اسسس السلوك فى الصحة والمرض2020 2اسس السلوك فى الصحة والمرض Principles ٠٩٠٢٣٥

Secondly years- First term
Aswan University
Faculty of Nursing
2021-2020
1
‫‪Principles of behavior in health and illness‬‬ ‫‪2014‬‬
‫رؤية ورسالة كلية التمريض جامعة اسوان‬
‫الرؤية‪:‬‬
‫تسعى كلية التمريض – جامعة أسوان إلى اإلرتقاء بالرعاية الصحية واالستجابة إلىى‬
‫احتياجىىاا المجتمىىن وأن تفىىون واعلىىة ومت اعلىىة مىىن التاىىور العلمىىى والتق ىىى وىى مجىىا‬
‫بىىرامت رراسىىية وتةريويىىة متميىىير مواكوىىة للمعىىايير ا كاريمي ىة‬ ‫التمىىريض وكل ى مىىب ا ى‬
‫المحلية والعالمية لتخريت اريت مؤهل علميا ً ومه يا ً قارر على الم اوسىة وى سىو العمىل‬
‫وكذل يسعى لت مية القةرر الوحثيه لةى باحثيها للمساهمة ال عالة وى حىل مكىاكل المجتمىن‬
‫الصحية‬
‫رسالة الفلية ‪:‬‬
‫إعةار اريت مؤهل ميور بأصو المعروة العلمية والتىةري علىى المهىاراا المالوبىة‬
‫و ى مجىىا التمىىريض لتقىىةيا الرعايىىة التمرياىىية المتفاملىىةو سىىوا ًء وقاييىىة أو ع جيىىة أو‬
‫تأهيليىة والعمىل علىىى التاىوير المسىىتمر وى العمليىىة التعليميىة و متابعىىة إحتياجىاا الرعايىىة‬
‫الصحية و المجتمن و اإلستجابة لها بإعةار اريت متمييو كاا جورر ومهاره عاليةو قاررر‬
‫على الم اوسة و سو العمل كخةمة أساسىية مىب أجىل الت ميىة الكىاملة للمجتمىن بجميىن‬
‫وئاته‬
‫‪2‬‬
Principles of behavior in health and illness 2014
Principles of behavior in health and illness:
General Introduction of the course:

This introductory course focuses on the concept of health,
and issues related to the promotion, maintenance and restoration
of health. Nursing roles and values will be emphasized. Estab-
lishes a firm basis on which to build subsequent practical nursing
courses. The emphasis is on the essential principles, concepts,
and skills needed for the student to begin learning the role of a
practical nurse. Fundamental principles, concepts, and technolo-
gy for the safe performance of basic nursing skills are provided
through faculty guided campus laboratory and off-campus learn-
ing experiences in acute and long-term adult health care settings.
Learning objective:
By the end of these units, the student will be able to:
1. Apply models of behavior to understand factors that influ-

ence health actions at the individual, family and friends,
community and national/society level.
2. Identify the contribution of nursing patient relation ship
3. Defined and explain the personality
4. Identify the patient right.
5. Discuss stress and stress management.
6. Apply models of self-awareness.
7. Interpret the contents of self-awareness.
3
Purpose of the course:
This overview course is designed to provide students with

basic information concerning the interaction of biological, psy-
chological, behavioral, sociocultural, and environmental process-
es that function in the promotion of health and prevention of dis-
ease. Theories developed to explain health and illness behaviors
at the intrapersonal, interpersonal, and group/community levels
are introduced and critiqued. Ethical considerations inherent to
efforts designed to produce health-related behavior change are
examined.
Learning Outcomes:
1. An understanding of influences on health and illness behavior

is necessary in order to plan effective health promotion inter-
ventions.
2. Influences on behavior operate at the individual, family and
friends, community, national/society level.
3. A range of models can be applied to understanding influences
on behavior and health decision-making.
4. Influences of stressed management on patient behavior.
5. Patient understanding and aware of my-self.
4
Course Contents
No Lecture Page
The First Chapter

Concept of Illness behavior
6
1 Health and illness behavior 14
2 Somatoform disorders: 25
– Somatization
– Sick role behavior r
The Second Chapter

3 Nurse and Patient Relationship 41
4 Personality 54
5 Patients Rights 60
6 Stress and Stress Management 68
The Third Chapter

7 Self Awareness 84
8 Self-Concept 92
5
First Chapter
Concept of Illness behavior
Overview
1. Generally, health-related behavior of healthy people and

those who try to maintain their health are considered as be-
haviors related to primary prevention of disease.
2. Such behaviors are intended to reduce susceptibility to dis-
ease, as well as to reduce the effects of chronic diseases
when they occur in the individual
3. Secondary prevention of disease is more closely related to the
control of a disease that an individual has or that is incipient
in the individual. This type of prevention is most closely tied
to illness behavior.
4. Tertiary prevention is generally seen as direct towards reduc-
ing the impact and progression of symptomatic disease in the
individual. This type of prevention is highly related to the
concept of sick-role behavior
5. In general, illness and sick-role behavior are viewed as char-
acteristic of individuals and as concepts derived from socio-
logical and socio-psychological theories.
6
Figure (1) describes patient's reactions to the experience of being sick.
Illness behavior and sick role:
1. The term illness behavior describes patient's reactions to the

experience of being sick.
2. Aspect of illness behavior have sometimes been termed the
sick role, the that society ascribed to people when they are ill
3. The concept of illness behavior was largely defined and
adopted during the second half of the twentieth century
4. Broadly speaking, it is any behavior undertaking by an indi-
vidual who feels ill to relieve that experience or to better de-
fine the meaning of the illness experience.
5. There are many different types of illness behavior that have
been studied.
6. Some individuals who experience physical or mental symp-
toms turn to the medical care system for help; others may
turn to self help strategies; while others may decide to dis-
miss the symptoms.
7
7. Everyday life, illness' behavior may be a mixture of behav-

ioral decisions.
8. For example, an individual faced with recurring symptoms of
joint pain may turn to complementary or alternative medicine
for relief.
9. However, sudden, sharp, debilitating symptoms may lead one
directly to a hospital emergency room.
10. In any event, illness behavior is usually mediated by strong
subjective interpretation of the meaning of symptoms.
11.As with of human behavior, many social and psychological
factors intervene and determine the type of illness behavior
held by individuals and health care practitioners.
12.The differing worldviews of patients and practitioners are
now seen as highly relevant to illness behavior.
13.The medical practitioner and the individual experiencing
symptoms go through very different apprised of the meaning
of the symptoms.
14.There is the recognition of the strong relationship between
the physical and mental experience of symptoms and the
meaning of that experience for illness behavior.
15.David mechanic, a pioneer in the study of illness behavior,
best summarizes the current perspective on illness behavior:
illness behavior arise from complex causes, including biolog-
ical predisposition, the nature of symptomatology, learned
patterns of response, attributional predispositions, situational
influences, and the organization and incentives characteristic
of the health care system that effect access, responsiveness
and the availability of secondary benefits.
8
Sick-role behavior
The sick role is a concept arising from the work of the im-
portant American sociologist. Parsons was a structural func-
tionalist who argued that social practices should be seen in
terms of their function in maintaining order or structure in
society.
Thus, person was concerned with understanding how the
sick person related to the whole social system, and what the
person's function is in that system.
Ultimately, the sick role and risk-role behavior could be
seen as the logical extension of illness behavior to complete
integration into medical care system. Parson's argument is
that sick-role behavior accepts the symptomatology and di-
agnosis of the established medical care system, and thus al-
lows the individual to take on behaviors compliant with the
expectations of the medical system.
Basically, Parsons defined the "sick role" as having four
chief characteristics:
First
The sick person is freed or exempt from carrying out
normal social roles. The more severe the illness, the more
one is freed from normal social roles. Everyone in society
experiences this; for example, a minor chest cold "allow"
one to be excused from small obligation such as attending a
social gathering. By contrast, a major heart attack "allows"
considerable time away from work and social obligations.
Second
People in the sick role are not directly responsible for
their plight.
9
Third
The sick person need to try get well. The sick role is
regarded as a temporary stage of deviance that should not
be prolonged if at all possible.
Finally
Sick role the sick person or patient must seek competent
help and cooperate with medical care to get well. This con-
ceptual schema many reciprocal relations between the sick
person (the patient), and the healer (the physician). Thus the
function of the physician is one of social control.
1.The sick role includes being excused from responsibili-

ties and the expectation of wanting to obtain help to
get well.
2.Illness behavior and the sick role are affected by peo-
ple's previous experiences with illness and by their
cultural beliefs about disease.
3.The influence of culture on reporting and manifestation
of symptoms must be evaluated
4. Some disorders, varies little among cultures, whereas
others, the cultural mores may strongly shape the way
patient presents the condition
5.The relation of illness to family processes, class status,
and ethnic identity is also important.
6.The attitudes of people and cultures about dependency
and helplessness greatly influence whether and how a
person asks for help, so do such psychological factors
as personality type and the personal meaning the per-
son attributes to being ill.
10
7. Some people experience illness as overwhelming loss;

others see in the same illness a challenge they must
overcome or a punishment they deserve.
Assessment of illness behavior
1. Prior illness episodes, especially illness of standard severity

(childbirth , renal stones, surgery)
2. Cultural degree of stoicism
3. Cultural beliefs concerning the specific problem
4. Personal meaning of or beliefs about the specific problem.
Particular question to ask to elicit the patient's explanatory
model:
1. What do you call your problem? What name does it have?
2. What do you think caused of your problem?
3. Why do you think it started when it did?
4. What does your sickness do to you?
5. What do you fear most about your sickness?
6. What are the chief problems that your sickness has cause to you?
7. What are the most important results you hope to receive from
treatment?
8. What have you done so far to treat your illness?
11
Predicable reaction to illness:
– Intrapsychic
– Lowered self-image ' loss' grief
– Threat to homeostasis ' fear '
– Failure of (self) care, helplessness, hopelessness
– Sense of loss of control ' shame (guilt) '
– Clinical
– Anxiety or depression
– Denial and anxiety
– Depression, bargaining and blaming
– Regression, isolation, dependency, anger, acceptance
12
Defense mechanisms in illness
1. People unconsciously use defense mechanism to protect

themselves from realities that cause conflict and anxiety
2. The patient's use of defense mechanisms can act as a barrier
to the physician in obtaining information and in gaining pa-
tient's compliance
3. Two of the most common defense mechanisms used by peo-
ple when they are ill are denial and regression.
Patient denial
1. In denial a patient unconsciously refuses to admit to being
ill or to acknowledge the severity of the illness
2. This can be helpful initially because it can protect the indi-
vidual from the physical and emotional consequences of
intense fear.
3. However , denial can be destructive in the long term if it
hinders the patient from seeking treatment
Regression
1.The patient reverts to a more child-like pattern of behavior

that may involve a desire for more attention and time from
the physician
2.This can make it more difficult for the physician to interact
with and treat the patient effectively
3.It can make the patient more dependent and less able to take
decision regarding his/her illness
13
Health and illness behavior
Learning objective and outlins:
By the end of these units, the student will be able to:
1. Define Health and illness behavior.
2. Explain ten general category used for recognition of illness.
3. Discuss the stages of illness behaviors.
4. Explain factors affecting on health and illness behavior.
5. Recognize the behavioral therapy.
6. Identify the techniques used for therapy.
7. Interpret benefits of therapy.
8. Analyze the risk of behavioral therapy.

9. Discuss how to preparing for behavioral thereby.
14
Health and illness behavior

Introduction:
Health and illness behaviors are associated with level of

disability, quality of life, patterns of illness, and risk of death. It
is tempting to view such health-related outcomes solely through
the lenses provided by the biomedical sciences; however, the be-
haviors that importantly shape individuals' experiences of sick-
ness or wellness, and life or death, are more completely under-
stood from a sociological perspective.
Definitions of health behavior:
health behavior refers to the actions of individuals, groups,

and organizations, as well as the determinants, correlates, and
consequences, of these actions—which include social change,
policy development and implementation, improved coping skills,
and enhanced quality of life.
Or.
"those personal attributes such as beliefs, expectations, mo-

tives, values, perceptions, and other cognitive elements; person-
ality characteristics, including affective and emotional states and
traits; and overt behavior patterns, actions, and habits that relate
to health maintenance, to health restoration, and to health im-
provement."
15
Preventive health behavior:
Involves any activity undertaken by individuals who believe

themselves to be healthy for the purpose of preventing or de-
tecting illness in a asymptomatic state. Include self-protective
behavior, which is an action intended to confer protection from
potential harm, such as wearing a helmet when riding a bicy-
cle. or wearing a condom during sexual activity. Self-
protective behavior is also known as cautious behavior.
Illness Behavior:
The manner in which individuals monitor the structure and

functions of their own bodies, interpret symptoms, take reme-
dial action, and make use of health care facilities.
OR
Illness behavior:
Any activity undertaken by individuals who perceive

themselves to be ill for the purpose of defining their state of
health, and discovering a suitable remedy.
Sick-role behavior:
Involves any activity undertaken by those who consider

themselves to be ill for the purpose of getting well. It includes
receiving treatment from medical providers, generally involves
a whole range of dependent behaviors, and leads to some de-
gree of exemption from one's usual responsibilities.
16
Self-Care Behavior:
Self-care behavior involves taking actions to improve or

preserve one's health. Self-care is often thought of in terms as
prevention or self-treatment of definable health problems or
conditions, but it can also include primary prevention in the ab-
sence of any symptoms. Self-care includes the actions taken to
treat symptoms before (or instead of) seeking professional med-
ical attention, such as eating chicken soup, drinking liquids.
Dietary Behavior:
Dietary behavior refers to eating patterns that people en-

gage in, as well as behaviors related to consuming foods, such
as shopping, eating out, or portion size. Dietary behavior differs
from some other types of health behavior in that it is, in its
basic forms, essential for life.
Substance-Use Behavior:
Substance-use behavior focuses on the use of both licit and

illicit mood-altering substances. This category of substances,
typically referred to collectively as "drugs," includes tobacco,
alcohol, caffeine, marijuana, cocaine, heroin, "designer drugs,"
and prescription medications taken improperly.
NB:
Illness behavior begins prior to the use of services with the

recognition of illness or sickness.
17
While a complex array of variables might explain variations

in interpretation of sickness,
They can be summarized in ten general categories:
1. the visibility, recognizability, or perceptual salience of de-

viant signs and symptoms;
2. the extent to which the person perceives the symptoms as
serious (that is, the person’s estimate of the present and fu-
ture probabilities of danger;
3. the extent to which symptoms disrupt family, work, and
other social activities;
4. the frequency of the appearance of deviant signs and
symptoms, or their persistence, or their frequency of recur-
rence;
5. the tolerance threshold of those who are exposed to and
evaluate the deviance signs of symptoms;
6. the information available to, the knowledge of, and the cul-
tural assumptions and understanding of the evaluator;
7. the degree to which autistic psychological processes (per-
ceptual processes that distort reality) are present;
8. the presence of needs that conflict with the recognition of
illness or the assumptions of the sick role;
9. the possibility that competing interpretations can be as-
signed to the symptoms once they are recognized; and
18
10.the availability of treatment resources, their physical prox-

imity, and the psychological and monetary costs of taking
action (including not only physical distance and costs of
time, money, and effort, but also stigmatization, resulting
social distance, and feelings of humiliation resulting from
a particular illness decision).
Stages of Illness Behavior:
Stage 1: Symptom Experience
The person is aware that something is wrong. A person usu-

ally recognizes a physical sensation or a limitation in functioning
but does not suspect a specific diagnosis.
Stage 2: Assumption of the Sick People
If symptom persist and become severe, clients assume the

sick role. At this point, the illness becomes a social phenome-
non, and sick people seek confirmation from their families and
social groups that they are indeed ill and that they be excused
from normal duties and role expectations.
Stage 3: Medical Care Contact
If symptoms persist despite the home remedies, become

severe or require emergency care, the person is motivated to seek
professional health services. In this stage the client seeks expert
acknowledgement of the illness as well as the treatment.
19
Stage 4: Dependent Client Role
The client depends on health care professionals for the re-

lief of symptoms. The client accepts care, sympathy and protec-
tion from the demands and stresses of life. A client can adopt
the dependent role in a health care institution, at home, or in a
community setting. The client must also adjust to the disruption
of a daily schedule.
Stage 5: Recovery and Rehabilitation
This stage can arrive suddenly, such as when the symptoms

appeared. In the case of chronic illness, the final stage may in-
volve in an adjustment to a prolong reduction in health and
functioning.
Factors affecting on health and illness behaviors:

personality characteristics
social experiences
social positions
Behavioral Therapy
This treatment can help patients cope with certain mental dis-
orders. It can also be used to treat:
Autism
Personality disorders
Substance abuse
Eating disorders
20
This therapy is also used on patients with chronic diseas-

es to help manage pain. For example, cancer patients use
learned techniques to better cope with radiation therapy. Doc-
tors often recommend behavioral modification to pregnant
women who can’t safely take medications. This form of treat-
ment can also help with emotional grief.
Therapists Techniques Used
Therapists create treatment plans specifically tailored to

individual conditions. Some exercises may include:
1. Discussions about coping mechanisms

2. Role playing
3. breathing and relaxation methods
4. positive reinforcement
5. activities to promote focus
6. journal writing
7. social skills training
8. modifications in responses to anger, fear, and pain
Therapists sometimes ask patients to think about situations

that scare them. The goal is not to frighten them but to help them
develop different coping skills.
21
Figure (2) Behavioral management.
Benefits of Therapists Techniques:
General benefit is increased quality of life.
Specific benefits vary depending on what condition is being

treated. These can include:
1. reduced incidents of self-harm

2. improved social skills
3. better functioning in unfamiliar situations
4. improved emotional expressions
22
5. less outbursts
6. better pain management
7. ability to recognize the need for medical help
Risks of Behavioral Therapy:
The goal of behavioral therapy is to limit self-harm. The

risks for this treatment are minimal.
1. Exploring feelings and anxieties can cause bursts of crying

and anger.
2. The emotional aftermath of therapy can be physically ex-
hausting and painful.
3. A therapist will help to improve coping mechanisms and to
minimize any side effects from therapy.
Preparing for Behavioral Therapy
Generally, a primary physician or neurologist will refer pa-

tients to another doctor who specializes in behavioral therapy.
Some psychotherapists also perform these treatments. Always
check the credentials of your therapist.
A credible behavioral therapist should have a degree as well

as a license or certification.
23
Because therapy sessions are frequent, it is important that the

patient and doctor get on well. Patients can request a consul-
tation before beginning treatment.
Therapy sessions can become a financial burden. Some insur-

ance providers do cover behavioral therapy. Others may only
grant a portion of the costs or allot a certain number of ses-
sions per year.
Before beginning therapy, patients should discuss the cover-

age with your health insurance company and create a pay-
ment plan.
Figure (3) Health insurance company and create a payment plan.
24
Somatoform Disorders
Introduction
Somatoform disorders are mental illnesses that cause

bodily symptoms, including pain. The symptoms can't be traced
back to any physical cause. In addition, they are not the result of
substance abuse or another mental illness. People with somato-
form disorders are not faking their symptoms. The pain and other
problems they experience are real. The symptoms can significantly
affect daily functioning.
Definition
Somatoform disorders are mental illnesses that cause bodily

symptoms, including pain. The symptoms can't be traced back to
any physical cause. And they are not the result of substance abuse
or another mental illness.
Types and Symptoms of Somatoform Disorders:
Symptoms and their severity vary depending on the type of

somatoform disorder. There are several types of somatoform dis-
orders:
1. Somatization disorder:
This is also known as Briquet's syndrome. Patients with

this type have a long history of medical problems that starts be-
fore the age of 30.
25
The symptoms involve several different organs and body

systems. The patient may report a combination of:
pain
neurologic problems
gastrointestinal complaints
sexual symptoms
Many people who have somatization disorder will also have an

anxiety disorder.
2. Undifferentiated somatoform disorder:
This is a less specific version of somatization disorder. A

diagnosis requires that a person have one or more physical
complaints of unexplained symptoms for at least six months.
3. Hypochondriasis:
People with this type are preoccupied with concern they

have a serious disease. They may believe that minor complaints
are signs of very serious medical problems. For example, they
may believe that a common headache is a sign of a brain tumor.
4. Body dysmorphic disorder:
People with this disorder are obsessed with -- or may ex-

aggerate -- a physical flaw. Patients may also imagine a flaw
they don't have.
26
5. Conversion disorder:
This condition strikes when people have neurological

symptoms that can't be traced back to a medical cause. For ex-
ample, patients may have symptoms such as:
Paralysis
Blindness
Hearing loss
Loss of sensation or numbness
6. Pain disorder:
People who have pain disorder typically experience pain

that started with a psychological stress or trauma.
For example, they develop an unexplained, chronic headache

after a stressful life event.
– Pain is the focus of the disorder. But psychological factors

are believed to play a role in the perception and severity of
the pain.
– People with pain disorder frequently seek medical care.
They may become socially isolated and experience prob-
lems with work and family life.
27
7. Somatoform disorder not otherwise specified:
1. People with this type may have conditions that have features
of other somatoform disorders. But they do not meet the full
criteria for any other diagnosis.
2. Conditions that fall into this category include pseudocyesis.
This is the mistaken belief of being pregnant based on other
signs of pregnancy, including an expanding abdomen; feeling
labor pains, nausea.
Treatment of Somatoform Disorders
1. A strong doctor-patient relationship is a key to getting help

with somatoform disorders.
2. Seeing a single health care provider with experience manag-
ing somatoform disorders can help cut down on unnecessary
tests and treatments.
3. The focus of treatment is on improving daily functioning,
not on managing symptoms.
4. Stress reduction is often an important part of getting better.
5. Counseling for family and friends may also be useful.
6. Cognitive behavioral therapy may also help relieve symp-
toms associated with somatoform disorders.
7. The therapy focuses on correcting.
28
Somatization
Introduction
Patients with somatization disorder also show high levels of
worry, anxiety, and increased reactions in response to physical
symptoms. Individuals with somatization disorder typically visit
many doctors in pursuit of effective treatment. Somatization dis-
order also causes challenge and burden on the life of the caregiv-
ers or significant others of the patient.
Definition:
Somatization disorder (also Briquet's syndrome or hysteria)
is a somatoform disorder characterized by recurring, multiple, and
current, clinically significant complaints about somatic symptoms.
Symptoms:
Somatic symptoms are defined as distressing physical or bodi-

ly symptoms, including
– Pain
– Intense fear,
– Concerns,
– Disturbances in optimal functioning.
29
Figure (4) symptoms that are seen in patients with SSD.
There are a number of symptoms that are commonly seen in

patients with SSD.
Pain symptoms Pseudoneurological symptoms
– Diffuse pain – Amnesia

– Joint pain – Loss of voice
– Pain in limbs – Seizures
– Headaches – Difficulty with walking
– Difficulty with swallowing
Reproductive organ symptoms Cardiopulmonary symptoms
– Painful sensations in sex or- – Palpitations

gans/genitals – Chest pain
– Irregularity in menstrual cycles – Dizziness
– Excessive menstrual bleeding – Shortness of breath at rest
– Pain during sex
Gastrointestinal symptoms Other common symptoms
30
– Nausea – Vague food allergies

– Vomiting – Chronic fatigue
– Abdominal pain – Sensitivity to certain chemical
Somatic symptom disorder
A somatic symptom disorder, formerly known as a somatoform

disorder, is a mental disorder characterized by physical symptoms
that suggest physical illness or injury – symptoms that cannot be
explained fully by a general medical condition or by the direct ef-
fect of a substance, and are not attributable to another mental dis-
order (e.g., panic disorder).
Diagnostic criteria
Each of the specific somatic symptom disorders has its own

diagnostic criteria.
Treatments
To date, cognitive behavioral therapy (CBT) is the best estab-

lished treatment for a variety of somatoform disorders including
somatization disorder:
– CBT aims to help patients realize their ailments are not cat-
astrophic and to enable them to gradually return to activities
they previously engaged in, without fear of “worsening their
symptoms.”
– Consultation and collaboration with the primary care physi-
cian also demonstrated some effectiveness.
31
–
The use of antidepressants is preliminary but does not yet
show conclusive evidence.
– Electroconvulsive shock therapy (ECT) has been used in
treating somatization disorder among the elderly; however,
the results were still debatable with some concerns around
the side effects of using ECT.
Overall, psychologists recommend addressing a common dif-

ficulty in patients with somatization disorder in the reading of their
own emotions.
This may be a central feature of treatment; as well as develop-

ing a close collaboration between the GP, the patient and the men-
tal health practitioner.
32
Nursing Care
Somatic symptom disorder emergency department care
– Somatic symptom disorders may present to the emergency

room for assessment and treatment during periods of acute
increase in symptom severity.
– Electroconvulsive therapy is not effective for somatic symp-
tom disorders, but it may successfully treat somatic symp-
toms related to an underlying mood disorder.
– Obtain necessary studies to rule out physical causes such as
myocardial infarction or appendicitis.
– Intravenous or oral acute sedation with benzodiazepines
may be used. Avoid long-term benzodiazepines for somatic
symptom disorders.
– Avoid acute or long-term narcotic analgesics for somatic
symptom disorders.
Conversion disorder emergency department care:
o Conversion disorder may be interpreted by the patient and

family as a sign of an acute and potentially catastrophic
medical condition.
o Emergency department personnel should quickly rule out
potential life-threatening, disabling, or treatable causes for
the symptoms.
33
o Emotional support should be provided to patient's family

members.
o Early consultation with a psychiatrist may limit unnecessary
medical or surgical interventions.
o Referral to psychiatrist may be prefaced by stating that the
cause for the medical symptoms have not been found and
that in similar cases,
o Assessment of the role of stress by a medical psychiatrist
may be helpful in reducing the discomfort experienced by
the patient.
Psychosocial interventions (primary care management)
The primary care physician should inform the patient that the
symptoms do not appear to be due to a life-threatening, disabling,
medical condition and should schedule regular visits for reassess-
ment and reinforcement of the lacking severity of ongoing symp-
toms.
Psychosocial interventions for specific somatic symptom dis-

orders
Somatization disorder:
– This is now typically diagnosed as somatic symptom disorder.

Patients may resist suggestions for individual or group psycho-
therapy because they view their illness as a medical problem.
34
– Patients who accept psychotherapy may be able to reduce

health care utilization.
– Psychosocial interventions that focus on maintaining social
and occupational function despite chronic medical symptoms
may be helpful.
Conversion disorder:
– Limited studies about specific psychotherapy exist for conver-

sion disorder.
– Behavior therapy or hypnosis may be effective.
– Symptoms often resolve spontaneously.
Hypochondriasis:
– This is now typically diagnosed as a somatic symptom disor-

der or primary anxiety disorder.
– Physicians should attempt to answer questions and reduce the
patient's fear of a specific illness.
– Group psychotherapy may provide social support and reduce
anxiety.
– Cognitive therapy strategies may help by focussing on distort-
ed disease-related cognitions.
– Individual insight-oriented psychotherapy has not been proven
effective.
35
Cognitive-behavioral therapy:
– In particular, this type of therapy is especially effective for pa-

tients who fit the criteria for a depressive disorder.
– Cognitive-behavioral therapy was superior to control condi-
tions, with even greater effects to groups restricted to partici-
pants with depressive disorder.
36
sick role
Introduction:
The general idea is that the individual who has fallen ill is not
only physically sick, but now adheres to the specifically patterned
social role of being sick. ‘Being Sick’ is not simply a ‘state of fact’
or ‘condition’, it contains within itself customary rights and obliga-
tions based on the social norms that surround it.
Definition of sick role:

The protective role given an individual who is physically or
mentally ill or injured it may be assumed by the individual or it
may be imposed as a part of social custom.
Figure (5) Outlined two rights of a sick person.
37
The theory outlined two rights of a sick person and two obli-
gations:
Rights:
1. The sick person is exempt from normal social roles

2. The sick person is not responsible for their condition
Obligations:
1. The sick person should try to get well

2. The sick person should seek technically competent
help and cooperate with the medical professional
There are three versions of sick role:
1. Conditional
2. Unconditionally legitimate By family
3. Illegitimate role: condition that is stigmatized by others
Criticisms:
Rejecting the sick role.
1. This model assumes that the individual voluntarily ac-

cepts the sick role.
2. Individual may not comply with expectations of the
sick role, may not give up social obligations, may re-
sist dependency, may avoid public sick role if their ill-
ness is stigmatised.
3. Individual may not accept ‘passive patient’ role.
38
Doctor Patient relationship:
1. Going to see doctor may be the end of a process of

help seeking behavior.
2. Differential treatment of patient, and differential doctor
patient relationship- variations depend on social class,
gender and ethnicity.
Blaming the sick.
1. ‘Rights’ do not always apply.

2. Sometimes individuals are held responsible for their
illness, i.e. illness associated with sufferers lifestyle.).
3. In stigmatised illness sufferer is often not accepted as
legitimately sick.
Chronic Illness.
1. Model fits acute illness (measles, appendicitis, rela-

tively short term conditions).
2. Does not fit Chronic/ long-term/permanent illness as
easily, getting well not an expectation with chronic
conditions such as blindness, diabetes.
3. In chronic illness acting the sick role is less appropriate
and less functional for both individual and social sys-
tem.
4. Chronically ill patients are often encouraged to be in-
dependent.
39
Second
Chapter
40
Therapeutic nurse-patient relationship
Learning objective and Outlines:
1. Introduction.
2. Definition of therapeutic nurse-patient relationship.
3. Discussed purpose of therapeutic nurse-patient relationship.
4. Identify factors of nurse-patient relationship.
5. Explain types of relationships.
6. Enumerate comparison between therapeutic and social rela-

tionship.
7. Interpret Phases of nurse-patient relationship:
o Pre-orientation phase.
o Orientation phase.
o Working phase.
o Termination phase.
8. List principles of nurse-patient relationship.
9. Analyze barriers to establish a therapeutic relationship.
41
Therapeutic nurse-patient relationship
Introduction
The therapeutic relationship differs from the social or intimate

relationship in many ways because it focuses on the needs, experi-
ences, feelings, and ideas of the patient only. An understanding of
the factors influencing communication, therapeutic communica-
tion process provide the foundation for developing a therapeutic
relationship with a client.
Definition
A therapeutic relationship is a planned and goal –directed

communication process between a nurse and a patient for provid-
ing care to the patient and the patient 's family or significant oth-
ers.
Figure (6) Therapeutic nurse patient relationship.
42
Purpose of therapeutic nurse patient relationship

1. To help patient to solve problems.
2. Help patient to cope more effectively and achieve develop-
mental goals.
3. Help nurse to assess and meet patient needs.
4. To enhance patient wellbeing.
5. To promote recovery.
6. To support the self-care functioning of the patient.
Factors of nurse-patient relationship (basic ingredients)
1. Empathy:
1. Empathy is the ability of the nurse to perceive the meanings
and feelings of the patient and to communicate that under-
standing to the patient.
2. The nurse must understand the difference between empathy
and sympathy (feelings of concern or compassion one shows
for another.
For example:
'' I see you are sad ----how can I help. (Empathy).
'I feel so sorry for you. (Sympathy).
43
2. Genuineness:
1. The nurse achieves validity with the patient through sincerity
and behavioral congruence.
2. The nurse is sincere, honest, and authentic when interacting
with the patient.
3. Self-disclosure:
The nurse shares appropriate attitudes, feelings, and be-
liefs and services as a role module to the client.
4. Respect:
1. The nurse considers the client to be deserving of high re-
gard.
2. Respect doesn't depend on the person's behavior; instead,
the person is regarded as worthwhile simply for being
human.
3. It does not mean that the nurse accepts all aspects of a
person's behavior or encourages it; the nurse must sepa-
rate that behavior from the person.
5. Confrontation:
1. The nurse approaches the client in a direct manner, usual-
ly because of perceived discrepancies in the patient's be-
havior.
44
2. Confrontation is used to help the patient develop an

awareness of incongruent behavior. For example, a client
may say he will attend therapeutic group sessions, then
not show up for group without a good reason. The nurse
confronts the client by pointing out this in consistent be-
havior.
Figure (7) Team therapeutic relationship.
45
6. Positive regard:
Positive regard implies respect. It is the ability to view
another person as being worthy and as some who has strengths
and achievement potential.
7. Successful communication:
It helps the patient to express his feeling and needs for
the nurse, to meet these needs during their relationship.
8. Trust:
Trust refers to feeling of confidence in building a relation
with other.
Types of relationships
1. Therapeutic relationships:
The therapeutic relationships between nurse and patient dif-
fer from both a social and an intimate relationship, in that the
nurse maximum inner communication skills, understanding of
human behaviors and personal strengths.
2. Social relationships:
It is primarily initiated for the purpose of friendships, socializa-
tion, enjoyment, or accomplishing a task.
46
3. Intimate relationships:
Occurs between two individuals who have an emotional com-
mitment to each other.
Comparison between therapeutic and social relationship

Item Therapeutic Social
Definition The therapeutic relationships It is primarily initiated for the
between nurse and client differ purpose of friendships, social-
from both a social and an inti- ization, enjoyment, or accom-
mate relationship, in that the plishing a task.
nurse maximum inner commu-
nication skills, understanding of
human behaviors and personal
strengths.
Key focus The patient. Both participants.
goals Meeting patient's needs. Meeting own needs mutual
Help patient to identify feel- companionship, enjoyment,
ings and concerns, problem and interaction.
solving, cope, and adapt in re- May lead to intimacy and
lation to health care situation. commitment.
Self- Nurse as- Each

assessment sesses own role, communi- person assesses how own
cation skills, values, and needs for enjoyment af-
how these affect the profes- fection, and sharing, or
sional relationship. love and intimacy, are met
in the relationship.
47
Phases of nurse-patient relationship
1. Pre-orientation phase:
This initial phase gather data about the patient, his or her condi-
tion, and preset situation. Information is taken from all available
sources as patient's chart, staff situation, physician report, input from
family or any reliable source.
2. Orientation phase:
It consists of introduction and an agreement between nurse and
patient about their mutual role and responsibilities. The nurse and
patient get to know each other and trust is developed.
Characterized by:
1. Nurse and patient are stranger to each other.
2. Lock of trust.
3. Lack of knowledge.
4. Having high level of anxiety.
5. High level of dependency.
Issues need to be addressed during orientation phase:
1. The parameters of relationship.
2. Formal or informal contract.
3. Confidentiality.
48
4. Termination.
The contract
A contract is established in the orientation phase of the
relationship. Nurses most frequently use verbal, informal con-
tract with patient in acute care settings in which the patient and
the nurse are more continually together.
The nurse explains the purpose of the meetings, what

may be expected during the meetings, and the roles of both nurse
and patient. Together they determine short term and long term
objectives.
Working phase
The orientation phase ends and the working phase
begin when the patient takes responsibility for his or her behav-
ior change.
During the working phase that the nurse and patient to-
gether identify and explore area in the patient life that are cours-
ing the patient problem.
Characterized by:
1. Lowering of anxiety level.
2. Increased feeling of trust.
3. Nurse and patient are more knowledgeable about sit-
uation.
49
4. Patient looks forward nurse visit usually.
The tasks of the working phase of the therapeutic relation-

ship include the following:
1. Maintain the relationship.
2. Gather further data.
3. Facilitate behavioral change.
4. Overcome resistance behaviors.
5. Evaluate problems and goals.
Termination phase:
Termination is the closure of the relationship. Termination

begins in the orientation phase when the nurse states meeting
times with patient.
Characterized by:
1. Patient symptoms relief.
2. Improve social functioning.
3. Greater sense of identity and fairly independent.
4. Accomplishment of goals.
5. Read for separation may arouse in both patient and nurse.
Tasks of the termination phase include the following:
50
1. Spacing contacts with the patient further a part or decreas-

ing the length of appointment to allow for increased inde-
pendence.
2. Expressing feeling about the loss of the relationship.
3. Establishing a more relaxed, less intense interaction.
4. Focusing on the future.
5. Providing necessary referrals and links with community
resources.
Principles of nurse-patient relationship:
1. The relationship is therapeutic rather than social:

It is formed to help patient to solve problems, make deci-
sions, achieve goals,
2. The focus remains on the patient issues rather than the nurse
or other issues.
3. The relationships is purposeful and goal directed:
Once goals are established, the nurse and the patient agree
to work toward those goals and put intentions into action and
modify strategies when necessary until the identified goal are
achieved.
3. It is objective versus subjective in quality: Objectivity
refers to remaining free from bias and personal identi-
51
fication in the interaction with the patient and being

able to process information based on.
Barriers establishing a therapeutic relationship
1. Judgmental attitude
Judgmental attitudes, which clients can easily detect, will

halt the therapeutic relationship before it begins.
2. Excessive probing
Being in therapeutic relationship does not give nurses un-

limited permission to invade the patient's privacy.
3. Lack of self-awareness
Patients must feel safe with the nurse. They must able
to sense that the nurse can handle what they are saying without
becoming overwhelmed by the nurse's reactions.
Figure (8) Health team.
52
Personality
Outlines
1. Introduction.
2. Definition.
3. Factors influencing personality.
4. Characteristics of healthy person.
5. Personality theories (psycho-social theory Erikson).
6. Personality assessment.
7. References.
53
Personality
Introduction
All people, including you and me, have a personality, and every
person each has a unique personality. It is what makes us the per-
son we are. Our personalities control our behaviors, thoughts,
emotions and even our unconscious feelings. It makes it possible
to predict how a person will act or react under different situations.
Definition
Personality: It can be termed as the combination of qualities mental,
physical and moral that set one apart from others.
OR
It is the complex of all the attributes--behavioral, tempera-

mental, emotional and mental--that characterize a unique individu-
al; "their different reactions reflected their very different person-
alities.
OR
54
Personality refers to distinctive set of traits, behavior style, and pat-

terns that make up our character and individuality.
Factors influencing personality:
1. Hereditary factors
Hereditary determines the mainlines of personality

(through genes).
2. Social factors:
Parental relationship, peer relations Beliefs, values, behavior,
contact with group.
3. Physical factors;
Physical health and vitality, body built, state of nutrition,
presence of physical defect.
4. Psychological factors:
Sense of security, love, self-
expression, individual accom-
plishment that are the result of
learning and adaptation.
55
Figure (9) individual accomplishment
Characteristics of healthy person

1. Satisfying role performance
2. Positive self concept. The individual expect to be successful in

life
3. Positive and accurate body image, healthy body and awareness
would be based on self-observation and appropriate con-
cern for one physical wellbeing.
4. Realistic self ideal, attainable life goal that are valuable

5. Clear senses of identity give his life direction and purpose.
56
Figure (10) Characteristics of healthy person
Personality assessment:
Projective tests can provide insight into patient personality,
mood, and psychopathology . These tests include (draw-a person
test, Minnesota multiphase personality inventory (MMPI), Sen-
tence completion test, Thematic Apperception Test.
1. Draw a person test
In draw person test, the patient draw human figure of each sex,
the drawings may be interpreted information about client's concepts
of their own bodies, their relationship with persons of opposite sex,
the same sex, and parents .
This test also can be used to estimate child development level.
2. Minnesota Multiphase Personality Inventory (MMPI)

MMPI is complex and lengthy test consisting of 550 questions
asked of the client, scoring done in relation to nine areas:
Preoccupation about body disease: depression, hysteria, antiso-
cial personality: masculine or feminine feature: paranoid qualities:
anxiety, phobias, and psychogenic feature State: schizophrenic fea-
ture and manic feature.
57
Clinical profile of personality structure is drawn from client re-

sponse in these areas.
3. Sentence completion test

In the sentence completion test, the patient complete series of sen-
tences. A sentence might begin (when I get angry, I--------) the re-
sponse may reveal patient fantasies, fears, anxieties.
4. Thematic Apperception Test

In the Thematic Apperception Test patient is shown series of
picture depicting ambiguous situation and asked to tell story de-
scribing each picture.
The picture themselves are quite ambiguous, so that what client
choose to say reveal aspects of their own emotional live.
58
Patient rights
Outlines:
1. Definition of a right.
2. Definition of patient rights.
3. A patient bill of rights.
4. Psychiatric patient’s rights.
5. Child’s rights.
6. Patient’s responsibilities.
7. Nursing role toward patient rights.
8. References.
59
Patient rights
Introduction:
The patient bills of rights are written to safeguard the rights of

people when they come for health care and to provide guidelines as
to how they can expect to be treated by health care providers. These
patient rights were devised to inform patients about what they could
expect from their physician-patient relationship or the hospital-
patient relationship.
Definition of a right:
Is described as a power, privilege of existence to which one has
just a claim.
Definition of patient rights:

A bill of particulars designed to protect patient by establishing
standards governing the hospital and professional staff responsibility
to patients and families.
A patient bill of rights:
60
1. The patient has the right to considerate and respectful care.
The right of respectful care has direct meaning for nursing, as

nurses
have the most contact with patients in a hospital setting. Respectful
care implies that such factors as individual preferences, developmen-
tal needs, cultural and religious practices, and age differences are
considered and incorporated into care.
61
2. The patient has the right to obtain from his physician complete,
current information concerning his diagnosis, treatment, and prog-
nosis. In terms that the patient be reasonably expected to under-
stand.
62
3. The patient has the right to receive from his physician the infor-
mation necessary to give informed consent.
Explaining that it is the person’s right to know the risks as well as

the benefits of treatment helps people to understand why the physi-
cian's explanation was in such details.
Figure (11) patient bill of rights
Example:
Ten years ago, if a person was to have a procedure such as a
lumbar puncture (where a needle is inserted into the spinal canal un-
der sterile conditions and cerebral spinal fluid is withdrawn for anal-
ysis), the physician can merely announced to the patient what he was
63
going to do and added a little more than "Don’t worry, it is a simple

procedure", today in these same circumstances the physician must
legally name the risks involved (the needle could strike a nerve
which could cause paralysis), infection could be introduced at the
time of insertion and alternatives to the procedure.
Although this approach is necessary (a legal requirement), it also

invariably adds a great deal of worry.
4. The patient has the right to refuse the treatment to the extent per-
mitted by law and to be informed of the medical consequences of his
action.
64
Figure (12) patient bill of rights
5. The patient has the right to every consideration of his privacy (con-
fidentiality).
6. The patient has the right to expect that all communications and
records pertaining to his care should be treated as confidential.
7. The patient has the right to expect that within its capacity a hospital
must make reasonable response to the request of a patient for ser-
vices.
Figure (13) patient Responsible for providing as much information as possible
65
Patient’s responsibilities:
1. Responsible for providing as much information as possible
about his or her health and medical history.
2. Responsible for asking the care provider when do not under-
stand medical words or instructions about plan of care.
3. Responsible for following plan of care.
4. Responsible for acting in a manner that is respectful of other
patients, staff
5. Report changes in his/her condition or symptoms including
pain to a member of the health care plan.
6. Accept responsibility for his/her health outcome, if choose
not to follow treatment
Nursing role toward patient rights:
1. Right to health care is accessible and that meets professional
standards. Regardless of setting.
2. Right to courteous and individualized health care that is equita-
ble, human, and given without discrimination as to race, color,
creed, sex, national origin source of payment, or ethical or polit-
ical beliefs.
3. Right to information about their diagnosis, prognosis, and treat-
ment, including alternatives to care and risk involved.
4. Right to information about the qualifications, names, and titles
of healthcare personnel.
66
5. Right to information and continuity of healthcare.

6. Right to information on the charges for services, including the
right to challenge these.
7. Inform the patient about the importance of follow up and to fol-
low plan of care.
67
Stress management
Learning objective and Out line:
At the end of lecture, the student will be able to:
1. introduction
2. Definition
– Homeostasis
– Stress
3. Explain type of stress.
4. Definition of stressors
5. Enemare types of stressors
6. Stages of stress:
7. Discussed factors that influence on the response to stress:
8. Analyze signs& symptoms of stress
9. Descript coping methods (Defense mechanisms)
10. A play stress management for nurses : {ways of stress man-
agement }
11. Analyze stress and nursing process.
68
Stress management
Introduction:
Stress is what you feel when life's demands exceed one's abil-
ity to meet those demands. In fact, prolonged stress, whether a re-
sult of mental/ emotional up set or due to physical factors such as
malnutrition, surgery ,chemical exposure ,excessive exercise ,sleep
deprivation ,or a host of other environmental causes results in pre-
dictable systemic effects.
Homeostasis:
Astate of balance in the body
Homeo = same; stasis = standing.
Definition:
It is a dynamic process to maintain several conditions in the
internal environment within a given range. The balance or equilib-
rium among the physiologic, psychological, sociocultural , intellec-
tual, and spiritual needs of the body.
These include but are not limited to

1. Blood pH
2. Oxygen tension
3. Blood pressure
4. Temperature
69
5. Glucose concentration
6. Body water content
Stress:
Definition:
Is a condition or feeling experienced when a person per-
ceives that demands exceed the personal and social resources
the individual is able to mobilize.
OR
Is physical, mental, psychological or spiritual response to
any stressors or tension or physiological reactions that may lead
to illness a physical or psychological stimulus that can produce
mental illness.
Figure (14) Pessimistic Persons Are More Reactive to Stressors
70
– Type A Behavior Pattern

– characterized by competitiveness, impatience, ambi-
tion, hostility, & a hard-driving approach to life is as-
sociated with increased risk of heart disease
– Type B Behavior Pattern
– characterized by a patient, relaxed, easygoing approach
to life, with little hurry or hostility only half as likely
to develop heart disease
Figure (15) Pessimistic Persons Are More Reactive to Stressors
71
Types of stress:
1. Eustress:
Is a positive form of stress, usually related to desirable
events in a person's life. It prepares the muscles, heart and mind
for the strength needed for what ever is about to occur .
Examples: marriage, birth of baby, Job promotion.
2. Distress:
Negative stress in this type the mind and body undergoes
when the normal routine is constantly adjusted and altered. The
mind is not comfortable with this routine. May be acute stress or
chronic stress
Acute stress is common in people who take too many re-
sponsibilities and are overloaded or overworked.
Chronic stress is a prolonged stress that exists for weeks,
months, or even years.
This stress is due to poverty, broken or stressed families and
marriages,
Examples: work demand, death of friend or family member,
car troubles, change of Job place.
72
Definition of stressors:
It is a source of stress anything causes a person to experience
stress.
Types of stressors:
1. Physical stressors
Example: noise, bright light .heat.
2. Physiological stressors
Example: pain ,hunger , infection.
3. Psychological stressors
Example: divorce, loss of job, death of love one, retire-
ment.
4. Social relation ships (interaction with people)
Example: rudeness, bossiness.
5. Occupational
Example: rules, regulation.
6. Financial
7. Life style choices
Example: not enough sleep, over load schedule
Stages of stress:
Stage 1: Alarm
1. Increased secretion of corticosteroid and resultant change.
2. Increased activity of sympathetic nervous system.
73
3. Hormones such as cortisol and adrenalin released into the

blood
4. stream to meet the threat or danger. The body’s resources
now mobilized.
5. Increased norepinephrine secretion by adrenal medulla
6. Flght- or- flight’’ syndrome change.
7. Low resistance to stressor.
Posterior pituitary:
↑ADH→↑Water reabsorption.
↓Urine out put.
Figure (16) Physical stressors.
74
Anterior pituitary
ACTH→Adrenal cortex
↑Cortisol→↑Gluconeogensis.
↑Protein metabolism.
↑Fat metabolism.
↑Aldosterone→ ↑Sodium reabsorption.
↑Water reabsorption.
↓Urine out put
Sympathetic nervous system and adrenal medulla:
↑Epinephrine→ ↑heart rate.
↑O2 intake
↑Blood sugar.
↑ Nor epinephrine→ ↑Blood flow to
skeletal muscle. Arterial blood pressure
Stage 2: Resistance
1. Parasympathetic nervous system returns any physiological
functions to normal levels while body focuses resources
against the stressor.
2. “Fight-flight” syndrome disappears.
3. A High resistance (adaptation) to stressor.
75
Stage 3: Exhaustion
If stressor continues beyond body’s capacity, organism
exhausts resources and becomes susceptible to disease and
death.
Factors that influence on the response to stress:
1. Personality perception
2. Past experiences
3. Intensity of the stressor
4. Development stage
5. Scope of the stressor
Signs& symptoms of stress
Physical Stress Symptoms:
1. Breathlessness
2. Headaches
3. Hyperventilating
4. Increased heart rate
5. Indigestion
Psychological Stress Symptoms:

1. Anxious
2. Blaming others
3. Depression
4. Depressed/Anxious thinking
5. Excess guilt
76
Behavioral Stress Symptoms:

1. Aggression
2. Agitation
3. Crying
4. Decreased/increased sexuality
5. Difficulty with relationships.
Coping:
Coping can be either Positive or Negative
1. Positive coping: includes activities such as exercise
and use of social support.
2. Negative coping: include substance abuse and denial.
Coping with stress:

There are several things that you can do to help yourself cop-
ing. For things that happen every day, it can be useful to think of
your stress as a puzzle to be solved:
1. Think about the situations that stress you, and how you be-
have.
2. Think about how you could behave differently in these situa-
tions, so that you would feel more in control.
77
3. List all the things you can think of that would make life easi-
er or less stressful - write them down on a piece of paper.
This can help you sort things out in your head.
Coping methods (Defense mechanisms):

Are unconscious processes used by individuals in adjustment
to life stressors:-
1. Avoidance: Mentally or physically avoiding something that
causes distress.
2. Conversion: subconscious conversion of stress into physical
symptoms.
3. Denial: refusing to acknowledge that an event has occurred.
4. Displacement: shifting of intended action to a safer target.
5. Regression: returning to a child state to avoid problems.
6. Repression: subconsciously hiding uncomfortable thoughts.
Coping Strategies:
1. Emotion-focused coping: Involves managing the emotions
that an individual feels when a stressful event occurs. e.g.,
discussion of feeling with a friend or taking a hot bath, going
for a run.
78
2. Problem Focused Coping : to resolve the problems causing

stress e.g. setting priorities or collecting information and
seeking advice would be considered problem-focused coping
Coping strategies as social support, Exercise, journaling, art
therapy, and humor.
Stress Management:
Steps of stress management:

ABC’s of Stress Management
– Awareness- be honest with and to yourself
– Belief- believe in yourself
– Commitment- be committed to work on stress recogni-
tion and reduction
Suggestions for stress management:
1. Establish a regular program of exercise and activity to focus
energy expenditure.
2. Eliminate or restrict the amount of alcohol , caffeine , and
other mood , altering substances as a means of managing
stress.
3. Learn to accept failure {you’re own and others } and turn it
into a constructive experience.
4. Develop support systems with colleagues and friends.
5. Have an optimistic view of the world and believe that most
people are doing the best they can.
79
Stress management for nurses : {ways of stress management }

1. Supportive internal messages
Is referred to as “self - talk “or internal messages. Internal
messages have definite effects on daily functioning and self-concept
A constant stream of negative self-messages can lead to generalized
feelings of inferiority and self-doubt. Instead to control them by
substituting supportive messages to help cope with difficulties.
2. Making life style changes:

1. Make proper scheduling of day-to-day work.
2. Take sufficient time to do things.
3. Do not make your self-overburdened.
4. Keep time to relax and sleep daily.
5. Practice meditation.
3. Exercising.
Physical activity or exercise is a technique that helps counter the
effects of the stress response . Such as:
4. Vigorous physical exertion:

Helps to release tension from the muscles and is a natural
outlet when the body is in a fight-or-flight state of arousal .
- Aerobic exercise:
Examples of aerobic exercise include running ,bicycling
,swimming. Cross-country skiing ,brisk walking and rowing.
80
Researchers have recognized that walking for 20 to30 minutes

a day is beneficial and is associated with decreased risk for
cardiovascular disease.
Health benefits of exercise:
1. Improves muscular strength and flexibility
2. Improves cardio vascular efficiency.
3. Lowers resting heart rate.
4. Reduces blood cholesterol levels.
5. Reduces general anxiety and depression .
4. Relaxation techniques
Relaxation is a process that decreases the wear and tear on

your mind and body from the challenges and hassles of daily life.
1. Deep breathing: Is a simple technique and effective in re-

ducing anxiety, depression, irritability, muscular tension, and
fatigue. A good guideline is to practice deep breathing for a
few minutes 3 or 4 times a day.
5. Visualization and imagery:
An attempt to affect an unconscious process by using a conscious

suggestion or a mental picture of the desired change.
81
6. Meditation:
A traditional Eastern religious technique to achieve mental

and physical relaxation. Four elements include a quiet place; a com-
fortable position; an object to dwell on such as a word or symbol;
and a passive attitude.
7. Therapeutic Massage:
8. Yoga:
Stress and the Nursing process:

Nurses can help clients understand their anxiety and learn cop-
ing mechanisms through:
1. Assessment.
2. Nursing Diagnosis.
3. Planning/Outcome Identification.
4. Nursing Interventions.
Assessment
1. What are the patterns of stressors?
2. What are the typical responses to stressful situations?
3. What are the cause-and-effect relationships among stressors
and thoughts, feelings, and behaviors?
4. What is the past history of successful coping mechanisms?
82
Nursing Diagnoses
Nursing diagnoses that may occur in response to stressors in-
clude:
1. Impaired adjustment
2. Defensive coping
3. Sleep Pattern Disturbance
4. Post-trauma syndrome
5. Impaired Social Interaction
Planning/Outcome Identification
1. Identify situations that increase stress and anxiety.
2. Verbalize a plan to decrease the effect of common stressors.
3. Differentiate positive and negative stressors.
4. Categorize stressors.
5. Demonstrate stress-management exercises.
6. Verbalize a plan for stress management, including necessary
lifestyle modifications.
Nursing Interventions
1. Meeting basic needs.
2. Minimizing environmental stimuli.
3. Verbalizing feelings.
4. Involving family and significant others.
5. Using Stress-Management techniques.
6. Crisis intervention.
83
Third
chapter
84
Self-awareness
Learning objective and Outline:

At the end of lecture, the student will be able to:
1. Introduction.
2. Definition of self-awareness.
3. Explain Importance of self-awareness.
4. Discussed Personality traits that affect self-awareness.
5. Analyze Johari window.
6. Defined Self-assessment.
7. Interpret self-intervention.
8. Descript improving self-awareness.
85
Self-awareness
Introduction
Self-awareness is a cornerstone in therapeutic relationships.
Self-awareness allows the nurse to observe, pay attention and un-
derstand the responses and reactions of clients when interacting
with them.
Definition of Self Awareness:

Is a process of understanding one's own values, beliefs, thoughts,
feelings, attitudes, motivations, strengths and limitations and recog-
nizing how they affect others with whom we interact.
Or
Self-awareness is the explicit understanding that one exists. Fur-

thermore, it includes the concept that one exists as an individual,
separate from other people, with private thoughts.
Importance of self-awareness
1. By developing self-awareness the nurse can establishing and
maintaining therapeutic relationship.
2. Self-awareness increases self-understanding, self-acceptance
and options for action.
86
3. Understanding and acceptance of self allows the nurse to

acknowledge a patient's differences and uniqueness.
4. Self-awareness helps you to know your strengths and limita-
tions, so you can avoid uncontrollable or danger situations.
Figure (17) Personality affects self-awareness
Personality traits can affect self-awareness

1. Extrovert personality
Is an outgoing person who relates more easily to people and
things in the environment, likes to take charge of situations, and
have little difficulty socialization.
2. Introvert personality:
Introversion is the tendency to focus one's attention towards
the inner, mental world rather than external, physical "reality".
87
Is a quite individual who relates better to the inner world of

ideas, thoughts, and feelings, prefers to be follower, and usually lets
others initiate and direct interventions.
3. Open minded person:
– An open-minded person is someone who is willing to consid-
er ideas, opinions and arguments purely on their merit.
– Don't make decision until they are aware of all the facts per-
taining to a certain situation.
4. Judgmental person:
Is often inflexible and run the risk of neglecting the perception of
others, possibly arriving at an opinion based on their own values
without enough facts or enough regard for what other people many
feel or think. .
Johari window:
The Johari Window model is a simple and useful tool for illustrating
and improving self-awareness, and mutual understanding between
individuals within a group.
Definition of Johari window:
It is analysis of known and unknown aspect of self and they relat-
ed to self-awareness and awareness of others. Johari window each
window (quadrant) of self-awareness; each one describes one aspect
of the self.
88
Figure (18) Johari window
Quadrant (1)
Called the open quadrant, it includes the behaviors, feelings, and
thoughts known to the individual and others.
Quadrant (2):
Is called the blind quadrant it includes all those things (the behav-
iors, feelings, and thoughts) that others know but that the individual
doesn't know.
89
Quadrant (3):
Is the hidden quadrant, it includes those things (the behaviors, feel-
ings, and thoughts) about himself that only the individual knows
and not known to others.
Quadrant (4):
Is the unknown quadrant, containing (the behaviors, feelings, and
thoughts) unknown to the individual and to others.
The following principles may help to clarify how the self-

functions
[
Self-Assessment
Is a process of using self therapeutically requires that nurses
identify their own feelings, thoughts, and behaviors that emerge in
response to clients' behaviors or external factors.
Self-assessment is an essential ingredient of therapeutic use

of self and an integral part of therapeutic relationships.
90
Figure (19) principles clarify self-functions
Self-assessment questions that promote self-awareness in nurse:

1. Who am I?
2. what is my purpose in life?
3. What are my weakness and strength?
4. How do I interact with men? With women? -
5. Do I behave in a particular way with people I like? Dislike?
6. How do I express anxiety?
Self-intervention:
Is the process of understanding and modifying forces within
the self that provide anxiety and interfere with the nurse-client re-
lationship:
91
1. Intervention with the self enables nurses to deal with their own
reactivity and "triggers" and thus help clients with all kinds and
degree of problems.
2. Nurses attempt to discover the forces within themselves that in-
fluence the nurse-patient relationship.
3. Ones these thoughts, feelings, values, and behaviors have been
discovered, specific ways in which they positively or negatively
affect relationship with the clients are examined.
4. In addition, modify negative forces so that they can increase
nurse effectiveness as a caregiver.
Improving self-awareness
The goal of increasing self-awareness is to enlarge the area of
quadrant one and reducing the size of other three quadrants, to in-
crease self-knowledge, it is important to:
1. Listen to self:
2. Allow genuine emotion to be experienced, Identifies and ac-
cept personal needs, exploring personal thoughts, feelings,
memories and impulses.
3. Listen to and learn from others.
4. Self-disclosing or reveal to others important aspects of the
self.
92
Self-concept
Introduction
The human begins are different from the most complex an-
imals in a significant ways they are aware of themselves and
have a concept of self. As children grow and develop they learn
to identify and define themselves as individuals, they develop a
picture (point of view) of how they are, and then they use that
picture as a frame work for perceiving, experiencing, and evalua-
tion the world.
Definition of self-concept:
Is the accumulation of knowledge about the self-such as
beliefs regarding personality traits physical characteristics ,
abilities, values.
Other Definition:
The mental image or perception that one has of oneself.
93
Figure (21) Self-concept.
Component of self- concept

I. Body image
Definition:
Body image is the subjective view a person has about his
or her physical appearance.
Factors affecting body image:-

a. irreversible changes in body image such as (amputation,
mastectomy, hysterectomy, colostomy, scars and burns)
b. changes in body size, shape, and appearance (rapid weight
gain, weight loss, skin infection)
c. pathological process that cause changes in the structure or
function of body (arthritis, heart disease).
d. failure of body part to function (paraplegia)
II. Self- esteem

Definition:
Self- esteem refers to the extent to we like, accept or approve of
ourselves. Self- esteem always involves a degree of evaluation
and we may have either a positive or a negative view of ourselves
Types of self- esteem:
1. High self esteem i.e. we have a positive view of ourselves.
This tends to lead to:
a. Confidence in our own abilities.
94
b. Self acceptance.
c. Not worrying about what others think.
2. Low self esteem i.e. we have a negative view of ourselves.
This tends to lead to:
a. Lack of confidence.
b. Want to be / look like someone else.
c. Always worrying what others might think.
Factors that influence self- esteem:
The reaction of others:
If people admire us, flatter us, seek out our company, listen
attentively and agree with us we tend to develop a positive
self-- esteem. If they avoid us, neglect us; tell us things about
ourselves that we don't want to hear we develop a negative
self-image.
1. Comparison with others:
If the people we compare ourselves with (our reference
group) appear to be more successful, happier, richer, better
looking than ourselves we tend to develop a negative self-
image.
2. Physiological changes:
3. Identification:
95
They also become part of our personality i.e. we identity

with the positives we occupy, the roles we play and the group
we belong to.
III-Ideal self
Definition:
Is the person's perception of how one should behave, based
on certain personal standers.
Factors which influence of ideal self:
1. The ways in which others (particularly significant others)
react to us.
2. How we think we compare to others.
3. Our social roles.
4. The extent to which we identify with other people.
IV. Role performance
Definition:
1. Role is a set of behaviors by which a person participates in
social groups.
2. Roles involve expectation or standards of behavior or that
have been accepted by society or social group such as fami-
ly or community.
Factors influence a person's adjustment to the role he occu-
pies:
1. The clarity of the behaviors appropriates to the role and
96
one's knowledge of specific role expectations.

2. The consistency of the response of significant others to
one's role.
3. The compatibility and complementary of various roles.
Types of roles:
1. Ascribed roles:- which the individual has no choice .
Example of as ascribed role include age and sex.
2. Assumed roles:-which the individual selects or achieves by
choice.
Example occupation and marital or family roles.
One of difficult problems faced in growing up is established of an
independent life this primarily occurs during adolescence and ear-
ly adulthood when great ambiguity in role definitions occurs.
V. identity
Definition:
1. It is the synthesis of all self representation into an organized
whole.
2. Identity involves the internal sense of individuality, unity of
a person over time and in various circumstances.
Attributes of identity:-
3. The individual recognize himself as an intact bodily organ-
ism, separate from other organism.
97
4. The individual acknowledge his sexuality.

5. The individual is aware of the relationship between past,
present, and future.
6. The individual has goals of value that can be realized.
7. The individual regard the various aspect of himself, such as
roles, values.
Factor affecting self-concept:
1. Altered health status :
Some illness may impair self- concept For example there is
social stigma against mental illness many people fear can-
cer and isolate which leading to low self- esteem.
2. Developmental transition :
Self- concept change through life process of growth and de-
velopment. For example as the pregnancy progresses the
women's body image adjusts to accommodate the idea that
the baby is a separate individual after delivery the women
who has positive self- esteem will accept and love the baby.
1. Experience:
a. Self concept affecting individual's experience that
allows opportunities for success and failure.
b. People who have experienced several failures begin to
view
themselves as failures a negative self-concept is the result
98
of repeated failures. On the other hand people achieve

a task begin to see themselves in appositive manner.
1. Coping and stress tolerance :
That affect self - concept people who coping with stress
and resolve conflict develop healthy self- concept.
2. Culture: Children internalizing belief behavior teaching they
are exposed.
3. Biological make up:
Include ages, weight, height, skin color affect self- concept.
Types of self concept
Positive self concept
Characteristics of Positive self concept:
1. Stable and diversified self-knowledge (self-awareness).
2. Realistic self- view and self- respect.
3. Positive self- evaluation and acceptance of self "strengths and
weakness"
4. Exhibit clear sense of self and others, understanding their roles
in the real world.
5. Have high self- esteem.
99
Figure (22) The Self.
Negative self concept

Characteristics of Negative self- concept :
1. Reflecting in feeling of worthlessness.
2. Lack of respect of oneself and abilities.
3. Have a narrowed or distorted perceptual field.
4. His anxiety level will rise quickly and he feels easily threatened.
5. Unable to build adaptive coping skills.
6. Withdrawal from social contacts.
7. Increase dependence of others.
8. Self destructive behavior (Alcohol, drug abused).
Assessment of self-concept:
1. We provide a series of measures that programs may use to as-
sess the self-concept.
2. -We provide items to measure each of the following domains
of self-Concept:
a. Scholastic competence.
100
b. Athletic competence.
c. Physical appearance.
d. Peer acceptance.
e. Conduct / morality
Assessment for self-concept
A . subjective data :
Asking the person the following questions about self concept.
1. How would you describe yourself?
2. Most of the time, how do you feel about yourself?
3. It this a problem for you?
4. Do you find things frequently make you feel angry, anxious,
afraid and sad?
5. What helps you when you feel hopeless, or out of control of your
life ?
B . Objective data :
1. Through direct observation.
2. Include behavior manifestation such as lack of eye contact, phys-
ical observations such as amassing body part function.
3. observe some behaviors such as weeping, hides a body part does
this manifest body image disturbance.
101

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Secondly years- First term

‫رؤية ورسالة كلية التمريض جامعة اسوان‬

‫رسالة الفلية ‪:‬‬

Principles of behavior in health and illness:

General Introduction of the course:

By the end of these units, the student will be able to:

1. Apply models of behavior to understand factors that influ-

Purpose of the course:

This overview course is designed to provide students with

1. An understanding of influences on health and illness behavior

The First Chapter

1 Health and illness behavior 14

– Sick role behavior r

The Second Chapter

6 Stress and Stress Management 68

The Third Chapter

1. Generally, health-related behavior of healthy people and

Figure (1) describes patient's reactions to the experience of being sick.

Illness behavior and sick role:

1. The term illness behavior describes patient's reactions to the

7. Everyday life, illness' behavior may be a mixture of behav-

1.The sick role includes being excused from responsibili-

7. Some people experience illness as overwhelming loss;

1. Prior illness episodes, especially illness of standard severity

Predicable reaction to illness:

– Lowered self-image ' loss' grief

– Threat to homeostasis ' fear '

– Failure of (self) care, helplessness, hopelessness

– Sense of loss of control ' shame (guilt) '

– Denial and anxiety

– Depression, bargaining and blaming

– Regression, isolation, dependency, anger, acceptance

Defense mechanisms in illness

1. People unconsciously use defense mechanism to protect

1.The patient reverts to a more child-like pattern of behavior

Health and illness behavior

Learning objective and outlins:

By the end of these units, the student will be able to:

1. Define Health and illness behavior.

2. Explain ten general category used for recognition of illness.

3. Discuss the stages of illness behaviors.

4. Explain factors affecting on health and illness behavior.

5. Recognize the behavioral therapy.

6. Identify the techniques used for therapy.

7. Interpret benefits of therapy.

8. Analyze the risk of behavioral therapy.

Health and illness behavior

Health and illness behaviors are associated with level of

Definitions of health behavior:

health behavior refers to the actions of individuals, groups,

"those personal attributes such as beliefs, expectations, mo-

Preventive health behavior:

Involves any activity undertaken by individuals who believe

The manner in which individuals monitor the structure and

Any activity undertaken by individuals who perceive

Involves any activity undertaken by those who consider

Self-care behavior involves taking actions to improve or

Dietary behavior refers to eating patterns that people en-

Substance-use behavior focuses on the use of both licit and

Illness behavior begins prior to the use of services with the

While a complex array of variables might explain variations

They can be summarized in ten general categories: