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![Page 1: Copyright © 2008 Delmar Learning. All rights reserved. Unit 30 Caring for the Emotionally Stressed Patient.](https://reader038.fdocuments.us/reader038/viewer/2022110208/56649ddd5503460f94ad53b9/html5/thumbnails/1.jpg)
Copyright © 2008 Delmar Learning. All rights reserved.
Unit 30
Caring for the
Emotionally Stressed Patient
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Copyright © 2008 Delmar Learning. All rights reserved.
Objectives
• Spell and define terms.• Define mental health.• Explain the interrelatedness of physical
and mental health.• Understand mental health as a process
of adaptations.
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Objectives
• Identify commonly used defense mechanisms.
• Define anxiety disorder, affective disorder, eating disorder, and substance abuse and give examples of each.
• Describe ways to help patients cope with stressful situations.
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Objectives
• Identify the signs and symptoms of maladaptive behaviors that should be documented and reported.
• List nursing assistant measures in providing care for patients with adaptive and maladaptive reactions.
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Objectives
• Identify professional boundaries in relationships with patients and families.
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Introduction
• Varying degrees and differing aspects of health
• A person in poor physical health may be mentally healthy– Self-reliant– Able to make decisions – Live an effective, productive life
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Introduction
• In contrast:– A person with good physical health may
not be able to cope with and adapt to changes
– This inability limits the person’s chances to participate successfully in society
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Mental Health
• Mental health– Exhibiting behaviors that reflect a person’s
adaptation, or adjustment, to the multiple stresses of life
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Mental Health
• Some multiple stresses include:– Illness – Hospitalization– Loss of a loved one– Loss of a job– Loss of status– Relationships
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Relationships
• Patients with mental disorders – Have an increased risk for substance
abuse disorders
• Patients with substance abuse disorders– Have an increased risk for mental
disorders
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Defense Mechanisms
• A person acts in protective ways when he or she is:– Unable to cope with stress – Feels that a situation threatens self-esteem
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Defense Mechanisms
• Some of the commonly used defense mechanisms include:– Repression– Suppression– Projection– Denial– Reaction formation
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Defense Mechanisms
• Other adaptive behaviors include:– Displacement– Identification– Compensation– Conversion– Fantasy– Undoing
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The Demanding Patient
• In every nursing care situation– You will meet patients who are very
demanding– This can be a difficult experience for
everyone if it is not handled correctly
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Maladaptive Behaviors
• Mental illness or maladaptive behavior– Occurs when behaviors and responses
disrupt a person’s ability to function smoothly within the family, environment, or community
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Anxiety Disorder
• Anxiety is fear, apprehension, or sense of impending doom– Physical symptoms may also be present
• Anxiety disorder – Part of a group of mental illnesses
involving anxiety as a response to stress
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Types of Anxiety Disorders
• Generalized anxiety (most common)• Panic disorder
– Panic attacks
• Obsessive-compulsive disorder (OCD)• Post-traumatic stress disorder (PTSD)
– Most common in combat veterans or survivors of major trauma
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Types of Anxiety Disorders
• Phobias– Different types of fears
• Snakes, rats, spiders• Crowds, fear of flying, etc.
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Types of Anxiety Disorders
• Phobias– Some people try to conceal their fears by
using humor– They make comments such as, “If God
wanted me to fly, He would have given me wings.”
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Affective Disorders
• Characterized by a disturbance in mood• Called mood disorders
– Usually marked by a profound and persistent sadness
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Affective Disorders
• Common affective disorders are:– Bipolar affective disorder– Seasonal affective disorder (SAD)– Borderline personality disorder– Schizoaffective disorder
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Depression
• Most affective disorder• It is also common in older people, but
younger people also may experience depression– Ranging from mild to severe
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Depression
• Often masked by symptoms that make it seem as though the patient is physically ill– Such as sleeping much of the time
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Borderline Personality Disorder
• Borderline Personality Disorder (BPD)– Sometimes considered a controversial
diagnosis– Cause is not definitely known
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Borderline Personality Disorder
• Patients usually feel very unstable and:– Often impulsive– Fear abandonment– Prone to self‑injurious behavior and self-
mutilation– Sometimes suicidal– Often feel empty or bored
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Borderline Personality Disorder
• Patients usually feel very unstable and:– Are usually very manipulative– Have difficulty maintaining stable
relationships– Usually have concrete opinions– May have difficulty with emotional
reasoning
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Borderline Personality Disorder
• Patients usually feel very unstable and:– Often have relationship problems– May have difficulty functioning according to
society’s rules
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Borderline Personality Disorder
• Considered very difficult to treat• Characterized by unstable mood and
self-image• Unstable intense, interpersonal
relationships
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Borderline Personality Disorder
• Patient may abuse drugs to:– Diminish symptoms– Enhance low self-esteem– Decrease feelings of guilt– Amplify feelings of diminished individuality
• Avoid confrontations with the patient
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Eating Disorders
• Group of disorders – Characterized by disturbances in appetite
or food intake and body self image
• Conditions overlap– Patients try to conceal the problem, making
these conditions difficult to identify
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Eating Disorders
• Common eating disorder– Anorexia nervosa
• Person fears obesity and believes he or she is fat, despite having a skeletal appearance
• Person limits food through diet, exercise, purging, and taking laxatives ad diuretics
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Eating Disorders
• Common eating disorder– Bulimia nervosa
• Person binge eats huge amounts, then vomits (purges) to undo the binge
• Binge eating causes feelings of guilt, depression, and self‑condemnation
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Eating Disorders
• People with bulimia also use:- Laxatives, diuretics, and vigorous exercise
to lose weight - To be diagnosed with bulimia:
• Behavior must occur at least twice a week for three months in a row
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Agitation
• Inappropriate verbal, vocal, or motor activity – Due to causes other than disorientation or
real need
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Disorientation(Disordered Consciousness)
• Condition in which a person shows a lack of reality awareness with regard to:– Time– Person– Place
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Disorientation(Disordered Consciousness)
• Disorientation may be mild or severe, temporary or prolonged
• It is important to report patient behavior, actions, and responses
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Hypochondriasis
• Patient imagines or magnifies each physical ailment– Some authorities believe that
hypochondriasis is an expression of depression
– One way some individuals reduce stress
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Paranoia
• Extreme maladaptive response to stress– Characterized by a heightened, false
sense of self-importance and delusions of being persecuted
– Believe that everyone is against them– Refer to Nonpharmacologic Approaches to
Care
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Nonpharmacologic Approaches to Care
• Psychotherapy• Cognitive therapy• Behavioral therapy • Relaxation skills• Meditation• Biofeedback
• Acupuncture• Hypnotherapy• Self-help groups• Support groups• Exercise• Education
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Mental Health versus Substance Abuse
• Treatment needs of patients who have a psychiatric disorder in combination with a substance abuse disorder:– Differ significantly from the treatment
needs of patient with either a substance abuse disorder or a psychiatric disorder by itself
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Mental Health versus Substance Abuse
• Clinicians and other workers– Must differentiate between psychiatry and
substance abuse disorders• By obtaining a thorough history of symptoms
and disorders
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Substance Abuse
• Characterized by the use of one or more substances– Alcohol or drugs– Alter mood or behavior– Resulting in impairment
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Substance Abuse
• Use of the substance(s) results in:– Maladaptive pattern of behavior– Strained finances– Irresponsibility– Inability to fulfill social or occupational
obligations
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Substance Abuse
• Substance abuser– Uses despite knowing it is dangerous or
illegal – Uses illegal (street) drugs or misuses
prescription drugs without proper physician knowledge or oversight
• Refer to Signs and Symptoms of Dependency/Addiction
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Similarities of Mental Health and Addiction Treatment Systems• Variety of treatment settings and
program types• Public and private settings• Multiple levels of care• Biopsychosocial models• Increasing use of case and care
management
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Signs and Symptoms of Dependency/Addiction
• Pathologic, often progressive and chronic process
• Compulsion and preoccupation with obtaining a drug or drugs
• Loss of control over use or substance abuse-induced behavior
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Signs and Symptoms of Dependency/Addiction
• Continued use despite adverse consequences
• Tendency for relapse after period of abstinence
• Increased tolerance and characteristic withdrawal
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Components of Drug Dependence1
• Psychologic dependence:– Centers on the user’s need of a drug to
reach a level of functioning or feeling of well-being
1 American Society of Addiction Medicine.
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Components of Drug Dependence1
• Physical dependence:– Physiologic dependence– Establishment of tolerance– Evidence of an abstinence syndrome– Withdrawal upon cessation of substance
abuse
1 American Society of Addiction Medicine.
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Symptoms: Substance Abuse
• Significant impairment or distress • Failure to fulfill roles at work, home, or
school• Persistent use in physically hazardous
situations
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Symptoms: Substance Abuse
• Recurrent legal problems related to use• Continued use despite interpersonal
problems
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Medication Misuse
• Describes the use of prescription medications outside of medical supervision or advice
• Not an abuse problem– High-risk behavior
• May or may not involve or lead to substance abuse
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Medication Misuse
• May promote the reemergence of psychiatric symptoms
• May cause toxic effects and psychiatric symptoms if it involved overdose
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Mental Health and Addiction Treatment Systems
• Potential pitfall – Prescribing psychoactive medications to
psychiatric patient without first determining if the individual has a substance abuse disorder
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Mental Health and Addiction Treatment Systems
• In treating dual disorders– Balance must be made between behavioral
interventions and psychiatric medications as needed for the recovery process
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Alcoholism
• Some people use alcohol as a means of coping with stress
• The National Institute for Alcohol Abuse– Reports that two-thirds of the senior
population uses alcohol– Fifteen percent of them become alcoholics
• Alcoholism is regarded as a disease
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Delirium Tremens
• Patients who are withdrawing from alcohol may have delirium tremens (DTs)
• DTs signify withdrawal– Begin about 48 to 96 hours after the last
drink
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Delirium Tremens
• Signs and symptoms are:– Severe confusion– Tremors– Hallucinations– Overactivity of the nervous system– Seizures
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Delirium Tremens
• DTs can become life threatening– Require immediate treatment– Refer to Psychotic Disorders
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Psychotic Disorders
• Stimulant-Induced symptoms– Acute stimulant intoxication (chronic) can
cause symptoms of psychosis– Delirium, delusions, prominent
hallucinations, incoherence, and loosening of associations
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Psychotic Disorders
• Stimulant-Induced symptoms– Stimulant delirium often includes formication
(a tactile hallucination of bugs crawling on or under the skin)
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Psychotic Disorders
• Depressant-Induced symptoms– Acute withdrawal from alcohol, barbiturates,
and benzodiazepines • Can produce a withdrawal delirium, especially
with heavy use and high tolerance due to a concomitant physical illness
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Psychotic Disorders
• Psychedelic- and Hallucinogen-induced symptoms– Psychotic symptoms are possible in
chronic, high-dose patterns due to virtue of drugs’ stimulant properties
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Psychotic Disorders
• Psychedelic- and Hallucinogen-induced symptoms– Can cause hallucinogenic hallucinosis
• Perceptual distortions• Maladaptive behavioral changes• Impaired judgment
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Acute Treatment Strategies
• Management of intoxication and withdrawal
• Medical treatment• Psychiatric treatment
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Assessing the Patient’s Behavior
• An initial assessment of a patient’s mental and emotional state– Made by a licensed care provider– Refer to Stages of Assessment
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Assessing the Patient’s Behavior
• Because you make frequent contact with the patient– You can make a valuable contribution to
the nursing assessment process by making careful and sensitive objective observations
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Stages of Assessment
• Assessing danger to self or others• Medical assessment• Initial addiction assessment• Social assessment• Violence towards others
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Stages of Assessment
• Assessing mood symptomatology• Medical assessment• Psychiatric and addiction screening• Assessment instruments• Psychosocial assessment
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Key Issues and Concerns
• Patient contracting– May involve a patient’s promise to avoid
certain self-harm or high-risk behavior
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Key Issues and Concerns
• Transference and countertransference – Both rely on the mechanism of projection
• Combination of personal past experiences along with feelings experienced during course of therapy
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Key Issues and Concerns
• Clear boundaries – Ethical and practical ground rules that help
a therapist to be therapeutically helpful to patients
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Key Issues and Concerns
• Changing roles – People with personality disorders may
include: • Victim• Persecutor• Rescuer
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Key Issues and Concerns
• Resistance– Patients with personality disorders often
exhibit acting-out behaviors – These were developed as psychological
defenses and survival techniques
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Key Issues and Concerns
• Subacute withdrawal may include:– Mood swings– Irritability– Impairment in cognitive functioning– Short- and long-term memory problems– Intense craving for substances
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Key Issues and Concerns
• Symptom substitutions– Compulsive behaviors – Eating disorders– Compulsive spending, gambling, and sex
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Key Issues and Concerns
• Somatic complaints• Therapists should watch for use of:
– Prescription and over-the-counter drugs – Drug-seeking behaviors
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Key Issues and Concerns
• Staff well-being can be compromised– When working with patients with
personality disorders
• Therapists – Should join or develop support systems
with others in the field
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Professional Boundaries
• As a nursing assistant:– You must stay within certain professional
boundaries while caring for each patient
• Boundaries – Unspoken limits on the physical and
emotional relationships with patients
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Ethical Behavior with Patients and Families
• Patients expect you, as the nursing assistant, to act in their best interests and treat them with dignity
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Ethical Behavior with Patients and Families
• You do this by:– Not taking advantage of a patient’s
situation– Avoiding inappropriate involvement in each
patient’s personal and family relationships
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Consequences of Boundary Violations
• Boundary violations – Lead to inappropriate relationships with
patients and/or their families– Cloud your clinical judgment – May lead to serious consequences
• Such as inappropriate sexual relationships
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Enabling Behavior
• Reacting to a patient in a way that shields the person from the full impact of his or her behavior
• Enabling differs from helping– It allows (and often encourages) the
person to be irresponsible
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Enabling Behavior
• By learning and respecting professional boundaries– You will avoid helping others
inappropriately
• Enabling behavior creates dependency– Rather than moving the patient toward
independence and good mental health
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Enabling Behavior
• Examples of enabling behaviors that you should avoid are:– Keeping secrets about a patient’s behavior
from others– Making excuses for a patient’s behavior– Acting to get a patient out of personal
trouble
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Enabling Behavior
• Examples of enabling behaviors that you should avoid are:– Attempting to control patients’ lives and
activities– Doing things for the patient that he or she
should do
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Zone of Helpfulness
• Keep your behavior in the zone of helpfulness– This avoids crossing professional
boundaries and enabling patients
• Refer to Figure 30-20
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Zone of Helpfulness
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Assisting with Behavior Problems
• Follow the care plan • Control your responses and reactions• Be a good communicator• Avoid lying to the patient or making
promises you cannot keep
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Assisting with Behavior Problems
• Never discuss facility or staff problems with patients
• If a patient complains, inform the nurse
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Assisting with Behavior Problems
• Attempt to learn the cause of the behavior– Remove cause (or trigger), if known
• If the care plan states to respond to a specific behavior– Apply approaches when behavior starts
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Assisting with Behavior Problems
• Do not wait until the patient loses control
• Practice empathy• Modify your own behavior in response
to the patient’s behavior
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Assisting with Behavior Problems
• Watch how the patient responds to you– Adjust approaches, equipment, routines,
etc., if necessary
• Discuss pleasant information– Provides a source of strength, comfort, and
support
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Assisting with Behavior Problems
• Look for unmet needs and meet them– If possible
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Assisting with Behavior Problems
• Give patients as much control as possible– Offer choices and encourage patients to
direct their care
• Smile– Make sure your body language sends a
positive message
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Long-Term Treatment Goals
• Addiction treatment• Psychiatric treatment• Long-term treatment needs• Family issues• Eating disorders and gambling