NCM117 – CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF
BEHAVIOR: Acute and Chronic
I. INTRODUCTION AND HISTORY OF
PSYCHIATRIC NURSING
A. EVOLUTION OF PSYCHIATRIC-MENTAL
HEALTH CARE
1) EARLY HISTORY
 Associated with sin and
demonic possession.
 Perceived as incurable
 Treatment was inhumane
and brutal
2) THE MIDDLE AGES
 Not cared by families
 Often imprisoned or live on
the streets
 Hospital of St, Mary of
Bethlehem (one of the first
hospital)
 Refuge for the destitute and
afflicted
3) THE 15TH THROUGH THE 17TH
CENTURIES
 Skepticism about the
curability was rampant
 Thought to have no feelings
 Believed to lack
understanding
 Treated like animals
 Men and women not given
separated quarters (no
privacy)
 Care administered by
attendants
 Witch-hunts and executions
culminated the deeply
rooted ideas about mental
illness
B. BENCHMARKS IN PSYCHIATRIC
HISTORY
 Rosenblant’s ABC of community
response
o Assistance (least restrictive)
– provided food and money
and often enabled the
family to maintain its
integrity as a unit
o Banishment – wandering
band of “lunatics” .. living
no one cared how, and
dying no one cared where”
o Confinement (most
restricted) – chained.
4) THE 18TH CENTURY
 French and American
revolutions
 Campaigns for the abolition
of slavery through
championing of the equal
rights for women
 Care for the impoverished
a) BENJAMIN RUSH(1745 – 1813)
 Emphasized need for
pleasant surroundings.
 Diversional and moral
treatment
 Inducement of fright
cause mentally ill to regain
their sanity.
 Credited with inventing
the tranquilizer chair and
the gyrator
b) Phillippe Pinel (1745 – 1826)
 Advocated kindness,
understanding and moral
treatment
 Placed in charge of a large
hospital in Bicerte
 Releasing the insane of
societal attitudes towards
those suffering from
mental illness
c) William Tuke (1732-1822)
 advocated humane
treatment of the mentally
ill
 raises money to establish
homes
d) Franz Anton Mesner (1734 –
1815)
 renewed the art of
suggestive healing a form
of hypnotism
PERIOD OF ENLIGHTENMENT
 PHILIPPE PINEL (France) and William
Tuke (England)
 PINEL – unchained the mentally ill;
superintendent of the French
institution, Bicente (men) and
Salpetriere(Women)
 TUKE – established the York Retreat
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NCM117 – CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF
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 The insane were no longer treated as  Established the mental
less human hygiene movement in
 Human dignity was upheld promoting the early
 The ASYLUM Movement was detection of mentally
developed – protection, social treatment
support, or sanctuary from the d) Emil Kraepelin (1858 – 1926)
stresses of life  Devised a classification of
5) THE 19TH CENTURY: THE EVOLUTION mental disorders
OF THE PSYCHIATRIC NURSE  Emphasis on the
 First psychiatric nurse hospital observation and research in
in America at Williamsburg, condition known as
Virginia, in 1773 praecox dementia and
 Mclean Asylum, the first U.S. mania
institution to provide humane e) Eugene Bleuler (1857 – 1939)
treatment  Coined the term
 The psychiatric nursing role SCHIZOPHRENIA (splitting of
had not yet established the mind)
 Mental health condition  Biochemical reaction –
became deplorable need for could be inherited
reform was urgent Side note: experiences for
6) THE 20TH CENTURY: THE ERA OF hallucinations
PSYCHIATRY  Included the 4A’s (apathy
 Improved social attitudes (affect blunting), autism,
promoted sensitivity ambivalence{presence of
toward the mentally ill two opposing feelings},
a) ADOLPH MEYER (1866 – 1950) looseness of association)
 Focused on physical and f) Sigmund Freund (1856 – 1939)
emotional maturational neurologist
changes  Credited with the
 Emphasized the need to development of
study the person’s whole psychoanalysis,
environment psychosexual theories, and
 Introduced the concept of neurosis.
commonsense psychiatry  Popularized the term
b) Dorothea Lynde Dix (1802 – CATHARSIS, dream
1887) interpretations, and
 Led the crusade about the explanation for hysteria
inhumane treatment and  Side notes: LISTEN TO
condition of mentally ill VOICE RECORD AROUD
patients that led to 42MINS (sobrang
proliferation of the state galit/anger) EX.
hospitals DISPLACEMENT */sinuntok
c) Clifford Beers (1876 – 1943) - pader
former mentally ill patient  Established the basis
 Contributed to preventive psychoanalytical technique
care through his classic  MOTHER: most significant
work, A MIND THAT FOUND person during infancy
ITSELF, published in 1908 g) Carl Gustav Jung (1875 – 1961)
 A descriptive account of his  Founded analytic
tormenting experiences psychology

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 NCM117 – CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF
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 Proposed and originated technique), herbs, and
the concepts of extroverted nutritional approaches
and introverted personality c. TRENDS IN PSYCHIATRIC-MENTAL
 Focused on2 the creative HEALTH NURSING
impulse and spirituality of — Influenced by the social and
the individual economic climate of the times
h) Karen Horney (1885 – 1952) — 1960s and 1970s changes
 Neuroses stem from within health facilities
cultural factors and paralleled the
impaired interpersonal deinstitutionalization of mental
relationships health care
i) Harry Stack Sullivan (1892 – — 1980s there was an enormous
1949) growth in freestanding
 Postulated the hypothesis psychiatric facilities that
of interpersonal theory resulted in client abuse and
 Stimulated the misuse of health care to fill
development of empty beds
multidisciplinary — decrease in the number of
approaches to psychiatric psychiatric admissions and
and milieu therapy eventual closure of psychiatric
PERIODS OF SCIENTIFIC STUDY units and hospitals
 FREUD – emphasized the importance — increase loss of job
of early life experiences in shaping — Evidences-based health care is
mental health the driving force behind
 KRAEPELIN – developed classification treatment approaches
of mental illness — Future trends, demands of
 BLEULER was optimistic about advanced technology
treatment — Research
 Human could be studied, and that — New lifestyle pattern
study held promise for treating and B. MENTAL HEALTH TEAM
curing mental health problems (INTERDISCIPLINARY TEAM)
 The study of the mind and treatment a. PSYCHIATRIST
approaches flourished  Serves as the leader of the
 “DECADE OF THE BRAIN” - (Kraepelin) team responsible for making
7) THE 21ST CENTURY diagnoses and prescribing
 Neuroscience and genetics treatment
opportunities b. CLINICAL PSYCHOLOGIST
 Understanding of the link between  Involved in administering and
behavior and emotions, brain, and interpreting psychological
genes testing
a. INFORMATION SYSTEMS: Internet  Provide psychotherapy and
and cyberspace behavioral modification
— EX. Telemedicine or telemental c. PSYCHIATRIC SOCIAL WORKER
health care  primarily involved in
b. COMPLEMENTARY THERAPIES identifying and dealing with
— Aromatherapy, acupuncture, social issues that affect clients
massage therapy, biofeedback and their families gather
(may naka hooked na mag psychological data on
rerelease ng mga relaxation admission provide crisis

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NCM117 – CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF
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intervention and MENTAL GEALTH AND MENTAL-ILLNESS
psychotherapy CONTINUUM
d. PSYCHIATRIC CLINICAL NURSE MENTAL HEALTH
SPECIALIST  Refers to the ability of people -
 Presents educational couples, families, and communities -
programs for nursing staff to respond adaptively to internal and
 Provides consultation services external stressors.
to nurses who require  Being at peace with oneself, with
assistance in the planning and others, with nature, and with god.
implementation of care for  mens sana in corpore sano in
individual clients societe. (a sound mind in a sound
e. Psychiatric Nurse body in a sound society)
 Provides ongoing assessment VARIABLES AFFECTING MENTAL HEALTH
of the client condition 1. BIOLOGICAL FACTORS - prenatal and
 Administers medication perinatal influences, physical health,
 Assists clients with neuroanatomy, and physiology.
therapeutic activities as 2. SOCIOCULTURAL FACTORS - family
required stability, child-rearing patterns,
 Focus is on one-to-one economic level, housing,
relationship development membership in a minority, religious
f. OCCUPATIONAL THERAPIST influences, and values.
 Primarily involved in  SIDE NOTE: Considering the
providing an array of activities economic status / finances
that enable client to gain skills (Poor and Wealthy)
to perform ADL 3. PSYCHOLOGICAL FACTORS - parent,
 Creative activities and sibling, and infant/child relationship,
therapeutic relationship skills IQ, self-concept, skills, talents, and
are used emotional developmental level.
g. MENTAL HEALTH WORKER OR
PSYCHIATRIC AIDE MENTAL HEALTH AND MENTAL-ILLNESS
 Functions under the CONTINUUM
supervision of the psychiatric a) NEUROBIOLOGICAL FACTORS
nurse — Selve made his explanation of
 Provide direct care to clients stress in terms of adaptation. 3
h. INTERNIST OR PRIMARY CARE STAGES: GENERAL
PROVIDER ADAPTATION SYNDROME
 Co-occurrence of medical 1. ALARM REACTION - initial reaction
problems and conditions to stress
necessitates collaboration (ex. a. SIDE NOTE: Fight or flight
DM, HTN, Convulsions) 2. STAGE OF RESISTANCE - reaction to
i. DIETICIAN continued stress. (homeostasis =
 Plans nutritious meals for all balance)
clients 3. STAGE OF EXHAUSTION - results
j. CHAPLAIN from prolonged exposure to stress
 Assess, identifies, and attends a. SIDE NOTE: resulting to
to the spiritual needs of decrease immune system =
clients and their family physical or psychological
members effect
B. CULTURAL FACTORS

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NCM117 – CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF
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— concerns about heath disparities and  Defense mechanisms
changing demographics must be a share two common
priority to ensure cultural features: (1) they all
competence. (except SUPPRESSION)
C. PSYCHOLOGICAL FACTORS operate on an
— plays a pivotal role in a person's unconscious level and
ability to mobilize adaptive coping  (2) they deny, falsify, or
processes. distort reality to make it
1. EGO FUNCTION AND HEALTH less threatening.
— Ego Although we cannot
o the major personality survive without defense
mechanism that mediates mechanisms, it is
between the person and possible for our defense
the environment mechanisms to distort
o described as the guardian of reality to such a degree
vital balance. that we experience
— a. Ego function difficulty with healthy
o refers to the inherent ability adjustment and personal
growth.
to adapt to internal and
A. LEVELS OF DEFENSE MECHANISMS:
external demands or stress
1. PSYCHOTIC MECHANISMS -
of environment
commonly in healthy individuals
— b. Defense mechanisms
before age 5
o refers to a predominantly
i. Delusional projections -
unconscious & involuntary;
involves attributing
self-protective process that
unacceptable thoughts,
seeks to shield the ego from
emotions and impulses to
intense feelings or affect or
another source that is not
impulses.
based in reality = FALLS
o Side Note/Additional:
FALSE BELIEF
 Defense Mechanisms
ii. Denial - unconscious refusal
and Anxiety - additional
to admit an unacceptable
 Freud (1969) believed
idea or behavior
that anxiety is an
(ALCOHOLIC, DENYING THE
inevitable part of living.
REALITY)
 The environment in
iii. Distortion - believing
which we live presents
something to be true when
dangers and insecurities,
it is not
threats, and
iv. Splitting - black or white
satisfactions. It can
2. IMMATURE MECHANISMS -
produce pain and
common in ages 3 and 15
increase tension or
a. Projection - unconsciously
produce pleasure and
(or consciously) blaming
decrease tension. The
someone else for one's
ego develops defenses,
difficulties.
or defense mechanisms,
i. Interjection = panloob
to ward off anxiety by
b. Schizoid fantasy - tendency
preventing conscious
to retreat into fantasy to
awareness of
avoid the present situation
threatening feelings.
(casual daydreaming)

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NCM117 – CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF
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c. Hypochondriasis
exaggerated psychosomatic
symptoms
d. Passive aggressive behavior
- expression of negative
feeling, resentment, and
aggression in an unassertive
passive way.
e. Acting-out – impulsivity
f. Identification - conscious or
unconscious after
respected person
g. Rationalization - conscious
or unconscious attempts to
prove that one's feelings or
behaviors are justifiable
(sourgraping)
h. Regression - unconscious
return to an earlier and
more comfortable
developmental stage
i. Dependency - constantly
seeking approval.
3. NEUROTIC DEFENSES - common
in ages 3 and 90
a. Intellectualization
consciously or
unconsciously using only
logical explanations without
feelings.
b. Repression - unconscious
and involuntary forgetting
of painful ideas, events, and
conflicts (unconscious
forgetting)
c. Displacement
unconsciously discharging
pent-up feelings to a less
threatening object.
d. Reaction-formation
conscious behavior that is
the exact opposite of an
unconscious feeling
e. Dissociation - unconscious
separation of painful
feelings and emotions from
an unacceptable idea,
situation, or object
f. Emotional isolation
inability to share one's
- feelings with others. (fear of
abandonment)
4. MATURE MECHANISMS
a. Altruism - a sense of
unconditional concern for
the welfare of others
b. Humor - overt expression of
ideas and feelings
(especially those that are
unpleasant to focus on or
a too terrible to talk about)
that gives pleasure to
others.
c. Sublimation - consciously or
unconsciously channeling
instinctual drives to
acceptable activities
d. Suppression – conscious
exclusion from awareness
anxiety-producing feelings,
ideas and situations
e. Undoing – consciously doing
something to counteract or
makeup for a wrongdoing.
5. OTHERS:
- a. Introjection – unconsciously
incorporating values and
attitudes of others as if they
were your own.
b. Compensation – consciously
covering up for a weakness
by making up a desirable
trait.
c. Conversion – unconscious
expression of intrapsychic
- conflict symbolically
through physical symptoms.
UNTIL HERE ANG QUIZ :>
B. LEVELS OF PRACTICE
- 1. GUIDING PRINCIPLES:
a. The nurse views the client as a
holistic being.
b. The nurse focuses on the client's
strength and assets, not on his
weaknesses and liabilities.
c. The nurse accepts the client as a
unique human being who has value
and worth exactly as he is
- d. The nurse has a potential for
establishing a relationship with
most if not all clients.
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NCM117 – CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF
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5 Aspect of Physical Attending o Standard VH. Evaluation - expected
S Facing SQUARE outcome
O OPEN Posture ADVANCED PRACTICE INTERVENTION:
L Slightly LEANING forward o Standard VI. Psychotherapy
E EYE Contact o Standard VJ. Prescriptive authority and
R RELAXED treatment - uses procedure and
treatment in accordance to state and
e. The nurse explores the client's federal law
behavior for the need it is designed o Standard VK. Consultation - provides
to or the message it is services and enhance abilities of other
communicating. clinicians.
f. The nurse views the client's THE ROLE OF PSYCHIATRIC NURSE AS A
behavior non-judgmentally while TEAM MEMBER
assisting him to learn more 1. Ward manager - monitors operations
effective adaptations. 2. Socializing agent - helps to recognize
g. The quality of the interaction in and cope stress
which the nurse engages with the 3. Counselor - emphatic listener
client will be directed to a more 4. Parent surrogate
satisfying interpersonal 5. Patient advocate
relationship. 6. Teacher - focused on acquiring SKA.
STANDARDS OF CARE 7. Technical role
Standard I. Assessment - collects patients 8. Therapist - uses the principles
data. developed through the practice of
Standard I. Diagnosis - analyze the psychotherapy.
assessment. 9. Reality base - help client make
Standard III. Outcome Identification – decision.
ultimate goal 10. Health role model call
Standard IV. Planning - with the family
(prevent / interventions) THEORIES OF HUMAN BEHAVIOR
Standard V. Implementation - of intervention 1. PSYCHOANALYTICAL THEORY
o Standard VA. Counseling - assist's in o Sigmund Freud: The Father of
improving or regaining previous coping Psychoanalysis believed that
abilities. personality is formed during early
o Standard VB. Milieu Therapy - maintain childhood, particularly the first 6
therapeutic environment. (example: years of life
rehab centers) modify and improve to a) Personality
maintain therapeutic environment.  Sum total of the individual
o Standard VC Promotion Self-Care  Refers to all that the individual
Activities - foster mental and physical is, feels and does consciously
well-being. and unconsciously; manifested
o Standard VD. Psychobiologic as interaction in his
Interventions - restore and prevent environment
further disability. b) Divisions of the Mind:
o Standard VE. Health Teaching - assist in 1. Consciousness/Conscious –
productive and healthy patterns of living i. all memories that
o Standard VF Case Management - remain within an
coordination with health care services individual's awareness.
and continuity of care ii. thought to be under the
o Standard VG. Health Promotion and control of the ego
Maintenance 2. Unconsciousness

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NCM117 – CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF
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i. all memories, conflicts, o Dorothea orem - needs a
experiences, and material composite self-care action to
that have been repressed survive
and cannot be recalled at o A person is best understood by
will observing what he or she does in a
3. Pre/Subconsciousness particular situation
i. all memories that may have 3. COGNITIVE THEORY
been partially forgotten, o Emphasize the mental processes
can be recalled to involved in knowing
consciousness with some o Piaget, developed a theory of
effort reasoning base on the responses of
c) Structures of Personality children and young people
1. Id- pleasure principle ----------End of lecture notes 03/20/23----------
— Meeting demands
through the use of 4. COGNITIVE-BEHAVIORAL MODEL
fantasies and images o Cognitive framework is often related
2. Ego - reality principle to the behavioral framework.
— Comprises of rational, o Both models concentrate on learning
logical thinking and and changing behavior
intelligence o Based on the premise that a person
— Developed at age 3
can't be frightened and relaxed at the
3. Superego – “The Conscience” same time.
— Inner control, concerned 5. HUMANISTIC
with right or wrong
o focuses on a person's positive
— Developed at age 5
qualities, his or her capacity to change,
 Superego is composed of:
and the promotion of self-esteem.
— Ego Ideal - rewards the
o Abraham Maslow's Hierarchy of
person with feelings of
Needs (start from the bottom)
well-being and pride
when person conforms
to the demands of the
superego.
— Conscience - punishes
the person with guilt
feelings when person
deviates from the
demands of the
superego.
o SIDE NOTES: PRIORITIZE EMOTIONS if
— *It is important to note
the patient is anxious.
that the rewarding and
o Carl Rogers: Client Centered Therapy
punishing of the
6. INTERPERSONAL THEORY
superego is based on the
internalized standards of o Harry Stack Sullivan: Interpersonal
right and wrong and not Relationships and Milieu Therapy
on reality. believed that one's personality
2. BEHAVIORAL THEORY involves more than individual
characteristics, particularly how one
o Emphasis is on the behaviors of the
interacts with others
person
o Identified 3 components of the self-
o B.f. skinner, is a prominent
system:
behavioral theorist
o "good me"  experience is rewarded

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NCM117 – CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF
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o "bad me"  negative feedback such
as punishment (leads to overwhelming
anxiety)
o "not me"  fear, trauma and
repressed
7. BIOPHYSIOLOGICAL THEORY
o It has been suspected that heredity
and environment are more closely
interwoven.
8. SOCIO-CULTURAL
o Referred to as "third mental health
revolution."
o The community and the cultural
setting, the wider social forces that
shape and color the patient's life, take
centerstage.
C. PRINCIPLES AND TECHNIQUES OF
PSYCHIATRIC NURSING INTERVIEW
1. BASIC PRINCIPLES
a. Do not reinforce or argue on patient's
hallucinations or delusions (false fake
belief that is real to the patient).
b. Orient patient to time, person, and
place
c. Do not touch patients without
warning them.
d. Avoid whispering or laughing when
patients are unable to hear all of the
conversations.
— Side notes: always provide and
ensure the safety of the client.
e. Reinforce positive behavior.
f. Avoid competitive activities with
some patient.
g. Do not embarrass patient. (Always
recognize/d the participation of the
client)
h. For withdrawn patients, start with
one-to-one interactions.
i. Allow and encourage verbalization of
feelings.
2. GENERAL PRINCIPLES
a. Be calm when talking to patients
(Anxiety is contagious)
b. Accept patients as they are but do not
accept all behaviors.
c. Keep promises.
d. Be consistent. (if you are not
consistent, you can be easily be
manipulate by the client)
e. Be honest.
E. NURSING DIAGNOSIS
1. Alteration in Health Maintenance
2. Altered Nutrition: Less than Body
Requirements
3. Altered Nutrition: More than Body
Requirements
4. Anxiety
5. Body Image Disturbance
6. Ineffective Family Coping:
Compromised
7. Ineffective Individual Coping
8. Self-esteem Disturbances
9. Powerlessness
10. Sleep Disturbance
ALTERATION IN PATTERN OF HEALTH
AXIETY
 Anxiety Response and Anxiety Disorders
 Definition: ANXIETY
— Is a complex combination of
emotions that includes FEAR,
APPREHENSION, and WORRY, and is
often accompanied by physical
sensations such as palpitations,
nausea, chest pain and/or shortness
of breath.
 Characteristics
— It is provoked by the unknown.
— It therefore precedes all new
experiences (entering school,
moving to a new place, starting a
new job).
— It is communicated interpersonally.
Predisposing Conditions:
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a. Prolonged unmet needs of
dependency, security, love, and
attention
b. Stress threatening security of self-
esteem unacceptable thoughts or
feelings surfacing to consciousness,
(e.g. Rage, erotic impulses,
flashbacks)
THEORIES OF ORIGIN
1. FREUD
o It is due to the conflict bet the id and
the superego. The ego serves a
battleground as it tries to mediate the
demands of the 2 clashing
personalities.
2. SULLIVAN
o Believed that through the close
emotional bond between the mother
and the child, anxiety is first conveyed
by the mother to the infant.
o Anxiety in later life arises in
interpersonal situation.
3. WILL
o Believed that low self-esteem is
related to predisposition to anxiety.
4. LEARNING THEORY
o Parental influence affects how a child
responds to anxiety. The parents’
appropriate emotional response gives
the child security and helps him learn
constructive ways of coping on his
own.
LEVEL OF ANXIETY
1. MILD/ALERTNESS LEVEL (+1)
 Associated with normal tension of
everyday life.
• The individual is alert.
• Perceptual field is increased.
• Produce growth and productivity.
• Increases learning.
 Uses adaptive coping mechanism to
solve problems, rational, objective, and
alleviate anxiety. (asking question)
 COPING MECHANISMS used to relieve
anxiety in stressful conditions:
1. Sleeping
2. Eating
3. Physical exercise
4. Smoking
5. Crying
6. Yawning
7. Drinking
8. Daydreaming
9. Laughing
10. Cursing
11. Pacing
12. Foot swinging
13. Fidgeting
14. Nall biting
15. Finger tapping
16. Talking to someone with whom
one feels comfortable
Nursing Interventions: (MILD ANXIETY)
1. Recognize anxiety by statements such
as "I notice you being restless today."
2. Explore causes of anxiety and ways to
solve problems that cause anxiety by
statements such as "Lets discuss ways
to….(solve your problem)”
2. MODERATE/APPREHENSION LEVEL (+2)
 The response of the body to
immediate danger and focus is
directed to immediate concerns.
 Narrows the perceptual field to pay
attention to particular details.
 Selective inattentiveness occurs.
 The increased tension makes this the
optimal time for learning.
 SIDE NOTES: Physiological
Manifestations:
— Muscle tension
— Excessive sweating (diaphoresis)
— Dry mouth
— High pitch voice
— Frequent urination
 Increased muscular tension and
restlessness are evident.
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 The person uses palliative coping
mechanisms.
Nursing Interventions: (MODERATE
ANXIETY)
1. Provide outlets for anxiety.
2. Tell the patient “It’s alright to cry.”
3. Engage in motor activity to reduce
tension.
4. Make patient be aware of his
behaviors and feelings.
5. Encourage client to move from
affective to cognitive mode.
6. Refocus attention.
7. Encourage client to talk about feelings
and concerns.
8. Help the client identify thoughts and
feelings that occurred prior to the
onset of anxiety.
9. Provide anti-anxiety oral medications.
3. SEVERE/FREE-FLOATING (+3)
 Creates a feeling that something bad is
about to happen or feeling of an
impending doom.
 Fight and flight response sets in
 Narrow perceptual field occurs.
 Focus is on specific details or scattered
details so that learning and problem-
solving is not possible. (restless,
irritable, .. Maladaptive defense/coping
mechanism will starts here)
 All behavior is directed at relieving the
anxiety.
 The individual has much difficulty
completing even the simplest tasks.
 The individual needs direction to focus.
 Dilated pupils, fixed vision.
 Uses maladaptive coping mechanisms.
Nursing Interventions: (SEVERE ANXIETY)
1. Do not attack coping mechanisms.
2. Stay calm and stay with the patient.
3. Give short and explicit direction.
4. Modify the environment.
a. Set limits
b. Limit interaction with others
c. Reduce environmental stimuli
5. Provide IM anti-anxiety medications.
4. PANIC LEVEL (+4)
 Feelings of helplessness and terror
 Most intense state of anxiety
 The personality and behavior is
disorganized (because of fear)
 (Most destructive and challenging level)
 Behavior may be characterized by wild
and desperate actions or extreme
withdrawal.
 Can experience unable to speak or move
or the opposite/either way.
 Cannot think rationally.
 Unable to communicate or function
effectively.
 Inability to concentrate.
 If prolonged, can lead to exhaustion and
death.
 The person uses dysfunctional coping
mechanism.
Nursing Interventions: (PANIC ANXIETY)
1. Guide patient step by step to action
2. Assume a calm manner with the
patient.
3. Restrain if necessary .
COPING AND PRECAUTIONS
 At the mild and moderate levels:
o Discuss the anxiety-provoking
situation with someone whom a
patient trust or engaging in a
relaxing activity, like a workout or
meditation.
 Severe and panic levels of anxiety
o Might require the patient to
enter into a less stressful
environment or seek professional
help.
SIDE NOTES: All level of anxiety can be
normal depending on a certain situation and
in a brief period, not prolonged period of
time
ANXIETY DISORDERS
 Are a group of conditions marked by
extreme or pathologic anxiety or
dread
 Can occur at any age:
o Primary – starts in infancy.
o Subsequent anxiety – ??
 Affect twice as many women as men.
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NCM117 – CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF
BEHAVIOR: Acute and Chronic
 Sufferers experience disturbances of  Diminished ability to focus or
thinking mood, behavior, and think clearly even with direction.
physiologic activity.  Fear of losing control or going
crazy
PANIC DISORDER  Paresthesia
 Most severe form
 Occur suddenly without warning (Out NURSING DIAGNOSIS: PANIC DISORDER
of the blue) — Panic Anxiety r/t real or perceived
 Affects twice as many women as men. threat
 Onset is from late adolescence to mid-
adulthood. NURSING INTERVENTION: PANIC
 Peak intensity is within 10 to 16 DISORDER
minutes. 1. Stay with the client until the attack
 Roughly 2% to 4% experiences panic subsides.
disorder sometime in their live 2. Provide a safe, calm environment:
decrease environmental stimuli.
 DEFINITION: persistent fear (1 month)
3. Avoid touching her until you have
 Begins in young adulthood 20 – 24
established rapport.
years old.
4. Allow her to pace around the room to
 CAUSES:
help her expend energy.
 Genetic (EX. Twins{RISK}, first
5. Administer tranquilizers as ordered.
degree relative)
Assess for effectiveness and for side
 Biochemical abnormalities:
effects.
(Neurobiological factors, affected
6. Identify thoughts or feelings prior to
is LYMBHIC SYSTEM that controls
the onset of anxiety.
electrical impulses,
7. Identify "self-talk" clients might use at
neurotransmitters, Gamma-
this time. (Encouraging self “kaya ko
Aminobutyric Acid {GABA})
‘to = positive self-talk) (Internal
 Autonomic factors
monologue) (Affirmation)
 Cognitive and behavioral factors
8. Teach relaxation techniques.
 Psychological factors (REPRESSED
SIDE NOTES: PHYSIOLOGICAL
 Medical Conditions
SYMPTOMS OCCURS FIRST before
 Life events
psychological symptoms.
 SIGN AND SYMPTOMS:
 Palpitations and rapid heartbeat
TREATMENT: PANIC DISORDER
 Sweating
A. COGNITIVE THERAPY
 Generalized weakness or
trembling. o Teaches them to replace those
 Shortness of breath or rapid, negative thoughts with more realistic,
shallow breathing positive ways of viewing the attacks.
 Sensations of choking, B. BEHAVIORAL THERAPY
smothering, or a o Involves desensitization (gradual
 Jump in the throat. exposure to fear)
 Chest pain or pressure (rapid
heartbeat)
 Abdominal pain, nauseam
heartburn, diarrhea, or other GI
distress
 Dizziness, tingling sensations, or
light headedness
 Chills, pallor or flushing.

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NCM117 – CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF
BEHAVIOR: Acute and Chronic
o Help the patient deal with the
situational avoidance associated with
panic attacks.
C. RELAXATION TECHNIQUES
o Help the patient cope with a panic
attack by easing physical symptoms
and directing her attention elsewhere.
a. Deep breathing exercises
b. Progressive relaxation
c. Positive visualization or guided
imagery (happy memories)
d. Listening to calming music
PHARMACOLOGIC THERAPY
a. Combining an anti-anxiety drug or
anti-depressant or a combination of
both - promotes rapid stabilization of
panic symptoms. Ex. Valium
b. Beta blockers - to prevent rapid HR,
and tremors and other symptoms from
developing.
GENERALIZED ANXIETY DISORDER
 Characterized by excessive-
uncontrollable worry about everyday
things for at least 6 months or longer.
 The individual is unable to control the
worry.
 CAUSES:
o Generic factors (FAMILY
HISTORY)
o Biochemical abnormalities
o Psychosocial and environmental
factors (such as experiences of
LOSS) (childhood abuse)
 SIGNS AND SYMPTOMS:
o Restlessness or feeling on edge.
o Fatigue
o Impaired concentration
o Irritability
o Muscle tension
o Sleep disturbance
o Excessive worry about a number
of events that the individual finds
difficult to control.
 Anxiety interferes with social,
occupational, or other important areas
of functioning, and is not a direct
result of a medical condition or
substance abuse. (need to seek
professional health)
NURSING DIAGNOSIS: PANIC DISORDER
— Powerlessness r/t impaired cognition
NURSING INTERVENTION: PANIC
DISORDER
1. Encourage client’s participation
indecisions and client’s responsibility
in his/her care and future.
2. Encourage the client to keep a
journal of thoughts and feelings.
3. Help identify areas of life situation
that client can control. (Assistance)
4. Help client identify areas that are
not within his or her ability to
control.
5. Encourage verbalization of feelings.
6. Teach the client that one lapse is not
a relapse.
TREATMENT:
a. Biofeedback - use of sensitive
instrumentation to provide internal
physiological processes.
b. Psychotherapy - helps the patient
identify and deal with the cause of
anxiety, anticipate her reactions, and
plan effective responses to deal with
anxiety (reconstruction)
c. Cognitive therapy - the patient is
taught to record her worries and list
evidence that justifies or contradicts
each one.
d. Pharmacologic therapy
1. ANTI-ANXIETY AGENTS
a. Benzodiazepines - reduces
anxiety by decreasing
vigilance and easing
somatic symptom.
b. Buspirone - initial drug of
choice for anxious patients
with a history of
substance abuse (lesser
side effects that causes
less sedation)
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NCM117 – CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF
BEHAVIOR: Acute and Chronic
POSTTRAUMATIC STRESS DISORDER (PTSD)
o May occur after someone
experiences or witnesses a serious
traumatic event, such as wartime
combat, a natural disaster, rape,
murder, torture, sexual
molestation, physical attacks, being
threatened with a weapon, and
childhood physical abuse.
o Full symptom picture must be
present for more than one month.
o HYPERVIGILANCE (easily startled) –
extreme alertness. Always on the
look-out for hidden dangers.
Specially in interpersonal
relationship (CENTRAL FEATURE for
PTSD)
o ABUSE IN ANY FORM
o TRAUMA
o Characterized by persistent and
recurrent flashbacks, reliving the
event, or nightmares of the event -
along with avoidance of reminders of
it.
o Those who survived a catastrophe
that took many lives may also have
survivor's guilt.
o They become hypervigilant, easily
aroused, and easily startled.
o CAUSES:
 Traumatic events
 Biochemical factors
 The alpha2-adrenergic
receptor response that
inhibits stress-induced
release of norepinephrine
is impaired.
o Signs and Symptoms:
 Anger
 Poor muscle
 Chronic anxiety and tension
 Avoidance of people, places,
and things associated with
traumatic experience.
 Emotional detachment
numbness (difficulty
maintaining personal
relationships, lack of attention,
difficulty in loving or affection,
avoiding people and activities)
 Depersonalization (feeling of
disconnected with one’s body
and thought) (no actual self)
{feeling of cannot control
yourself, more on observation
outside your body}
 Difficulty concentrating
 Difficulty falling or staying
asleep.
 Hyper alertness, hyperarousal,
and exaggerated startle reflex
 Inability to recall details of the
traumatic event (most common
defense mechanism is
REPRESSION)
 Labile affect (sudden change in
mood)
 Social withdrawal (avoid people
and activities that you usually
do  can progress to social
isolations *blocking of friends
and family*)
 Decreased self-esteem (rape
victim)
 Loss of sustained beliefs about
people and society
 Hopelessness  worse thing
that can happen to a person.
 Sense of being permanently
damaged
 Relationship problem
 Survivor’s guilt
DEFENSE MECHANISMS:
1. Denial
2. Suppression
3. Repression
THREE STAGES OF RECOVERY AFTER
TRAUMA:
A. THE VICTIM STAGE:
1. Pre-discovery of the trauma
2. Early awareness
3. Discovery – repression, brought awareness
B. SURVIVOR STAGE
or - overcome
in C. THRIVER STAGE
- to live with the effects of the trauma
- gain control of thy-self
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NCM117 – CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF
BEHAVIOR: Acute and Chronic
VARIABLES INCLUDE CHARACTERISTICS
RELATING TO THE TRAUMA:
1. The TRAUMATIC EXPERIENCE
2. The INDIVIDUAL – depending on the
coping mechanism
3. The RECOVERY ENVIRONMENT – support
system is vital
TREATMENT
o Desensitization - through gradual
exposure to stressful stimuli
o Medications:
1. Benzodiazepines
2. Beta-blockers
3. Lithium carbonate
4. Selective Serotonin Reuptake
Inhibitors (SSRIs)
NURSING DIAGNOSIS
Post trauma Syndrome r/t distressing event
NURSING INTERVENTIONS:
1. Assess for any suicidal or
homicidal thoughts and
feelings.
2. Spend time with client, allowing
client to go at own speed
regarding describing present or
past traumatic.
3. Obtain Accurate history from
significant others about the
trauma
4. Remain nonjudgmental in your
interactions.
5. Listen attentively to client's
description of the event.
6. Encourage the expression of
feelings through talking,
writing, crying, or other ways
the client is comfortable with.
7. Assess family and social support
system.
OBSESSIVE-COMPULSIVE DISORDER (OCD)
o Characterized by unwanted, recurrent,
intrusive thoughts or images
(obsessions), which the person tries to
alleviate through repetitive behaviors
or mental acts (compulsion)
o Weak underdeveloped EGO
o OBSESSIONS are defined as:
—
Recurrent and persistent
thoughts, impulses, or images that
are experienced at some time
during the disturbance as
intrusive and inappropriate and
that cause marked anxiety or
distress.
— the thoughts, impulses, or images
are not simply excessive worries
about real-life problems.
o COMPULSIONS are defined as:
— Repetitive behaviors or mental
acts performed by the patient,
who feels drive to perform them
in response to an obsession or
according to rules that must be
applied rigidly.
— Recognizes that her behavior.
 Cleaning. Repeatedly washing their
hands, showering, or constantly
cleaning their home,
 Checking. Individuals may check
several or even hundreds of times to
make sure that stoves are turned off
and doors are locked.
 Repeating. Some repeat a name,
phrase, or action over and over,
Slowness. Some individuals may take
an excessively slow and methodical
approach to daily activities, they
may spend hours organizing and
arranging objects.
 Hoarding. Hoarders are unable to
throw away useless items, such as
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NCM117 – CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF
BEHAVIOR: Acute and Chronic
old newspapers, junk mail, even 4. TCAs
broken appliances.
 ADDITIONAL:
 Washers: Are afraid of
contamination and wash their hands
compulsively.
 Doubters and sinners: Are afraid of
things not being absolutely perfect
and the disastrous consequences of
imperfection.
 Checkers: Repeatedly worry about
harm by checking things (oven is off,
doors are locked, etc.). NURSING DIAGNOSIS:
 Hoarders: Worry that something - Ineffective coping r/t excessive negative
terrible will happen if they throw beliefs about self
something away, so they store
everything. NURSING INTERVENTIONSS:
 Counters and arrangers: Are 1. Ask specific questions about her
obsessed with order and symmetry. thoughts and behavior, specially
These individuals will often have physical cues.
superstitions or beliefs about specific 2. Let the patient know that you are
colors and numbers. aware of his/her behavior.
 CAUSES: 3. Use a cognitive and unhurried
1. Genetic factors approach.
2. Biological aspects 4. Gradually begin to limit amount of
a MRI time for rituals.
b Position emission 5. Give positive reinforcement for non-
tomography (PET) ritualistic behavior.
c Anatomic physiologic
disturbance
3. Physiologic factors – Sigmund LOSS AND GRIEF
Freud (conflict between ID &
superego)
4. Research – behaviorist LOSS
5. Can relate to Beta hemolytic .. — The fact or process of losing
something or someone.
SIGN AND SYMPTOMS — Unrecoverable and usually
— Repetitive thoughts that can cause unanticipated and non-recurring
stress (obsessions) removal of, or decrease in, an asset or
— Repetitive behaviors resource.
— Social impairment caused by GRIEF
preoccupation with obsessions and — Emotional response to a loss
compulsions. — Melancholy
— Perceived need to achieve. — Is a deep emotional and mental
anguish that is a response to the
PARMACOLOGIC INTERVENTIONS: subjective experience of loss of
1. Benzodiazepines something significant.
2. MAOIs (anti-depressant)
3. SSRIs (anti-depressant MOURNING is the psychological process
) most effective is PROZAC through which the individual passes on to

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NCM117 – CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF
BEHAVIOR: Acute and Chronic
successful adaptation to the loss of a valued — Allowed to gradually prepare. Allows
object. meaningful time with an individual
to have closure.
BEREAVEMENT includes grief and mourning — Felt prior to loss or illness of
– the inner feeling and outward reactions of someone you love.
survivor. (emotional reactions and followed — Due to unknown, what, when will it
by rituals) happened
HOW TO HELP THE FAMILY AND PATIENT
GOALS OF GRIEVING PROCESS DURING A PERIOD OF ANTICIPATORY
o Healing the SELF GRIEVING (Doka, 2001)
o Recovering from the LOSS o Validate expression of anticipatory
grief
NORMAL GRIEF REACTIONS: o Inform the patient and the family
 Depressed mood about the disease and its symptoms.
 Insomnia o Invite patients and families to deal
 Anxiety with emotional issues.
 Poor appetite o Acknowledge the losses and changes
 Loss of interest in their lives.
 Guilt o Explore ways of coping.
 Dreams about the decreased
 Poor concentration THE FOUR GIFTS OF RESOLVING
 Psychological state RELATIONSHIPS
o Shock I. FORGIVENESS - ("I'm sorry"; "I
o Denial forgive you")
o Yearning or searching for the — First step is to admit to the
deceased. wrongs and hurts experienced in
the relationship.
PRECIPITATIONG FACTORS OF GRIEF: — The intention is to forgive, seek
1. Death in family forgiveness, and release the
2. Separation hurt for healing to occur.
3. Divorce II. LOVE - ("I love you"):
4. Physical Illness — The second gift is to express
5. Work failure disappointment love to each other.
— The end of life is a wonderful
TYPES OF GRIEF time for people to fully express
1. ANTICIPATORY GRIEF what they mean to each other.
— is the reaction to a death you were — Ultimately, the message is that
able to anticipate such as when an all people are loved for being,
individual dies from a long-term rather than for what they have
illness. done or achieved.
— Grief that occurs preceding a loss III. GRATITUDE – (“Thank you”)
can be confusing, as you may feel — This is the moment to take the
conflicted or guilty for experiencing time to thank each other for
grief reactions about someone who what each has been in the
is still here. other's life.
— “FEAR & ANXIETY are no longer part — To receive a person's undivided
of anticipatory grief than attention is precious. It is
conventional grief.” especially important to
— Example: cancer, distemper for dog acknowledge the things that
the patient took for granted.

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NCM117 – CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF
BEHAVIOR: Acute and Chronic
IV. FAREWELL ("Good-Bye, I'll be
okay"):
— Many people say that they hate
good-byes. "I don't do good-
byes," they may say. It is
resisted for several reasons.
Saying good-bye brings up
feelings of grief and finality.
SIGNS OF ANTICIPATORY GRIEF
o Feelings of emptiness or of being
lost.
o A sense of being numb or fatigued.
o A feeling of unreality or disbelief
o Periods of weeping or raging
o A desire to run away from the
situation.
o A need to protect the patient from
suffering or death by overseeing
every detail of care.
o Worry about the future and the
unknown
o Anger at the patient, medical
professional, or both
o Pronounced clinging or dependency
on the patient or other family
members.
2. COMPLICATED GRIEF
— The sadness of losing someone you
love never goes away completely,
but it shouldn't remain center stage.
— lf the pain of the loss is so constant
and severe that it keeps you from
resuming your life, you may be
suffering from a condition known as
complicated grief.
— At least six months or several years
— “Traumatic or prolonged grief”
— Can make you feel worthless and
suicidal.
TYPES OF COMPLICATED GRIEF
» CHRONIC GRIEF – Strong grief
reactions that do not subside and
last over a long period of time.
Continually experiencing extreme
distress over the loss with no
progress towards feeling better or
improving functioning. (Similar to
complicated grief, chronic grief is
prolonged grief that does not seem
to reduce in severity over a period of
time)
» DELAYED GRIEF – When grief
symptoms and reactions aren't
experienced until long after a
person’s death or a much later time
than is typical. The griever, who
consciously or subconsciously avoids
the reality and pain of the loss,
suppresses these reactions.
(Typically, delayed grief is brought
on by another big event or loss - like
another death, loss of a job, etc.
Delayed grief is also often caused by
a difficult grieving situation.)
» EXAGGERATED GRIEF – An
overwhelming intensification of
normal grief reactions that may
worsen over time.
a. Characterized by extreme and
excessive grief reactions
possibly to include:
b. nightmares,
c. self-destructive behaviors,
d. drug abuse,
e. thoughts of suicide,
f. abnormal fears,
g. and the development or
emergence of psychiatric
disorders.
o MASKED GRIEF - reactions that
Impair normal functioning however
the individual Is unable to recognize
these symptoms and behaviors are
related to the loss. Symptoms are
often masked as either physical
symptoms or other maladaptive
behaviors.
o DISENFRANCHISED GRIEF - the loss
cannot be openly acknowledged,
socially validated, or publicly
mourned.
— RELATIONSHIP IS NOT RECOGNIZED
— THE LOSS IS NOT RECOGNIZED
— THE GRIEVER IS NOT RECOGNIZED
(Elective abortion, UFD, Giving a
child for abortion, loss of a pet)
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NCM117 – CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF
BEHAVIOR: Acute and Chronic
— WHEN DEATH IS STIGMATIZED
(victim of abuse)
SYMPTOMS OF COMPLICATE GRIEF
— Intrusive thoughts or images of your
loved one
— Denial of the death or sense of
disbelief
— Imagining that your loved one is
alive.
— Searching for the person in familiar
places
— Avoiding things that remind you of
your loved one.
— Extreme anger or bitterness over the
loss
— Feeling that life is empty or
meaningless.
FIVE STAGE OF GRIEF – KÜBLER ROSS
1. DENIAL AND ISOLATION
¬ The first reaction to learning of
terminal illness or death of a
cherished loved one is to deny the
reality of the situation.
¬ It is a normal reaction to rationalize
overwhelming emotions.
¬ It is a defense mechanism that
buffers the immediate shock.
¬ We block out the words and hide
from the facts. This is a temporary
response that carries us 1through
the first wave of pain.
2. ANGER
¬ As the masking effects of denial and
isolation begin to wear, reality and
its pain re-emerge. We are not
ready.
¬ The intense emotion is deflected
from our vulnerable core,
redirected, and expressed instead as
anger.
¬ The anger may be aimed at
inanimate objects. complete
strangers, friends, or family.
¬ Anger may be directed at our dying
or deceased loved one. Rationally,
we know the person is not to be
blamed.
3. BARGAINING
¬ The normal reaction to feelings of
helplessness and vulnerability is
often a need to regain control.
¬ If only we had sought medical
attention sooner
¬ lf only we got a second opinion from
another doctor.
¬ If only we had tried to be a better
person toward them.
¬ Secretly, we may make a deal with
God or our higher power in an
attempt to postpone the inevitable.
This is a weaker line of defense to
protect us from the painful reality.
¬ Focuses on the PAST.
4. DEPRESSION
¬ Two types of depression are
associated with mourning.
¬ The first one is a reaction to practical
implications relating to the loss.
Sadness and regret predominate this
type of depression. This phase may
be eased by simple clarification and
reassurance. We may need a bit of
helpful cooperation and a few kind
words.
¬ The second type of depression is
more subtle and. in a sense, perhaps
more private. It is our quiet
preparation to separate and to bid
our loved one farewell.
¬ Focuses on the PRESENT
5. ACCEPTANCE
¬ Reaching this stage of mourning is a
gif not afforded to everyone.
¬ Death may be sudden and
unexpected o we may never see
beyond our anger or denial. It is not
necessarily a mark of bravery to
resist the inevitable and to deny
ourselves the opportunity to make
our peace.
¬ This phase is marked by withdrawal
and calm. This is not a period of
happiness and must be distinguished
from depression.
¬ Will and testaments
¬ Acceptance Is not moving on, but
end of the grieving process.
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NCM117 – CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF
BEHAVIOR: Acute and Chronic
COMMON SYMPTOMS OF LOSS AND GRIEF o Withdrawing from others;
— Shock and disbelief feeling less interested in the
— Sadness world.
— Guilt o Dreaming of the decease.
— Anger o Avoiding reminders of the
— Fear deceased.
— Physical symptoms
o Sadness MAJOR TASKS OF THE GRIEF PROCESS:
o Anger o Acceptance of the loss,
o Guilt and self-reproach o Acknowledgment of the intensity of
o Anxiety the pain,
o Loneliness o Adaptation to life after the loss, and
o Fatigue (external = how does the death
o Helplessness affect..
o Shock o Internal = ??
— Physical Sensations o Spiritual = ??
o Hollowness in the chest o Cultivation of new relationships and
o Tightness in the chest activities
o Tightness in the throat
o Oversensitivity to noise 3.
o Feeling that nothing is real,
maybe even feeling that
oneself is not real
breathlessness, feeling
short of breath.
o Muscle weakness
— Cognitions
o Disbelief, thinking the loss
did not happen.
o Confused thinking, difficulty
concentrating,
forgetfulness.
o Preoccupation, obsessive
thoughts about the
deceased or what was lost.
o Sensing the presence of the
deceased, thinking the
deceased is still there.
o Hallucinations, seeing
and/or hearing the
deceased.
— Behaviors
o Trouble falling asleep or
waking up too early.
o Eating too much or too
little.
o Absent-minded behavior

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