Maslow’s Hierarchy of Needs

Maslow emphasized and individual’s motivation in the continuous quest for self-actualization. An
individual’s position within the hierarchy may reverse from a higher level to a lower level based on life
circumstances

Maslow describes self-actualization as being “psychologically healthy, fully human, highly evolved, and
fully mature.”

1. Self-Actualization: the individual possesses a feeling of self-fulfillment and the realization of his or
her highest potential

2. Self-Esteem/Esteem of Others: the individual seeks self-respect and respect from others, works to
achieve success and recognition in work, and desires prestige from accomplishment

3. Love and Belonging: needs are for giving and receiving of affection, companionship, satisfactory
interpersonal relationships, and identification with a group

4. Safety and Security: needs at this level are for avoiding harm, maintaining comfort, order, structure,
physical safety, freedom from fear, and protection

5. Physiological Needs: basic fundamental needs include food, water, air, sleep, exercise, elimination,
shelter, and sexual expression

Phases in the Nurse-Client Therapeutic Relationship - What Occurs in Each Phase, Nursing
Interventions/Actions

 Pre Interaction Phase: This is before you meet your client. This phase is about collecting
information previous to see the client to make sure you know as much as possible about
him/her. Obtain information from the chart, significant others or other health team members.
The downfall is that you can have preconceived judgments about the patient. Examine one’s
own feelings, fears, and anxieties about working with a particular client. The nurse needs to be
aware of how these preconceptions may affect her ability to care for individual clients

 Orientation (introductory) Phase:

• Creates an environment for trust and rapport

• Establish contract for intervention
• Gather assessment data from the patient (objective/subjective)
• Identify client’s strengths and weaknesses
• Formulate nursing diagnoses
• Set mutually agreeable goals
• Develop a realistic plan of action
• Explore feelings of both client and nurse

Interactions may remain on a superficial level until anxiety subsides. Several interactions may be
required to fulfill the tasks associated with this phase
 Working Phase:

- Maintain trust and rapport

- Promote client’s insight and perception of reality

- Use problem-solving model to work towards achievement of established goals

- Overcoming resistance behaviors on the part of the client as the level of anxiety rises in
response to discussion of painful issues

- Continuously evaluate progress toward goal attainment

• Transference: occurs when the client unconsciously displaces (or “transfers”) to the nurse
feelings formed toward a person from the past

- This feelings toward the nurse may be triggered by something about the nurse’s
appearance or personality characteristics that remind the client of the person

- Transference can interfere with the therapeutic interaction when the feelings being
expressed include anger and hostility. Anger towards the RN can be manifested by
uncooperativeness and resistance to the therapy

- In case of transference the nurse should work with the patient in sorting out the past
from the present and assist the patient into identifying the transference and reassign a
new and more appropriate meaning to the current nurse-patient relationship. The goal
is to guide the patient to independence by teaching them to assume responsibility for
their own behaviors, feelings, and thoughts, and to assign the correct meanings to the
relationships based on present circumstances instead of the past

• Countertransference: it refers to the nurse’s behavioral and emotional response to the

client

- These responses may be related to unresolved feelings toward significant others from
the nurse’s past or they may be generated in response to transference feelings on the
part of the client. The nurse may be completely unaware or only minimally aware of
what’s happening

- In case of countertransference the nurse should be assisted by other staff members to

identify her feelings and behaviors and recognize the occurrence of the phenomenon

 Termination Phase:
- Therapeutic conclusion of relationship occurs when:

 Progress has been made towards attainment of the goals

 A plan of action for more adaptive coping with future stressful situations
has been established
  Feelings about termination of the relationship are recognized and explored
(the client may feel sad & feel a loss & show behavior and as a result
transference can occur

 The RN should use therapeutic closure, by establishing the reality of the

separation and resist being manipulated into repeated delays by the patient

Nursing Process Related to Patient’s with Mental Illness

The nursing process is the same for mentally ill patients, there is only some differences on how you do
the assessment, in which you focus on psychological and social factors, observation of the client and
his/her environment, subjective/objective data.

The patient is more looked in a holistic way. You also assess for spirituality, learning needs, suicidal
thoughts. The most important assessment is to diagnose the level of risk which requires priority, as it
can be a life-threatening potential

What are the statistics for prevalence of mental illness?

1/4 people have a mental health diagnosis

2/3 college students that are depressed do NOT seek help
1100 college students commit suicide each year

64% of college students with mental illness withdraw from college

Male veterans are twice as likely to die by suicide as compared with their civilian peers

List characteristics of mental health

- Deal with conflicting emotions

- Live without undue fear, guilt, or anxiety
- Take responsibility for one’s own actions
- Think clearly
- Negotiate each developmental task

 Biological makeup
 autonomy and independence
 self-esteem
 capacity for growth
 vitality
 ability to find meaning in life
 What is the DSM? “Diagnostic and Statistical Manual of Mental Disorders (DSM-5)”

A taxonomy used to provide a standard nomenclature of mental disorders, define characteristics of

disorders, and assist in identifying underlying causes of disorders.

Mental disorders are manifestations of

- Behavioral
- Psychological
- Biological
Dysfunction of the individual

Behavioral - observable behaviors and what one can do externally to bring about
behavior changes.

Classical Conditioning – behavior can be changed through conditioning with external or

environmental conditions or stimuli.

Operant Conditioning – people learn from their behavior from their history or past
experiences.

Describe each axis of the DSM

I: clinical disorder that is the focus of tx (ex: major depression)

II: personality disorders & mental retardation (ex: borderline personality)
III: medical conditions (ex: asthma)
IV: psychosocial & environmental problems (ex: occupational problems)
V: global assessment of functioning
Score 0-100
Current/highest level of functioning (ex: 45/70)
Higher score = higher level of functioning

Mental Health: State of wellbeing which every individual realizes their own potential, can cope with
stress of life, work productively and fruitfully and is able to make a contribution to community.

• ‘Mental wellbeing’ – a positive concept. Refers to resilience and good functioning, also
incorporates flourishing, happiness and getting the most out of life

Mental illness: A clinically recognizable set of symptoms related to mood, thought, cognition and
behaviour that is associated with distress and interferes with normal functioning.

• A diagnosed clinical condition

Therapeutic relationship: Purposeful, goal driven relationship between nurse and pt, aiming to
support the patient in their recovery.

• Elements: Trust, respect, empathy, collaboration, listening, communication.

How does therapeutic relationship and communication contribute to person centered care?

• Focus on individual needs, respect pt choices/beliefs/goals, tailored to individual

Resilience or “hardiness,” sense of belonging, reality orientation, and coping or stress mgmt. abilities.
Process of:
- adapting
- recognizing feelings
- dealing with those feelings
- learning from the experience

Interpersonal factors:
• effective communication
• helping others
• intimacy
• maintaining a balance of separateness and connectedness

Social/Cultural factors:
• sense of community
• access to resources
• intolerance of violence
• support of diversity among people
• mastery of the environment
• positive yet realistic view of the world

Therapeutic Relationships

• Therapeutic use of self “distinct gifts” each one of us has that can be used to creatively
form positive bonds with others
o Influenced by personality characteristics of patient and nurse

• Goals and Functions

o Facilitates communication of distressing thoughts and feelings
o Assists patients with self-care and independence
o Helps patients examine self-defeating behaviors/thoughts and test alternatives
▪ Ex. Focusing on what other people should be doing rather than what you
should be doing
o Maximizes communication skills, helps understand behavior, and enhances patient
growth

• Steps: Identify and explore patient needs, establish clear boundaries, explore alternative
 problem solving skills, encourage behavioral change

• Boundaries
o Physical boundaries, informal boundaries, personal space

o Transference: Patient unconsciously transfers feelings and behaviors related to

significant figures in the patient’s past onto the nurse

o Countertransference: Nurse unconsciously (and inappropriately) transfers feelings and

behaviors from significant figures in nurse’s past onto the patient

o Self-Check on Boundaries

▪ Boredom and indifference

▪ “Rescuing” the patient
▪ Over-involvement
▪ Over-identification
• Ex. If the patient asks a personal question, tell them we are here to
talk about them

o Peplau’s Model

▪ Peplau was the “mother of psychiatric nursing”—developed and defined the

interpersonal relationship between nurses and patients
▪ Phases
• Pre-orientation phase
• Orientation phase
o Establishing rapport and confidentiality
o Contract (boundaries)
o Terms of termination
• Working phase
• Termination phase

• Therapeutic techniques Silence, active listening, clarifying, (paraphrasing, restating,

reflecting, exploring), open-ended, projective, and presupposition questions

• Non-therapeutic techniques Excessive questioning, giving approval/disapproval, “why”

questions, giving advice, eye contact and touch depending on culture

Role of the Psychiatric Nurse vs an ARNP

Nurses: can do counseling, teaching, advocating

ARNP: can provide psychotherapy, admits and discharges pts, able to prescribe meds
Therapeutic Communication (Feedback, Silence, Empathy) vs Non-Therapeutic Communication
Techniques

Therapeutic Communication Techniques:

- Using Silence: it allows the client to take control of the discussion, if he or she desires. The
nurse can be silent, or the patient or both

- Accepting: conveys positive regard

- Giving Recognition: acknowledging, indicating awareness

- Offering Self: making oneself available

- Giving Broad Openings: allows client to select the topic of conversation

- Offering General Leads: encourages client to continue

- Placing the Event in Time or Sequence: clarifies the relationship of events in time

- Making Observations: verbalizing what is observed or perceived

- Encouraging Description of Perceptions: asking client to verbalize what is being perceived

- Encouraging Comparison: asking the client to compare similarities and differences in ideas,
experiences, or interpersonal relationships

- Restating: lets client know whether an expressed statement has or has not been understood

- Reflecting: directs questions or feelings back to client so that they may be recognized and
accepted

- Focusing: taking notice of a single idea or even a single word

- Exploring: delving further into a subject, idea, experience, or relationship

- Seeking Clarification and Validation: striving to explain what is vague and searching for
mutual understanding

- Presenting Reality: clarifying misconceptions that client may be expressing

- Voicing Doubt: expressing uncertainty as to the reality of client’s perception

- Verbalizing the Implied: putting into words the feelings the client has expressed only indirectly

- Formulating a Plan of Action: striving to prevent anger or anxiety from escalating to an

unmanageable level the next time the stressor occurs
 - Empathy: Ex. I see you may be having a difficult time (don’t feel bad for the person, don’t show
sympathy)

- Feedback: it is based on perception of the other person’s behavior or action, it is not

evaluative, and it is therapeutic

o Feedback is useful when is descriptive rather than evaluative and focused on the
behavior rather than on the client

o It’s specific rather than general

o It’s directed towards behavior that the client has the capacity to modify

o Imparts information rather than offers advice

o It’s well timed

- Another therapeutic technique is to help the person put their thoughts/experiences into feeling
as oppose to telling them what to do

Nontherapeutic Communication Techniques

- Giving Reassurance: may discourage clients from further expression of feelings if client
believes the feelings will only be belittled

- Rejecting: refusing to consider client’s ideas or behavior

- Giving Approval or Disapproval: implies that the nurse has the right to pass judgment on the
“goodness” or “badness” of client’s behavior

- Agreeing/Disagreeing: implies that the nurse has the right to pass judgment on whether
client’s ideas or opinions are “right” or “wrong”

- Giving Advice: implies that the nurse knows what is best for client and that client is incapable
of any self-direction

- Probing: pushing for answers to issues the client does not wish to discuss causes client to feel
used and valued only for what is shared with the nurse

- Belittling Feelings Expressed: causes the client to feel insignificant or unimportant

- Making Stereotyped Comments, Clichés, and Trite Expressions: these are meaningless in a
nurse-client relationship

- Using Denial: blocks discussion with the client and avoids helping him or her identify and
explore areas of difficulty

- Interpreting: results in the therapist’s telling client the meaning of his or her experience
 - Introducing an Unrelated Topic: causes the nurse to take over the direction of the discussion

Levels of Anxiety

Anxiety Psychological Responses Physiologic Responses

Level

Mild Wide perceptual field Restlessness

Sharpened senses Fidgeting
Increased motivation GI “butterflies”
Effective problem solving Difficulty sleeping
Increased learning ability Hypersensitivity to noise
Irritability
Moderate Perceptual field narrowed to immediate task Muscle tension
Selectively attentive Diaphoresis
Cannot connect thoughts or events independently Pounding pulse
Increased use of automatisms Headache
Dry mouth
High voice pitch
Faster rate of speech
GI upset
Frequent urination
Severe Perceptual field reduced to one detail or scattered Severe headache
details Nausea, vomiting, and diarrhea
Cannot complete tasks Trembling
Cannot solve problems or learn effectively Rigid stance
Behavior geared toward anxiety relief and is Vertigo
usually ineffective Pale
Doesn’t respond to redirection Tachycardia
Feels awe, dread, or horror Chest pain
Cries
Ritualistic behavior
Panic Perceptual field reduced to focus on self May bolt and run
Cannot process any environmental stimuli Or
Distorted perceptions Totally immobile and mute
Loss of rational thought Dilated pupils
Doesn’t recognize potential danger Increased blood pressure and
Can’t communicate verbally pulse
Possible delusions and hallucination Flight, fight, or freeze
May be suicidal
Working with Anxious Clients
- Mild Anxiety  requires no direct intervention.
 Patient can learn and solve problems and are eager for information.

- Moderate Anxiety  speak in short, simple, and easy-to-understand sentences

 Stop to ensure that the client is still taking in information correctly; may
need to redirect.

- Severe Anxiety  goal to lower patient’s anxiety level to moderate or mild before
proceeding with anything else.
 Low, calm, and soothing voice
 Walking with patient if they’re unable to sit still
 Help patient to take deep even breaths

- Panic-level Anxiety  PATIENT SAFETY is the primary concern

Psychodynamic Theories

Intrapsychic/Psychoanalytic Theories

Freud (1936) saw a person’s innate anxiety as the stimulus for behavior. He described defense
mechanisms as the human’s attempt to control awareness of and to reduce anxiety.

Defense mechanisms are cognitive distortions that a person uses unconsciously to maintain a sense of
being in control of a situation, to lessen discomfort, and to deal with stress. Because defense
mechanisms arise from the unconscious, the person is unaware of using them. Some people overuse
defense mechanisms, which stops them from learning a variety of appropriate methods to resolve
anxiety-producing situations. The dependence on one or two defense mechanisms also can inhibit
emotional growth, lead to poor problem-solving skills, and create difficulty with relationships.

Interpersonal Theory

Harry Stack Sullivan (1952) viewed anxiety as being generated from problems in interpersonal
relationships. Caregivers can communicate anxiety to infants or children through inadequate nurturing,
agitation when holding or handling the child, and distorted messages. Such communicated anxiety can
result in dysfunction such as failure to achieve age-appropriate developmental tasks. In adults, anxiety
arises from the person’s need to conform to the norms and values of his or her cultural group. The
higher the level of anxiety, the lower the ability to communicate and to solve problems and the greater
the chance for anxiety disorders to develop.
Hildegard Peplau (1952) understood that humans exist in interpersonal and physiologic realms; thus, the
nurse can better help the client to achieve health by attending to both areas. She identified the four
levels of anxiety and developed nursing interventions and interpersonal communication techniques
based on Sullivan’s interpersonal view of anxiety. Nurses today use Peplau’s interpersonal therapeutic
communication techniques to develop and to nurture the nurse–client relationship and to apply the
nursing process.

Behavioral Theory

Behavioral theorists view anxiety as being learned through experiences. Conversely, people can change
or “unlearn” behaviors through new experiences. Behaviorists believe that people can modify
maladaptive behaviors without gaining insight into their causes. They contend that disturbing behaviors
that develop and interfere with a person’s life can be extinguished or unlearned by repeated
experiences guided by a trained therapist.

CULTURAL CONSIDERATIONS
Asian cultures often express anxiety through somatic symptoms such as headaches, backaches,
fatigue, dizziness, and stomach problems.

One intense anxiety reaction is koro, or a man’s profound fear that his penis will retract into the
abdomen and he will then die.
Accepted forms of treatment include having the person firmly hold his penis until the fear
passes, often with assistance from family members or friends, and clamping the penis to a
wooden box. In women, koro is the fear that the vulva and nipples will disappear.

Susto is diagnosed in some Hispanics (Peruvians, Bolivians, Colombians, and Central and
South American Indians) during cases of high anxiety, sadness, agitation, weight loss, weakness,
and heart rate changes.

The symptoms are believed to occur because supernatural spirits or bad air from dangerous
places and cemeteries invades the body.

Positive reframing means turning negative messages into positive messages.

Ex: “My heart is pounding. I think I’m going to die!” to  “I can stand this. This is just
anxiety. It will go away.”

Decatastrophizing involves the therapist’s use of questions to more realistically appraise the
situation.

Ex: “What is the worst thing that could happen? Is that likely? Could you survive that? Is
that as bad as you imagine?” The client uses thought-stopping and distraction techniques
to jolt himself or herself from focusing on negative thoughts 
- Splashing face with cold water
 - Snapping a rubber band worn on the wrist
- Shouting

Assertiveness training helps the person take more control over life situations.

Ex: using “I” statements to identify feelings and to communicate concerns or needs to
others.
- “I feel angry when you turn your back while I’m talking”
- “I want to have 5 minutes of your time for an uninterrupted conversation
about something important”
- “I would like to have about 30 minutes in the evening to relax without
interruption.”

Drugs Used to Treat Anxiety Disorders

Generic (Trade) Drug Classification Used to Treat

Name

Alprazolam (Xanax) Benzodiazepine Anxiety, panic disorder, social phobia,

Buspirone (BuSpar)
Clorazepate (Tranxene)
Chlordiazepoxide (Librium)
Clonazepam (Klonopin)
Clonidine (Catapres)
Diazepam (Valium)
Fluoxetine (Prozac)
Hydroxyzine (Vistaril,
Atarax)
Imipramine (Tofranil)
Meprobamate (Miltown,
Equanil)
Oxazepam (Serax)
Paroxetine (Paxil)
Propranolol (Inderal)
Sertraline (Zoloft)
agoraphobia
Nonbenzodiazepine Anxiety, social phobia, GAD
anxiolytic
Benzodiazepine Anxiety
Benzodiazepine Anxiety
Benzodiazepine Anxiety, panic disorder
Beta-blocker Anxiety, panic disorder
Benzodiazepine Anxiety, panic disorder
SSRI antidepressant Panic disorder, GAD
Antihistamine Anxiety
Tricyclic antidepressant Anxiety, panic disorder, agoraphobia
Nonbenzodiazepine Anxiety
anxiolytic
Benzodiazepine Anxiety
SSRI antidepressant Social phobia, GAD
Alpha-adrenergic agonist Anxiety, panic disorder, GAD
SSRI antidepressant Panic disorder, social phobia, GAD
 Psychotropic medications:

Psychotropic: psychiatric medications that alter chemical levels of the brain = impact mood + behavior
 Antipsychotics, antidepressants, mood stabilizers, ADHD drugs, anti-anxiety

NEUROTRANSMITTERS:
Dopamine: r/t psychosis (schizophrenia)
Serotonin: mood disorders (depression)

Benzodiazepines, Nonbenzodiazepines, Antidepressants: SSRI’s

 Short-term or prn use only

Mode of action:
- Potentiates GABA (neurotransmitter important in relaxation)
- CNS depressant
 Pregnancy class D **

Most common:
- Diazepam (Valium)  LONG ACTING
- Alprazolam (Xanax)
- Clonazepam (Klonopin)
- Lorazepam (Ativan)
- Chlordiazepoxide (Librium): not used for anxiety but can be used for alcohol withdrawal
symptoms
- Midazolam (Versed): used in conscious sedation

Side Effects: Benzodiazepines

 Drowsiness
 Dizziness
 Hypotension
 Hepatic dysfunction

Patient Teaching:
 Do NOT combine with alcohol
 NOT for long-term use as tolerance/addiction develop
 Don’t discontinue abruptly
 Take as directed

Nursing Considerations:
- Check renal and hepatic function
- NOT for patients at high risk for suicide
- Assess for R/f falls
- Contraindicated in sleep apnea
 - Long-term use means patient need deeper sedation during operative procedures

Benzodiazepine TOXICITY
 Very frequently used in overdose/suicides

 S/S: Excessive sedation

Respiratory depression
Coma
 Antidote: Flumazenil (Romazicon) IV

Buspirone (BuSpar)  nonbenzo.

Mode of action:
- Binds to serotonin, dopamine receptors
 Pregnancy class B **
- safe for long-term use

Side Effects: Buspar

 Dizziness
 Drowsiness
 Fatigue
 Insomnia
 Hypotension
 Palpitations

Patient Teaching/Nursing Considerations:

 Alcohol, caffeine, cigarette smoking decreases its effect
 Grapefruit juice increases its sensitivity
 Delayed onset; 7-10 days to START working to 2 weeks
 Don’t discontinue abruptly
 Renal/liver impairment

Antihistamine:
Hydroxyzine (Vistaril, Atarax)

Side Effects:
 Drowsiness
 Ataxia
 Hypotension
Beta blockers: Anticonvulsants:
Atenolol (Tenormin) Carbamazepine (Tegretol)
Propranolol (Inderal) Gabapentin (Neurontin)
Valporic acid (Depakote)

 Take 6-8 weeks to reach full therapeutic value

Mode of action:
- Alleviate anxiety by working on the GABA neurotransmitter
- Elevate levels of serotonin

Side Effects:
 HA
 Anhedonia
 Somnolence
 Nausea
 Insomnia
 Sexual dysfunction
 Weight gain
 Mania
 Suicide risk
 Platelet dysfunction

Antidepressants: SSRI’s

Most common: Side Effects:

- Citalopram (Celexa) - Nausea
- Escitalopram (Lexapro) - Insomnia
- Fluoxetine (Prozac) - Dizziness
- Paroxetine (Paxil) - Weight loss/gain
- Sertraline (Zoloft) - Anxiety + restlessness
- Decreased sex drive
- Dry mouth
- Fatigue

Use in caution/don’t use:

- MAOI’s
- Coumadin
- Digoxin
- Tricyclic Antidepressants
- Haldol
- Lithium
- Ambien
- NSAID’s
 Herbal Products
(short-term use & PRN only)

Kava (kava kava)

* not to be taken during pregnancy, lactation, or children <12 w/other CNS depressants

Mode of action:
- Similar to benzodiazepines, also muscle relaxant properties

Side Effects:
- Impaired judgment & thinking
- Thrombocytopenia
- Leukocytopenia
- Dyspnea
- Pulmonary hypertension
- Liver toxicity

Melatonin

Mode of action: Side Effects:

 Helps sleep-wake cycle - sedation
 Use cautiously if given with CNS depressants - confusion
- HA
- tachycardia

Contraindicated:
- Hepatic disease
- CVA
- Depression
- Neurologic disorders

Valerian root

Mode of action: Side Effects:

 May increase GABA - drowsiness
 Generally taken for sleep - HA
 Use cautiously if given with CNS depressants - dry mouth

Contraindicated:
- Alcohol use
- Pregnancy & lactation
- Must stop weeks before surgery
 Anxiety Disorder
Characterized by persistent, excessive worry.

Treatment/management/interventions of anxiety:
 CBT
 Meds
 Meditation, relaxation techniques
 Journaling
 Exercise
 Distraction
 Guided Imagery
 Building self esteem
 Dietary adjustments

GAD – generalized anxiety disorder:

Excessive, long term worry/anxiety that is not focused on any one object or situation
 Usually around activities or situations e.g. work, school, home
 Anxiety disrupts daily functioning during the majority of days over at least a 6 month period
 More prevalent in females

Symptoms:
- Worry
- Restlessness
- Fatigue
- Difficult concentrating
- Irritability
- Tension
- Sleep disturbances

Phobic disorder:
Irrational fear and anxiety triggered by a specific stimulus or situation
Disability occurs due to narrowing of activities etc. to avoid contact with object/situation

Social phobia:
 Fear of social or performance situations
 Hypersensitivity to criticism
 Low self-esteem, poor social skills
 Often leading to avoidance behavior

Specific phobia:
 Anxiety provoked by exposure to specific feared object or situation – often leading to distress &
avoidance

Agoraphobia:
 Fear of having a panic attack after having one previously
OCD – obsessive compulsive behavior:

 Repetitive obsessions – distressing, persistent, intrusive **

 Compulsions and rituals
o Ex: hand washing, ordering, checking

Panic disorder:
The presence of recurrent, unexpected panic attacks followed by at least one month of persistent
concern about having another panic attack, or a significant behavioral change r/t the PA

 Individual must have experienced at least 2 panic attacks to be diagnosed

 Body’s fight or flight mechanisms create sensation that the body is in danger
 SSRI’s are the FIRST LINE choice in medication to prevent PA (smaller doses)

2 types:
 Panic disorder with agoraphobia
 Panic disorder without agoraphobia

Symptoms: (s/s same as Panic attack)

- Increased HR, RR, BP
- Perspiration
- Trembling
- SOB
- Nausea
- Dizziness

PTSD – post traumatic stress disorder:

Anxiety disorder resulting from traumatic experience

Symptoms:
- Recurrent, intrusive recollections of the event
- Dreams of event
- Avoid talking/thinking about the trauma
- Decreased interest and participation in important activities
- Detached

Predisposing factors:
 Background
 Presence of preexisting mental disorder
 Patient’s pre morbid personality

Panic attack:
 Not a disorder in itself
 A discrete period of intense fear or discomfort in the absence of real danger
 Obsessive–Compulsive and Related Disorders

compulsions – ritualistic or repetitive behaviors or mental acts that a person carries out
continuously in an attempt to neutralize anxiety

Dermatillomania – compulsive skin picking, often to the point of physical damage; an impulse control
disorder

excoriation – skin picking; dermatillomania; categorized as a self-soothing behavior

exposure – behavioral technique that involves having the client deliberately confront the situations
and stimuli that he or she is trying to avoid

obsessions – recurrent, persistent, intrusive, and unwanted thoughts, images, or impulses that cause
marked anxiety and interfere with interpersonal, social, or occupational function

oniomania – compulsive buying; possessions are acquired compulsively without regard for cost or
need for the item

onychophagia – compulsive nail biting

response prevention – behavioral technique that focuses on delaying or avoiding performance of

rituals in response to anxiety-provoking thoughts

trichotillomania – compulsive hair pulling from scalp, eyebrows, or other parts of the body; leaves
patchy bald spots that the person tries to conceal

Somatic Symptom Illnesses:

Somatic symptom illnesses are chronic or recurrent; changes occur slowly.
 If treatment is effective, the client should make fewer visits to physicians as a result of
physical complaints, use less medication and more positive coping techniques, and increase
functional abilities.

 Often have sleep pattern disturbances, lack basic nutrition, and get no exercise.
 Multiple prescriptions for pain or other complaints.

Nursing diagnoses:

 Ineffective Coping
 Ineffective Denial
 Impaired Social Interaction
 Anxiety
 Disturbed Sleep Pattern
 Fatigue
 Pain
Clients with conversion disorder may be at risk for disuse syndrome from having pseudoneurologic
paralysis symptoms. In other words, if clients do not use a limb for a long time, the muscles may
weaken or undergo atrophy from lack of use.

Treatment outcomes for clients with a somatic symptom illness may include the following:

 The client will identify the relationship between stress and physical symptoms.
 The client will verbally express emotional feelings.
 The client will follow an established daily routine.
 The client will demonstrate alternative ways to deal with stress, anxiety, and other feelings.
 The client will demonstrate healthier behaviors regarding rest, activity, and nutritional intake.

Providing Health Teaching

The nurse must help the client learn how to establish a daily routine that includes improved health
behaviors. Adequate nutritional intake, improved sleep patterns, and a realistic balance of activity
and rest are all areas with which the client may need assistance. The nurse should expect resistance.

Ex: Nurse: “Let’s take a walk outside for some fresh air.” (encouraging collaboration)
Client: “I wish I could, but I feel so terrible, I just can’t do it.”
Nurse: “I know this is difficult, but some exercise is essential. It will be a short walk.”
(validation; encouraging collaboration)

CLIENT/FAMILY EDUCATION
 Establish daily health routine, including adequate rest, exercise, and nutrition.
 Teach about relationship of stress and physical symptoms and mind–body relationship.
 Educate about proper nutrition, rest, and exercise.
 Educate client in relaxation techniques: progressive relaxation, deep breathing, guided imagery,
and distraction such as music or other activities.
 Educate client by role-playing social situations and interactions.
 Encourage family to provide attention and encouragement when client has fewer complaints.
 Encourage family to decrease special attention when client is in “sick” role.
TERVENTIONS
 Health teaching
 Establish a daily routine.
 Promote adequate nutrition and sleep.
 Expression of emotional feelings
 Recognize relationship between stress/coping and physical symptoms.
 Keep a journal.
 Limit time spent on physical complaints.
 Limit primary and secondary gains.
 Coping strategies
 Emotion-focused coping strategies such as relaxation techniques, deep breathing,
guided imagery, and distraction
 Problem-focused coping strategies such as problem-solving strategies and role-
playing
Points to Consider – Somatoform Disorders
 Carefully assess the client’s physical complaints. Even when a client has a history of a
somatoform disorder, the nurse must not dismiss physical complaints or assume they are
psychological. The client actually may have a medical condition.

 Validate the client’s feelings while trying to engage him or her in treatment; for example, use a
reflective yet engaging comment such as “I know you’re not feeling well, but it is important to
get some exercise each day.”

 Remember that the somatic complaints are not under the client’s voluntary control. The client
will have fewer somatic complaints when he or she improves coping skills and interpersonal
relationships.

conversion disorder – sometimes called conversion reaction; involves unexplained, usually sudden
deficits in sensory or motor function related to an emotional conflict the
client experiences but does not handle directly

disease conviction – preoccupation with the fear that one has a serious disease

disease phobia – preoccupation with the fear that one will get a serious disease

emotion-focused coping strategies – techniques to assist clients to relax and reduce feelings of stress

fabricated and induced illness – factitious disorders characterized by physical symptoms that are
feigned or inflicted on one’s self or another person for the sole
purpose of gaining attention or other emotional benefits; also called
factitious disorder, imposed on self or others

factitious disorder – imposed on self or others; hypochondriasis

hysteria – refers to multiple, recurrent physical complaints with no organic basis

illness anxiety disorder – preoccupation with the fear that one has a serious disease or will get a
serious disease; also called hypochondriasis

internalization – keeping stress, anxiety, or frustration inside rather than expressing them outwardly

la belle indifférence – a seeming lack of concern or distress; a key feature of conversion disorder

malingering – the intentional production of false or grossly exaggerated physical or psychological

symptoms

Munchausen’s syndrome – a factitious disorder where the person intentionally causes injury or
physical symptoms to self to gain attention and sympathy from health-
care providers, family, and others
Munchausen’s syndrome by proxy – when a person inflicts illness or injury on someone else to gain
the attention of emergency medical personnel or to be a hero for “saving” the victim

pain disorder – has the primary physical symptom of pain, which generally is unrelieved by analgesics
and greatly affected by psychological factors in terms of onset, severity, exacerbation,
and maintenance

primary gain – the relief of anxiety achieved by performing the specific anxiety-driven behavior; the
direct external benefits that being sick provides, such as relief of anxiety, conflict, or
distress

problem-focused coping strategies – techniques used to resolve or change a person’s behavior or

situation or to manage life stressors

psychosomatic – used to convey the connection between the mind (psyche) and the body (soma) in
states of health and illness

secondary gain – the internal or personal benefits received from others because one is sick, such as
attention from family members, comfort measures, and being excused from usual
responsibilities or tasks

somatic symptom disorder – characterized by multiple, recurrent physical symptoms in a variety of

bodily systems that have no organic or medical basis; also called
somatization disorder

somatization – the transference of mental experiences and states into bodily symptoms

DID – dissociative identity disorder

 Essential feature of a disruption in the usually integrated functions of consciousness, memory,
identity, or environmental perception.
 Interferes with relationships, ability to function in daily life, and ability to cope with the realities
of the abusive or traumatic event.
 Much more prevalent among those with histories of childhood physical and sexual abuse.

Dissociative amnesia: cannot remember important personal information; includes a

fugue experience where the client suddenly moves to a new geographic location with no
memory of past events, and often the assumption of a new identity.

Dissociative identity disorder (formerly multiple personality disorder): displays two or

more distinct identities or personality states that recurrently take control of his or her
behavior. This is accompanied by the inability to recall important personal information.

Depersonalization/derealization disorder: persistent or recurrent feeling of being

detached from his or her mental processes or body (depersonalization) or sensation of
being in a dream-like state where the environment seems foggy or unreal (derealization).
The client is not psychotic or out of touch with reality.
ETHICAL ISSUES
Ethics is a branch of philosophy that deals with values of human conduct related to the rightness or
wrongness of actions and to the goodness and badness of the motives and ends of such actions.
Ethical theories are sets of principles used to decide what is morally right or wrong.

Utilitarianism is a theory that bases decisions on “the greatest good for the greatest number.”
Decisions based on utilitarianism consider which action would produce the greatest benefit for the
most people. Deontology is a theory that says decisions should be based on whether or not an
action is morally right with no regard for the result or consequences. Principles used as guides for
decision making in deontology include autonomy, beneficence, nonmaleficence, justice, veracity, and
fidelity.

Autonomy refers to the person’s right to self-determination and independence. Beneficence

refers to one’s duty to benefit or to promote the good of others. Nonmaleficence is the
requirement to do no harm to others either intentionally or unintentionally. Justice refers to
fairness; that is, treating all people fairly and equally without regard for social or economic status,
race, sex, marital status, religion, ethnicity, or cultural beliefs. Veracity is the duty to be honest or
truthful. Fidelity refers to the obligation to honor commitments and contracts.

All these principles have meaning in health care. The nurse respects the client’s autonomy
through patient’s rights and informed consent, and by encouraging the client to make choices about
his or her health care. The nurse has a duty to take actions that promote the client’s health
(beneficence) and that do not harm the client (nonmaleficence). The nurse must treat all clients
fairly (justice), be truthful and honest (veracity), and honor all duties and commitments to clients
and families (fidelity).

Ethical Dilemmas in Mental Health

An ethical dilemma is a situation in which ethical principles conflict or when there is no one clear
course of action in a given situation. For example, the client who refuses medication or treatment is
allowed to do so on the basis of the principle of autonomy. If the client presents an imminent threat
of danger to self or others, however, the principle of nonmaleficence (do no harm) is at risk. To
protect the client or others from harm, the client may be involuntarily committed to a hospital, even
though some may argue that this action violates his or her right to autonomy. In this example, the
utilitarian theory of doing the greatest good for the greatest number (involuntary commitment)
overrides the individual client’s autonomy (right to refuse treatment). Ethical dilemmas are often
complicated and charged with emotion, making it difficult to arrive at fair or “right” decisions.

Many dilemmas in mental health involve the client’s right to self-determination and
independence (autonomy) and concern for the “public good” (utilitarianism). Examples include the
following:
  Once a client is stabilized on psychotropic medication, should the client be forced to remain
on medication through the use of enforced depot injections or through outpatient
commitment?
 Are psychotic clients necessarily incompetent, or do they still have the right to refuse
hospitalization and medication?
 Can consumers of mental health care truly be empowered if health-care professionals “step
in” to make decisions for them “for their own good?”
 Should physicians break confidentiality to report clients who drive cars at high speeds and
recklessly?
 Should a client who is loud and intrusive to other clients on a hospital unit be secluded from
the others?
 A health-care worker has an established relationship with a person who later becomes a
client in the agency where the health-care worker practices. Can the health-care worker
continue the relationship with the person who is now a client?
 To protect the public, can clients with a history of violence toward others be detained after
their symptoms are stable?
 When a therapeutic relationship has ended, can a health-care professional ever have a social
or intimate relationship with someone he or she met as a client?
 Is it possible to maintain strict professional boundaries (i.e., no previous, current, or future
personal relationships with clients) in small communities and rural areas, where all people in
the community know one another?

The nurse will confront some of these dilemmas directly, and he or she will have to make decisions
about a course of action. For example, the nurse may observe behavior between another health-care
worker and a client that seems flirtatious or inappropriate. Another dilemma might represent the
policies or common practice of the agency where the nurse is employed; the nurse may have to
decide whether he or she can support those practices or seek a position elsewhere. An example would
be an agency that takes clients with a history of medication noncompliance only if they are scheduled
for depot injections or remain on an outpatient commitment status. Yet other dilemmas are in the
larger social arena; the nurse’s decision is whether to support current practice or to advocate for
change on behalf of clients, such as laws permitting people to be detained after treatment is
completed when there is a potential of future risk for violence.

CONTENT AREAS FOR ETHICAL CODE

 Compassion, respect, human dignity, and worth
 Primary commitment to patients
 Promotion of health, safety, and patient rights
 Responsible, accountable provision of care
 Professional growth and competence of the nurse
 Promotion of safe, ethical health care/work environment
 Advancement of the nursing profession
 Collaboration with others
 Maintain integrity of profession, include social justice
Ethical Decision Making
The ANA published a Code of Ethics for Nurses in 2001 to guide choices about ethical actions. A
new, revised code of ethics is scheduled for release in 2015.
Models for ethical decision making include gathering information, clarifying values, identifying
options, identifying legal considerations and practical restraints, building consensus for the decision
reached, and reviewing and analyzing the decision to determine what was learned.

SHARED DECISION MAKING

Health literacy is essential for shared decision making. In mental health, persons with severe illnesses
often do not participate fully in this process. The authors propose an integrative model that increases
health literacy and fosters shared decision making in mental health settings.
The next step is to implement such a model consistently in a mental health setting to determine its
effectiveness in terms of health literacy, shared decision making, and patient satisfaction and participation
in the process.

SELF-AWARENESS ISSUES
All nurses have beliefs about what is right or wrong and good or bad. That is, they have values just
like all other people. Being a member of the nursing profession, however, presumes a duty to clients
and families under the nurse’s care: a duty to protect rights, to be an advocate, and to act in the
clients’ best interests even if that duty is in conflict with the nurse’s personal values and beliefs. The
nurse is obligated to engage in self-awareness by identifying clearly and examining his or her own
values and beliefs, so they do not become confused with or overshadow a client’s. For example, if a
client is grieving over her decision to have an abortion, the nurse must be able to provide support to
her even though the nurse may be opposed to abortion. If the nurse cannot do that, then he or she
should talk to colleagues to find someone who can meet that client’s needs.

Points to Consider When Confronting Ethical Dilemmas

 Talk to colleagues or seek professional supervision. Usually, the nurse does not need to resolve
an ethical dilemma alone.

 Spend time thinking about ethical issues and determine what your values and beliefs are
regarding situations before they occur.

 Be willing to discuss ethical concerns with colleagues or managers. Being silent is condoning the
behavior.
Levels of Care Within the Healthcare Community (Interventions at Each Level)

Primary prevention

• Primary prevention is defined as reducing the incidence of mental disorders within the population
• It is focused on targeting groups at risk and providing educational programs

Ex. Doing counseling before getting married

• The services are offer in settings that are convenient to the public such as churches, schools,
colleges, community centers, YMCA and YWCA, workplace of employee organizations, meeting of
women’s group, health fairs and community shelters

Secondary Prevention

 It deals with reducing the prevalence of psychiatric illness by shortening the course
(duration) of the illness

 It is accomplished through early identification of problems and prompt initiation of effective

treatment and referrals

 There is already an existing problem and you do interventions to prevent that it gets worst
Ex. If a couple is married and are having marital problems, you recommend counseling

 Services can be offered for the followings:

o Ongoing assessments on individual at risk for illness exacerbation:

 during home visits, day care, in community health centers

o Provision of care for individuals in whom illness symptoms have been accessed:

 individual or group counseling, medication administration, education and

support during periods of high stress---crisis intervention, staffing rape crisis
centers, suicide hotlines, homeless shelters, shelters for abuse women,
mobile medical health units

o Referrals for treatment of individuals in whom illness symptoms have been

accessed:

 support groups, community mental health centers, emergencies services,

psychiatrist or psychologist, and day or partial hospitalization.
 Tertiary prevention

 Reducing the residual defects that are associated with severe and persistent mental illness

 It is accomplished by preventing complications of the illness and promoting achievement of

everyone’s maximum level of functioning

o Ex: A person has chronic mental illness and you do rehabilitation so that the
condition does not get worst

 Nursing in tertiary prevention focus on helping clients learn or relearned socially

appropriate behaviors so that they may achieve a satisfying role within the community.

 At this level, you also do teach and referrals---look at samples on pg 749

 Nursing care at the tertiary level of prevention can be administer on an individual or group
basis and in a variety of settings such as inpatient hospitalization, day and partial
hospitalization, group home or halfway house, shelters, home health care, nursing homes,
and community mental health centers.

Roles of the Nurse in Various Levels of Care in the Community

Case Manager: is the nurse responsible for negotiating with multiple health care providers to
obtain a variety of services for the client. The case manager coordinates the
person care across the entire spectrum of what is happening in the community

 Case management has been shown to enhance the client’s functioning by

increasing ability to solve problems, improving work and socialization skills,
and endeavoring to diminish dependency on others

Role of the Nurse in Psychiatry:

 The role of the psychiatry nurse is to assist the client’s successful adaptation to stressors within
the environment

 Goals are directed toward change in thoughts, feelings, and behaviors that are age-appropriate
and congruent with local and cultural norms

The Role of Legal Implication

Nursing Process Related to Patient’s with Mental Illness

The nursing process is the same for mentally ill patients, there is only some differences on how you do
the assessment, in which you focus on psychological and social factors, observation of the client and
his/her environment, subjective/objective data. The patient is more looked in a holistic way. You also
assess for spirituality, learning needs, suicidal thoughts. The most important assessment is to
diagnose the level of risk which requires priority, as it can be a life-threatening potential
Restraints and Seclusion
 Seclusion: the involuntary confinement of a patient alone in a room or area
from which the patient is physically prevented from leaving, equipped with a
security window or camera for direct visual monitoring.

o Any sharp or potentially dangerous objects are removed

o Seclusion decreases stimulation, protects others from the client, prevents

property destruction, and provides privacy for the client.

o “short-term seclusion” is permitted only when the client is imminently

aggressive and dangerous to himself or others

o Considered as LAST RESORT

o Aim to prevent imminent and serious harm to self or others

o Requires clinical observation by RN/MO at 15 mins intervals

 Monitor breathing
 Levels of agitation

o Review by AP must be at the 4/24 interval

o Can be initiated by senior nurse on duty or AP (or delegate)

o Report back to chief psychiatrist

 Restraint: any manual method, physical or mechanical device, material, or

equipment, that immobilizes or reduces the free ability of the patient to move his
or her limbs. Considered LAST RESORT

o Seclusion or restraints are only used after alternative interventions have

been tried including:

 Verbal intervention
 Behavioral care plan
 Medication
 Decrease in sensory stimulation
 Removal of problematic stimulus
 Presence of OS
 Frequent observation or one on one observation

 To administer treatment or medical treatment

 Requires face-to-face eval by licensed independent practitioner w/I 1 hour of
restraint/seclusion and every 8 hours after
 A MD order needed every 4 hours
o FOR A CHILD – order needed every 2 hours w/ face-to-face eval Q4 hours
  Documented assessment by the nurse every 1 to 2 hours
 Patients need close monitoring and frequent assessments
 Hydration, toileting, nutrition, and comfort are essential (Maslow’s hierarchy)
 Used to prevent patients from self-harm or harming others and must be
discontinued as soon as possible
 Written record must be completed every 15 minutes; monitor vital signs; debrief
with patients
 Anger control assistance (common sense with aggressive patients)

 Chemical Restraint:
o Medication provided as a way to reduce:
 Symptoms and treat illness
 High levels of agitation and aggression
 Consider the use of ‘chemical restraint’ in ED & MHU
 Is it for the provision of care OR behavioral modification?
 Symptom amelioration is not the principal focus of strengths
recovery models of MH
 Fine balance between symptom amelioration & unwanted
side effects resulting in non-adherence to all forms of
treatment.

Nursing Considerations:

 Nurses act as advocates

 Need to understand the need for the MHA and how it protects & supports
decisions in treatment & care
 Uphold the ethical practices in care
 Involve the person, NP, families & careers in all aspects of care
 Reduce the use of restrictive practices

Apply primary terms and concepts (i.e automony, morals, values, etc): Principles of Bioethics

Bioethics: ethics that encompass all those perspectives that seek to understand
human nature and behavior, the domain of social science, and the natural world.
Broadly grouped under the rubric of “life sciences”.
The heart of bioethics are 3 paramount human questions.
1)What kind of person should I be in order to live a moral life and make good
ethical decisions?
2)What are my duties and obligations to other individuals whose life and well-
being may be affected by my actions?
3)What do I owe the common good or the public interest in my life as a member
of society?
autonomy: self-determination; being independent and self-governing.
beneficence: principle of doing good.
morals: like ethics, concerned with what constitutes right action; more informal
and personal than the term ethics.
nonmaleficence: principle of avoiding evil.
fidelity: keeping promises and commitments made to others.
breach of duty: the nurse (or physician) failed to conform to standards of care,
thereby breaching or failing the existing duty; the nurse did not act as a
reasonable, prudent nurse would have acted in similar circumstances
Principle Moral Rule Implications for Nursing Practice
Autonomy Respect the rights Provide the information and support
(self- of patients or their patients and families need to make the
determination) surrogates to make decision that is right for them, including
health care collaborating with other members of the
decisions. health care team to advocate for the
patient.

Avoid causing Seek not to inflict harm; seek to prevent

Nonmaleficence harm. harm or risk of harm whenever possible.

Beneficence Benefit the Commit yourself to actively promoting

patient, and the patient’s benefit (health and well-
balance benefits being or good dying). Be sensitive to the
against risks and fact that individuals (patients, family
harms. members, and professional) may identify
benefits and harms differently. A benefit
to one may be a burden to another.

Justice Give each his or Always seek to distribute the benefits,

her due; act fairly. risks, and costs of nursing care justly.
This may involve recognizing subtle
instances of bias and discrimination.
 Fidelity Keep promises. Be faithful to the promise you made to
the public to be competent and to be
willing to use your competence to benefit
the patients entrusted to your care. Never
abandon a patient entrusted to your care
without first providing for the patient’s
needs.

Torts

Intentional vs. unintentional torts

There are intentional and non-intentional torts. It doesn’t matter if you meant to do harm to a
person, just that the harm was done by the nurse’s neglect. Some of the intentional torts are:

 Assault and battery – Assault being the threat or an attempt to do bodily harm and
battery is when the assault is followed through with. This includes the willful, angry or
violent way you could touch even something that was attached to or on a person, like
their cloths. So, an aide undressing someone in an angry willful way could be considered
battery. Threatening to do it would be assault. Giving a shot to a person who refused is
battery.

 Defamation of character – Can be written or verbal- now can be electronic with

social media as well. This can be anything that sullies the reputation of another (even if
it’s a true exaggerated thing that is getting passed around).

 Invasion of Privacy – Which is constitutional right via the Constitution. HIPPA also
falls under this umbrella. So, ALL their information is private, spoken/written/electronic,
even just the reason for their visit with no name attached to it is private.

 False imprisonment – Unjustified retention or prevention of the movement of another

person without proper consent can constitute false imprisonment. For example, only a
reasonable amount of restraint should be used in circumstances that warrant it. The
indiscriminate and thoughtless use of restraints on a patient can constitute false
imprisonment

 Fraud – Is willful and purposeful misrepresentation that could cause, or has caused, loss
or harm to a person or property. Misrepresentation of a product is a common fraudulent
act. A person fraudulently misrepresenting oneself to obtain a license to practice nursing
 may be prosecuted under the state’s Nurse Practice Act. Also, misrepresenting the
outcome of a procedure or treatment may constitute fraud.
Unintentional Torts

Negligence and malpractice – Negligence is defined as performing an act that a

reasonably prudent person under similar circumstances would not do or, conversely,
failing to perform an act that a reasonably prudent person under similar circumstances
would do. As the definition implies, an act of negligence may be an act of omission or
commission. Malpractice is the term generally used to describe negligence by professional
personnel.

Liability involves four elements that must be established to prove that malpractice or
negligence has occurred: duty, breach of duty, causation, and damages. Duty refers to an
obligation to use due care (what a reasonably prudent nurse would do) and is defined by
the standard of care appropriate for the nurse–patient relationship. Breach of duty is the
failure to meet the standard of care. Causation, the most difficult element of liability to
prove, shows that the failure to meet the standard of care (breach) actually caused the
injury. Damages are the actual harm or injury resulting to the patient. These all relate to
Standard of Care, or what a reasonably prudent Nurse would or would not have done.

Rights of Clients and Related Issues

Clients receiving mental health care retain all civil rights afforded to all people except
the right to leave the hospital in the case of involuntary commitment.

- right to refuse treatment

- to send and to receive sealed mail
- have or refuse visitors.
 Any restrictions (e.g., mail, visitors, and clothing) must be made for a verifiable,
documented reason. These decisions can be made by a court or a designated
decision-making person or persons, for example, a primary nurse or treatment
team, depending on local laws or regulations.

Examples include the following:

 A suicidal client may not be permitted to keep a belt, shoelaces, or scissors

because he or she may use these items for self-harm.
 A client who becomes aggressive after having a particular visitor may have that
person restricted from visiting for a period of time.
 A client making threatening phone calls to others outside the hospital may be
permitted only supervised phone calls until his or her condition improves.

Duty to Warn Third Parties

One exception to the client’s right to confidentiality is the duty to warn, based on the
California Supreme Court decision in Tarasoff vs. Regents of the University of
California. As a result of this decision, mental health clinicians may have a duty to
warn identifiable third parties of threats made by clients, even if these threats were
discussed during therapy sessions otherwise protected by privilege.
When making a decision about warning a third party, the clinician must base his or
her decision on the following:

 Is the client dangerous to others?

 Is the danger the result of serious mental illness?
 Is the danger serious?
 Are the means to carry out the threat available?
 Is the danger targeted at identifiable victims?
 Is the victim accessible?

For example, if a man were admitted to a psychiatric facility stating he was going to
kill his wife, the duty to warn his wife is clear. If, however, a client with paranoia were
admitted saying, “I’m going to get them before they get me,” but providing no other
information, there is no specific third party to warn. Decisions about the duty to warn
third parties are usually made by psychiatrists or by qualified mental health
therapists in outpatient settings.

Cycle of Abuse and Violence

- Abuse is another reason often cited for why women have difficulty leaving
abusive relationships.
- Initial episode of battery or violence is followed by a period of the abuser
expressing regret, apologizing, and promising it will never happen again; the
honeymoon period.
 Assessment
- gives an example of questions to ask using the acronym SAFE (stress/safety,
afraid/abused, friends/family, and emergency plan)

SAFE QUESTIONS
 Stress/Safety: What stress do you experience in your relationships? Do you feel safe in
your relationships? Should I be concerned for your safety?

 Afraid/Abused: Have there been situations in your relationships where you have felt
afraid? Has your partner ever threatened or abused you or your children? Have you ever
been physically hurt or threatened by your partner? Are you in a relationship like that now?
Has your partner ever forced you to engage in sexual intercourse that you did not want?
People in relationships/marriages often fight; what happens when you and your partner
disagree?

 Friends/Family: Are your friends aware that you have been hurt? Do your parents or
siblings know about this abuse? Do you think you could tell them, and would they be able to
give you support?

 Emergency plan: Do you have a safe place to go and the resources you (and your children)
need in an emergency? If you are in danger now, would you like help in locating a shelter?
Would you like to talk to a social worker/a counselor/me to develop an emergency plan?

 Dos and Don’ts of Working with Victims of Partner Abuse

Don’ts Dos

 Don’t tell the victim what to do.  Do believe the victim.

 Don’t express disgust, disbelief, or
anger.
 Don’t disclose client
communications without the
client’s consent.
 Don’t preach, moralize, or imply
that you doubt the client.
 Don’t minimize the impact of
violence.
 Don’t express outrage with the
perpetrator.
 Don’t imply that the client is
responsible for the abuse.
 Don’t recommend couples’
counseling.
 Do ensure and maintain the client’s
confidentiality.
 Do listen, affirm, and say, “I am sorry you
have been hurt.”
 Do express, “I’m concerned for your safety.”
 Do tell the victim, “You have a right to be
safe and respected.”
 Do say, “The abuse is not your fault.”
 Do recommend a support group or an
individual counseling.
 Do identify community resources, and
encourage the client to develop a safety
plan.
 Do offer to help the client contact a shelter,
the police, or other resources.
 Don’t direct the client to leave the  Do accept and respect the victim’s decision.
relationship.  Do encourage development of a safety plan.
 Don’t take charge and do everything
for the client.

Ostracism, ignoring and excluding a target individual, has recently emerged as

one of the more common and damaging forms of bullying. The victim
experiences threats to belonging, self-esteem, meaningful existence, and sense
of control. Ostracism may pose an even greater threat to children’s adjustment
than bullying.

intergenerational transmission process explains that patterns of violence are

perpetuated from one generation to the next through role modeling and social
learning
Sodomy anal intercourse

CULTURAL CONSIDERATIONS
Although domestic violence affects families of all ethnicities, races, ages, national
origins, sexual orientations, religions, and socioeconomic backgrounds, a specific
population is particularly at risk: immigrant women. Battered immigrant women face
legal, social, and economic problems different from U.S. citizens who are battered and
from people of other cultural, racial, and ethnic origins who are not battered.

 The battered woman may come from a culture that accepts domestic violence.

 She may believe she has less access to legal and social services than do U.S. citizens.

 If she is not a citizen, she may be forced to leave the United States if she seeks legal sanctions
against her husband or attempts to leave him.

 She is isolated by cultural dynamics that do not

permit her to leave her husband; economically, she may be unable to gather the resources to
leave, work, or go to school.

 Language barriers may interfere with her ability to call 911; learn about her rights or legal
options; and obtain shelter, financial assistance, or food.

It may be necessary for the nurse to obtain the assistance of an interpreter whom
the woman trusts, make referrals to legal services, and assist the woman to contact
the Department of Immigration to deal with these additional concerns.
Cultural Differences and Appropriate (nursing) Interventions/Responses (i.e. Communication,
Dietary, etc.
Do not assume that all individuals who share a culture or ethnic group are the same. This is stereotyping
and should be avoided.

A. Communication: How to communicate with someone who does not speak your language
and you do not have a translator?

- Use body language such as nonverbal communication (hand gestures)

- Use simple terms when communicating especially if they have little understanding of the
language

B. Diet: Respect cultural differences in regards to food.

Ex: special food accommodation. You need to find out dietary preferences (may possibly allow
family members to bring food for the patient specially kids)

C. Meds:

- Be sensitive to each cultural perspective of health care practitioner and needs in medication
(i. e., folk medicine, healer, curanderos etc.).
- You may need to bring this people to help the client collaborate with the treatment)

D. Strive to gain pt.’s trust. Do that by understanding and accommodating to pt.’s culture

ADD UNIT 3 questions