile dysfunc-
tion related to diabetes and treatment for prostate cancer in men, inadequate
lubrication in women, and arthritis causing movement limitations. Surgical
procedures that are more common in the elderly persons, such as prostatectomy,
mastectomy, hysterectomy, and ostomies, also affect the older adult’s sexuality.
Institutionalization is a particular problem for elderly people because the staff
at such facilities may not understand or be sensitive to the sexual needs of
their residents.

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See Box 14–1 for guidelines for an interview with a patient with a sexual

Behavior and Appearance
• Reluctance to answer questions related to sexual functioning
• Concern over changes in sexual performance, body image
• Withdrawn, isolated, embarrassed
• Inappropriate sexual acting out, such as pinching or teasing the nurse,

exposing genitalia, or wearing seductive clothing
• May verbalize changes in functioning caused by illness, injury, or surgery

Chapter 14 ■ Problems with Sexual Dysfunction 281

• May be shy or insecure about the sexual aspects of their professional role,

even though they are sanctioned to touch others in an intimate and personal
manner and to ask personal questions, including questions about sexual
matters, related to their patients’ health.

• May experience anxiety, even revulsion, when dealing with sexual questions
or behaviors while caring for their patients.

• May deny their own or their patients’ sexuality by avoiding any verbal or
behavioral interaction regarding sexual function, for instance, avoiding sub-
ject of sex, responding to sexually oriented questions in a vague manner, or
using euphemistic expressions like “private parts” or “down below” when
referring to genitalia.

• May use hospital rules to sidestep patients’ sexual concerns. For example,
may assign male staff members to male patients when sexual behaviors or
concerns develop.

• May not recognize or may actually encourage patients’ becoming emotion-
ally involved with them.

• May experience pity for patients who are unable to perform some sexual
acts after injury such as spinal cord injury. May feel insulted, denigrated,
or angered by patient behaviors such as flirting, pinching, and exposing
body parts.

• May feel uncomfortable dealing with sexual dysfunction in patients.
• May have a mistaken belief that the seriously ill do not have sexual needs

or desires and may show a lack of tolerance and empathy for a patient’s sex-
ual concerns during illness.

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Mood and Emotions
• Fear about future limitations of sexual performance or attractiveness
• Fear, anxiety, or guilt about sexual abilities or loss of function resulting

from illness, injury, or surgery
• Presence of stressors affecting sexual functioning, such as job problems,

financial worries, religious conflict, value conflict with family or partner, or
separated or divorced partner

• Discomfort over lack of privacy, frequent physical examinations, or invasive

• Depression over lack of sexual satisfaction or loss of relationships

Thoughts, Beliefs, and Perceptions
• Lack of knowledge or incorrect information about sexual functioning
• Change in self-concept or body image caused by illness, injury, or surgery
• Denial or misinterpretation of partner’s reactions to sexual functioning
• Denies any concerns about sexual functioning but acts in a sexually inap-

propriate manner with staff or others

282 Chapter 14 ■ Problems with Sexual Dysfunction

BOX 14–1
Guidelines for an interview with a Patient
Having a Sexual Problem
These questions serve as a guideline. Adjustments in the focus and depth of
the assessment depend on the nature of the patient’s problem and the nurse’s
level of comfort in discussing sexual concerns.
1. Does patient’s current physical condition affect level of sexual function?
2. Does patient have concerns about body image or self-esteem related to ill-

ness, injury, or surgery?
3. What does patient know about potential or expected changes in sexual

function related to the illness, injury, or surgery?
4. What significance does the physical change or limitations have on the

patient’s perceptions and understanding of sexual function?
5. What are patient’s previous sexual patterns?
6. What does patient’s spouse or partner understand and believe about the

patient’s sexual function and the impact of the illness, injury, or surgery?
7. What is patient’s outlook and prognosis regarding sexual function?
8. What is patient’s level of comfort and willingness to discuss sexual func-

tion with health professional, spouse, others?
9. Would patient and partner benefit from more education, counseling, or


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Relationships and Interactions
• Sexual dissatisfaction or decreased sexual desire
• Altered relationship with significant other
• Partner unavailable, unwilling, or abusive
• Poor past sexual relationships, absent or negative sexual teaching

Physical Responses
• Painful intercourse
• Inability to complete intercourse, early ejaculation, impotence in men
• Menopausal changes in women because of age, surgery, or medications

(such as chemotherapy) causing vaginal dryness and lack of interest

Pertinent History
• Physical diseases or injuries affecting sexual functioning
• History of depression
• History of sexual abuse or rape
• Alcohol or other substance abuse
• Previous sexual dysfunction, such as impotence, painful intercourse, pre-

mature ejaculation, or lack of lubrication in women


Any patient experiencing sexual dysfunction needs a thorough assessment of all
medications being taken. Then alternative drug choices as well as changes in
doses and timing can be tried. Hormonal therapy may be appropriate treatment
in some cases. For example, postmenopausal women may benefit from estrogen
replacement therapy or estrogen creams to reduce discomfort during intercourse.
Antidepressants can contribute to sexual dysfunction in some, but in others, they
have been known to increase desire and reduce depression. Any medications that
would increase patient comfort such as analgesics may also be helpful to reduce
pain during sexual contact. Medications to treat erectile dysfunction are now
readily available. They include sildenafil (Viagra), tadalafil (Cialis), and varde-
nafil (Levitra). These medications block the actions of an enzyme that inhibit an
erection. These medications do not result in sexual arousal but contribute to an
erection in the presence of arousal.

Nonpharmalogical treatments for erectile dysfunction include penile implants.
Androgen replacement therapy is now being used to treat reduced sexual desire
in women (Cameron & Braunstein, 2004). A variety of herbal products are used
by individuals of different cultures to enhance sexual functioning (e.g., ginseng,
saw palmetto).

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Sex Therapy
A patient may need to seek out individual, couple, or group therapy to treat sex-
ual dysfunction. Many mental health professionals have specific training for sex-
ual dysfunction. In addition, the patient may wish to seek out a professional who
has obtained certification as a sex therapist from a national organization.


SEXUAL DYSFUNCTION evidenced by erectile dysfunction, premature ejac-
ulation, vaginismus, dyspareunia, or other changes in sexual behavior related
to illness

Patient Outcomes
• Relates valid, accurate information regarding sexual anatomy and func-

• Able to verbalize correct information about previously believed myths

and misinformation about sexual matters
• Identifies alternate sexual expressions that are pleasurable
• Discusses sexual functioning using correct information

Patient and Partner Outcomes
• Participate in treatment or practices that mediate problem or facilitate

and enhance current sexual functioning

• Create an atmosphere of understanding, openness, and acceptance

between patient and nurse.
• Eliminate or reduce causes for patient to feel embarrassed while dis-

cussing sexual functioning.
• Provide privacy, and be nonjudgmental and supportive.
• Begin with other subjects, such as physical or family questions, then

move on to questions on biologic aspects of sexuality, such as age at
menarche and onset of sexual development, before discussing sexual
behaviors or fears. Focus on general knowledge and expectations before
moving on to specific individual concerns.

• Determine patient’s knowledge and attitudes about sexuality and sexual

• Focus on patient’s knowledge of anatomy and functioning of body parts
that may be affected by disease, injury, or surgery.

• Pay attention to attitudes and words used by patient.

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• Identify any misinformation, myths, or beliefs that may affect patient’s
adjustment to changes in sexual functioning. Validate correct informa-
tion and correct erroneous information.

• Accept person’s feelings and concerns; explore cultural, social, religious,
and parental influences on current beliefs.

• Provide new information appropriate to patient’s maturational or educa-
tional level; include spouse or partner as appropriate.

• Discuss with patient and partner the various etiologies for specific diag-
noses; explain cause of problem, if known; provide information about its
treatment and prognosis.

• Explore alternatives such as lubricants, estrogen creams, pharmacologi-
cal treatment for erectile dysfunction.

• Encourage couple to talk over the effect of dysfunction on their relation-

• Discuss alternate methods of sexual gratification with patient or partner.
• Refer to a urologist or other specialist for further evaluation regarding

surgical procedures for penile implants, or vaginal reconstruction when

• Refer for further evaluation, counseling, or therapy, if indicated.

SEXUAL DYSFUNCTION evidenced by impotence, premature ejaculation,
lack of sexual desire or arousal or other dissatisfying changes in sexual behav-
ior related to inability to adapt to life stressors, e.g., divorce, death, loss of job,

Patient Outcomes
• Identifies stressors affecting sexual function
• Identifies constructive coping patterns and sexual practices
• Resumes previous sexual activity

• Assess for factors causing patient’s ineffective coping and their influence

on sexual function.

• Help the patient to understand and discuss the relationship between life
stressors and poor sexual functioning.

• Help patient to determine which stressors can be changed and which he
or she has no control over.

• Discuss the modifications of or changes in ways of dealing with stressors.
Assist in problem solving for alternatives.

• Help the patient identify alternative methods to reduce sexual energy
when partner is unavailable or unwilling, such as the role of regular phys-

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ical exercise, alternative sexual practices (self-stimulation, increased
social activities if spouse or partner is absent or deceased). Provide edu-
cational materials, as needed.

• Refer patient or partner for further counseling or therapy, as indicated,
such as consider referrals to marriage counselor, sex therapist, social
services as indicated by patient’s specific problems.

INEFFECTIVE SEXUALITY PATTERNS evidenced by actual or anticipated
negative changes in sexual activity and/or identity related to changes in or loss
of body part or physiologic limitations.

Patient Outcomes
• Shows increased acceptance of change in or loss of body part

• Identifies practices that assist in restoration of sexual function despite
change in or loss of body part

• Identifies practices that conserve energy and oxygen requirements for
sexual activity

• Discusses change in or loss of body part and its influence on sexual func-

Patient and Partner Outcomes
• Identifies mutual concerns
• Shows increased acceptance of change or loss
• Identifies and uses practices that assist in satisfying sexual functioning

• Determine the level of acceptance or adaptation of the patient or partner

to the changed or lost body part or function. Note patient’s reactions,
such as anger, depression, or denial. Explain normal feelings about loss,
grief, and change.

• Convey an attitude of acceptance. Be sensitive to the patient’s cues that a
concern exists, and encourage any attempts to discuss the problem or fear.

• Respect the patient’s need for privacy.

• Facilitate the partner’s and family’s understanding of patient’s condition
and concerns.

• Encourage need to share by listening and answering questions.

• Include spouse or partner in counseling and teaching if he or she express
readiness. Also include spouse or partner in discussions about fear of
future losses, fear of rejection by loved ones, and fear of physically hurt-
ing partner.

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• Help the patient realize that body changes and losses are acceptable to
others by spending time with the patient, appropriate touching, and
teaching about care during regular nursing care.

• Ask about strengths of relationship with partner and encourage discus-
sion of alternative sexual activities.

• Do not assume that patient knows about how the illness or injury affects
sexuality. Many patients do not ask questions or give any indication at
all about their concerns.

• Check to determine whether the patient understands medical terminology
by asking for feedback on what he or she comprehends. Use pictures and
verbal explanations when providing information or giving instructions.

• Provide information over short, repeated visits so that patient has time to
think over what you have discussed and to formulate questions for later

• Check which medications the patient is taking, and inform the patient
about any adverse effects on sexual function.

• Encourage the patient to resume sexual activity as close to previous pat-
tern as physically possible. Teach specific information applicable to indi-
vidual physical condition:

• For the patient with an ostomy, provide information on ways to con-
trol drainage odor.

• Refer to enterostomal nurse specialist for assistance with appliances.
Refer to other specialists as needed.

• For the patient with cardiac or respiratory disease, teach techniques for
conserving oxygen and reducing cardiac workload.

• Identify the symptoms that indicate sexual activity should be termi-

• Provide information on specific techniques if patient is unable to move
legs because of arthritis or spinal cord injury.

• Teach patient to take pain medication before sexual activity for pain
caused by arthritis, cancer, and so on.

• Promote the use of alternative methods of sensory and perceptual stimu-
lation, such as body massage.

• Refer the patient and partner to further educational material, self-help
support organizations, and therapy as needed. Many self-help groups
offer support related to sexual concerns; these include the United Ostomy
Association, Arthritis Foundation, American Cancer Society, organiza-
tions for the disabled, and Reach for Recovery.

ate sexual behavior in the medical setting related to ineffective coping.

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288 Chapter 14 ■ Problems with Sexual Dysfunction

Patient Outcomes
• Decreases or eliminates sexual acting-out behavior

• Demonstrates willingness to discuss meaning of behavior and its impact
on others

• Demonstrates other behaviors for maintaining sexual identity

• Identifies appropriate ways to meet sexual needs in medical setting

• Assess meaning of sexual behavior as release of sexual needs or anxiety,

aggression, fear of loss of identity, reaction to change in or loss of body
part, or need for closeness.

• When inappropriate behaviors occur, identify what happened before act-
ing out.

• Discuss behaviors with patient, and attempt to understand meaning of
behavior to patient.

• Give patient feedback about staff reactions to behaviors. Help patient to
understand their impact on other patients and staff. Point out which
behaviors are most disturbing.

• Set clear limits with patient about what specific behavior is inappropri-

• Discuss more appropriate ways for patient to meet sexual needs, such as
exercise, reading, or spending private time with partner.

• Ensure that the patient knows that sexual acting out is not needed to
maintain nurse’s interest or concern as a person.

• Provide time to talk with or give physical care to patient when sexual
behaviors are not occurring.

• Provide opportunity for the patient to express feelings about sexual iden-
tity and the impact of illness, injury, or surgery on body image and self-

• Discuss and negotiate ways to provide privacy during long-term hospi-

• Provide structured activity or active games. If appropriate, ask volunteers
to arrange for activities outside the current environment.

• Conduct care plan conference to discuss problem and appropriate inter-
ventions. When embarrassed or frustrated by sexually acting-out patient,
get backup from other staff members, consultants, or administrator who
can assist in setting limits and determining care plan goals.

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Coping, Ineffective
Knowledge, Deficient
Self-Concept, Disturbed
Social Interaction, Impaired
Social Isolation


• Review with the patient and sexual partner, if requested, any effects of med-
ications that may affect sexual function. Reinforce need to report these to
physician so that alternatives can be found.

• Teach probable causes and treatment for sexual dysfunction if patient and
partner request this information.

• Provide information on birth control and prevention of sexually transmit-
ted diseases, as appropriate.

Chapter 14 ■ Problems with Sexual Dysfunction 289


• Onset of sexually “acting-out” behaviors inappropriate to medical

• Increased staff complaints or conflict over management of patient

• Increased staff anxiety over dealing with sexually inappropriate

• Increased sexually inappropriate behavior in other patients
• Patient’s sexual behavior interfering with treatment
• Staff inability to provide needed information or counseling to patient


• Mental health professional
• Social Worker
• Nurse manager or educator
• Psychiatric Team
• Advanced Practice Nurse
• Chaplain
• Attending Physician

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290 Chapter 14 ■ Problems with Sexual Dysfunction

• Provide information on the impact of surgery, illness, and medication on
sexual functioning.

• Ensure patient has needed information about use of special devices and
drugs, e.g., penile implants, Viagra.


• Use objective, nonjudgmental terms to describe the patient’s sexual behavior.
• Document the patient’s sexual concerns even if you do not feel comfortable

providing information or education.
• Document the selected interventions for dealing with inappropriate sexual

behavior on the patient care plan for consistency.
• Document the patient’s understanding of cause and treatment of sexual dys-

function. Include responses of family members if they are involved in patient
education and treatment.


• Consult with physician and inform patient and partner about appropriate
resources related to sexual dysfunction.

• Provide referrals to appropriate support groups.
• Inform other health-care professionals of patient’s inappropriate sexual

behavior if patient is being transferred to another facility.
• Inform patient and partner about expected changes in sexual behavior or

dysfunction as disease progresses or patient is rehabilitated.
• Provide referral information for further sexual counseling or therapy if


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Problems with Pain

The Patient in Pain

Learning Objectives
• Differentiate between acute, recurrent, and chronic nonmalignant and

malignant pain.
• Examine the reasons for underassessment and undertreatment of pain.
• Describe important factors to be considered in the assessment of pain.
• Describe the role and routes of opioid and nonopioid analgesics in pain

• Discuss the importance of alternative (nonpharmacological) methods of

pain relief.

Acute pain – Pain, usually of shorter duration, that acts as a warning and

protective mechanism. Usually subsides as healing takes place.
Addiction – A psychological process, in contrast to drug tolerance, that

involves the repeated use of a drug or drugs for psychological, not medical,
reasons. Patients who are psychologically dependent on a drug (addicted)
will continue to desire the drug even though the pain is resolved.

Cancer pain – Usually placed in a category of its own. Even if it lasts for more
than 6 months, it is often treated like acute pain because of its progressive
nature. Sometimes referred to as malignant pain.

Chronic pain – Pain that lasts beyond the ordinary duration of time that an
insult or injury to the body needs to heal. Types of chronic pain include
recurrent acute pain with potential for recurrence over a prolonged period,
with pain-free intervals between episodes; chronic acute pain, which may

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last months or years, but has a high probability of ending; and chronic,
benign (noncancer) pain, which occurs almost daily and has existed for 6
or more months. It is now believed that different mechanisms may be
involved in development of chronic pain and it is not just a matter of a
longer occurrence of acute pain.

Drug tolerance – A physiological response of the body, not under the person’s
control, in which the drug loses its effectiveness after repeated use. Occurs
in almost all patients using opioids longer than 7 to 10 days. Needs to be
taken into consideration when determining correct dosage of analgesic
because the patient may require increased doses to achieve the same effect.

Pain – An unpleasant sensory and emotional experience arising from actual
or potential tissue damage caused by a noxious stimulus.

Pain tolerance – Duration and intensity of pain that an individual is willing to
tolerate at any one time. Pain tolerance changes within an individual from
one pain experience to another.

Placebo – Any medical or nursing measure that works because of its implicit
or explicit therapeutic intent rather than its chemical or physical properties.

Pseudo-addiction – Patient behaviors that may mimic drug-seeking behav-
iors and occur when pain in undertreated.

Referred pain – Pain felt at a site other than the injured or diseased organ or
body part. The pain of coronary artery insufficiency, for example, is often
referred to the left shoulder, arm, or jaw, and pancreatic pain may be
referred to the middle back.

Pain is what the person experiencing it says it is, exists when and where he
or she says it does. The patient is the authority about his/her own pain.
(McCaffery, 1968)

Pain is a universal experience occurring in all age groups and is the most
frequent reason why people seek health care. It is also the most feared

symptom (Daudet, 2002). Much progress has been made over the last decade
in understanding pain mechanisms and the epidemiology of pain. The subject is
important for all clinicians because the frequency and perhaps the severity of
pain may increase now that progress in medical science has increased sur-
vival through old age and chronic illness, and now affects more people than
ever before.

Studies continue to show that pain is underassessed and undertreated by
health-care professionals. The American Pain Society (2003) reports that the
most common reason for unrelieved pain in the American health-care system is
the failure of medical personnel to routinely assess pain and pain relief. The clas-
sic study by Marks and Sachar (1973) reported that 73% of hospitalized medical
patients experienced moderate to severe pain despite receiving parenteral opioid
analgesics. Recent research indicates that nurses and physicians continue to
undertreat pain in patients because they do not understand pain management

292 Chapter 15 ■ Problems with Pain

15 Gorman(F)-15 11/5/07 4:56 PM Page 292

principles, they fear causing the patients’ dependence on opioids, and they have
poor knowledge of opioids, adjuvant therapies, and the components of pain
assessment (McCaffery & Ferrell, 1997). Despite the establishment of federal
guidelines on pain management (Agency for Healthcare Policy and Research,
1992, 1994), many patients of all ages still suffer unnecessary pain in all health-
care settings and at home (Twycross, 1999; Weiner, Peterson, Ladd, McConnell,
& Keefe, 1999; Paice & Fine, 2006). In 2001, the Joint Commission on Accred-
itation of Healthcare Organizations implemented pain management standards
that mandate frequent assessment and appropriate interventions.

Pain is a multidimensional and complex phenomenon, requiring effective
assessment and management. Many disciplines are involved in pain management
in a variety of clinical settings. Optimal pain management depends on coopera-
tion among the different members of the health-care team throughout the
patient’s course of treatment (Stratton, 1999).

The nurse usually has the most significant influence on management of the
patient’s pain because of having the most frequent contact with the patient. Con-
sequently, the nurse is in a unique position to identify the patient who has pain;
to appropriately assess the pain and its impact on the patient and family, to ini-
tiate action to alleviate pain using available resources, and to evaluate the effec-
tiveness of those actions.

Patients vary greatly in their responses to pain and its interventions, as well as
in their personal preferences and expectations regarding pain relief. Therefore
rigid prescriptions for the management of pain are inappropriate. An effective
pain management program will incorporate the following requirements and prin-
ciples (McCaffery, 1999; American Pain Society, 2003):

1. Pain intensity and relief must be assessed and reassessed at regular intervals
in a consistent manner (Fig. 15–1).

2. Patient preferences must be respected when selecting methods of pain man-

3. Each institution must develop an organized program to evaluate the effec-
tiveness of pain assessment and management.

4. Establishing positive relationships between patients and health-care profes-
sionals is an important part of successful pain control. Patients should be
informed that information about options to control pain is available and
they are welcome to discuss their concerns and preferences with the health-
care team.

5. Unrelieved pain has severe negative physical and psychological conse-
quences. Aggressive pain prevention and control can yield both short-term
and long-term benefits. Although complete elimination of some pain may
not be practical or even desirable, techniques are now available to make
pain reduction a realistic goal.

6. Prevention is better than treatment. Pain that is established is more difficult
to control. The goal should be reduced pain at all times, with “round-the-
clock” medications if needed.

Chapter 15 ■ Problems with Pain 293

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294 Chapter 15 ■ Problems with Pain

Initial Pain Assessment Tool

AgePatient’s Name Room


Right Left

Right Right






Left Left




1. LOCATION: Patient or nurse mark drawing.

2. INTENSITY: Patient rates the pain. Scale used
Worst pain gets:
Best pain gets:
Acceptable level of pain:


3. QUALITY: (Use patient’s own words, e.g., prick, ache, burn, throb, pull, sharp)




10. PLAN:



8. EFFECTS OF PAIN: (Note decreased function, decreased quality of life.)

Accompanying symptoms (e.g., nausea)
Physical activity
Relationship with others (e.g., irritability)
Emotions (e.g., anger, suicidal, crying)

FIGURE 15–1. Initial Pain Assessment Tool. (Source: From McCaffery M., & Pasero
C: Pain: Clinical manual (2nd ed.) (p. 60). St. Louis: Mosby, with permission.)


The exact mechanism of transmission and perception of pain are not completely
understood; however, neurophysiological, psychological, and sociological
research has contributed to the formation of pain theories.

15 Gorman(F)-15 11/5/07 4:56 PM Page 294

The Gate Control theory, originally proposed in 1965 by Melzack and Wall,
suggests that pain occurs when smaller diameter type A nerve fibers and very
small diameter type C fibers are stimulated. These afferent, or sensory, fibers pen-
etrate the dorsal horn of the spinal cord and end in the substantia gelatinosa.
When the sensory stimulation reaches a certain critical point, the “gate” opens
and allows nearby transmission cells to project the pain message to the brain. In
contrast, the large-diameter type A sensory fibers inhibit pain transmission. When
these fibers are stimulated, fast-conducting afferent fibers oppose the smaller
fibers’ input and activate the substantia gelatinosa “gate” to close, thus blocking
nerve transmission.

This theory explains why external methods of pain control work. For example,
stimulating the large-diameter type A fibers by massage, applying heat or cold,
acupuncture, or transcutaneous electric nerve stimulation (TENS) can override
sensory input in the smaller diameter type A fibers and block pain transmission at
the gate. Cognitive techniques, such as distraction, biofeedback, relaxation, and
guided imagery, operate through the efferent fibers, closing the gate.

In the 1970s, the body’s own internally secreted opioid-like substances, called
endorphins, were identified. Research found that the brain triggers the release of
endorphins, which lock into the narcotic receptors at nerve endings in the brain
and spinal cord to block the transmission of pain signals, preventing the impulse
from reaching consciousness. This research has helped to explain why pain per-
ception and the need for analgesia can vary greatly from one person to another.
Endorphins are depleted with prolonged pain, recurrent stress, and the prolonged
use of morphine or alcohol. Endorphin levels are increased during brief pain
episodes, brief stress, physical exercise and sexual activity, massive trauma, some
types of acupuncture, and some types of TENS, and possibly with placebos.
Much of the recent research in this area supports patient-controlled interventions
for pain (Ellis, Blouin, & Lockett, 1999).

A number of neurotransmitters have been discovered that are found to con-
tribute to the carrying of the pain impulse. These include glutamate and sub-
stance P. A number of drugs are being investigated that inhibit binding of
excitatory amino acids such as glutamate that normally binds to N-methyl-D-
aspartate (NMDA). NMDA antagonists including drugs that contain dextro-
mathorphan and ketamine seem to block the transmission of the pain impulse.
This may be one of the mechanisms of actions of methadone.

The multiple opioid receptor theory recognizes that not all opioids work the
same way and some cannot be switched back and forth without adverse conse-
quences. There are at least three types of opioid receptor sites in the spinal column.
Each type binds somewhat differently with different types of opioids. For exam-
ple, opioids like butorphanol tartrate (Stadol) or nalbuphine (Nubain) (agonist-
antagonist drugs) antagonize the effects of other narcotics like morphine and can
contribute to withdrawal rather than pain relief. Knowledge of this theory
enhances appropriate selection of analgesics (Ripamonti, Zecca, & Bruera, 1997).

Gender and social and cultural factors also affect the pain response by
influencing how the individual interprets pain and how he or she responds

Chapter 15 ■ Problems with Pain 295

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emotionally. Through family, social, and cultural values and attitudes, the patient
learns which types of pain responses are appropriate within his or her group. Of
course, family and social influences change as a child matures. By the time adult-
hood is reached, the individual may have modified or even rejected many family
values or taken on the values of another subgroup. If the patient’s values conflict
with those of his or her family, additional stress and anxiety may be felt. This
may explain why certain patients act differently when family members are pres-
ent (Fillingim, 2000; Wessman & McDonald, 1999).

Other factors influencing pain behaviors may include the body part involved,
the patient’s socioeconomic status and religious beliefs, and experience with folk
medicine or alternative therapies. A patient’s language and vocabulary affect the
way in which pain is described. Do not be too quick to assume that you under-
stand what the patient is trying to say, especially if his or her native language and
ethnic background are different from yours.


Chronic pain is a significant health problem. For example, 10% to 15% of adults
in the United States are estimated to have some form of disability from back pain
(Borsook, McPeek, & Lebel 1996). One in five Americans suffer from chronic
pain (Sternberg, 2005). In addition to disrupting employment, chronic pain can
contribute to family problems and social isolation.

Although acute pain is associated with anxiety, chronic pain is more associated
with depression. Chronic pain patients are also at higher risk for dependence and
abuse of medication because their pain is often not relieved and they begin taking
larger doses in hopes of obtaining relief and treating their depression. Health-care
professionals may become frustrated and eventually deny the patient the pain med-
ications, making assumptions that the patient is drug-seeking (pseudo-addiction).
The chronic pain patient usually requires a multidisciplinary pain team.

The physiological and psychological risks associated with untreated pain are
greatest in frail patients with other illnesses, such as heart or lung disease; those
undergoing major surgical procedures; and very young or very old patients.
Untreated pain can contribute to complications because the patient is unable to
cough or deep breathe or get adequate rest or nutrition. Uncontrolled pain in
dying patients contributes to the wish to hasten death and is the most frequently
stated fear. In patients with psychiatric diagnoses such as depression, schizophre-
nia, dementia, malingering, and hypochondriasis, pain may be the chief present-
ing complaint. Treating the underlying psychiatric disorder should lead to
reduction in pain. Patients with alcohol or drug withdrawal syndromes need spe-
cial consideration in their pain management, especially if they also have other
medical problems.

Patients with a history of substance abuse are often undertreated for pain lead-
ing to increased hospital length of stay, frequent readmissions, and increased out-
patient and emergency visits (Kirsh & Passik, 2006; Grant, Cordts, & Doberman,

296 Chapter 15 ■ Problems with Pain

15 Gorman(F)-15 11/5/07 4:56 PM Page 296

2007). Long term use of opioids can result in hypersensitivity to pain resulting in
further complications. Undertreatment of these patients is often caused by health-
care professionals’ misconceptions about addiction.

Each individual experiences and expresses pain in a unique manner, depend-
ing on age, gender, culture, and previous pain experience (Box 15–1). All pain is
real to the person experiencing it, regardless of its physical or psychological eti-
ology. Each person’s ability to tolerate pain is also unique. Depending on the sit-
uation, pain tolerance can vary even in the same individual. Anxiety or
depression can decrease pain tolerance. Most people with severe or prolonged
pain also have emotional changes related to their pain.

About one third of all patients with a diagnosed physical cause for their pain
respond to placebos. Nurses should be aware that a positive response, meaning
that the patient gets relief after taking the placebo, cannot be used to prove that
the pain is psychologically induced. Sometimes just listening to the patient,

Chapter 15 ■ Problems with Pain 297

BOX 15–1
Factors Influencing Pain Tolerance
Factors that may increase or decrease tolerance:
• Past experiences with painful stimuli (e.g., surgery, trauma, illness)
• Knowledge about cause of pain, its treatment, and probable outcome
• Personal meaning of pain (e.g., recurrence of cancer, day off from school or

• Knowledge and experience in coping with pain, willingness to try new tech-

• Stress, fatigue, energy levels
• How others treat person when he or she has pain (e.g., secondary gains)
• Available resources (e.g., money for treatment)
• Interactions with healthcare providers (e.g., preventive approach: pain is

treated early or patient has to prove that pain is “real” before anything is
done to help relieve it)

• Cultural background: some cultures encourage the expression of even mild
discomfort, whereas others expect stoic, quiet tolerance of even very severe

Factors that usually decrease pain tolerance:
• Disbelief on the part of others
• Lack of knowledge about pain, pain-relief measures
• Fears about addiction, loss of control over pain
• Poor experiences with past pain-relief efforts
• Disability, increasing or long-term
• Fatigue and monotony

15 Gorman(F)-15 11/5/07 4:56 PM Page 297

acknowledging the pain, and the act of giving a medication can enhance pain
relief. Today, it is generally considered unethical for a doctor to prescribe a
placebo to treat pain without informing the patient that he/she may be receiving
one (Oncology Nursing Society, 1996).

The benefits of adequate and consistent pain management are significant. Ben-
efits include earlier and easier mobilization, shorter hospital stays, increased
productive rehabilitation, and earlier return to previous work or lifestyle; or if the
patient’s condition is terminal, increased comfort and peace of mind. These out-
comes should be expected and worked toward with every patient experiencing
pain (de Rond, deWit, vanDam, & Miller, 2000; Raines, 2000).


As with adults, pain is one of the most feared symptoms in children (Collins &
Walker, 2006). Research indicates that younger children, including neonates, may
experience some pain more intensely than older children. For children who can-
not communicate verbally about their pain, one needs to assess pain by observ-
ing physiologic changes, nonverbal behavior, and vocalizations, such as crying or
groaning. Consult parents or guardians about how the child expresses pain at
home. Knowledge of the child’s age, health status and developmental level gives
insight into how pain may be expressed (McGrath & Finley, 1999; Twycross,
Moriarity, & Betts, 1998; Hunt, 2006).

If painful procedures are needed, be sure they are performed outside the child’s
room or playroom so that his or her bed, room, and playroom continue to be safe
places. If the child is verbal, try to use his or her words for pain when asking
about the discomfort. The Wong-Baker Faces Pain Rating Scale is particularly
geared to children as well as adults with dementia (Fig. 15–2).

Most dosage recommendations for opioid analgesics in children are not sup-
ported by double-blind studies, and underdosing is especially common. Using
weight in kilograms to determine doses is useful in many cases when opioids are
needed. Initial recommended doses must be viewed as educated guesses and
should be adjusted either up or down according to the individual child’s response.
Toddlers and older children may obtain pain relief from cutaneous stimulation
such as massage and TENS and distraction, similar to adults. Adolescents may
report more pain than younger children, especially if the pain is chronic.

Older Adults
Pain is not an inevitable part of aging; however, elderly people are at greater risk
for many disorders that may result in pain, such as arthritis, cardiovascular dis-
ease, osteoporosis, falls, hip fractures, and cancer (Horgas & Elliot, 2004;
Barkin, Barkin & Barkin, 2005). Older patients may deny pain more frequently
than other age groups because they fear the consequences of admitting pain, such
as longer hospitalization or more tests, or they have the mistaken belief that pain

298 Chapter 15 ■ Problems with Pain

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is normal for their age. Special efforts must be taken to adequately assess pain,
especially in confused elderly people. Dementia patients are particularly vulnera-
ble to undertreatment of pain because of their inability to express themselves.
Some myths about pain in older adults include that pain is a normal part of aging
and opioids cannot be used safely with this population (Curtis, 2006).

Polypharmacy is of special concern in elderly persons. Because of the physio-
logical changes that occur with aging, drug half-life and clearance times
are increased. This can lead to increased and unexpected side effects and toxic-
ity, making pain control more difficult in this group. Unrelieved pain may also
contribute to confusion and dementia. Adjuvant analgesics must be used
with caution in elderly patients because sedation, confusion, and the sedative
and anticholinergic effects of many of these drugs can contribute to many
other problems. Low starting doses are recommended. Long-acting analgesics
may be more likely to cause side effects. A trial of low-dose immediate release

Chapter 15 ■ Problems with Pain 299

0 1 2 3 4 5 6 7 8 9 10











Simple Descriptive Pain Intensity Scale

0-10 Numeric Pain Intensity Scale


0 1 2 3 4 5
No Hurt Hurts

Little Bit

Little More

Even More

Whole Lot

Which Face Shows How Much Hurt You Have Now?

B Wong-Baker FACES Pain Rating Scale

FIGURE 15–2. Pain Rating Scales (Sources: [A] Agency for Health Care Policy and
Research. (1994). Management of cancer pain. Clinical practice guideline.
Rockville, MD: Public Health Service, US Department of Health and Human
Services (DHHS); [B] From Hockenberry, M. J., Wilson, D., & Winkelstein, M. L.
(2005). Wong’s essentials of pediatric nursing [7th ed.] [p. 1259]. St. Louis:
Mosby. Used with permission. Copyright, Mosby.)

15 Gorman(F)-15 11/5/07 4:56 PM Page 299

analgesics given on a routine basis can be helpful to determine if the dementia
patient’s behavior is due to pain.

Older adults are more likely to be fearful of using narcotic analgesics owing to
long-held beliefs that morphine is associated with death or narcotic use leads to
addiction. This can present a significant barrier to effective pain relief. Assess any
fears the patient may have regarding taking narcotics. Fear of constipation is also
a frequently seen barrier.

300 Chapter 15 ■ Problems with Pain

• May rely more on physiological changes or signs such as vital signs, body

movement, facial gestures, and other nonverbal behavior than on patients’
own verbal reports to assess patient’s pain.

• May become insensitive to patient’s expressions of pain.
• May have difficulty accurately assessing the patient’s pain. Varying opinions

among staff members over interpretation of behaviors suggesting pain and
selected pain control modalities can lead to very divisive conflicts among
staff members.

• May feel extremely frustrated over what can be done to help the patient.
• May fear causing a patient’s addiction if the patient requires narcotics for

an extended period of time.
• May think that the need for greater pain control is more acceptable for cer-

tain types of pain, such as cancer pain.
• May believe that patients will always accurately report pain when they

have it.
• May become frustrated over what to do when a patient denies having pain

to the physician but continues to request pain medication from nursing staff.
• May feel manipulated by patients who staff members believe are faking

pain for the purpose of obtaining more medication.


Behavior and Appearance
• Verbalizes pain rating and describes location and character of pain
• Guarded positioning
• Tense or grimacing facial expression
• Rubbing, pulling at, splinting, or protecting painful area
• Fatigued, lethargic
• Crying or moaning
• Restless

15 Gorman(F)-15 11/5/07 4:56 PM Page 300

Mood and Emotions
• Fearful, anticipating more pain
• Angry, irritable, frustrated
• Depressed, hopeless, withdrawn
• Feeling out of control or helpless about pain if relief is inadequate

Thoughts, Beliefs, and Perceptions
• Wide variations in beliefs about pain, its causes, and methods for relief
• May be confused and unable to concentrate
• Lack of information or misinformation about pain control methods
• Decreased motivation to participate in activities of daily living
• Unwillingness to try alternative pain-relief methods
• Lack of trust in caregivers if pain is not relieved

Relationships and Interactions
• Patient may withdraw socially or have angry outbursts related to pain.
• Secondary gains may influence pain behaviors. For instance, family mem-

bers may cater to patient’s needs more attentively if he or she is in pain.
• Caregivers may avoid the patient because of previous experiences when he

or she was in pain, may have feelings of helplessness.

Physical Responses
• Increased blood pressure, pulse, respirations
• Diaphoresis
• Tremors
• Redness and swelling around painful area

Pertinent History
• Previous pain experiences
• Effect of pain on work, sleep, eating, elimination, and sexual patterns
• Previous and current use of narcotics or other analgesics
• Drug or alcohol dependency
• Litigation pending after injury or an accident
• Medical problems, surgical procedures, and injuries


Behavior and Appearance
• Verbalizes pain rating or describes pain
• Presence of pain for longer than expected

Chapter 15 ■ Problems with Pain 301

15 Gorman(F)-15 11/5/07 4:56 PM Page 301

• Difficulty maintaining job or other activities
• Frustration, fatigue
• Changes in muscle tone and reflexes

Mood and Emotions
• Depression
• Hopelessness
• Suicidal ideations
• Anger and bitterness
• Preoccupied with pain
• Fear that caregiver will give up on patient and pain problem

Thoughts, Beliefs, and Perceptions
• Fear that pain is intractable and will always affect family, work, social life,

finances, and mood
• Perceives others as not believing that he or she is in pain
• Fears losing control over the pain and that the medication will lose effec-

tiveness or be withdrawn before pain resolves
• Has misinformation about effectiveness or alternative pain-relief methods
• Lacks trust in caregivers who do not acknowledge or treat his or her pain

Relationships and Interactions
• Social isolation and withdrawal
• Family or work relationships may have changed since pain became chronic
• Patient’s dependency increases with pain
• Patient withdraws from usual activities and friends
• Patient experiences decreased social activities and reduced satisfaction with

relationships and diminished sexual interest
• Family experiences fear and frustration about the patient’s using pain for

secondary gains

Physical Responses
• Anorexia or weight gain
• Impaired mobility
• Insomnia
• Intermittent pain relief with rest; pain recurring with increased stress or cer-

tain activities

Pertinent History

• Pain of long duration
• Changes in mood, sleep, appetite, and activity patterns

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15 Gorman(F)-15 11/5/07 4:56 PM Page 302

• Constipation related to prolonged use of narcotics
• Litigation pending after injury
• Prolonged use of medication without effective pain relief
• Physical dependency on pain medications, other drugs, or alcohol since pain

became chronic
• Financial problems caused by cost of medical care
• Possible multiple medical complaints, little satisfaction with treatment
• Seeking out numerous doctors for treatment


Several types of drugs are available to treat pain. Selection is based on the cause
of the pain, its intensity and duration, and the patient’s response. Mild intermit-
tent pain may be treated with salicylate analgesics, acetaminophen, or nons-
teroidal anti-inflammatory agents (NSAIDS). These drugs have specific upper
dose limits due to their side effects. More severe, acute pain may need opioid
analgesics such as morphine or oxycodone. Determining the most effective med-
ication requires careful assessment of the cause of the patient’s pain and his or
her perception of the pain and underlying condition. Opioid analgesics generally
have no upper dose limits short of side effects.

Factors that influence the effectiveness of medication to relieve pain include:

• Route of administration (Table 15-1)
• Amount and frequency of dosage
• Anticipated onset and duration of action
• Method of drug’s action (central versus peripheral)
• Previous experience with medication

The patient experiencing pain needs to be constantly reevaluated to ensure that
he or she receives maximal relief with the least potent drug. For instance, a surgi-
cal patient may require parenteral opioid analgesics immediately after surgery. As
healing occurs, the drug can be titrated to a less invasive method and a lower dose
while still maintaining adequate pain control. An equianalgesic list (Table 15–2)
gives the dose and route of administration of one drug that produces approxi-
mately the same degree of analgesia as the dose and route of administration of
another drug. There are many differences among individual patients, so these lists
serve only as guidelines to the relative equivalences of various analgesics. Dose
and time intervals must be titrated for each patient (Agency for Health Care Pol-
icy and Research, 1992, 1994). Patients with chronic pain may need opioids, and
the long-acting preparations are particularly useful because they avoid the fluctu-
ating blood levels of analgesics. The World Health Organization Pain Ladder is a
useful model to follow for cancer pain (WHO, 2006).

Chapter 15 ■ Problems with Pain 303

15 Gorman(F)-15 11/5/07 4:56 PM Page 303

304 Chapter 15 ■ Problems with Pain

TABLE 15–1
Analgesic Routes of Administration

Oral Sublingual
• The preferred route
• Cost effective
• Safe easy administration
• Variety of forms (pills, liquid)
• Must be able to swallow and


IV Push IV Infusion
• Fast onset for intermittent pain
• Short-acting
• Less painful than SQ if IV in place
• Can be prone to side effects

Patient Control Analgesia Subcutaneous
• Fast onset for intermittent pain
• Short-acting
• Patient has control
• Patient must be awake and able to

comprehend instructions

Subcutanous Infusions Rectal
• Effective alternative to IV drip

when no IV access
• Only small volume (1-2 cc/hr) can

be given.

Transdermal Epidural
• Effective for constant pain when

stable dose of analgesia needed.
• Route of choice if patient unable

to swallow, unable to absorb, or is

• Can be prone to side effects

Source: Adapted from Pasero, C., Portenoy R. K., & McCaffery, M. (1999). Opioid analgesics. In M. McCaf-
fery & C. Pasero (Eds.), Pain: clinical manual (2nd ed.) (pp. 161-299). St Louis: Mosby.

• Easy administration even if patient

• Most long-acting products cannot
be given this route.

• Absorption sometimes erratic

• Effective for constant pain
• Allows for rapid dose titration
• Preferred access is central line
• Accumulation of drug can con-

tribute to side effects

• Faster onset than oral/slower
than IV

• No IV access needed
• May be painful

• Safe alternative to oral
• Many oral drugs can be given this

• Contraindicated in thrombo-

cytopenia, neutropenia

• Most effective in intractable pain
when traditional routes ineffective

• May have less side effects since
lower doses used

• Requires surgical placement of
catheter and more monitoring.

15 Gorman(F)-15 11/5/07 4:56 PM Page 304


TABLE 15–2
Opioid Analgesics Commonly Used for Severe Pain

Equianalgesic Starting Oral
Name Dose (mg) Dose

Morphine- Adults Children Precautions and
like agonists Oral Parenteral (mg) (mg/kg) Comments Contraindications












Standard of
for opioid

(MS Contin,
SR) release
drug over
8–12 hours.

shorter dura-
tion than

For all opioids, cau-
tion in patients
with impaired ven-
tilation, bronchial
asthma, increased
intracranial pres-
sure, liver failure









306 TABLE 15–2
Opioid Analgesics Commonly Used for Severe Pain—cont’d

Equianalgesic Starting Oral
Name Dose (mg) Dose

Morphine- Adults Children Precautions and
like agonists Oral Parenteral (mg) (mg/kg) Comments Contraindications







4 acute
1 chronic


2 acute
1 chronic








Good oral
potency, long
plasma half-
life (24–36

Long plasma
(12–16 hours)

25 mcg/hour,
equivalent to

Accumulates with
repeated dosing,
requiring decreases
in dose size and
frequency, espe-
cially on days 2–5

Accumulates on
days 2–3

Because of skin
reservoir of drug,
12-hour delay in
onset and offset of
transdermal patch;
fever increases
dose rate.










Equianalgesic Starting Oral
Name Dose (mg) Dose

Morphine- Adults Children Precautions and
like agonists Oral Parenteral (mg) (mg/kg) Comments Contraindications



— 1 — —

release mor-
phine, 50 mg/
day. Oral
fentanyl citrate
available for
treatment of
pain in chronic
cancer pain
already taking
clock opioids.
Buccal form of
fentanyl (Fen-
tora) now

5 mg rectal sup-
pository �
5 mg morphine

Transdermal patch
must be applied
to area of body
with subcuta-
neous fat to
ensure absorp-

Like parenteral










TABLE 15–2
Opioid Analgesics Commonly Used for Severe Pain—cont’d

Equianalgesic Starting Oral
Name Dose (mg) Dose

Morphine- Adults Children Precautions and
like agonists Oral Parenteral (mg) (mg/kg) Comments Contraindications


Mixed agonist-



Source: Adapted from American Pain Society. (2003). Principles of analgesic use in treatment of acute pain and cancer pain (5th ed). Skokie, IL: American Pain Society.







shorter act-
ing than

Not available
orally, not
under Con-
trolled Sub-
stances Act

Like nal-

Normeperidine (toxic metabo-
lite) accumulates with repeti-
tive dosing, causing CNS
excitation; avoid in children
with impaired renal function
or who are receiving mono-
amine oxidase inhibitors

Side effects profile makes this
drug unacceptable to use for
most pain

Incidence of psychoto-
mimetic effects lower than
with pentazocine; may pre-
cipitate withdrawal in nar-
cotic dependent patients

Like nalbuphine









Chapter 15 ■ Problems with Pain 309

Patients on one or more other medications need to be evaluated for possible
drug interactions. Drug pharmacokinetics may change because of alterations in
cardiac, renal, and liver function; respiratory rate; and gastrointestinal absorp-
tion. Fever, sepsis, burns, and shock also affect drug effectiveness. Patients with
psychiatric conditions who take antianxiety agents or psychoactive drugs must
also be evaluated for possible drug interactions, in particular, the added sedative
effects of opioids and many of the psychotropic drugs. Clinicians should be
aware that patients in these categories might not respond as expected to pain
medication (Borsook, McPeek, & Lebel, 1996).

A factor contributing to undertreatment of pain can be created by the patient
who fears taking opioids. Some patient barriers to taking adequate analgesics
include fear of side effects (particularly constipation and sedation), and associa-
tion of opioids with addiction and death.

A variety of herbal products are being used to treat pain, including capsicum
ointments, evening primrose for arthritis, and chamomile for migraines. A vari-
ety of alternative approaches that may be used include acupuncture, magnet ther-
apy, and biofeedback.


PAIN, ACUTE evidenced by report of moderate pain, changes in autonomic
nervous system (increased heart rate and blood pressure), and reduced ability
to perform ADLs related to surgery, injury, or illness

Patient Outcomes
• Reports decreased pain levels
• Identifies previously successful pain-relief techniques to use now to

decrease pain
• Identifies and minimizes factors that precipitate or aggravate pain
• Participates in assessment of pain and effectiveness of pain-relief methods
• Demonstrates increased mobility and activity

• Perform a thorough pain assessment. Ask patient to rate pain on a con-

sistent scale such as 0 to 10, with 0 being no pain and 10 being the worst
possible pain. Determine if the patient can relate more to a visual pain
scale (Fig. 15–2). Use the same tool each time you assess that patient’s
pain. Be sure to determine the patient’s perception of his or her pain, pre-
vious effective pain methods used, and any misperceptions the patient
has about effective pain-relief methods.

• To reduce the patient’s anxiety, explain the causes of pain, if known.
• Teach the patient and family about factors that may increase or decrease

pain. Try to minimize factors that increase pain perception.

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• Teach about any necessary painful procedures before they occur to reduce
stress over anticipating the procedure. Patient teaching should include:

• Basic description of the procedure or test, its purpose, and equipment
to be used

• A description of any sensations likely to be experienced
• Anticipated duration of procedure and discomfort
• Measures that can be used to reduce discomfort

• Provide accurate information about analgesics to reduce fear or miscon-
ceptions about addiction, tolerance, and physical dependence. Recognize
that the patient or family may become anxious when medications are
changed. Discuss any changes in medication, dose, or frequency with
physician, and plan how to inform the patient about the pain control
goals and parameters.

• Provide relief measures at regular intervals rather than on an as-needed
basis, even when the pain is still tolerable. Do not expect the patient to
wait until pain is unbearable to administer the next dose.

• Use the following approaches when administering analgesics:

• Determine whether and when to give as-needed medications.
• Choose the appropriate analgesic when more than one is ordered.
• Evaluate the effectiveness of administering medications at regular

• Monitor responses to administered medications and report promptly

any adverse reactions and when they are ineffective.
• Suggest appropriate changes based on knowledge of the patient and

previous response to pain-relief measures.

• Check with patient 30 minutes after administering a pain medication to
assess its effectiveness. Include patient in rating level of pain before and
after medication or other pain-relief method used. Use the same pain rat-
ing scale each time you assess the patient to ensure accurate evaluation.

• Encourage patient’s participation in using alternative pain-relief methods
such as relaxation exercises or use of heat or cold. Instruct the patient
about rigid body position, which can increase pain, and techniques to
reduce muscle tension:

• Select a time when patient is relatively comfortable and able to con-
centrate so that teaching will be more effective.

• Use pillows or other supports to splint and support body parts and
reduce muscle tension.

• Discuss effects of stress, monotony, fatigue, and distraction on pain per-

• Provide for privacy for pain expressions if the patient desires.
• Try to limit the number of caregivers interacting with patient and mak-

ing decisions about pain management.

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• Provide opportunities for rest and therapeutic use of distraction, such as
visits or watching television, between uncomfortable treatments.

• If patient has a current or past history of drug or alcohol abuse, he or she
still needs strong opioids to treat an acute pain problem. Putting this
patient on an around-the-clock dosing schedule of analgesics is usually
recommended to avoid euphoria. Other suggestions include long-acting
analgesics and making a contract with the patient about what medica-
tions can be given. Discuss patient’s concerns about taking opioids.

• Consult with other staff members or the physician about increased med-
ication at bedtime and before painful procedures to keep pain at tolera-
ble levels throughout the day and to maximize patient’s participation in
required activities.

• Institute measures to reduce any adverse effects of narcotics. For
instance, administer stool softeners and stimulant laxatives (e.g., senna-
based products) to combat constipation, antiemetics for nausea, and
nonalcohol-based mouthwashes or mouth moisturizers for dry mouth.

• Help the patient to cope with the consequences of pain by encouraging
discussion of fears, anger, and frustrations; acknowledge difficulty of sit-
uation; and praise and reinforce any efforts to handle pain.

• Consult with pharmacist and physician about alternative opioid and
analgesic combinations.

• Consider using aspirin or acetaminophen simultaneously with opioid for
maximal effect if appropriate. Also consider use of NSAIDs for periph-
eral pain.

PAIN, CHRONIC evidenced by ongoing episodes of pain, difficulty perform-
ing usual activities, and other effects of chronic pain, such as sleep distur-
bance or poor nutrition related to effects of illness, surgery, or injury more that
lasts beyond the ordinary duration of time that body needs to heal.

Patient Outcomes
• Participates in assessment of pain
• Uses one or more alternative measures to manage pain
• Demonstrates reduced intensity of depression
• Increases participation in activities
• Decreases use of pain behaviors for secondary gain
• Decreases dependence on analgesics when pain controlled

• Assess patient’s previous and current pain behaviors.
• Encourage the patient to learn and use noninvasive pain-relief methods,

such as muscle relaxation, deep breathing, guided imagery, distraction,
TENS, and application of heat or cold.

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• Incorporate family or caregivers in alternative pain-relief measures.
• Use analgesic medications in conjunction with alternative pain-relief

measures to effectively control pain.
• Discuss with physician or pharmacist plan for weaning patient off opi-

oids and onto non-narcotics. Titrate parenteral pain medications and
switch to oral doses as soon as possible while ensuring adequate pain

• Teach patient and family that oral medication, when prescribed in appro-
priate dose and frequency, can be as effective as parenteral.

• Administer a loading dose and then maintain a therapeutic drug level of
oral medications when first switching to gain the patient’s confidence in
new treatment.

• Ask patient to participate in evaluation of pain-relief methods by keep-
ing his or her own pain diary.

• Help family or caregiver to recognize and decrease pain behaviors for
secondary gain.

• Promote optimal mobility and meaningful activity in patient.
• Assess patient’s nutrition and elimination functions related to use of med-

ications and decreased mobility or activity.
• Assess patient’s sleep pattern, levels of depression, or other psychological

reactions to prolonged pain. Consider use of adjuvant treatments, as

• Provide the patient and family with the opportunity to discuss
fears, anger, and frustration in a private setting. Acknowledge the
difficulty of the situation and any of the family’s efforts to help the
patient cope.

• As indicated, refer the patient for evaluation at a multidisciplinary pain
clinic if problems are not improved before discharge.


Comfort, Impaired
Coping, Ineffective
Self-Concept, Disturbed
Sleep Pattern, Disturbed
Spiritual Distress
Thought Processes, Disturbed

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• Provide information about all pain-relief methods available to the patient.
Keep the patient and family informed about changes in treatment plan.

• Teach relaxation techniques (Box 3.2).
• Instruct the patient and family on the use of the pain rating scale.
• Allow the patient to make choices about relief methods used. Involve him

or her in assessment of pain; teach how to use pain flow sheet or keep a pain
diary, and select appropriate alternative pain-relief measures based on activ-
ities and effectiveness of relief methods.

• Initiate teaching with the patient, family, or caregiver related to pain-relief
methods to be used after discharge. Review with them the ordered discharge
medications, potential adverse effects and how to manage them, what to
report to physician, and effective alternative pain-relief measures.

• A useful website for patients and family is (Amer-
ican Pain Foundation).

Chapter 15 ■ Problems with Pain 313


• Pain-relief measures are ineffective.
• Pain levels increase.
• Patient or family is unwilling to learn about alternative methods of

pain relief.
• Psychiatric problems are interfering with patient’s use of prescribed

pain-relief methods.
• There is increased frustration from dealing with the patient’s or fam-

ily’s pain behaviors.
• Analgesics ordered are ineffective and physician refuses to make

• Patient continues or increases use of pain behaviors for secondary gain.
• There are concerns over patient’s or family’s ability to manage pain

after discharge.
• Evidence of abuse of opioids.


• Pain team
• Addiction specialists
• Social Worker
• Palliative Care Team/Hospice
• Attending Physician

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• Include the selected pain rating scale in the assessment and evaluation doc-
umentation. Besides the pain rating, document location and description of
the pain.

• Use objective, nonjudgmental terms to describe pain behaviors and
responses to pain relief measures. When possible, use the patient’s own
words to describe the pain.

• Document the response to all pain relief measures.
• Document any factors or activities that increase or decrease pain.
• Note all side effects of analgesics.


• Review with the patient, family, or caregiver the patient’s progress with pain
management since admission.

• If patient is being discharged with prescriptions for opioids, give referrals
for local pharmacies that carry these medications.

• Allow sufficient time for the patient to adjust to the change from parenteral
to oral administration of pain medications and to practice alternative pain-
relief measures before discharge.

• Consult with the physician if patient’s pain is not controlled before dis-
charge or if pain is expected to continue for some time thereafter. Obtain a
home health referral to assess pain at home and follow up with medication
compliance and monitor side effects.

• Instruct the patient, family, or other caregivers on how to use a pain flow
sheet or maintain a pain diary at home.

• Suggest that the patient be referred to an appropriate pain treatment center
where multidisciplinary treatment is offered.

• Include the selected pain rating scale in all assessment and evaluation docu-

• Use objective, nonjudgmental terms to describe pain behavior and responses
to pain-relief measures. When possible, use the patient’s own words when
describing the pain.

• Document patient’s responses to all pain-relief measures used.
• Document any factors or activities that the patient or family can identify

as an increase or decrease in pain tolerance or effectiveness of pain-relief

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Problems with Nutrition

The Patient with Anorexia
Nervosa or Bulimia

Learning Objectives
• Describe the similarities and differences between anorexia nervosa and

• Formulate nursing diagnoses and interventions for patients with anorexia

nervosa or bulimia.
• Identify common nurses’ reactions to the patient with anorexia nervosa

or bulimia.
• Describe the complications of anorexia nervosa and bulimia.

Anorexia nervosa – A potentially life-threatening eating disorder character-

ized by self-starvation in a relentless pursuit of thinness, an intense fear of
becoming fat, and delusional disturbance of body image.

Binge eating disorder – Recurrent episodes of binge eating that lead to feel-
ings of distress. Not associated with purging.

Binge – Rapid consumption of large amounts of food in a short period of
time (usually less than 2 hours).

Bulimia (bulimia nervosa) – An eating disorder characterized by some of
the following: consuming large quantities of food in a short time terminat-
ing in abdominal pain, sleep, social interruption, self-induced vomiting, and
laxative use.

Compulsive overeating – Consuming large volumes of food without purging.

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Eating disorders – Gross disturbances in the patterns of ingesting food.
Purge – Planned or unplanned episode to undo damage of binge, including

self-induced vomiting, laxative use, or diuretic use.

Dieting is a national obsession, especially with women. Numerous fitness clubs
are filled with individuals trying to attain the idealized thin, muscular body.

Cochrane (1998) reports that more than 50% of American women are on a diet
at any one time. Extreme thinness is increasingly common in models and actresses
as the idealized image. It seems that it has become accepted behavior to be
obsessed with body weight and shape, and to view food as a source of stress. Self-
esteem and happiness in young girls are often linked to weight and body shape.
Adolescent girls may be rewarded for dieting with either increased social accept-
ance or praise from parents (White, 2005). When this social influence is combined
with certain biological, psychological, and family dynamics influences, it could be
the beginning of an eating disorder (Yager & Anderson, 2005). Eating disorders
have little to do with simply not eating enough or overeating. Rather, they are psy-
chiatric disorders with substantial emotional and physical consequences.

Anorexia nervosa and bulimia (sometimes called “bulimia nervosa”) most
commonly occur in young women, and the incidence of these disorders is on the
rise. One to five percent of young women suffer from them (Wolfe, 1998).
Women and girls are 10 times more likely to suffer from these disorders than men
and boys. Male reports of eating disorders may be underreported though (Spader,
2007). Patients with an eating disorder may be treated in psychiatric facilities,
but may require admission to an acute-care hospital for treatment of complica-
tions or for initial diagnosis to rule out other conditions. There are many simi-
larities between these two eating disorders and long-term anorexics may develop
bulimia in later life (Table 16–1).

The term anorexia (as in anorexia nervosa) is really a misnomer because this
condition has very little to do with appetite. It has more to do with the person’s
morbid fear of obesity causing obsessive fear of losing control of food intake. In
fact, the person is often hungry and views the discomfort of hunger as a reminder
of the deprivation he or she needs to inflict on himself or herself. Only in the late
stages is appetite actually lost. The distorted body image causes the patient to
view himself or herself as fat even though appearing emaciated. No amount of
weight loss relieves the anxiety, causing this deadly cycle to continue. Complica-
tions can continue for years, even after successful treatment.

The American Psychiatric Association (2000) reports 0.5% to 3.7% of women
suffer from anorexia nervosa in their lifetime. Often diagnosed in adolescence,
anorexia nervosa is often viewed as representing struggles with autonomy and
sexuality. Poorer prognosis is associated with an older age of onset, a lower
minimum weight, and vomiting. Purging, which promotes electrolyte imbalance
and arrhythmias, is usually combined with compulsive exercise, making a most
lethal combination. Successful treatment is measured by weight gain, return of
menstruation (usually absent in anorexic women), and reduced number of

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compulsive behaviors. Early intervention is associated with improved prognosis.
Full recovery of weight, growth and development, menstruation, and normal
eating behavior occurs in at least 50% to 70% of treated adolescents (Yager
& Anderson, 2005).

Bulimia was officially designated as a psychiatric disorder in 1980 and is harder
to diagnose than anorexia. It is more common than anorexia and affects a larger
cross-section of the population. Sadock and Sadock (2003) report that the inci-
dence is 1% to 3% of young women. As with anorexia, bulimia is mainly a con-
dition of younger women; however, some studies show that about 10% of bulimics
are male (DSM-IV-TR, 2000). Men with bulimia tend to be older at onset. Both
men and women often demonstrate difficulties with impulse control, associated

Chapter 16 ■ Problems with Nutrition 317

TABLE 16–1
Comparing Anorexia Nervosa and Bulimia

Anorexia Nervosa Bulimia







• More than 95% female
• Younger adolescent onset
• Fairly rare

• Emaciated
• Below normal weight

• Rigid, perfectionistic
• Overprotection

• Introverted
• Socially isolated
• High achiever
• Excessive exercise

• Cachexia
• Hair loss
• Amenorrhea
• Dry skin
• Pedal edema

• 5%–18% mortality rate
• Frequent life-long prob-

lems with food
• Bulimia
• Depression

• 90% female
• Young adult onset more

• 2–3 times more frequent

than anorexia

• Normal or overweight
• Weight fluctuations

• More overt conflict

• Impulsive
• More histrionic, acting


• Dehydration
• Chronic hoarseness
• Chipmunk facies

(parotid gland enlarge-

• Death is rarer
• Life-long problems with


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with higher incidence of drug abuse and acting-out behavior such as petty crime.
The long-term prognosis is unclear because the relapse rate remains high.

Unlike the patient with anorexia, the one with bulimia uses food as a tempo-
rary relief of stress, which leads to binge eating. The resulting sense of shame and
disgust then causes the patient to purge by induced vomiting or use of laxatives.
The cycle of bingeing and purging may begin as a way to lose weight but can
become a compulsive behavior.

Bulimia is associated with fewer life-threatening complications than anorexia,
but it can lead to chronic conditions including sore throat, dental erosion, and
parotid gland enlargement from chronic vomiting. Electrolyte imbalances from
chronic use of laxatives, diuretics, enemas, and emetics can occur. A bulimic indi-
vidual can consume thousands of calories in a short time.

A third eating disorder recently listed in the DSM-IV-TR (2000) is binge eat-
ing disorder, which involves eating large quantities without purging. People suf-
fering from this disorder are most often obese or exhibit fluctuations in weight.
Weight-loss programs report seeing more clients with this disorder. This disorder
is believed to be much more common that anorexia or bulimia.


Individuals with eating disorders report a premorbid history of dieting and
attempts to control their weight. What makes this progress to anorexia ner-
vosa or bulimia is unclear, but most likely genetic, biological, psychological,
and family factors are all involved. There are many similarities in etiological
theories between these two conditions. Both disorders are also significantly
associated with depression and family dynamics, in which food plays a large
symbolic role.

Anorexia nervosa may have genetic influences because there is an increased
incidence of its occurrence among daughters and sisters of anorexics. The bio-
logic influence may be multifactoral. Research suggests that there is an interrela-
tionship between multiple neurotransmitters, including dopamine that regulates
appetite, body size, and fat distribution. Dysfunction of the hypothalamus has
also been implicated. Because the symptoms usually begin in adolescence, hor-
monal changes may be an important contributor.

Psychoanalytic theory suggests that the core of anorexia can be a child’s fear
of maturing and unconscious avoidance of developmental tasks. By not eating,
the person forestalls sexual development and maintains his or her role as child in
the family. Other dynamics include perfectionist tendencies developed through
demanding, overachieving parents and a profound disturbance in the mother-
child relationship. Anorexia gets out of control as the person tries to achieve the
perfect image. Many family therapists believe that anorexia symptoms represent
a dysfunctional family situation. The patient tries to present a “perfect good girl”
image, trying to meet the family’s distorted view of perfection. Also, the eating
disorder gives the patient a sense of control that counteracts the feelings of loss
of control, anxiety, and need to avoid conflict. Some reports indicate that a

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mother’s preoccupation with weight and food can be a source of conflict between
mother and child, and the eating disorder becomes a means of control for the
child. An overwhelming sense of worthlessness in the child may also be respon-
sible. Comorbid psychiatric disorders include major depression, anxiety disor-
ders, and obsessive-compulsive disorder (Yager & Anderson, 2005).

Specific theories on the cause of bulimia are limited. Biological views regard
low levels of the neurotransmitters norepinephrine and serotonin as associated
with bulimia. Low serotonin is known to increase the need for intake of carbo-
hydrates and is also associated with depression. Bulimia may be related to
impaired satiety mechanism.

Family dynamics in bulimia are often characterized by a high degree of con-
flict, marital discord, and acting out. This may contribute to the patient’s devel-
oping increased anxiety with intimate relationships and a fear of abandonment
and conflict surrounding parental authority. Low self-esteem contributes to feel-
ings of inadequacy and a deep-rooted sense of shame and guilt. Some studies have
noted an increased incidence of family members with a history of alcoholism and
the possibility of physical or sexual abuse. These individuals are more likely to
have comorbid psychiatric disorders, including borderline, panic disorder, and
major depression.


Anorexic and bulimic patients may have a history of being overweight when
young. Anorexics have been noted to weigh more at birth. Bulimics may have a
history of anorexia when younger, as well as a tendency for obesity within the

Life-threatening complications from anorexia include cardiac arrhythmias,
electrolyte imbalance, and cardiomyopathy. Serious bulimia complications can
include electrolyte imbalance and erratic blood sugars.


Children and Adolescents
Anorexia and bulimia remain a condition generally seen in adolescence and
young adulthood. Children as young as 8 years old often admit to preoccupation
with diet and atypical eating habits. A sense of self-consciousness and insecurity
with one’s body is a normal part of growth and development; however, children
whose self-esteem becomes more closely tied to satisfaction with their body size
tend to become more prone to eating disorders. This is often influenced by the
way in which adult caregivers perceive and respond to them. Children who are
overweight may experience increased criticism and demands made upon them,
leading to low self-esteem. In adolescence, awareness of cultural ideals becomes
even stronger. Adolescents may notice that thinner contemporaries have more
friends or dates.

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Behavior and Appearance
• Emaciated

• Tends to cover up body with large clothing in attempt to hide appearance,
although some may exhibit thinness with a sense of pride

• Avoids being weighed; may try to manipulate weight by putting weights in

• High achiever in school and work

• Ritualistic behavior surrounding food (such as eating every third bean)

• Spends time with food-oriented activities, such as cooking or shopping for

• At mealtimes, tries to hide not eating by:

• Cutting up food to give appearance of less food present

• Moving food around plate

• Hiding pieces of food in pockets or under plate

• Exercising obsessively (possibly in secret)

• Using laxatives or foods with a laxative effect excessively

• Not giving a realistic picture of his or her eating patterns

320 Chapter 16 ■ Problems with Nutrition

• May feel shocked or disgusted by patient’s behavior or appearance.
• May resent the patient because of the belief that the disorder is self-inflicted.

This may make it difficult to express empathy, which, in turn, may make
the patient feel rejected.

• The nurse may feel helpless to change the patient’s behavior, leading to
anger, frustration, and criticism.

• The nurse may inadvertently re-create family power struggles with patient
by trying to make the patient eat by nagging, cajoling, arguing, or even
tricking. This will inhibit a trusting nurse-patient relationship.

• The nurse may feel overwhelmed with the patient’s problems, leading to
feelings of hopelessness or to the setting of rigid limits to feel more in con-
trol of the patient’s behavior.

• Many nurses become embroiled in power struggles with these patients,
which may trigger angry responses in the nurses.

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Mood and Emotions
• Has high anxiety associated with mealtimes, weight gain, being weighed,

and especially any control issue
• When under stress, may feel need to starve self more
• Experiences feelings of sadness and low self-esteem
• May feel need to punish self for feelings of pleasure
• Denies feelings of sadness or anger and often appears pleasant and compliant

Thoughts, Beliefs, and Perceptions
• Distorted attitude toward appearance, weight, and food that overrides

hunger and reason
• Distorted body image: sees self as fat despite others saying that the opposite

is true
• Perfectionist, compulsive, rigid
• Seeing self as helpless and dependent; great difficulty making decisions
• Possible mental status changes from malnutrition such as memory lapses,

poor attention span, poor judgment, and bizarre behavior
• Denying seriousness of low body weight

Relationships and Interactions
• Introverted; avoids intimacy and sexual activity
• Secretive
• Fears trusting others; needs to be in control

Physical Responses
• Extreme weight loss; weight less than 85% of that expected for age and

• Cachexia
• Fatigue
• Amenorrhea
• Hair loss; presence of lanugo (fine body hair covering)
• Low pulse rate, low blood pressure, low body temperature
• Chronic constipation
• Dry skin
• Altered laboratory values including low hemoglobin and hematocrit (or

high if dehydrated), hypokalemic (especially if using laxatives or diuretics),
high blood urea nitrogen (BUN), and serum creatinine

• Insomnia

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• Consuming large volumes of fluid to distend stomach, which may lead to

• Pedal edema related to malnutrition
• In late stages, may exhibit arrhythmias and congestive heart failure
• Pathological fractures caused by bone loss from estrogen deficiency and

ovarian dysfunction

Pertinent History
• Involved in activities in which small size is important, such as ballet or gym-

• Uses food-oriented coping mechanisms, such as stopping eating or excessive

eating, to deal with stress
• Family history of depression, eating disorders


Behavior and Appearance
• Weight is normal, slightly overweight, and fluctuating.
• Routinely goes into the bathroom shortly after meals.
• Eats normally or sparingly when with others, and binges in private. Purging

behaviors may follow, including self-induced vomiting, laxative or diuretic
misuse, fasting, or excessive exercise.

• May appear normal without obvious problems.
• Functions normally.
• Behavior is sometimes histrionic or impulsive.
• Tends to act out.

Mood and Emotions
• Binge triggered by some emotional stress; initially some relief of anxiety

during the binge but tension slowly increases as feelings of remorse and guilt

• Purge in response to feelings of remorse and guilt
• Anxiety over appearance and weight
• Anxiety around mealtimes as patient fears loss of control
• Feelings of anxiety, depression, self-disgust

Thoughts, Beliefs, and Perceptions
• Perfectionist
• Preoccupied with appearance, weight
• Self-critical

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• Very aware that own behavior is abnormal
• Feels powerless over binge-purge cycle
• Believes he or she is unable to change
• Suicidal thoughts

Relationships and Interactions
• Overt conflict within family
• Goes to great lengths to keep binge-purge behavior a secret from others
• Generally social and gregarious, with a strong need to be accepted by others
• Sexually active

Physical Responses
• If bingeing: abdominal pain, malaise, fluctuating blood sugars.
• If vomiting, chronic hoarseness, parotid gland enlargement causing chip-

munk facies, dental caries, loss of enamel on teeth, skin changes over
dome of the hand (if use finger down throat to induce vomiting). Use of
ipecac to induce vomiting can induce cardiac symptoms including palpita-
tions, chest pain.

• If abusing laxatives, abdominal pain and diarrhea.
• Other symptoms may include dehydration, hypokalemia, and cardiac


Pertinent History
• Anorexia nervosa as a teenager
• Drug or alcohol abuse (especially cocaine as a way to control appetite)
• Involvement in activities in which weight must be kept down such as mod-

eling, ballet, athletics


The Agency for Healthcare Research and Quality (2006) found that medications
were of limited value in treatment of anorexia. Antidepressants, particularly flu-
oxetine (Prozac), and other selective serotonin reuptake inhibitors (SSRIs) have
been used in patients with clinical depression, anxiety, and obsessive-compulsive
symptoms for both anorexia and bulimia (Yager et al, 2006). Fluoxetine in
higher doses has been helpful in bulimia. Some antidepressants and atypical
antipsychotic drugs also cause weight gain as a side effect. Antipsychotic med-
ications may be used in patients who are extremely obsessive compulsive. Tri-
cyclic antidepressants and monoamine oxidase inhibitors are generally not used
in anorexia because of increased side effect profile in malnourished individuals.

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Antianxiety medications have also been useful. Bulimics have also been treated
with lithium and phenytoin (Dilantin). Anorexics may resist taking medication
just as they do food, and it becomes another part of the power struggle to get the
patient to comply.

Over-the-counter diet aids and herbal products may be used in the hopes of
promoting weight loss.

The dietary regimen for the anorexic patient generally involves a slow, steady
weight gain of no more than 3 pounds per week (Yager & Anderson, 2005). Too-
rapid weight gain can put undue stress on the heart and precipitate complica-
tions. Management by a clinical dietitian or nutrition support team is essential.
These patients need careful assessment of their nutritional needs. In severely ill
patients, malnutrition must be treated before any improvement from psychother-
apy can be expected. For life-threatening situations, aggressive nutritional inter-
ventions are required. This may include enteral feedings with nasogastric or
gastrostomy tubes or total parenteral nutrition. Some patients do well with these
aggressive measures because they are relieved that they do not need to make deci-
sions about food. Others may react with resentment and feel an increased loss of
control, causing the patient to take more drastic control measures such as
increasing exercise, using laxatives, or changing the drip rate or solution being
infused. Bulimic patients need dietary education and supervision to control
weight. Patients who have bariatric surgery need close nutritional monitoring
and special attention to vitamin and mineral intake.

Individual and group psychotherapy is essential in treating patients with bulimia
and anorexia nervosa. Because patients with both conditions also commonly
exhibit troubled family relationships, family therapy is also needed. The treat-
ment plan for anorexia nervosa may include a behavior modification and cogni-
tive therapy program. Patients are given rewards for any weight gains and
increased restrictions for any weight loss or self-destructive behaviors. To
increase the chance of success, patients should participate in developing the
treatment plan. Written contracts that clearly explain the patient’s behavioral
expectations have been effective.

Bulimics may also benefit from keeping a diary of their food intake, feelings,
and binge-purge behaviors. Patients who are hospitalized in the acute setting may
benefit from evaluation by a psychiatrist.


denced by weight loss, avoidance of food, excessive exercise, hiding food, self-
induced vomiting related to self-starvation, binge-purge cycle.

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Patient Outcomes
• Increased oral intake (anorexia nervosa)
• Weight gain at rate of no more than 2 pounds per week or per prescribed

treatment plan (anorexia nervosa)
• Reduced incidence of strenuous exercise (anorexia nervosa) and/or purg-

ing (bulimia)

• Recognize that patient may be very defensive about eating behavior and

attempts to keep it secret. Mealtimes may be very stressful. Create envi-
ronment of acceptance to encourage a trusting nurse-patient relationship.

• If personnel are available, stay with patient during meals to be sure
food is actually eaten. Create a social atmosphere rather than a supervi-
sory one.

• Give patient as much control as possible around eating behavior. Encour-
age him or her to select some foods. Set limits, however, on length of
mealtimes. Lengthy mealtimes tend to increase anxiety and acting-out

• Monitor food and fluid intake. Measure urinary and fecal output. Assess
skin turgor. Do this in a matter-of-fact manner. Avoid power struggles or
criticism. For example, note what patient has eaten without scowling or
making demands. Recognize that telling a patient, “You have to eat
more” will create tremendous anxiety and probably lead to defiance.
For the patient at home, recognize that monitoring food intake and con-
trolling bingeing may be more difficult and require a commitment from
family members.

• Weigh patient regularly, using same scale. Treatment plan may include
setting a minimal safe weight range that must be maintained. This can
remove the power struggle from mealtimes because patient knows what
is expected.

• Set limits on dysfunctional behaviors such as strenuous exercise and use
of bathroom after eating.

• Set limits on time spent alone in the bathroom after meals. Also insist
that patient wait at least 30 minutes after eating before using bathroom.

• Present meals without threat, coercion, or criticism. Recognize that argu-
ing about food will only increase the problem. In addition, avoid cajol-
ing or tricking patient into taking more calories.

• If you suspect that patient is trying to sabotage the treatment plan, talk
openly with patient about your concerns. Be aware that patient may have
a need to hide food to give impression that he or she is eating.

• Reinforce the idea that patient can avoid more aggressive interventions,
such as tube feedings, by meeting acceptable minimal weight standards,

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per treatment plan. For example, patient may need to gain 2 pounds a
week. This can be a way for patient to maintain control because he or she
can decide how to accomplish it.

• For the patient who binges and/or purges, assess specifically what the
patient does including method of self-induced vomiting, laxative, or
diuretic use.

DISTURBED BODY IMAGE evidenced by inaccurate perception of appear-
ance and morbid fear of obesity related to distorted thoughts and inability to
perceive body size and physical needs realistically.

Patient Outcomes
• Verbalizes more realistic perception of his or her body
• Refers to body in a more positive way

• Encourage patient to express feelings, especially about the way he or she

thinks about or views himself or herself.
• Avoid overreacting to self-deprecating comments patient may make

about his or her body. Recognize that these feelings and images are very
real to the patient. For example, the patient may dwell on having “fat”
legs even though they may be very normal or even emaciated looking.
Listen to patient, and explore how the fear of fat creates distress. For
example, “I understand you see yourself as fat; however, I do not see you
the same way.” Avoid responding to patient’s self-deprecating remarks by
minimizing the patient’s statements.

• Encourage discussion of positive personal traits, especially regarding
patient’s body image.

• Encourage patient to dress attractively and to use makeup and jewelry, as

• Avoid insincere compliments about patient’s appearance.

INEFFECTIVE COPING evidenced by bingeing-purging behavior, obsessive
behavior around food related to disturbance in impulse control.

Patient Outcomes
• Verbalizes feelings to others while in care of the nurse
• Demonstrates reduced number of behaviors that would sabotage treat-

ment plan
• Demonstrates more adaptive coping mechanisms while in care of the

• Participates in decision making

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• If patient is panicked over personal feelings or behavior, remain calm and

help patient focus on ability to remain in control. For example, patient
may feel panicked over a weight gain and want to exercise or purge. Help
patient focus on short-term goals that he or she can achieve. Identify one
area over which the patient has some control. Reinforce coping abilities.

• Communicate support and empathy to patient. Be nonjudgmental to
encourage sharing of feelings and coping mechanisms. Demonstrate
acceptance by use of support and concern to help the patient feel lovable
and accepted.

• Recognize the importance of developing a trusting relationship with
patient. One or two staff members who attempt to develop a therapeutic
alliance with patient can be particularly helpful. Recognize that patient
may be very angry about entering treatment program. Developing a
trusting relationship will take time. Show acceptance by use of touch,
and if appropriate, talking about interests. Avoid just focusing on food.

• Be consistent in treatment plan. All staff members need to be aware of
how to handle sabotaging of plan, such as hoarding food or self-induced

• Listen for signs of perfectionist thinking and explore ways to challenge
unrealistic expectations. Recognize that patient may have very rigid,
fixed beliefs.

• Encourage patient to make small decisions. This tends to empower the
patient and assists in imparting a sense of control and accomplishment.

• Assess patient for depression, suicidal risk, and substance abuse, and
intervene as appropriate.

• Be aware of the family’s role in patient’s behavioral responses. Patient
may need help in seeing himself or herself as a capable person outside the
family unit.

POWERLESSNESS evidenced by feeling out of control in presence of food
related to inability to control bingeing and vomiting cycles.

Patient Outcomes
• Reduce incidence of bingeing and purging
• Able to describe triggers for bingeing and purging

• Educate about the binge and purge cycle and how it perpetuates itself.
• Explore with patient the triggers that bring on desire to eat excessively.

Once triggers are known, explore alternative ways to address them as in
call a friend, write in diary, exercise.

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• Explore the signals the patient feels that lead to purging. Encourage
him/her to write down feelings at that time.

• Encourage keeping a calendar of tracking symptoms and feelings.
• Challenge irrational thoughts that may take over when tension is build-

ing toward binging.


Denial, Ineffective
Family Coping: Compromised
Fluid Volume Deficit
Knowledge, Deficient
Self-Mutilation, Risk for
Sexual Dysfunction
Thought Processes, Disturbed

328 Chapter 16 ■ Problems with Nutrition


• Psychiatric Team
• Dietitian
• Internist
• Social Worker
• Attending Physician


• Patient expresses suicide thoughts or makes a suicide attempt.
• There is evidence of psychotic thinking, hallucinations, or

severe obsessive-compulsive behavior including repetitive obsessive

• There are signs and symptoms of severe malnutrition or serious com-
plications including cardiac symptoms, hypokalermia, or renal

• Patient demonstrates signs of substance abuse.
• Staff is in conflict over treatment plan.

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• Provide information on the long-term effects on the body of anorexia ner-
vosa and bulimia.

• Involve family in what symptoms to identify and report. Review with them
how to deal with self-destructive behaviors so as not to reinforce them.

• Provide information on the Twelve-Step Program as in Overeaters Anony-
mous for dealing with addictions if appropriate. This is helpful for some
people with eating disorders.

• Review nutritional information and recommended dietary program.
• Teach stress management and relaxation techniques to reduce anxiety, espe-

cially at mealtimes or when feeling need to binge-purge.
• Educate patient and family on the need to continue long-term treatment.
• For patients who use self-induced vomiting, encourage adequate dental care.
• Reinforce need for close medical supervision.
• Teach central line care and tube feeding administration, as appropriate.
• Provide education on health effects of laxative and diuretic abuse.


• Document intake and output.
• Document description of behavior at mealtimes, purging behaviors.
• Document description of interactions with family.
• Document patient’s verbalization about his or her body image.
• Document all self-destructive behavior.
• Review assessment of potential complications, for example, cardiac status.


• Psychiatric follow-up is essential, including family therapy. Referrals need to
be made for appropriate treatment.

• Refer for adequate nutritional support follow-up if appropriate, including
management of enteral feedings and central line care. If patient is being fol-
lowed by a home health agency, encourage referral to dietitian. Home
health agency social work and psychiatric home health referral may also be
helpful to encourage compliance with psychiatric care, for family support,
and for behavioral management.

• Refer patient and family to support groups, if available.
• Refer patient to dental care follow-up if patient is vomiting.
• Refer patient to Overeaters Anonymous, if appropriate.

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The Morbidly Obese Patient

Learning Objectives
• Differentiate obesity from morbid obesity.
• Identify potential lifestyle restrictions and prejudices faced by morbidly

obese persons.
• Describe effective interventions to enhance self-esteem for these patients.
• Identify common emotional reactions of nurses to the morbidly obese


Body mass index (BMI) – Describes body weight relative to body fat. It is cal-

culated by dividing weight in pounds by height in inches squared, then mul-
tiplying by 704.5.

Bariatric surgery – Surgery performed on morbidly obese to achieve restric-
tion in food intake.

Chronic obesity – Life-long overweight condition with few fluctuations.
Developmental obesity – Obesity that began in childhood or adolescence

and is often associated with problems of self-concept.
Ideal body weight – Standards based on actuarial tables of height and

Morbid obesity – A condition in which an individual is 100 pounds or 100%

over his or her ideal body weight or body mass index of greater than 40.
Obesity – Having an excess of adipose tissue and being at least 15% over

ideal body weight or body mass index of greater than 30.
Pickwickian syndrome – Extreme obesity in which demands of body size on

a small chest wall lead to cardiovascular and respiratory changes, includ-
ing hypoxemia, cyanosis, reduced vital capacity, and pulmonary edema.

Reactive obesity – Obesity that starts later in life and is the result of mal-
adaptive coping styles at times of stress such as death of a loved one or
leaving home.

The cultural ideal of the thin body has no greater dichotomy than the image
of those with extreme obesity, also known as morbid obesity. Although aes-

thetic preferences for body size and shape vary from culture to culture, today the
thin, fit body is idealized for both women and men in America. Prejudice against

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the obese has a significant impact on anyone with a serious weight problem, but
morbidly obese people often face outright discrimination.

The American population has been steadily gaining weight over the last
30 years. Currently two-thirds of Americans are classified as overweight and
30% as obese (National Health and Nutrition Examination Survey, 2000).
Extreme or morbid obesity is seen in only a small percentage of the population,
but its impact on health care is great because of the multiple medical compli-
cations caused by this condition. BMI is now the standard used to determine
obesity because it is more reflective of body fat percentages than the older ideal
body weight tables.

Morbid obesity affects all ages and races, although it is much more common
in lower socioeconomic groups. Obesity is equally distributed between men and
women. Potential health problems include a wide range of chronic conditions,
including hypertension, cardiac problems, diabetes, respiratory insufficiency, and
joint and back disorders. Risk of death increases with a BMI greater than 30.
Nutritional deficiencies are also extremely common because the obese person
may lack a well-balanced diet or experience protein deficiencies related to crash
dieting. Obesity is not classified as a psychiatric disorder in DSM-IV-TR, but
because of the emotional factors associated with it, it may be considered under
the psychiatric diagnosis Psychiatric Factors Affecting Medical Conditions
(Townsend, 2006).

Society often views these individuals as undesirable. They may be abused by
strangers and treated with contempt by family members. Even health-care pro-
fessionals may view them as emotionally disturbed, even though there is no
increased incidence of psychopathology in morbidly obese people. Others may
view these individuals as lazy, unkempt, and lacking in self-control. Many experts
promote viewing these individuals as having a chronic illness rather than a cos-
metic problem.

Morbidly obese people face discrimination particularly in the workplace
because they are viewed as less healthy, less diligent, and less intelligent than their
thinner peers. Certainly, with this kind of reaction, it is no wonder that these peo-
ple often experience poor self-esteem, feelings of isolation and helplessness, and
loss of control.

Morbidly obese individuals often have subjected themselves to many weight-
loss strategies, only to regain the weight, which increases the stress on the body.
Some studies suggest that individuals whose obesity has persisted for more than
5 years have very limited success with treatment.

Obesity is a complex issue, and any weight-loss program needs to include a
multidisciplinary approach. Successful weight-loss programs need to include
medically supervised diet and exercise programs, and emotional and social sup-
port. When these measures have been unsuccessful, some people pursue surgical
interventions, called bariatric surgery. Although many types of surgery for obe-
sity have been tried, the most successful today is the vertical band gastroplasty,
in which a smaller stomach pouch is created through gastric stapling (Weber &
Clavien, 2006). Another procedure is the lap band adjustable gastric banding

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system which is done laparoscopically. An access port is created to adjust the
band to restrict or increase food intake. These procedures are generally consid-
ered only for people with a BMI greater than 40 or those with BMI over 35 with
serious medical complications related to weight.

Some educators have noted that fewer than 50% of health-care professionals
advise obese patients to lose weight (Goldsmith, 2000). Some reasons for this low
percentage include discomfort about addressing the subject, lack of time to talk
with the client, and a belief that this recommendation will not make any differ-
ence. Yet a client is three times more likely to try to lose weight if he or she is
advised to by a health-care professional. However, extremely obese people may
avoid regular medical care because of shame about their weight.


Extreme obesity is a complex problem, and its etiology is probably multifactoral.
Most often it begins early in life.

The biological view considers that early onset is related to childhood develop-
ment of large-size adipose or fat cells. The cellular hypertrophy results from
increased food intake and decreased energy expenditure. Other factors may
include impaired hunger-satiety mechanism in the hypothalamus and endocrine
disorders, leading to slower metabolism or changes in insulin or cortisol produc-
tion. The set point theory focuses on the body as being programmed to maintain
a certain level of fat stores. This could explain why some people gain weight so
easily. Genetic studies have found that 60% of obese subjects have at least one
or both obese parents (Galzis & Kempe, 1989). A protein called leptin has been
identified to contribute to delayed satiety in some people.

Psychoanalytical theory views obesity as an expression of an intrapsychic con-
flict that occurred during the oral stage of psychosexual development. Unmet
needs and stress in an infant can lead to overeating to decrease anxiety, express
hostility, and compensate for lack of love. Unmet oral needs may contribute to
behaviors such as being demanding and impatient. Weight can provide a shield
against intimacy. This can explain why individuals who lose large amounts of
weight without adequate psychological support may experience intense anxiety
and feelings of vulnerability.

Learning theory looks at how overeating occurs in response to tension, stress,
or boredom. This can be a learned behavior from childhood, when parents used
food as a source of reward and attention. Increased obesity has also been found
in people with a history of sexual trauma. Large size can be an unconscious
mechanism for defense against an abuser. Binge-eating disorders may also be
present. These individuals may use food as escape from stress and depression.
Problems with bingeing are the most common reason for seeking counseling asso-
ciated with being overweight.

Sociocultural factors must be included because food and eating are such
important parts of our society. Social customs are often centered on food. Meal-
times may be an important part of family life and family traditions.

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Sedentary lifestyle, possibly related to a medical condition that limits mobility, is
a significant factor in developing morbid obesity. In addition, treatment regimens
for some conditions may increase the risk of severe obesity. Steroids can quickly
contribute to increased adipose tissue development, and some antidepressants,
antipsychotics, and estrogens can cause weight gain.

Obesity is particularly associated with heart disease, hypertension, and
increased total cholesterol.


Children and Adolescents
The rate of childhood obesity has dramatically increased in the past 30 years. At
least 15% of American children and adolescents are obese (National Health and
Nutrition Examination Survey, 2000). Obesity in childhood is linked to obesity
in adulthood (developmental obesity). In addition, obesity in adults in the child’s
life contributes to childhood obesity. The child may learn to use food for com-
fort, solace, reward, and love. Some other contributing factors include more
sedentary lifestyles with emphasis on television and computers, fast foods high in
calories and fat, and reduction in sports programs in schools. Obese children are
often seen by others as sloppy, less intelligent, lazy, and less likeable. Obese chil-
dren are often victims of teasing and social isolation, adding to poor self-image
and causing these children to retreat to food as a coping mechanism. Poor self-
image often remains throughout life regardless of the person’s educational or
vocational success. Childhood growth spurts may resolve some overweight ten-
dencies, but other children go on to be morbidly obese. Weight loss in children
must be approached cautiously to prevent nutritional imbalances.

Older Adults
A past history of obesity is the major contributor to obesity in elderly people. An
increased sedentary lifestyle as a result of failing health or medications, or poor
nutrition because of low income, low energy, or depression also contribute.

Chapter 16 ■ Problems with Nutrition 333

• May view patient as sloppy, lazy, weak, lacking impulse control, mentally ill
• May feel overwhelmed and hopeless with patient’s problems
• May resent the demands placed on the staff with the increased workload

created by patient’s size and need for special equipment
• May tend to focus on patient’s size rather than view him or her as an indi-

vidual with unique feelings
• May feel guilty for these negative feelings

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Behavior and Appearance
• Binge eating, secretive night eating, hoarding food
• Repeated dieting
• Dressing in large, oversized clothing
• Sedentary lifestyle, may avoid chance to exercise
• May exhibit night eating syndrome with cycle of insomnia, increased

hunger, eating large amounts, morning anorexia

Mood and Emotions

• Depression
• Difficulty being assertive
• Guilt, shame associated with overeating
• Strong emotions that trigger need to eat
• May feel hopeless, overwhelmed, out of control
• Unrealistic expectations, leading to disappointment

Thoughts, Beliefs, and Perceptions

• Finds many powerful meanings in food, such as comfort, love, and security
• Distorted body image
• May see self as thinner, possibly indicating denial, or larger than true self
• May respond to external cues and thoughts rather than hunger in deciding

what and when to eat
• If weight is lost, possible fears of success or intimacy on an unconscious

level when patient can no longer hide behind the weight

Relationships and Interactions

• May lack social skills
• May avoid social situations for fear of rejection
• May cover feelings of rejection by joking

Physical Responses

• Hypertension
• Diabetes
• Arthritis, trauma to joints and back
• High serum cholesterol

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• Cardiac disease
• Malnutrition
• Fatigue
• Dyspnea on exertion
• Pickwickian syndrome includes sleep apnea, daytime somnolence related to

carbon dioxide retention, and symptoms of congestive heart failure

Pertinent History
• Multiple attempts at weight loss
• Childhood obesity
• Chronic illness
• History of obesity and sedentary lifestyle


The drug traditionally used in weight-loss programs is amphetamine. It is
included in many over-the-counter “diet pills” even though they have been of lim-
ited benefit in suppressing appetite. In addition, they frequently have adverse side
effects, including hypertension, stroke, and renal failure. Antidepressants such as
sertraline (Zoloft) and fluoxetine (Prozac) have a side effect of anorexia and have
been used with success in long-term weight-loss programs. They also reduce irri-
tability associated with depression.

Searching for weight-loss drugs is the focus of much research. New weight loss
drugs include sibutramine (Meridia), which suppresses appetite by blocking
serotonin and norepinephrine; and orlistat (Xenical), which reduces absorption of
33% of dietary fat. In 2007, orlistat was released as an over-the-counter version
called Alli. Both drugs have significant side effects that limit their use including
depression and anxiety. Phentermine, an appetite suppressant, has been available
for many years and is used in many over-the-counter weight-loss products.

Administering any medications to morbidly obese people requires extra cau-
tion because some may require dose adjustments. Some medications may need to
be given in higher doses because of the increased body weight, whereas other
drugs, such as theophyllines, may need to be administered in lower doses because
the metabolism of the drug is affected by the patient’s lower protein or higher fat
stores. Check with the pharmacist for specific information on the chosen drug.
The route of administration can also affect absorption and distribution of the
drug. Drugs administered intramuscularly may not be absorbed if the needle does
not reach the muscle. If the medication is deposited in fat tissue, its absorption is
slowed and onset of action may be delayed. Intravenous administration may be
the most effective route. Because IV access is often difficult, central line insertion
may be the most efficient.

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Beginning and maintaining a weight-loss program in morbidly obese people
requires close medical and dietary supervision. It must be remembered that even
large persons can still be malnourished, and proper balance in the diet must be
addressed. A complete nutritional assessment needs to be done. Patients with
medical problems require very close supervision to maximize outcomes.


SELF-ESTEEM, DISTURBED evidenced by negative self-image, feelings of
powerlessness related to feelings of self-degradation and response of others to
the obesity.

Patient Outcomes
• Verbalizes positive traits about self
• Verbalizes concerns to nurse
• Demonstrates fewer self-critical remarks
• Participates in self-care

• Avoid preaching or criticizing about need for weight loss; these

approaches will only increase patient’s negative feelings and sense of
hopelessness and powerlessness.

• Provide privacy and treat patient with modesty. Be aware that patient
may be extremely sensitive to having body parts exposed.

• Have extra help available before turning or ambulating a patient to pre-
vent falling and help patient feel more secure.

• Have adequate-sized and reinforced equipment such as wheelchairs and
beds to avoid embarrassment of squeezing patient in to accommodate
your equipment. Check to see if patient has own custom wheelchair.
Have family bring clothing from home if hospital gowns are inadequate.

• Recognize that patient may feel very anxious about being stared at by
strangers, particularly in a hospital situation. Prepare other departments
for patient’s appearance and needs.

• Listen for cues as to how patient views self and appearance. If patient
makes self-deprecating remarks, explore these feelings. Focus on positive
traits other than body size. Patient does not need to be reminded of his
or her large size.

• Give patient the opportunity to share feelings. He or she needs to be
viewed as an individual and encouraged to identify feelings.

• Explore use of makeup, hairstyle, and dress, as appropriate, to increase
feelings of self-esteem.

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• Encourage the patient’s participation in treatment plan to avoid passiv-
ity. Provide encouragement to make decisions about all aspects of care.
Work with patient to problem-solve ways to maintain participation.

• Assess patient’s support system and encourage his or her involvement.

evidenced by morbid obesity related to excessive intake, emotional factors, or
altered health maintenance.

Patient Outcomes
• Begins to identify feelings or thoughts that contribute to overeating
• Demonstrates changes in eating patterns
• Identifies one short-term goal to attain
• Demonstrates nonfood-related coping mechanisms

• Assess patient’s condition and priorities of care before assuming that

treatment plan should include weight loss. Patient must be involved in
deciding if weight loss is a realistic objective at this time. Patient motiva-
tion is essential to the success of a weight-loss program.

• Obtain baseline weight. Identify scales adequate to handle patient’s
weight beforehand. Also, consider using two scales or, in the hospital set-
ting, use a bed with adequate built-in scales.

• Assess the patient’s eating patterns and typical daily intake. Provide a
supportive environment so that patient can feel secure to be honest. Rec-
ognize that patient may feel need to minimize his or her intake.

• Assess patient’s knowledge level about eating patterns. Be alert to beliefs
held about weight and weight loss by patient and family. For instance,
patient may say that the entire family is “fat” or “it’s genetic.”

• Assess skin and mobility. Patient may be prone to skin breakdown and
complications related to poor mobility or hygiene.

• Identify coping mechanisms to deal with stress and anger that do not
involve food, such as taking a walk, deep breathing, or talking to a
friend. Give patient feedback on alternative coping mechanisms and iden-
tify the link between stress and desire to eat.

• Focus on short-term goals to identify successes in weight loss or improved
mobility. Help the patient identify nonfood rewards when goals are met.

• For the patient at home, explain that removing easily accessible high-fat
and high-calorie foods from the house will lessen temptation.

• Assess family involvement. Recognize that family can consciously or
unconsciously sabotage weight-loss plans by exposing patient to old eat-
ing habits. Encourage the family to eat foods similar to those eaten by the
patient for shared meals.

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Activity Intolerance
Body Image, Disturbed
Coping, Ineffective
Gas Exchange, Impaired
Health Maintenance, Ineffective

338 Chapter 16 ■ Problems with Nutrition


• Patient experiences serious complications from diabetes, hyperten-
sion, or heart disease.

• Patient expresses desire to start a potentially dangerous quick weight
loss program.

• Patient exhibits signs of severe depression or self-destructive behaviors.
• Patient demonstrates signs of substance abuse.


• Weight loss specialists
• Internist
• Psychiatric Team
• Social Worker


• Provide information on starting an exercise and weight-loss program.
• Strongly encourage patient to maintain medical supervision for any weight-

loss or exercise program.
• Provide information on behavior techniques for weight loss, such as eating

slowly and serving smaller portions.
• Teach patient to become more aware of body signals of hunger and satiety.
• Teach appropriate exercises within patient’s ability. Explain that even mini-

mal exercise, such as short walks several times a day, can help reduce weight
and promote health.

• Teach patient how to monitor for possible complications such as diabetes
and cardiac problems.

• Give family information on weight loss, nutrition, and ways to support
patient’s health.

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• Consider focusing education on reducing medical complications and
increasing activity rather than just weight loss.

• Teach coping mechanisms to reduce anxiety that do not involve food.
• Encourage patient to continue in psychosocial support program after weight

loss is achieved to learn skills to deal with new image.


• Document baseline weight, mobility, and skin condition.
• Document response to activity.
• Document eating patterns.
• Note coping mechanisms in response to stress.
• Note indications of motivation regarding treatment.


• Provide referral information to support groups such as Weight Watchers or
Overeaters Anonymous as appropriate.

• Encourage nutritional and medical follow-up.
• Assess whether patient needs assistance with transportation to medical care.
• Provide information to home health agency or other health-care providers

on patient’s special equipment needs and other concerns.

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Problems Within the Family

Family Dysfunction

Learning Objectives
• Differentiate between traits of functional and dysfunctional families.
• Discuss the role of systems theory related to the family.
• Describe the signs of caregiver role strain.
• Identify effective nursing interventions to help the family cope with the

illness of one of its members.

Family dysfunction – A family that develops ways of interacting with one

another that leads to impaired functioning, both among the members and
outside the family boundaries.

Extended family – Family network beyond family of origin, including step-
parents, grandparents, aunts and uncles, and others.

Family – Two or more individuals who depend on one another for emotional,
physical, and economic support

Family of origin – Family into which one is born or adopted.

As the basic unit of society, the family is the most important influence on shap-
ing who we become. The traditional nuclear family, with two parents and

child or children, has undergone tremendous changes in the last few decades, and
some of these changes will affect generations to come. Changes from 20 years ago
include increased likelihood to be smaller, presence of multiple wage earners,
required child care assistance, and the presence of stepchildren. According to the

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most recent U.S. census data available, less than 25% of all U.S. families fit the
description of a traditional nuclear family. This is down from 44% in 1960. The
2000 U.S. census showed a 25% increase in female single-parent households and
a 62% increase in male single-parent households since the 1990 census. Single-
parent households represent the single biggest change in U.S. family life. Chang-
ing economic needs, changes in women’s and men’s roles, and a decreased
tendency to accept unsatisfactory relationships have contributed to a high
divorce rate and significant changes in family structures. Economic changes in the
United States have been a major contributor to the changing American family.
This is seen in more women working, the need for childcare, young adults still
living with their parents, and senior adults moving in together or with other fam-
ily members (Casper & Haaga, 2005).

Another new trend is the great increase of never married mothers (Casper &
Haaga, 2005). Single-parent households, stepfamilies, childless couples, and a
variety of combinations of cohabiting individuals are increasing. These new fam-
ily constellations are increasingly accepted in our society (Friedman, 1998;
Thornton & Young-DeMarcko, 2001; Harmon Hanson, 2005). The increasing
presence of immigrants from a variety of countries also influences families with
linguistic diversity and cultural conflicts between generations.

Stresses caused by relationship adjustments can influence one’s health status.
Also, a change in the health of any member of the family can create family dis-
organization or even a crisis when roles, patterns, or routines must be restruc-
tured. Anger, guilt, and denial may all occur as the members try to adapt.

Even in families that function satisfactorily, an illness may cause a tremendous
crisis as the family shifts life patterns to meet the demands created by the illness.
A family member may need to take on the added demands of being a caregiver
to an ill person at the same time as he or she is handling other major family
responsibilities. Even the healthiest functioning family may enter a crisis period
in response to a devastating illness or death. Relatives may need to move in,
which changes the social structure of the family, or the family may need to out-
lay large amounts of money to provide extended care, affecting the family’s
future goals. Changes in health of parents and siblings from one’s family of ori-
gin and extended family may require helping with caregiving.

Because of the impact illness has on the family and the family members have
on the patient’s recovery, members need to be involved in the patient’s treatment
plan. Family response can represent a major source of stress to the nurse as fam-
ily conflicts and dynamics are acted out. Family members’ own fears, lack of
sleep, conflicts with each other, and loss of emotional support can all contribute
to their sense of isolation and possible mistrust of healthcare professionals.


Bowen’s family system theory, developed in the 1950s, views the family as a
homeostatic system of relationships. This theory remains generally accepted. A

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change in functioning of one member results in compensatory changes in the
other members in an attempt to maintain equilibrium. For example, when a fam-
ily member becomes ill, other members will adapt to fill the roles of the ill mem-
ber while he or she is sick. The family system is always changing as it adapts to
internal and external stimuli in its attempt to remain stable.

All families have unwritten, covertly expressed rules, such as “conflict is
wrong,” and roles, such as “Dad makes the final decision.” These covert roles are
often more obvious when the family copes with stress and often requires an enor-
mous amount of adjustment when roles must be reversed. For example, if the
father, who makes all the decisions, becomes ill, a normally dependent member
may accept more of the decision-making responsibilities, reversing the established
roles. If past relationship problems do not support the changes, family members
may exhibit unhealthy behaviors such as anger (possibly directed at the hospital
staff) and guilt. The illness can also exacerbate any relationship problems among
other family members.

In stressful situations, family members may exhibit behaviors that seem to tem-
porarily help the relationship while they focus on the current crisis, reducing the
anxiety and intensity of existing relationship problems. Some of these attempts at
solutions can create more stress for a family member. At times, one member is
identified as the “problem” and the rest of the family focus attention on that mem-
ber and his or her problem. This is called scapegoating and allows the family to
avoid confronting the real conflicts within the family. For example, parents with
marital relationship problems may focus their attention on their child’s behavior
problems rather than their own.

Breakdown in family function occurs when dysfunctional communication is
predominant and rules of communication are ambiguous (Goldenberg & Gold-
enberg, 2004).


The family can play a key role in how a person responds to illness. Support and
love from family may encourage a patient to concentrate on healing and
strengthen his or her will to survive. In some families, however, the sick individ-
ual may be viewed as dependent and unacceptable, reducing his or her will to sur-
vive and remain a burden to the family.


The family represents the young child’s whole world. The family ideally gives the
child a supportive environment in which a sense of trust and seeing one’s self as
a separate, competent person is developed. As the child grows, the world expands

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outside of the family, exposing him or her to new ideas, conflicts, and inconsis-
tencies. Separation from this comfort can create an enormous amount of stress
for both child and family.

Other outside factors may influence this separation anxiety. Because more and
more children are being cared for by babysitters or in day care, adjustment to an
environment outside the home may be less stressful. However, if the child has
experienced a loss of a loved one, such as through death or divorce, separation
may be even more stressful.

The great increase in the number of stepfamilies has created new, compli_
cated relationships. Children must adapt to new family members, yet maintain
relationships with parents, siblings, and others. The last few decades have
also seen an increase in the number of single fathers and men involved in child

Middle Age
Sandwiched between caregiving for younger family members and older family
members can create added burdens at a time of life when the individual had
hoped to be free of extra responsibility. Bringing in parents or other older rela-
tives into the home can create more burden, especially if they have health con-
cerns. However, these older adults can also contribute to the family for emotional
and possible financial support (Casper & Haaga, 2005).

Older Adults
With today’s longer life expectancies, older people are more likely to become
incorporated into new families as they remarry, cohabitate, or maintain some
type of group living situation. Adjusting to a new spouse’s family at an advanced
age can be a challenge because adult children may be ambivalent, or even resent-
ful, about their parent’s new relationship. These new relationships can create
some major relationship problems within the families and may result in very dif-
ficult situations when the parent becomes ill.

The need to care for sick elderly relatives is also a source of family relation-
ship problems. Today, because many families do not have one member who
stays at home and has the ability to care for an ill parent, caregiving can become
a tremendous burden, both physically and financially. The caregiver may be
faced with overwhelming guilt and, possibly, anger. An ill parent may be viewed
as an intrusion into a family already overwhelmed with caring for the children
with both parents working. If an elderly person with a chronic illness is
admitted to the hospital, it is essential to assess how well the family is coping
with the situation and how well they are able to care for the elderly person. In
the home, be aware of what family members are trying to verbalize. Sometimes
they would like more assistance but hesitate to ask for it because they are too
afraid or feel guilty.

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Each family exhibits unique behaviors related to the normal roles established
within the family. Some of the common problem behaviors are listed in the fol-
lowing section.

Behavior and Appearance
• May exhibit behaviors that isolate others from family interactions.
• Change in behavior patterns when in the presence of various family mem-

• May exhibit a defensive response to staff members.
• May consistently place blame on others.
• May exhibit a lack of empathy toward the ill family member.
• May exhibit a lack of congruence between verbal and nonverbal com-

• Some family members may be open and realistic about diagnosis, treatment,

and prognosis, and others may deny any problem, blame the staff members
for the problem, or avoid the patient altogether.

Mood and Emotions
• May exhibit contradictory, confusing, or inappropriate reaction to the


Chapter 17 ■ Problems Within the Family 345

• May anticipate problems with all families because such problems are so

• May resent the disruption in routine that may result when family members

want to be involved in patient care
• May feel uncomfortable in the presence of family members acting out their

• May resent the family’s criticisms, which may be their attempt at maintain-

ing control of the situation
• May relate patient’s situation to personal family conflicts, possibly causing

uncomfortable feelings
• May become overinvolved with a patient’s family and experience the emo-

tional highs and lows related to patient’s progress and family response
• May incorrectly view a family as dysfunctional if their relationship styles

differ from the nurse’s past experience in a family
• May feel overwhelmed with dysfunctional family’s problems

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• May be unable to express or display feelings
• May avoid emotional situations

Thoughts, Beliefs, and Perceptions
• Family may indicate inaccurate or unrealistic beliefs about the patient’s con-

dition or prognosis or one’s ability to provide adequate care.
• Family may be operating on the basis of myths or inaccurate beliefs that

impede care.
• Family may think it is wrong to share concerns with others.
• Family may focus on personal reactions to the patient rather than objec-

tively viewing the patient’s needs.

Relationships and Interactions
• Roles among family members may be rigid.
• Individual family members may do anything to placate others to prevent an

angry response or rejection.
• Family may have difficulty managing conflict.
• Family may be in a state of constant conflict.
• Family may pay undue attention to the ill family member.
• Family may appear to get along well when the history suggests that rela-

tionship problems have existed in the past.
• Family members may evade opportunities for communication.
• Family may avoid visiting or having contact with the patient.
• There may be inappropriate or miscommunication among family members.

Communication may be unclear, nonspecific, or indirect.
• One family member may take the lead in defining the needs of the patient

and family, or several members may jockey to assume the lead role.

Pertinent History
• History of child abuse, domestic violence, elder abuse, or family conflict
• History of psychiatric illness or substance abuse
• Recent losses or deaths in the family and past significant losses or trauma


Family Therapy
Family therapy can be an important treatment to assist the family under stress.
When problems such as a psychiatric disorder, abuse, marital conflict, and sub-
stance abuse are present, a therapist can assist the family in dealing with the cur-
rent stressor and finding more long-term solutions to their relationship or
adjustment problems. Therapists may meet with all the family members or limit
meetings to a few key members. Young children can also be included.

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Social Services
Social service agencies can investigate needed support services for families in dis-
tress on either a long- or short-term basis. They can direct the families to agen-
cies that may provide additional finances or extra help, such as Meals on Wheels.


INTERRUPTED FAMILY PROCESSES evidenced by inability to meet
demands of its members, avoidance of making decisions, inappropriate com-
munication between members related to impact of ill member on family sys-
tem, dysfunctional family processes.

Patient and Family Outcomes
• Participates in treatment planning and care of ill family member
• Identifies resources available to assist family in coping
• Acknowledges diagnosis and prognosis of ill family member

• Identify the family constellation, patterns of family interactions, and fam-

ily leaders. Assess the ways in which the family members interact with
each other and the patient’s response to family involvement. Determine
from the patient whom he or she considers closest family and recognize
that this could be close friends rather than relatives. Avoid making
assumptions about whom the patient wants involved.

• With a large family, consider asking them to identify one member who
will get the information on the patient’s condition and take the responsi-
bility to share it with the rest of the family. This avoids the need for mul-
tiple calls for information.

• As appropriate, ask the patient whom he or she wants to be involved.
• Involve these family members in treatment plan. Inform them of what is

happening according to patient wishes. Take the time to orient family to
agency routines and visiting hours.

• Identify family support systems within the family.
• If family members exhibit disruptive behaviors, evaluate the underlying

reasons. Talk with patient and family to determine the cause.
• Analyze the family’s ability to care for the patient and what they need to

know when caring for the patient at home. Encourage family involve-
ment in basic care needs if acceptable to patient. Involving the family in
the care can help the patient accept his or her condition. For example,
having the spouse care for a condition such as a colostomy can give the
patient a sense that he or she is not disgusted by patient’s body.

• If patient does not want family informed of his or her condition, talk
with patient to identify reasons and fears. Not including the family may

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be a way of maintaining denial. Respect the patient’s wishes, but con-
tinue to talk regarding the risk of social isolation. If patient is seriously
ill, one person will need to be identified who knows his or her wishes.

• If family wants information withheld from the patient, discuss their fears.
Point out that hiding the truth is not helpful to the patient. Dishonesty
inhibits future trust and communication. Help family acknowledge their
fears. However, recognize that certain cultures have strict rules concern-
ing sharing bad news with loved ones, especially a parent. Avoid becom-
ing angry at this situation and alienating the family. The family could
distrust the healthcare team and block communication channels.

• Regularly assess the family’s awareness of patient’s condition and expec-
tations for recovery and future treatment. Avoid use of medical jargon.

• If the family seems to avoid involvement in the patient’s care or treatment
plan, determine the reason. Consider giving them one task to do at a time
to encourage their involvement without being overwhelmed.

• Encourage the family to verbalize their feelings about the illness. Respect
their need for privacy to express emotions. Encourage family to leave
patient’s room to discuss areas of conflict. Use open-ended questions to
promote sharing of feelings and concerns about problems with family

• Allow flexibility in visiting, if possible. Recognize the need for family
members to spend the night and for young children to be allowed to visit.
As needed, set clear limits on disruptive behavior, and limit the number
of visitors to reduce stress and fatigue on the patient. Encourage visitors
to coordinate who will visit on certain days and times.

• As needed, organize a care conference with family members to discuss
patient’s care needs and any conflicts the family and staff may be having.
Avoid having too many staff members in attendance because this could
intimidate family. Focus on reassuring the family of the care and concern
of the staff for the patient. Consider involving physician, social worker,
or clinical nurse specialist to help intervene if conflicts continue.

• Acknowledge and facilitate family strengths. Promote self-esteem of indi-
vidual family members by acknowledging their skills and influence on
patient (“Your spouse really perks up when you visit”).

CAREGIVER ROLE STRAIN evidenced by difficulty performing caregiving
activities, inability to meet other family responsibilities, depression, and anger
related to multiple losses and burdens associated with caregiving responsibilities.

Patient and Family Outcomes
• Expresses frustrations assertively
• Provides safe care to patient
• Maintains personal needs along with caregiver needs
• Identifies resources available for assistance

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• Assess caregiver’s ability to meet the demands of the patient’s care. Iden-

tify coping mechanisms and support systems available.
• Allow caregiver the opportunity to share feelings and concerns away

from the patient. Reinforce the need to express concerns and emotions.
Give caregiver permission to express negative feelings, such as anger and
resentment. Provide supportive, safe setting to do this. Reinforce the idea
that negative emotions are normal to reduce feelings of guilt.

• Encourage caregiver to be assertive in asking for assistance. Reinforce
that others may not know what caregiver’s needs are. This is especially
important if the caregiver tends to demonstrate martyr behavior.

• Be aware of outside stressors on family members influencing their reac-
tions. Fatigue and working long hours with an ill family member can
contribute to ineffective coping mechanisms. Talk with them about pos-
sible resources to reduce stress, including enlisting other family members
to help, reducing expectations, and hiring outside help.

• Assess caregiver’s expectations. Encourage caregiver to have realistic
expectations of what he or she can do.

• Remind the family that past conflicts do not disappear even when some-
one is ill. When family members must spend long hours providing care,
resentments can increase. Encourage the family to concentrate on dealing
with the immediate stressor while taking steps to work on unresolved
conflicts once the situation has resolved sufficiently.

• Encourage the caregiver to develop a routine to care for his or her own
needs of sleep, eating, and socializing to effectively care for the patient.
Enlisting other family members or hiring outside help can provide the
needed break. If the caregiver is unable to get out, help him or her iden-
tify ways of maintaining contact with friends by regular phone calls, let-
ter writing, and e-mail.

• At times families “promise” a loved one they will never put him or her in
a nursing home. Talk openly about how these promises are sometimes
made without realizing the full scope of the situation.

• Give caregivers recognition for the good job they are doing.
• Be alert to caregivers’ signs of increasing distress including depression,

suicidal risk, hopelessness, and signs of potential physical and emotional
abuse of the patient.


Anticipatory Grieving
Ineffective Family Coping: Compromised
Knowledge, Deficient

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350 Chapter 17 ■ Problems Within the Family


• Indication of family not acting in the best interests of the patient, such
as taking patient out of hospital against medical advice or pushing
inappropriate treatments.

• Any indication of abuse within the family must be reported per agency
policy and state law.

• Indications that patient is not being cared for adequately include poor
hygiene, pressure ulcers, poor nutrition, and dehydration.

• Be alert for destructive behavior within the family, such as substance
abuse, attacking each other, or demoralizing patient.


• Social Worker
• Local Family services agencies
• Child or Adult Protective services agencies

Sexual Dysfunction
Sleep Pattern, Disturbed


• Provide specific information about patient’s illness and care needs, such as
pamphlets, videos, and other patient education materials. Make sure these
materials match family members’ reading level and language.

• Review with family members what to expect from patient’s illness and how
it may affect communication and coping within the family. Let them know
that family problems can get either worse or better during this time of stress.

• Reinforce the need for family members to maintain own self-care routines
and to be aware of signs of stress that may lead to them being sick.

• Provide information on support groups and group education programs as
well as appropriate Web sites.

• Work with caregivers to develop routines that will make the care as easy as
possible. For example, setting up the patient’s room at home on the first
floor of a two-story house will reduce the caregiver’s need to go up and
down stairs all day.

• Prepare family for possible course of the illness and anticipated changes
in care.

• If the family is planning to hire help, provide suggestions on identifying and
managing possible problems, such as the attendant not showing up for work
on time or not caring for patient appropriately.

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• Describe which family members visit the patient and the interactions that

• Document information on family structure, which family members patient
lives with, and care resources available.

• Document teaching given to family and include their response to any edu-
cation given.

• Describe caregiver’s ability to provide patient care.
• Document family awareness of the patient’s condition and diagnosis.


• Involve family in the discharge plan early in the treatment.
• Consider a home health referral after the patient is discharged from the hos-

pital to assess caregiver’s ability to provide care.
• Provide specific referrals for additional help in the home or alternate care

• Provide specific information on appropriate support groups, such as for

family members of people with Alzheimer’s disease, stroke, or drug abuse.
Also give information on hotlines or other agencies that may be useful.

• Make sure social worker is involved; consider social work evaluation in the
home as well.

• Refer family to a family therapist, if appropriate.
• Identify appropriate equipment that will be needed in the home to provide

care (for example, oxygen, hospital bed, and wheelchair). Assist in making
arrangements for delivery or refer to social service.

• Communicate with home health agency regarding family communication
problems and conflicts that may affect care.

Family Violence

Learning Objectives
• Identify suspicious signs of child abuse, domestic violence, and elder

• Discuss common traits of victims of any type of abuse.
• Discuss common traits of abusers.
• Identify common nurses’ reactions to abuse.

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Abuse – Willful infliction of physical injury or mental anguish or the depriva-

tion by the caregiver of essential services.
Domestic (intimate partner, spouse abuse) violence – Intentionally inflicting

or threatening physical injury or cruelty to one’s partner.
Economic abuse (fiduciary) – Using another’s resources for one’s own per-

sonal gain without permission or making the victim financially dependent
on the abuser.

Family violence – At least one family member is using physical or sexual
force against another that leads to physical or emotional injury.

Incest – Any type of exploitive sexual experience between relatives or surro-
gate relatives before a victim reaches 18 years of age.

Neglect – Deliberate deprivation of necessary and available resources, such
as medical or dental care.

Physical abuse – Deliberate violent actions that inflict pain or nonaccidental

Psychological (emotional) abuse – Deliberate and willful destruction or sig-
nificant impairment of a person’s sense of competence by battering the vic-
tim’s self-esteem and inhibiting normal psychosocial development.

Sexual abuse – Using the victim for sexual gratification when the victim is
unable to resist or consent. This includes rape and developmentally inap-
propriate sexual contact, incest, and using a child for prostitution or pornog-

Shaken-baby syndrome – When an infant is violently shaken by the extremi-
ties or shoulders, usually out of frustration and rage over the child’s inces-
sant crying.

Family violence may be America’s number one public health issue, yet many
nurses caring for victims of this type of violence are often unaware that it is

occurring within the families of their patients. Child abuse, domestic violence
(also called intimate partner abuse), and elder abuse can lead to life-long emo-
tional and physical problems for the victims and tears away at the very fabric of
society as a whole. Carson & Smith-DiJulio (2006) note that 50% of all Ameri-
cans have experienced violence in their family. It occurs in all segments of soci-
ety. Family violence is often part of the history of violent criminals and runaways.

Victims are often too fearful or ashamed to report abuse, become adept at hid-
ing the signs, or use massive denial to convince themselves that the abuse is not
that bad, so that a violent family situation often goes unnoticed by outsiders.
Health-care professionals must be vigilant to recognize the overt and covert signs
of abuse. Every state mandates that suspected child abuse be reported, and some
states are enacting similar laws for domestic violence and elder abuse. The Joint
Commission on Accreditation of Healthcare Organizations (JCAHO) now also

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requires that standards for identifying and providing services to victims of child
abuse, domestic violence, and elder abuse be in place (2001). Nurses in all set-
tings must be alert to signs of abuse. Home health nurses in particular are in a
key role to identify abuse within a patient’s family.

Child abuse includes physical and emotional abuse, neglect, and sexual abuse,
and occurs at all socioeconomic levels. Although statistics are difficult to attain, it
is estimated that at least 1 million American children are victims of abuse and neg-
lect each year (2006 Center for Disease Control and Prevention). The youngest
children (less than 4 years of age) are the most vulnerable and the most likely to
die from abuse or neglect. Reported cases of child abuse have steadily increased
over the last few years, but many cases are not reported. Children are a most vul-
nerable segment of the population because they depend on others for all their
needs. Parents are the most common abusers. Shaken baby syndrome is a form of
child abuse that contributes to infant deaths each year (Center for Disease Con-
trol and Prevention, 2006).

Many states have passed laws for safe surrender sites of newborns if a mother
is unable to keep her child. Rather than abandoning an infant, mothers can leave
the infant at community locations that often include hospitals and fire stations.
Many at-risk teenagers who might be pregnant are often not aware of this law,
so community education that reaches teens in their communities must be pro-
vided to prevent abandonment and often death of these infants.

Victims of child abuse are at an increased risk of becoming abusers as adults.
Even though the child may hate the abusive situation, he or she never gets an
opportunity to observe healthy parenting or to learn adaptive coping mechanisms
to deal with frustration without violence. Other long-term effects include low
self-esteem, high risk for substance abuse, tendency toward depression, difficulty
trusting in close relationships, and violent lifestyle including crime. An early sign
of child abuse in the victim can be abuse of family pets by the child. Children may
try to deal with the situation by controlling another being or seeking an outlet for
their anger through a more vulnerable victim. Incarcerated youths are frequently
victims of child abuse and neglect (National Council on Child Abuse and Family
Violence, 2004).

Girls are the most frequent victims of sexual abuse. Eighty percent of sexually
abused children know their abuser, and about 50% of cases involve a parent or
caregiver (Mulryan, Cathers, & Fagin, 2000). Long-term effects of sexual abuse
include fear of intimacy, sexual problems, eating disorders, and an overwhelming
sense of powerlessness. Victims may block out the memory of these incidents
until later in life, when a major event or trauma triggers memory recall. Exploit-
ing children in pornography has been increasing with access to the Internet.

Domestic violence most often refers to men abusing their female partners.
However, women abusing their male partners or abuse within homosexual cou-
ples does occur. This is an enormous societal problem. Like child abuse, domes-
tic violence is found at all socioeconomic levels. It accounts for 22% to 35% of
emergency department visits for women (Shea, Mahoney, & Lacey, 1997). Vic-
tims of abuse may endure physical, emotional, and sexual abuse. The abuse may

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increase when the woman becomes pregnant if the abuser perceives competition
from the baby. The battered woman syndrome refers to the common personality
characteristics of these victims. These women are often economically dependent
on their spouse or partner, exhibit very low self-esteem, and believe that they
somehow deserve the abuse. Pediatricians may be the first to identify this victim
because the woman often will not seek medical attention for herself but will seek
it for her children. In addition, many times when there is domestic violence in the
home, the children are victims of abuse or neglect. The National Council on
Child Abuse and Family Violence in 2006 reports that women are more likely
than men to be killed by someone they know and one third of female homicide
victims are killed by their intimate partner (as compared with only 4% of men).
The victim of the abuse may also be the killer in retaliation for past abuse.

One of the most frequently misunderstood factors in domestic violence is why
these women remain with the abusers. It is important to understand that they
often feel trapped and have little money, resources, or support, and fear being
killed or losing custody of or potential injury to their children. Permeating all
these factors is the overwhelming sense of powerlessness.

Elder abuse includes neglect as well as physical, sexual, and emotional abuse.
Exploitation of the person’s financial reserves by family, hired help, or strangers
is also considered abuse. This can occur in the home or in residential facilities.
Gray-Vickrey (2000) notes that elder abuse affects 10% of the geriatric popula-
tion. This problem is greatly underreported and will continue to increase as the
population grows older. One problem in reporting it is the inconsistency of laws
defining elder abuse. Some states do not include neglect or psychological abuse in
their definition, so it is essential to be aware of how elder abuse is defined in the
state where you are working or reside. Because the abuser is often the victim’s
caregiver, even including the elderly spouse, victims rarely report the abuse. They
fear reprisals or abandonment because they are dependent on the caregiver. Soci-
ety’s lack of interest in elderly people may add to the underreporting. Caring for
a loved one with a cognitive impairment increases a caregiver’s risk for engaging
in abusive behaviors (VandeWeerd, Paveza, & Fulmer, 2005). Elder abuse can
also be difficult to detect by professionals because common signs such as bruis-
ing and skin tears may be common in older populations. The patient with demen-
tia is particularly vulnerable because he or she is unable to speak up or will not
be believed because of his or her intermittent confusion.


There are similarities in all types of family violence (Table 17–1). A family his-
tory of abuse remains a common thread, particularly in child abuse and domes-
tic violence. Childhood exposure to abuse increases a general sense of low
self-esteem and reduced ability to deal with frustration, as well as lack of role
models to learn to interact in a healthy relationship. Another similarity is the
presence of a vulnerable victim.

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Various theories examine what causes a person to abuse another.
Psychological theory suggests that abuse provides the abuser with a sense of

power and prestige that boosts his or her self-image. The abuser hates the vul-
nerable powerless feelings within himself or herself and is able to block them out
by creating (transferring) these denigrated feelings in others.

Sociocultural views examine the role of violence in our society. With easy
access to weapons and the frequent exposure to violence from the media, poten-
tial abusers can identify violence as a socially acceptable coping mechanism.
Another contributing factor is that abusers are often isolated with limited
resources for assistance. Alcohol and substance abuse by the abuser also con-
tributes by lowering impulses and inhibitions and reducing sensitivity to the
impact of their behavior.

Additional traits that contribute to child abuse include a parent who sees him-
self or herself in the child, the child not meeting parent’s expectations, and the

Chapter 17 ■ Problems Within the Family 355

TABLE 17–1
Characteristics of Victims

Type of Victim Characteristics




• Incest generally begins after 9 years of age
• Self-blame for family conflict
• Low self-esteem
• Fear of parent or caretaker
• Cheating, lying, low achievement in school
• Signs of depression, helplessness
• One child sometimes singled out in family due

to being labeled as “difficult,” product of
unwanted pregnancy, reminds the parents of
someone they dislike or even themselves, pre-
maturity (inhibited parent-child bonding)

• Low self-esteem
• Self-blame for batterer’s actions
• Sense of helplessness to escape abuse
• Isolation from family and friends
• Views self as subservient to partner
• Economic dependence on abuser

• Older than 75 years of age
• Mentally or physically impaired
• Isolated from others
• Female

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parent’s viewing the child as being there to satisfy the parent’s needs. At times, a
parent has no tolerance for normal child behaviors, such as crying, because of the
past experience of being unable to express these needs in childhood. So the child’s
normal behavior reminds the parent of his or her own unmet childhood needs
and unresolved anger toward his or her own parents. There is also a very high
correlation with drug and alcohol abuse in this parent. The other parent is usu-
ally aware of the abuse but remains unable or unwilling to intervene. That par-
ent may unconsciously deny the existence of abuse and is often a victim of
spousal abuse. Stepparents may also be abusers as hostility toward the new mate
or previous spouse is projected on the child. Incest in the family may be related
to sexual problems between husband and wife. Long-term effects for child abuse
victims include low self-esteem, difficulty trusting others, anxiety, anger, phobias,
depression, and eating disorders.

Domestic violence tends to escalate when the abuser is intoxicated. He or she
often displays tremendous jealousy and fears losing the partner. At the same time,
the abuser may blame the partner for his or her own problems. Inflicting injury
on the woman gives the male abuser a temporary sense of power and esteem.
Other factors contributing to domestic violence include the victim’s lack of finan-
cial support, belief that the children need both parents, and lack of a social sup-
port system.

As noted earlier, elder abusers are often caregivers. These abusers often have
limited coping mechanisms and limited support, and are emotionally and finan-
cially dependent on the elderly person. Most often, they live with the elderly vic-
tim. At times, family members can become abusers as resentment toward the
elder’s dependency increases, or as retribution for the elder’s perceived earlier fail-
ures as a parent.

Walker (1979) identified the cycle theory of family violence. This theory
includes the following stages:

1. Tension building stage: Minor incidents of pushing, shoving, and verbal
abuse occur.

2. Acute battering stage: Built-up tension is released by the abuser on the vic-
tim, leading to more brutal and uncontrollable abuse. Afterward, the
abuser often does not remember the intensity of the incident. The victim is
often able to remember the incident in detail without the emotion.

3. Honeymoon stage: The abuser has a sense of remorse that leads to a period
of apology, and attempts to make up for the abuse by presents, special
treats, and affection. The victim is finally receiving the love and attention
she or he so wants and desperately desires to believe there will be no fur-
ther abuse. This may allow the victim to forgive the abuser and even drop
legal proceedings or plans to report the abuse. Unfortunately, this stage is
usually short lived and, without intervention, becomes even briefer over
time. The intensity and frequency of the cycle and severity of injuries tend
to increase over time.

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Neurological impairment and substance abuse can trigger the abuse cycle by dis-
inhibiting impulse control in the abuser. Illness may be a risk factor to becoming
a victim. Resentments may build from caregiving responsibilities when the poten-
tial victim is dependent on the potential abuser. In addition, more violence may
be inflicted on the developmentally challenged child.

Early dementia may go undiagnosed by the primary care provider unless ade-
quate screening is done, along with communication from family who may be see-
ing the early signs (Cotter, 2005).

Chapter 17 ■ Problems Within the Family 357

• The most common reaction is anger and disgust directed at the abuser.

These strong negative feelings can cloud the nurse’s assessment and judg-
ment, and interfere with selecting appropriate interventions for the abuser.

• The nurse may feel great sympathy for the victim.

• The nurse may also feel anger toward the battered woman who displays
powerlessness. May blame her for staying with the abuser or being helpless
and become angry if she does not take advice offered.

• The nurse may feel overwhelmed with the family’s problems and helpless to
change them, especially if the possible victim denies abuse.

• The nurse may feel intense sadness and distress, which could lead to the
wish to save or “rescue” the victim. The nurse may act out these feelings
by making promises to the victim that in reality cannot be met or could
create an unsafe situation for both of them. This could isolate the victim
even more.

• Because abuse may be so upsetting, the nurse may deny evidence or refuse
to believe it, especially sexual abuse.

• The nurse may fear reporting abuse because of fear of getting involved, pos-
sible legal implications, or reprisals from abusers. The nurse may not want
to be responsible for displacing the victim from the family. (Note: most
states have Good Samaritan clauses in abuse laws that protect healthcare
professionals from liability in reporting.)

• Abuser may intimidate the nurse.

• The nurse may identify with the victim or abuser if he or she has had per-
sonal experience with abuse.

• May participate in a conspiracy of silence with others to avoid addressing
potential problems.

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for General Warning Signs of Abuse)

Child Behaviors and Symptoms
• History of injury inconsistent with child’s developmental level (for example,

baby turning on hot water)
• Failure to thrive; dull or inactive demeanor
• Signs of malnutrition, poor hygiene, or lack of health care
• Fears discussing how injuries occurred
• Lack of reaction to frightening events (for example, being given an injec-

tion) as child has learned to hide fear
• Unusual injuries such as cigarette burns, rope burns, spiral fractures from

twisting injury, bite marks
• Unexplained retinal hemorrhage, subdural hematoma—can be a sign of

“shaken baby syndrome”
• May demonstrate magical thinking that doctor or nurse will know family

• Fear of returning home
• Apprehension when hearing a child cry because he or she thinks another

child is being hurt
• Antisocial behavior, such as lying and stealing
• Wearing inappropriate clothing that covers bruises
• Bruises or bleeding in external genitalia
• Torn, bloody underclothing
• Pain on urination or frequent urinary tract infections
• Abnormal discharge or odor in genital area, indications of sexually trans-

mitted diseases
• Pregnancy in adolescent
• Sudden onset of sexually related behavior, such as excessive masturbation,

age-inappropriate sex play, or overseductive behavior
• Child being given a variety of gifts or privileges
• Change in behavior including depression, anxiety, regression, running away

from home, substance abuse, decline in school performance, inflicting abuse
on family pets or other animals

Parental/Abuser Behaviors
• Exaggerated or absent reaction to child’s injury
• Failure to show empathy for child
• Inconsistent explanations of injuries
• Care sought for child’s minor complaints but not for more obvious illness

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• Demands to take child home if pressured for answers or refuses hospital-

• Explanations not matching injuries; attempts to blame the child
• Nonabusing parent refusing to acknowledge even obvious abuse


• Injuries to head, abdomen, breasts, genitalia
• Injuries while pregnant
• Patterns left by item used to cause injury such as rope or teeth
• Frequent urinary tract infections
• Mother of abused child
• History of rape
• Lack of care for own chronic illness
• Demonstrates guilt for seeking treatment
• Use of alcohol or tranquilizers to cover hurt
• Indicates acceptance of violence as a way to maintain family
• Socially isolated with limited financial resources and family support
• Implies a sense of deserving abuse
• Stress-related complaints of headaches, insomnia, nervousness
• Wearing clothes and makeup to cover bruises
• Denies abuse or gives explanations that do not match injury

Chapter 17 ■ Problems Within the Family 359

BOX 17–1
General Warning Signs of Abuse
• Delay in seeking treatment for injuries, minimizing injuries
• History of being accident prone
• Pattern of injuries not accidental looking, for example, identical burns on

bottom of feet, identical injuries on both sides of head
• Multiple injuries in varying stages of healing
• Conflicting stories from victim and abuser about cause of injury
• Inconsistency between history and injury
• Unusual, even bizarre explanation for injuries
• Repeated visits to emergency rooms or clinics
• Previous report of abuse
• Patient reporting abuse
• Patient fearful of caregiver or partner
• Visits variety of doctors, emergency rooms for treatment

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• Minimizes injuries even when they become life-threatening
• Speaks for victim or does not let him or her speak
• Controlling, angry
• Does not want victim to be alone with healthcare providers
• Tends to isolate victim by eliminating his or her social support system
• Insists on taking patient back home even if inappropriate
• Criticizes or humiliates victim in front of others
• Access to guns, other weapons
• Abuses family pets
• Rationalizes actions (“she deserved it”)


• Evidence of malnutrition, dehydration, poor hygiene, pressure ulcers, not

receiving needed medical care
• Unusual injuries such as twisting fractures, cigarette burns on face or back,

perforated eardrums from being slapped
• Evidence of sexually transmitted diseases, unusual genital injuries
• Deterioration in mental status including confusion and depression
• Sudden lack of funds in person who previously had resources
• Frail, dependent, possible mental impairment requiring care from family

member or hired help
• Extreme dependency, attachment to new caregiver
• Evidence of inappropriate use of restraints

• Often lives with victim, lacks resources to live elsewhere
• Refusal to allow diagnostic tests, hospitalization
• Much younger than patient
• Cashes victim’s social security or pension checks
• Sudden, intense involvement with patient with little input from other fam-

ily members
• Evidence of drug or alcohol abuse or mental illness
• Expects dependent elder to meet his or her needs
• Caregiver overwhelmed with patient’s care needs, demonstrates frustration

and resentment, isolated with limited assistance
• Elderly spouse with dementia
• Coerces senior to change will to his or her benefit
• Shows no guilt or rationalizes actions

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Individual and group psychotherapy are often used to treat both victims and
abusers. For the victim, individual therapy may focus on the damage done to self-
esteem and facing and resolving intense emotions toward the abuser, as well as
toward others who may have tolerated the abuse (often the other parent in child
abuse). The victim should be removed from living with the abuser before entering
treatment to reduce the fear of retaliation. In domestic violence, therapists often
recommend that the couple separate for a period of time before starting treatment.

Children who are suspected victims of sexual abuse need to be evaluated by
therapy professionals in this specialty. Repressed, traumatic events of the past,
such as childhood sexual abuse, may also be uncovered during therapy as an
adult. This repressed abuse could be influencing the patient’s current life without
his or her knowledge. However, this is very controversial because repressed mem-
ories have been found to be inaccurate. Group therapy may also allow the victim
to learn from other victims and develop assertive skills.

More intensive psychotherapy or psychiatric treatment may be required for
the abuser if psychopathology is suspected.

Because family violence is a symptom of family dysfunction, family therapy is
often part of the overall treatment plan. When children are in the home where
abuse has occurred, they must be part of the healing process. In addition, support
group programs are available for both victims and abusers.


FAMILY COPING: DISABLING evidenced by child abuse related to history
of abuse in the family, lack of resources, isolation.

Child Outcomes
• Remains free from injury or neglect
• Seeks comfort and assistance from nurse

Parent Outcomes
• Seeks assistance for abusive behavior
• Demonstrates nurturing behavior toward child
• Refrains from abusive behavior

• Establish a trusting relationship with child and parents. Avoid threaten-

ing behavior or criticizing parents in front of child. See Table 17–2, Inter-
viewing an Abuser or Abuse Victim.

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17 Gorman(F)-17 11/5/07 5:02 PM Page 361

• Observe parent-child interaction closely, especially when both are under
stress. Observe caring and feeding behavior. In the home, observe sleep-
ing arrangements and environmental conditions.

• Recognize that the child very often will not betray his or her parents.
Even in the worst situations, the child may fear losing the only security
he or she knows and consequently, will deny any problems.

362 Chapter 17 ■ Problems Within the Family

TABLE 17–2
Interviewing an Abuser or Abuse Victim

Do Don’t

Conduct the interview in private.

Be direct, honest, and professional.

Be understanding.

Be attentive.

Inform the patient before making the
referral to child or adult protective
services and explain the process.

Assess for risk of danger and help
reduce that risk before discharge.

For Children

Tell the child that the interview is

Use age-specific language.
Ask the child to clarify his or her
meaning or words you do not

Tell the child whether any future
action will be required.

Source: Reproduced with permission: Smith-Dijulio, K., & Holzapfel, S. K. (1994). Families in crisis: Family vio-
lence. In E. M. Varcarolis (Ed.), Foundations of psychiatric mental health nursing. Philadelphia: WB Saunders.

Conduct the interview with a
group of interviewers.

Try to prove abuse by accusations
and demands.

Display horror, anger, shock, or
disapproval of the abuser or the

Place blame or make judgments
about the abuser or the victim.

Allow the victim to feel “at fault”
or “in trouble.”

Probe or press for answers the vic-
tim is not willing to give.

Force the child to remove clothing.

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• Involve the child in treatment plan to increase his or her sense of control.
• Demonstrate support, acceptance, and affection of the child. Reinforce

child’s self-esteem by positive feedback and recognition.
• If child needs discipline, discuss punishment, and clarify that no physical

abuse will be used. Consider referral for psychiatric or play therapy eval-
uation to better understand what is being expressed.

• Encourage play. Be aware that child may be better able to express feel-
ings through play.

• Reinforce parent’s strengths, and acknowledge importance of continuing
medical care for the child.

• Reinforce positive parenting behavior. Role-model caregiving behaviors
for them.

• Avoid hostility toward the parents. At the same time, maintain the child’s
safety. If child is at risk for being taken inappropriately by parents, have
staff remain in attendance with security nearby and inform the parents of
your reasons for doing so.

• If sexual abuse is suspected, child needs to be evaluated by appropriate
professionals, including psychologist, pediatrician, gynecologist.

• Be aware of agency policy and state laws on reporting suspected child
abuse. Contact supervisor and/or social worker to implement appropri-
ate reporting. Participate in collecting evidence, as indicated, and ensure
that proper procedures are followed.

• Be sure that supervisors, physicians, and social services are informed
when a suspected abuse is reported.

FAMILY COPING: DISABLING evidenced by domestic violence related to
vulnerable victim, abuser with family history of abuse, isolated, limited re-
sources, and/or intense jealousy.

Victim Outcomes
• Acknowledges the abuse
• Identifies options to escape abuser
• Remains in treatment even if pressured to not obtain care

Abuser Outcomes
• Seeks assistance for abusive behavior
• Refrains from harming others

• Establish a trusting relationship with the victim. Avoid displaying shock

or disgust at the story. Encourage victim to share fears and concerns. Ask
specific questions to avoid a vague response.

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• Assess the victim’s safety. If there is a risk, implement agency security poli-
cies, as appropriate. If victim is in the hospital, restrict phone calls and vis-
itors. Consider a pseudonym for the patient’s name. For patients at home,
determine need to involve the police and information on legal restraining
orders. If there are children in the home, determine their risk of injury. Be
aware of state and agency policies for reporting domestic violence.

• Reinforce victim’s self-esteem. Identify positive traits and coping mecha-
nisms. Encourage victim to talk about accomplishments and goals.

• Encourage victim’s participation in treatment plan including follow-up
with medical appointments. Help victim take control of some areas of his
or her life and make some decisions.

• If possible, identify available support systems and determine their aware-
ness of family’s problems. Encourage patient to involve some people who
can help. Support maintaining regular social contacts.

• Encourage realistic evaluation situation. Do not reinforce denial or

• Be aware that during the “honeymoon stage” the victim may not be will-
ing to discuss abuse. Describe the cycle of abuse to the victim. Give the
victim written information on resources to use at another time.

• Encourage problem solving. Challenge him or her to identify realistic
options, and reinforce all efforts to be assertive.

• Encourage talking about events that led up to the abusive event. Dispel
any myths of guilt or responsibility for causing or deserving the abuse.

• Be sure that supervisors, physicians, and social services are informed
when a suspected abuse is reported.

FAMILY COPING: DISABLING evidenced by elder abuse related to multiple
stressors associated with elder care.

Elder Outcomes
• Identifies resources available for assistance
• Remains safe and without injury
• Continues to receive adequate health care

Caregiver Outcomes
• Identifies resources available for assistance in patient care
• Demonstrates more effective coping mechanisms
• Provides safe care to the elderly patient

• Assess the elderly patient’s condition and determine the role of caregiver

in providing adequate care. Patients with pressure ulcers, dehydration,

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lacerations, and bruises need to be evaluated; however, be aware that
these may occur unrelated to abuse or neglect.

• If abuse is suspected, talk with patient and caregiver separately. With the
patient, listen to his or her description of the caregiver and any com-
plaints he or she may have. Then verify the information, if possible, with
the caregiver, other family members, or health-care providers. Establish a
trusting relationship with the caregiver by acknowledging positive
accomplishments, as well as the stress of caregiving.

• If signs of abuse occur in a long-term care facility, observe patient care
routines and the care of other patients. Note the use of restraints and the
quality of hygiene provided. In the home, if patient is being left alone
while restrained, action must be taken immediately to stop this unsafe

• Provide education to staff in long-term care on identifying and prevent-
ing abuse or neglect.

• Recognize that patients with altered mental status may falsely accuse
caregivers of abuse. However, every accusation must be evaluated.

• Encourage the patient to be as independent as possible by remaining
involved with family and friends, having his or her own telephone, and
having neighbors check his or her status regularly. Appropriate inde-
pendence will also promote self-esteem and self-reliance. Even in the
highly dependent patient, it is important to maintain the individual’s
sense of control.

• Encourage problem-solving skills in patient and caregiver. Promote their
abilities to find alternate solutions under stress.

• If patient is in an unsafe environment, implement agency policies and
state laws as appropriate to determine reporting mechanism and action.
If patient refuses to leave environment, determine patient’s ability to
make decisions. Involve physician and/or social worker as needed. Con-
sider psychiatric evaluation. Involve family and friends if needed to
encourage patient action.

• Determine caregiver’s stress level and determine if additional resources
are available and would defuse the situation.

• Be sure that supervisors, physicians, and social services are informed
when a suspected abuse is reported.


Caregiver Role Strain
Family Processes, Interrupted
Knowledge, Deficient

Chapter 17 ■ Problems Within the Family 365

17 Gorman(F)-17 11/5/07 5:02 PM Page 365

Parenting, Impaired
Post-Trauma Response
Rape-Trauma Syndrome
Violence, Risk for


• Teach effective parenting skills, including appropriate discipline. Abusive
parents need skills in disciplining children without violence and often need
to learn acceptable outlets for their frustration.

• Incorporate assertive skills to teach potential victims, including young chil-
dren, to speak up when rights are violated and learn to say no.

• Teach family members the signs of abuse and how to report it.
• Family members need guidelines for hiring caregivers and selecting assisted

living situation.
• Teach older adults how to avoid abusive situations by maintaining active

social network, and to seek legal advice before allowing anyone to take their
possessions or manage their finances. The American Association of Retired
Persons has written guidelines to avoid elder abuse. These can be accessed
through the Web site

• Teach a victim of domestic violence to identify a plan in advance to leave
home when needed. This plan should include having a place to go, setting
aside money, and implementing security measures for victim and children.

• When children must be removed from their home, prepare them for the
emotional grief response that may occur when they are separated from their
parents. No matter how bad the home was, children will still grieve. Be sure
they understand that they are not being punished.

• Suspected abusers need information on alternative ways to resolve conflicts.
If appropriate, refer them to counselors who specialize in abuse and can
educate them on the role of substance abuse and violence.

• Review with victims and abusers the need to involve family and friends for

• Ensure pregnant and at-risk teens know about safe surrender sites in the
community where newborns could be safely dropped off if decision made
not to keep the infant. (National Crime Prevention Council website can give
more information at


• If abuse is suspected, carefully document, possibly with photos, any evi-
dence of wounds, injuries, or poor hygiene. Follow institutional protocols
carefully if called upon to participate in evidence collection.

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• Document the nature of interactions between victim and abuser.
• Note victim’s reaction to the abuser, especially when discharging patient.
• Document victim’s report of abuse.
• Document interventions made, including reporting abuse and maintaining

patient safety.
• Document any discrepancies between the victim and potential abuser’s

explanation of injuries.

Chapter 17 ■ Problems Within the Family 367


• Aggressive, belligerent behavior escalates to violence.
• Presence of abuser leads patient to fear of violence or of being

• Abuser is intoxicated.
• Abuser intimidates patient or staff.
• Victim leaves healthcare agency to return to unsafe environment


• Social Worker
• Protective Service agencies
• Security/law enforcement


• Provide written information on appropriate resources, including parenting
support groups such as Parents Anonymous; parenting education programs;
shelters; safe houses; 24-hour local crisis hot lines for abuse or National
Child Abuse Hotline (1-800-4ACHILD); and National Organization for Vic-
tim Assistance (800-TRY-NOVA). If abuse is suspected and patient denies it,
provide the information, and encourage patient to keep it in a safe place. For
elder abuse, contact the local Adult Protective Services. Many Web sites are
available for assistance including National Clearinghouse on Child Abuse
and Neglect (, National Council on Child Abuse and Fam-
ily Violence (

• Additional Web sites include and www.acf.

• Provide information on legal referrals and security measures. If police are
involved, reinforce information they give to patient.

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368 Chapter 17 ■ Problems Within the Family

• If victim is staying in abusive situation because of fear of leaving family pet,
give information on local humane societies that can help with animal care
if the victim leaves the home. Veternarians may become aware of abuse
when a family pet is injured.

• As appropriate, refer patient for counseling or family therapy.
• Refer for home health follow-up to assess home environment. Inform all

referring agencies of concerns about abuse.
• Vocational counseling information may be helpful to the domestic violence

• Anticipate caregiver needs in the home and provide adequate support and

• Discuss day-care options for children or elderly people.

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Problems with
Spiritual Distress

The Patient with Spiritual

Margaret L. Mitchell, RN, MN,

Learning Objectives
• Define spiritual distress.
• Identify some life events and physical changes that may precipitate spir-

itual distress.
• Differentiate between religion and spirituality.
• Identify effective interventions for dealing with an individual experienc-

ing spiritual distress.
• Describe common nurses’ reactions to patients’ spiritual distress.

Chaplain – Clergyperson who has a formal relationship with a particular

healthcare organization.
Religion – A system of beliefs, worship, or conduct. Generally refers to formal,

institutionalized practices.
Spiritual distress – A disturbance in the belief or value system that is a per-

sonal source of strength and hope; may be accompanied by an inability to
carry out religious practices, possibly creating even more stress because the
individual cannot use spirituality to cope with stress.

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Spiritual leaders – Officers and persons who provide spiritual support, includ-
ing chaplains, priests, ministers, rabbis, monks, pastors, elders, deacons,
mullahs, or hajjis. There is a wide and diverse range of spiritual practition-
ers with a number of different titles.

Spirituality or worldview – Beliefs of individuals permeate all areas of their
life and influence attitudes, beliefs, values, and health.

All people have a spiritual dimension, regardless of whether or not they partic-
ipate in formal religious practices. Spirituality allows us to transcend the self

and connect with people, our surroundings, and powers outside of ourselves. Spir-
ituality can give meaning to life and impact the ability to trust, love, and forgive.
People need to find meaning beyond their current suffering. This allows them to
make sense of that situation (Kellehear, 2000). Spirituality is uniquely human; it is
universal and innate (Taylor, 2006). One of the difficulties with the Western view
of spirituality is that a separation is made between the “spiritual” and “physical”
realms. Other cultures, as well as alternative medicine are less inclined to have
such a rigid delineation between these areas. Religion is different from spirituality,
although it is complementary. Religion gives us tradition, ritual, and a specific doc-
trine. Spiritual distress is an existential crisis in which the beliefs or values around
which the person has organized his or her life are threatened. Various events along
the health-illness spectrum as well as outside crises could result in an episode of
spiritual distress. The events of September 11, 2001, for many, resulted in spiritual
distress, because life as it had been known could no longer be counted on to be
predictable. This also can be experienced on an individual or family basis as the
result of illness or major change in health. Parents’ belief system may be shaken
when they learn that their child has an incurable illness or will not recover from
an accident. For individuals, it can be learning of a life-threatening illness. When
people are faced with these situations, you may hear them say, “Life will never be
the same” or “How can I go on living?” The very foundation of their life as they
know it is threatened. They may no longer feel safe and able to go about their
everyday activities. Some may question their belief in God or other higher power.

Spiritual distress may manifest itself in many different ways. Individuals are a
complex combination of biological, psychological, sociocultural, and spiritual
parts, all interacting and affecting all other aspects of the individual’s life. An
insult to one’s spiritual dimension can affect every other dimension of the indi-
vidual and influence the patient’s experience of illness.

Spiritual distress occurs when a person believes that life no longer has mean-
ing or purpose, or experiences a sense of hopelessness. Like many other entities
that can be viewed on a continuum, spiritual distress may be a temporary, tran-
sient phenomenon in a response to a specific stressor or it may be a longer reach-
ing event prompting the individual to question or reexamine assumptions and
priorities. In a few rare instances, extreme spiritual distress may indicate psy-
chopathology. One aspect of spiritual distress is what Mary Elizabeth O’Brien
(2003) terms as spiritual pain. This includes a perception of loss or separation
from God; the experience of evil or disillusionment; a sense of failing God–the

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recognition of one’s own sinfulness or shortcomings and failings; a perception of
a lack of reconciliation with God; and a sense of loneliness of spirit. An example
of this is a woman, early in the AIDS epidemic, who following childbirth was
given a transfusion of HIV-infected blood. The mother developed AIDS. Her reli-
gious community was quite conservative and taught that HIV was God’s punish-
ment for those who disobeyed God. This patient and her family experienced not
only spiritual pain from a sense of separation and judgment from God but also
ostracism from her religious community.

In many ways, spiritual distress can follow a similar pattern to the grief
response. Grief over small losses may be short-term, and with proper support,
recovery will be rapid. Great losses affect the individual more profoundly and can
be seen in changes in the person’s mood, affect, energy level, interest in life, and
somatic condition. In the most extreme pathological grief, in which individuals
are not recovering, their ability to carry out activities of daily living is greatly
reduced and may sometimes require psychiatric hospitalization. Individuals expe-
riencing similar events such as death of a close family member may respond in a
myriad of ways.

Both grief and spiritual distress deal with loss. The major difference is that
spiritual distress disrupts the meaning that governs a person’s life. There may be
a perceived or real deterioration or collapse in his or her relationship with a
divine Supreme Being, or with persons who represent the Supreme Being. Accord-
ing to O’Brien, there can be a deep sense of hurt stemming from feelings of loss
or separation from God, a sense of personal inadequacy or failure before God
and profound loneliness of spirit (2003).

The presence of stressors does not necessarily predict or cause spiritual distress.
The Chinese character for crisis, which is a combination of the symbols for dan-
ger and opportunity, helps one to understand this. For some individuals, a stres-
sor or crisis, such as a life-threatening illness or tragedy, can ultimately become the
source of a tremendously positive experience. Although they readily acknowledge
that they would have never chosen such events, they ultimately view them not as
traumatic events but as opportunities for growth. In some ways, it parallels a
wilderness experience. The arduous physical demands allow an individual to tran-
scend his or her immediate surroundings and experience a sense of empowerment
that results in the person being better equipped to handle the challenges of life.

Nurses may feel uncomfortable or experience conflict when providing spiritual
support if the patient is religious and the nurse is not or if the patient’s expres-
sion of spirituality differs from that of the nurse. In addition, nurses may experi-
ence conflict with a patient’s belief system, as with a Jehovah’s Witness patient
who refuses a life-saving blood transfusion. These are normal responses to the
unknown. How one responds to a patient’s spiritual needs depends both on one’s
education and background. It is important, however, not to evaluate the patient’s
value system by personal standards. According to Stephenson, Drauker, and
Martsolf (2003), some individuals find it easier to describe their spiritual life in
terms of relationships and connections and disconnections. Relationships, which
were used to describe life stories of persons in hospice, applied equally to others
as well as God.

Chapter 18 ■ Problems with Spiritual Distress 371

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The increased cultural and religious diversity of our society has led to much
more diversity of religions in our health-care institutions. Nurses must be open
and more sensitive to religious customs that may be foreign to them. Being pres-
ent for Hindu prayers, respecting the practices of an Islamic patient, and observ-
ing death rituals for an Orthodox Jewish patient are all examples of this. Nurses
may need to seek out information on appropriate behaviors for religious groups
that are foreign to the nurse.

Patients’ responses to illness have been found to influence nurses’ own spiri-
tual beliefs. In a 1994 study by Taylor, Amenta, and Highfield, oncology nurses
ranked their patients as a major source of spiritual nurturing. Nurses, however,
may have difficulty providing spiritual care because of lack of skill, time con-
straints, or fear of being criticized by coworkers. For nurses uncomfortable with
religious language and concepts, it may be helpful to approach spiritual distress
from a cultural framework. In 1999, the Joint Commission for Accreditation of
Healthcare Organizations (JCAHO) added a standard on determining spiritual
support services for patients on their admission to healthcare institutions.
JCAHO current standards (2007) continue to emphasize spiritual care with par-
ticular emphasis on spiritual care for dying patients. Hospice care requires incor-
poration of a spiritual assessment and offering of chaplaincy services as part of
the Medicare Hospice Benefit. Nurses who work or have worked in this type of
setting have more exposure to working closely with chaplaincy and may be more
comfortable with addressing spiritual distress. There are many ways that nurses
can assist in spiritual caregiving as part of routine nursing care (Box 18–1).

372 Chapter 18 ■ Problems with Spiritual Distress

BOX 18–1
Nursing Activities to Promote Spiritual Caregiving
• Promote spiritual readings
• Advocate for finding a spiritual leader of patient’s faith
• Active listening
• Instilling hope
• Clarifying values
• Touch
• Encouraging meditation and prayer
• Supporting religious rituals
• Promoting being with nature
• Advocate for institution to provide spiritual reading material, religious

objects (prayer books, Sabbath candles, incense).

Source: Based on information from Taylor, E. J. (2006). Spirituality and spiritual nurture in cancer
care. In R. M. Carroll-Johnson, L. M. Gorman, & N. J. Bush (Eds.), Psychosocial nursing care
along the cancer continuum (2nd ed.) (pp. 117–131). Pittsburgh, PA: Oncology Nursing Press.

18 Gorman(F)-18 11/5/07 5:00 PM Page 372


Spiritual distress occurs when particular stressors or life events threaten the indi-
vidual’s belief system and affect biological, psychological, sociocultural, and spir-
itual aspects of life. These stressors may be unique to the individual, or they may
be similar to reactions experienced by others after certain shared events such as
September 11, 2001. The crisis may have a variety of causes, including loss of a
significant person, employment, position, or status; financial reversal; major ill-
ness or loss of a body part, or a change in self-image. In some cultures, it may
also result from shame. However, what is lost is not as important as the value
that the individual ascribes to it.

Cognitive theory looks at the effect of beliefs on feelings, and psychodynamic
theory helps one understand the underlying process of spiritual distress. For
instance, a great deal of spiritual distress can be experienced, even to the point of
affecting physical health, when a person believes that he or she can never be for-
given. A person’s belief in the ability to be forgiven may be associated with his or
her perception of how others show approval. The individual may accept forgive-
ness from God or a higher power in the same manner as forgiveness was accepted
from parents because the relationship with God or a higher power is often simi-
lar to the relationship with one’s parents.

Psychological theories look at the various dynamics that can result in spiritual
distress. A person with a high degree of inner strength, or ego functioning, may
experience less spiritual distress in response to a loss than one who has a lower
level of ego functioning. The way in which one normally adapts to crises and
changes will also influence the risk of spiritual distress. Persons who are inflexi-
ble may have more difficulty accepting major changes. Similarly, individuals who
are prone to anxiety may feel overwhelmed in the face of major change and have
difficulty dealing with it.

Crisis theory considers not only the normal changes in life and life event stres-
sors but also looks at the impact of disaster or massive crisis on the individual.
Faith or a belief system may help a person to cope with a crisis, but if the crisis
is of a high magnitude, the person may feel that his or her belief system is chal-
lenged or inadequate and may be of little help.

One of the hallmarks of a disaster or massive crisis, such as a devastating hur-
ricane, earthquake, or crash of an airplane, is the enormous sense of an individ-
ual’s loss of control and extreme feelings of vulnerability. There may be a sense
of betrayal, and the events may be expressed as not being “right.” The individ-
ual may reveal a sense of how things “should” be, his or her expectation of the
world. The sense of betrayal and anger may be expressed in spiritual terms such
as “How could God let this happen?”

A sense of mastery over one’s environment, highly prized in American cul-
ture, is threatened when a major crisis occurs. When an individual no longer
feels safe in usual activities, a feeling of unease can spread to other areas
of life.

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Although identifiable traumatic events may precipitate spiritual distress, it is
important to be aware of physiological conditions that may exacerbate the situa-
tion. Illnesses associated with increased sense of vulnerability and the possibility of
death (particularly cancer) may lead to heightened spiritual awareness. Similarly,
a patient’s moving from aggressive treatment to hospice care may be accompanied
with a number of spiritual issues as one’s mortality can no longer be denied. Pain,
suffering, and severe side effects may affect spiritual life. Patients may also have a
reduction in the energy they need for their usual means of spiritual coping, such as
praying and attending religious services. Advanced, serious illness may stimulate a
patient’s wish to repair past relationships and seek forgiveness for past wrongdo-
ings. Spiritual beliefs may support or promote these actions.

Although there is no clear relationship between specific disease entities and
spiritual distress, a spiritual state can be influenced by biological changes, such as
changes in neurotransmitters, endocrine levels, or blood chemistry. Just as there
are differences in coping mechanisms, there are differences in the way in which
the individual as an organism responds to illness. Even when an event appears to
be a precipitant for spiritual distress, biological factors could also be at work. A
complete physical assessment and supporting tests can help determine these bio-
logic factors. Also there is interplay between the physical disorder and mental
well-being. An individual who has not had mental illness or spiritual distress in
the past, may be affected by both physiological changes that impact things such
as moods and a general sense of well-being, as well as the emotional impact of
dealing with change and loss.

Spirituality and cancer has probably been studied the most. A diagnosis of
cancer can contribute to spiritual distress because the person questions the pres-
ence of a higher power, seeing the disease as a punishment for past wrongdoings.
It can also strengthen faith, provide motivation for increased use of prayer and
self-exploration (Taylor, 2006).


Because the belief systems of young children are not as developed as those of
adults, children may not be able to adequately verbalize their sense of spiritual
distress. Instead, they may present with such physical symptoms as weight loss,
failure to thrive, and reversal of developmental milestones. Most frequently their
stress is in response to loss of a parent or caretaker or a major change affecting
a parent or caretaker. The child can sense the distress of the parent. For example,
a young child may not fully understand the impact of death, but he or she can
sense, and be negatively affected by, the tremendous distress the loss of a child or
spouse can cause his or her caretaker. The child often responds by being more
clinging or dependent at times of crisis.

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Signs of distress in older children may be subtle. Some children experiencing
depression may act out in different ways. Behavioral problems may be exacer-
bated. It is important to pay attention to subtle changes in a child, such as a lack
of interest in usual pursuits, withdrawal or isolation, or a decrease in school per-
formance. One of the most traumatic events for children is loss of parents or sib-
lings by death or divorce. Children may mistakenly believe that they personally
caused the loss of the parent and may not comprehend other dynamics at work.
Children’s spiritual or religious beliefs are strongly influenced by those of their
parents. More questioning of parental values tends to occur when the child
becomes an adolescent.

Adolescents are generally more able to articulate distress, but they may be hesi-
tant to confide in an adult. More aware of the complexities of life and often hav-
ing a strong personal moral code, they may be traumatized by the failings of an
idealized parent. Loss of parents, siblings, classmates, or acquaintances by death,
divorce, or relocation can be tremendously stressful events for the adolescent.
Youths whose sexual orientation differs from parental or societal expectation
may either act out or experience their crisis in secret. Another traumatic event
includes sexual exploitation by peers or adults. Even though sexual activity dur-
ing teen years is rising, it may be exceedingly traumatic for the individual. Teens,
especially girls, must deal with the dilemma of pregnancy and the changes it will
make in their lives and those of their parents. Teens are also vulnerable to life’s
tragedies such as the death of a parent, or loss of a peer due to accident or sui-
cide, which can lead to questioning of spiritual beliefs and loss of hope.

Because adolescents are so impressionable and idealistic, they are very vulner-
able to the influence of cults and religious conversions. The beginning recognition
that life is not as ideal and perfect as they once believed may cause individuals to
lose hope and question their former spiritual beliefs. And if they unite with a par-
ticular belief system, because of their developmental stage, it would be antici-
pated that they may see things in absolute terms as “all or nothing” or “black
and white”. They may be as receptive to ideas that there may be a mixture of
good and bad, or positive and negative attributes.

Middle Age
Promoting spirituality in the family and active participation in religious commu-
nity with possible leadership roles may be important in this stage of life. Multi-
ple responsibilities may affect a person’s time and energy to achieve and meet all
the expectations.

Older Adults
Later life is a period characterized by extremes. There is tremendous variety in
functioning. For some, a significant change in physical or sensory functioning may
affect their view of self and their spiritual beliefs. Many individuals experience the

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death of a spouse and friends and changes in residence. Some may depend more
on their spiritual life as their acquaintances diminish and limitations grow. Spiri-
tual distress in older people often includes questions regarding the afterlife, values,
and reflections on the satisfaction and accomplishments of their lives. Forgiveness
related to past wrongdoings by themselves or others may become more important.

Religious teachings from childhood may become more important for some in
later years as people face changes and losses. However, sometimes attending wor-
ship services and participating in religious practices may be more difficult to
accomplish because of illness and fatigue or because of changes in mobility or
logistics of transportation. It may be that with age they do not have the same
level of independence and autonomy that they had during their younger years.
The later years can be difficult for those who have not had any particular reli-
gious beliefs and have not been affiliated with any religious body.

376 Chapter 18 ■ Problems with Spiritual Distress

• May not feel comfortable or adequately prepared to help patients with spir-

itual concerns.

• May be influenced by their own background, beliefs, values, and experi-
ences, which may differ from those of the patient.

• May react negatively or judgmentally, or distance themselves from patients
whose beliefs, practices, lifestyles, or cultures differ from their own.

• May focus attention on religious content rather than assessing other issues
that may be the cause of anxiety.

• May attempt to change or argue with religious content of patient’s beliefs.

• May confuse religious with spiritual beliefs.

• May feel powerless when unable to help patients with spiritual concerns.
Nurses may distance themselves from patients to cope with their own feel-
ings of inadequacy.

• May not understand the meaning of the loss from the patient’s spiritual per-
spective and may try to reassure the patient in ways that are not effective or

• May resent clergy because of their closeness and ability to meet some
patients’ needs.

• Conversely, out of feelings of fear and inadequacy, may refer patients to the
chaplain too quickly rather than attempt to deal with the concerns.

• May reassure patients based on their own knowledge of illnesses and fail to
hear the patients’ concerns.

• May feel judgmental about individuals expressing spiritual concerns or
practices, especially if those concerns are unfamiliar to the nurse.

• May feel anxious when encountering unfamiliar practices.

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Spiritual assessment is required as part of the overall patient assessment by
JCAHO. There are a number of models. One model for spiritual assessment is
called the HOPE Assessment as discussed in Chapter 3. Spiritual assessment pro-
vides the basis for the spiritual plan of care and for communication about the
care provided. The purpose of the assessment is to find out how a person finds
meaning and purpose in life and identify the concomitant behaviors, emotions,
relationships and practices. Fitchett (2002) points out that spiritual assessment is
an ongoing process. As the nurse becomes better acquainted with the patient,
there is the opportunity to develop a more comprehensive assessment and possi-
bly revise a previous assessment. See Box 18–2 for suggestions on questions to
ask in a spiritual assessment.

Behavior and Appearance
• Often has religious items or literature at bedside

• Frequently quotes from the Bible or other spiritual literature

• May display exaggerated religious rituals or behavior such as reading the
Bible excessively rather than talking

• May appear withdrawn and preoccupied with own beliefs, unable to focus
on conversations and events in immediate environment

• Makes constant reference to religious themes in conversation

• Asks frequent questions such as “Is this God’s will?” or “Why is God
letting me suffer?”

• Lethargic; may exhibit a lack of interest in surroundings

• May be overtly or passively suicidal

• Frequently questions others about their spiritual beliefs

• States that spiritual beliefs are no longer comforting

• Behavior changes, such as increased alcohol use or acting out

Mood and Emotions
• Highly anxious
• Denies emotions or concerns

Chapter 18 ■ Problems with Spiritual Distress 377

• May feel so stressed, overworked, or overwhelmed by the physical needs of
the patient or their own workload that they do not consider the spiritual

• May have trouble setting personal limits on the role of the nurse and spiri-
tual beliefs.

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378 Chapter 18 ■ Problems with Spiritual Distress

BOX 18–2
Assessing for Spiritual Beliefs
Initial Assessment
1. What is your source of strength and hope and meaning?
2. What is your religious affiliation, and how important is this in your life?

Any recent changes?
3. Is there a clergy person available to you while in the hospital?
4. Are there any religious or spiritual practices that are important to you

while in the hospital?
5. Are there any religious or spiritual articles that are important to you while

in the hospital?
6. Is there any spiritual literature that is important to you while in the hospi-

tal? Is there any religious music which is particularly significant to you?
Advanced Assessment
1. Has being sick or in the hospital made any difference in your feelings

toward God or in your beliefs?
2. What has bothered you the most about being sick or in the hospital?
3. What helps you the most when you are afraid or in need of special help?
4. What religious or spiritual idea or concept is most important to you?
5. What did your family believe? What was meaningful and important

to them?
6. What exposure, if any, did you have to religious or spiritual beliefs as

a child? Has that changed? How?
7. Have your religious interests arisen gradually or out of a crisis?
8. Do you have special religious leaders? How do you view them?
9. What would help you maintain your spirituality?

10. Does prayer provide comfort for you? If you pray, about what do you
pray? When do you pray?

11. What happens when you pray or meditate?

• Expresses bitterness or anger over perceived abandonment by God or belief
that God is causing the suffering

• Appears depressed
• Expresses feelings of helplessness or hopelessness
• Does not derive enjoyment and satisfaction from formerly pleasurable


Thoughts, Beliefs, and Perceptions
• Believes that nothing can help
• Exhibits global, all-or-nothing thinking

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• Believes that life is overwhelming and that he or she cannot continue living
• Questions long-held beliefs and may doubt his or her faith
• Believes that he or she has committed sins that cannot be forgiven
• Believes they may be separated from God or a higher power
• Is self-absorbed in own belief system
• Views self as guilty and in need of punishment
• Views self as spiritually superior to others
• Believes that a higher power requires suffering and pain and therefore

refuses pain control measures
• Views self as having a great mission to accomplish
• Claims to hear voices of God, Moses, or other religious figures
• Holds omnipotent view of self—a specialness that rests in the inability to be

forgiven by God or higher power

Relationships and Interactions
• Feels isolated and alone even in the presence of others
• May be so preoccupied that they are unable to interact with others
• Withdraws from others who do not share similar beliefs
• May experience change in relationship with family or friends who are

involved with religious beliefs
• May seek out members of similar religious group for support, caregiving

Physical Responses
• Reports increased discomforts
• Change in eating or sleeping patterns
• May have increase of somatic symptoms and medication-seeking behaviors

Pertinent History
• Involved in specific religious groups, cults, or a variety of different religious

• History of emotional disorders or emotionally charged previous situations,

such as abortion or catastrophic events


Some health-care agencies have full-time chaplains on staff. Others may have vol-
unteer chaplains or links to clergy in the community. Chaplains provide spiritual
counseling and are often knowledgeable about community support resources that
may be useful for the patient. Working with the social workers, they can help
in making funeral arrangements or locating needed services or volunteers.

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Chaplains can help both patients and staff members to find ways to cope with the
problem situation. However, not all patients hold clergy in high regard. Some can
talk about spiritual concerns more effectively to a nurse. Others may view clergy
negatively or with suspicion or fear that they are associated only with bad news,
depending on previous life experiences. Also, depending on the situation, the
patient may prefer to share concerns with a chaplain other than the one associ-
ated with the place where he or she worships.

Clergy are restricted as to what information they can share with nursing staff
and others. Like mental health professionals and lawyers, clergy are bound by
professional ethics and law regarding what they may reveal of anything told to
them in confidence.

Psychoactive substances can influence mood and consequently the way in which
the individual perceives the situation and how well he or she functions in
responding to it. This can contribute to spiritual distress. Nurses need to be
aware of the many prescription drugs that have such effects, such as beta-
blockers, steroids, antihypertensives, immunosuppressants, and chemotherapy.
Patient’s spiritual or religious beliefs may also influence their acceptance of some
medications such as analgesics and psychotropics. Individuals may believe that
these medications could block their access to their higher power.


SPIRITUAL DISTRESS evidenced by questioning beliefs, despair, hopelessness,
or inability to practice beliefs related to suffering, illness, or hospitalization.

Patient Outcomes
• Verbalizes “I feel better,” “I feel relieved,” “I feel at peace,” or similar

• Demonstrates increased social interaction
• Reports feeling rested and comfortable
• Demonstrates reduced crying or other signs of distress

• Empathize with patient’s degree of pain or despair.
• Recognize that your own personal values and beliefs may not be effective

for others. Be willing to set aside your own beliefs when analyzing the
patient’s spiritual needs.

• Become familiar with the patient’s beliefs and practices.
• Use self-disclosure of own spiritual beliefs only to foster patient’s thera-

peutic goals.

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• Use questions to determine the role that religion and spirituality play in
the patient’s life. For example, “The chart says you are Catholic. What
religious practices are important to you during your illness?”

• Seek assistance of or referrals to hospital chaplain or other resources
when you feel uncomfortable or unable to meet the patient’s spiritual
needs. Recognize the role that members of the patient’s church or temple
can play in providing support.

• Involve chaplains in team meetings and patient care conferences to col-
laborate on treatment plan.

• Promote use of prayer and scripture when appropriate if within patient’s
belief system (Box 18–3).

• Become familiar with agency policy regarding praying with patients.
• Provide supportive, private environment to meet spiritual needs.
• Be honest with the patient. If you are not comfortable praying, it is

appropriate to disclose this, but offer to be present while the patient says
a prayer.

• Substitute supportive response for prayer when the setting or timing is

Chapter 18 ■ Problems with Spiritual Distress 381

BOX 18–3
Guidelines for Use of Prayer and Religious Literature
1. Prayer combined with therapeutic use of self can be used to meet the

patient’s spiritual needs and show empathy. A therapeutic relationship
must already be established with the patient before engaging in prayer, a
more intimate form of communication.

2. Prayer can consist of simply sharing a few brief sentences to express an
immediate need or can be taken from a formally written source.

3. The request for prayer and religious literature should be initiated by
the patient. If you are not comfortable, discuss with colleagues other

4. Ask the patient to define the specific needs for which he or she is request-
ing prayer.

5. Ask what passages the patient wants to read and how they are significant.
6. Validate expressed feelings such as pain, fear, anxiety, stress, helplessness,

or anger at God.
7. Know that prayer can be an affirmation of God’s presence and hope for

the patient.
8. If reading from religious literature, select passages carefully. Consult with

chaplain or other staff if in doubt. Some passages may be misinterpreted,
be interpreted literally, or be beyond the level of this patient.

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• Work with patient and staff to adapt patient’s schedule or activities to
incorporate religious rituals whenever possible.

• Allow patient to ventilate thoughts and feelings. Explore what precipi-
tated the feeling of loss. Help patient clarify any underlying feelings of
guilt. Help the patient explore and evaluate whether the source is rational
or distorted.

• Help patient explore previously held false assumptions and, as indicated,
refer to spiritual passages affirming hope, if within the nurse’s comfort
and knowledge.

• Allow family to participate in religious rituals such as ritual body care
after death or baptism of a critically ill child.

• Be open to patient’s expression of spiritual concerns. Avoid dismissing
practices as inappropriate or pathologic.

• If the patient shares fears, remember that acceptance and listening are
more important than having the answers.

SPIRITUAL DISTRESS evidenced by religious delusions or obsessions related
to impaired thought process.

Patient Outcomes
• Demonstrates improved reality orientation
• Verbalizes concerns and conflicts
• Verbalizes improved sense of peace and well-being
• Demonstrates appropriate social interactions

• Become familiar with the norms of the patient’s particular religious group

to assess the patient’s deviation from standard practice.
• Be aware that delusions may represent areas of personal conflict or con-

cerns. For example, the Messiah complex may reveal that patient has a
need to feel special, and dwelling on past sins may show that patient feels
badly about self. Focus on feelings the patient is having rather than on
content of delusion.

• Use great caution in reinforcing religious beliefs with psychotic patients
because this may perpetuate reality distortions. Seek assistance from
available mental health resources as well as chaplain or clergy.

• Set limits on time spent talking about obsessions and performing ritual-
istic behavior with the patient. Make a contract regarding time when you
will listen. Be consistent.

• Encourage patient to discuss concerns other than religious issues. Bring
patient back to recent specific experiences or events.

• Avoid arguing with the patient about the validity of his or her beliefs.
Rather, acknowledge the feelings these beliefs may evoke, such as fear or

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• Recognize that reducing obsessional thoughts or compulsive behavior
may result in increased anxiety or possibly even a panic reaction (see
Chapter 7, Problems with Anxiety, for interventions). Discuss with the
physician the need for evaluation by a mental health professional and
appropriate medication.

HOPELESSNESS evidenced by depression, apathy, withdrawal, rejection of
spiritual beliefs related to loss, impending death, incurable disease, lack of
meaning; spiritual crisis.

Patient Outcomes
• Verbalizes phrases like “I hadn’t thought of it that way” or “I feel better”
• Demonstrates increased social interactions
• Able to identify one or more future goals

• Encourage patient to share feelings and concerns and talk about what has

triggered the sense of hopelessness.
• Maintain a concerned yet positive attitude around patient, but avoid an

overly cheerful approach that may inhibit communication.
• Focus on short-term, concrete goals; identify specific things the patient

can do now. For instance, focus on the pleasure of visiting with grand-
daughter today rather than the hope to be playing tennis next year. Make
a plan with patient for achievable goals, such as sitting up in chair for 5
minutes longer today than yesterday. Often a patient may feel less hope-
less and depressed if progress in one area can be achieved.

• Recognize that pain, fatigue, and other stressors will affect ability to
maintain hope. Use interventions to deal with these stressors.

• Seek out chaplain to discuss patient’s beliefs to help challenge hopeless-
ness and support a more hopeful view.

• Recognize that, with time to work through a loss or crisis, the patient
may be able to focus on the future. Allow the patient time to work
through the grieving process.

• Be aware of your own anxiety around patient. Patient could sense your
tension and think that his or her issues are unacceptable.



Grieving, Dysfunctional

Spiritual Well-Being, Readiness for Enhanced

Thought Processes, Disturbed

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384 Chapter 18 ■ Problems with Spiritual Distress


• Educate patient and family on ways to incorporate religious practices
into the treatment plan for the specific illness. For instance, the patient
can adapt dietary restrictions and fasting requirements around specific

• Educate the family on the importance of patient’s spiritual beliefs if the fam-
ily is not supportive of them.

• Encourage family to not impose their beliefs on the patient if they are

• Encourage family to bring in Bibles or religious articles, as appropriate.


• Document patient’s beliefs, especially as they relate to patient’s illness.
• Document conflicts between patient and family.
• Document patient’s response to visit with clergy.
• Document nursing interventions and patient responses to spiritual interven-

tions such as prayer, scripture reading, or meditation.
• For patient’s at the end of life, document any prayers or rituals done in

preparation for death, e.g., Sacrament of the Sick.


• Patient is suicidal or homicidal.
• Religious practices interfere severely with healthcare regimen.
• Patient becomes psychotic.


• Chaplain
• Patient’s personal spiritual leader
• Family members
• Social Worker
• Psychiatric Team

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Chapter 18 ■ Problems with Spiritual Distress 385


• Refer to clergy or agency chaplain, as appropriate.
• Encourage attendance at religious or health-related support groups, such as

Reach for Recovery.
• Encourage participation in patient’s own house of worship as indicated.
• Use members of patient’s religious community to assist with home care

when appropriate.

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SECTION III Special Topics

19Nursing Management
of Special Populations

The Patient with Sleep

Learning Objectives
• Differentiate between mild, moderate, and severe sleep pattern distur-

• Identify factors leading to poor sleep and fatigue.
• Select appropriate interventions for dealing with sleep pattern distur-


Fatigue – An overwhelming, sustained sense of exhaustion or lack of energy

and decreased capacity for physical or mental work.
Insomnia – Abnormal wakefulness or an inability to fall asleep easily or to

remain asleep during the night.
Narcolepsy – An infrequent but serious disorder consisting of recurrent

episodes of uncontrollable sleep.
Nocturnal enuresis – Involuntary loss of urine at night in absence of physical

disease when a child is of the age when he or she would be expected to
remain dry.

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Obstructive sleep apnea – A serious sleep-related breathing disorder mani-
fested by daytime sleepiness or excessive loud snoring. Frequently associ-
ated with cardiac dysrhythmias.

Sleep apnea – Cessation of breathing for at least 30 episodes during

Sleep deprivation – Periods without normal sleep pattern, resulting in irri-
tability, fatigue, difficulty concentrating and memory, poor muscle coordi-
nation, and sometimes hallucinations and illusions with delirium.

Sleep disorders – Chronic disturbance of sleep patterns affecting the
amount, quality, or timing of sleep or events occurring during sleep includ-
ing dysomnias (insomnia), hypersomnias (excessive sleeping), and para-
somnias (abnormal behavior during sleep as in sleepwalking).

Sleep is unconsciousness from which a person can be awakened by sensory
stimuli such as sound, light, and touch. Sleep disorders put an individual at

risk for experiencing a change in the quantity or quality of rest and sleep as
related to biological and emotional needs. Adverse physical, mental, and emo-
tional changes may occur if normal rest and sleep patterns are interrupted. Most
people have suffered from at least transient sleep disturbances. Many factors lead
to poor sleep, such as the environment of the sleeping area (levels of sound, light,
and temperature), the age and general physical and psychological condition of
the patient, and recent stressful events.

Sleep was considered a homogeneous quiet period with minimal brain
activity until the discovery of the electroencephalographic (EEG) record.
With this technology, the description of rapid eye movement (REM) and
nonrapid eye movement (NREM) periods during sleep and their association
with dreaming has provided better understanding of sleep physiology and sleep

Sleep research has shown that there are two types of sleep during a sleep
period: sleep when the brain is very active (REM) and sleep with slow
brain waves (NREM). The reason why these two types of sleep exist is unknown.
The sleep center is located in the pons and the medulla. Most sleep at night
is NREM sleep; it occurs when a person first falls asleep and is a deep and rest-
ful sleep.

On the basis of EEG studies, sleep is divided into five distinct stages: REM
sleep and four stages of NREM sleep.

Stage 1 NREM: Transition from wakefulness to sleep; about 5% of time spent
asleep in adults; person feels very drowsy; musculature relaxes.

Stage 2 NREM: Characterized by specific EEG waveforms; occupies about
50% of sleep time; muscles relax further; cerebral activity decreases.

Stage 3 NREM: Physiological changes evident; vital signs decrease; gastroin-
testinal functions and venous dilation increase to facilitate cellular metabo-
lism and exchange.

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Stage 4 NREM: Known as slowwave, deepest level of sleep with lowest level
of body function. Stages three and four together occupy about 10% to 20%
of sleep.

During NREM sleep, pulse and respirations drop 20% to 30%, blood pres-
sure decreases, muscles relax, skin vessels dilate (increasing heat loss), metabolic
rate decreases by 10% to 30%, and body temperature decreases. NREM stages
three and four tend to occur in the first half of the night and increase in duration
in response to sleep deprivation.

REM sleep occurs cyclically throughout the night, alternating with NREM
sleep about every 80 to 100 minutes, lasts about 5 to 30 minutes, and is associ-
ated with dreaming that is remembered. REM sleep increases in duration toward
the morning. During REM sleep, heart rate and respirations often become irreg-
ular and metabolism and temperature increase.

The need for sleep decreases with age: Newborns should sleep 18 hours or
more a day, school-age children and teenagers about 10 to 12 hours, adults 7 to
8 hours (National Institute of Neurological Disorders and Stroke, 2007). Sleep
needs increase during illness. Lack of sleep results in progressive deterioration of
mental functioning, physical fatigue, discomfort, and emotional instability. Ten
percent of the population has chronic insomnia that is associated with daytime
functional impairment and 30% to 40% have problems with some insomnia in
any given year (National Center on Sleep Disorders Research, 2006).

Sleep deprivation is a major concern for safety. Driving while drowsy creates
similar reactions as if driving while intoxicated. The National Sleep Foundation
(2007) reports that a person is too drowsy to drive if they are having problems
focusing their eyes, can’t stop yawning and cannot remember driving the last few
miles. Those at highest risk include shift workers driving home from work, peo-
ple with a history of sleep disorders, and business travelers suffering from jet lag.

Chronic insomnia can lead to the following daytime impairments: poor atten-
tion, concentration or memory; anxieties about sleep; making errors or mishaps
at work or driving; irritability; and tension headaches (Ramakrishnan & Scheid,

Eighty percent of patients with psychiatric disorders describe sleep complaints
(Czeisler, Winkelman, & Richardson, 2005). Depression is associated with
reduced total sleep time, a shift in REM activity, and early morning awakening.
Manic phase of bipolar disorder is associated with insomnia, shortened REM
latency, and increased REM activity. Schizophrenia is associated with frequent
awakenings and reduced slow wave sleep.

More than 100 different disorders of sleeping and waking have been identi-
fied. Both the American Psychiatric Association (2000) and the Association of
Sleep Disorders have developed a system for classifying sleep disorders into four
main categories (Box 19–1).

The term sleep hygiene is used to describe a holistic approach to sleeping that
encompasses many behaviors. Everyone should practice good sleep hygiene to
prevent or relieve insomnia, or simply to safeguard sleep, making it more restful
and pleasurable (Box 19–2).

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390 Chapter 19 ■ Nursing Management of Special Populations

BOX 19–1
Classifying Sleep Disorders
DSM-IV-TR Classification

• Dyssomnias—primary insomnia, primary hypersomnia, narcolepsy,
breathing-related sleep disorder, circadian-rhythm sleep disorder (jet lag,
shift work)

• Parasomnias—nightmares, sleep terror, sleepwalking
• Sleep disorder related to another mental disorder such as anxiety, grief,

depression, psychosis
• Sleep disorders caused by a medical condition and substance-induced sleep


Association of Sleep Disorders Centers Classification

• Problems with falling and staying asleep
• Problems with staying awake (excessive sleepiness)
• Problems with adhering to a regular sleep-wake schedule
• Sleep-disruptive behaviors (parasomnias) such as sleepwalking

BOX 19–2
Sleep Hygiene
Suggestions for Increasing Adequate, Restful Sleep

• Establish a regular time for going to bed and getting up in the morning, and
stick to it, even on weekends and during vacations.

• Use the bed for sleep and sexual relations only, not for reading, watching
television, or working; excessive time in bed seems to fragment sleep.

• Avoid naps, especially in the evening.
• Exercise before dinner. A low point in energy occurs a few hours after exer-

cise; sleep will then come more easily. Exercising close to bedtime, however,
may increase alertness.

• Take a hot bath about an hour and a half before bedtime. The body tem-
perature then begins dropping rapidly, which may help sleep after that time.
(Taking a bath shortly before bed increases alertness.)

• Do something relaxing in the half hour before bedtime. Reading, medita-
tion, and a leisurely walk are all appropriate activities.

• Keep the bedroom relatively cool and well ventilated.
• Do not look at the clock. Obsessing over time will just make it more diffi-

cult to sleep.

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Sleep disorders are often caused by a variety of medical and psychiatric disorders.
Short-term insomnia is often due to stress and acute grief. Some chronic sleep dis-
orders may be due to dysfunction with the sleep/wake cycle.

Before a sleep disorder diagnosis can be made, the patient should have a thor-
ough physical examination; review of all medications (prescribed, illicit, and
over-the-counter); and the person’s spouse or bed partner should be asked about
the person’s sleeping habits. Evaluating a sleep-wakefulness complaint requires a
thorough history that considers medical, toxic, and environmental conditions, as
well as drug and alcohol use. If tolerance to or excessive use of drugs or alcohol
is the likely cause of the insomnia, the patient must undergo withdrawal under
careful supervision. Sleep problems are associated with a long list of drugs,
including stimulants and alcohol. Hypnotics used over a long period of time can
also cause insomnia because of the development of tolerance and suppression of
REM sleep.

Insomnia is the most common sleep disorder across all ages (NIH, 2005). Anx-
iety and stress are the most common causes of intermittent, short-term insomnia.
Other common causes of short-term insomnia include medication side effects and
jet lag. Initial treatment for short-term insomnia includes behavioral approaches
and use of hypnotics for the short-term. In the absence of comorbidities, chronic
insomnia is now considered to be a primary disorder unto itself. Chronic insom-
nia is identified as symptoms of insomnia that last more than 30 days.

Sleep lab studies reveal that some patients with obstructive sleep apnea have
about 30 episodes of upper airway obstruction each night, resulting in an inabil-

Chapter 19 ■ Nursing Management of Special Populations 391

• A light snack before bedtime can help sleep, but a large meal may have the
opposite effect.

• Avoid fluids just before bedtime so that sleep is not disturbed by the need
to urinate.

• Avoid caffeine in the hours before sleep.
• Quitting smoking not only brings many health benefits to any smoker, it

also eliminates the effects of nicotine that contribute to sleep loss.
• When unable to sleep after 15 or 20 minutes, one should get up, go into

another room, and read or do a quiet activity using dim lighting until they
are sleepy again. (Do not watch television, which emits too bright a light.)

• Sleeping alone may be more restful than sleeping with another person. If a
person with insomnia is distracted by a sleeping bed partner, moving to the
couch for a couple of nights might be useful.

• Take a nap in the early afternoon if needed to stave off drowsiness. But
remember that naps can disrupt nighttime sleep. If you must nap, do so for
no longer than 30 minutes in the late afternoon.

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ity to achieve a deep sleep state because of hyperventilation, carbon dioxide reten-
tion, and severe hypoxemia. Treatment possibilities include weight loss for obese
patients and positive-pressure respiratory treatments (CPAP) to keep the airway
open. Surgical intervention (a procedure to remove excess tissue in the pharynx or
a tracheotomy) may be required for more serious cases. Sleep apnea is usually
caused by obesity and history of cardiovascular disease is another risk factor.

Narcolepsy is caused by an abnormality in REM sleep. It is sometimes accom-
panied by cataplexy (partial or complete loss of muscle tone), presleep hallucina-
tions, and sleep paralysis. These symptoms are more debilitating than the
sleepiness. Specific treatment includes short daytime napping and prescription of
a central nervous system stimulant.

Parasomnias including sleepwalking and nightmares are considered REM
sleep disorders. Treatment usually includes use of benzodiazepines.

Conditions most frequently associated with excessive daytime sleepiness
include the following:

• Regularly sleeping 10 to 14 hours
• Psychophysiological causes: Transient and situational sleepiness caused by

stress, boredom, or depression
• Nocturnal myoclonus, also known as “restless legs” or leg jerking
• Idiopathic central nervous system hypersomnolence not caused by head

• Menstrual cycle–associated syndrome: Increased daytime sleepiness around

time of period
• Self-induced insufficient sleep: Related to increased work hours, pressured

deadlines, or other self-imposed behavior.

Risk factors for sleep disorders include the following:

• Older age associated with more comorbidities
• Female gender
• Psychiatric disorder
• Medical condition
• Shift work


Many medical and psychiatric conditions affect the patient’s ability to main-
tain a normal sleep pattern. Patients with respiratory conditions, Alzheimer’s
disease, and chronic pain frequently complain of sleep problems. Anxiety, depres-
sion, mania, and delirium are also often accompanied by inability to sleep satis-

For hospitalized patients, institutional routines and policies, such as how late
sleeping medication may be given or giving baths on the night shift, can actually

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