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6054_IFC 20/07/17 11:58 AM Page 2

YOUR GUIDE TO

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6054_FM_i-xx 16/08/17 2:42 pm Page vi

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Library of Congress Control Number: 2014944300

ISBN: 978-0-8036-6054-0

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Names: Townsend, Mary C., 1941- author. | Morgan, Karyn I., author.
Title: Psychiatric mental health nursing : concepts of care in evidence-based
practice / Mary C. Townsend, Karyn I. Morgan.
Description: Ninth edition. | Philadelphia, PA : F. A. Davis Company, [2018]

| Includes bibliographical references (p. ) and index.

Identifiers: LCCN 2017009564| ISBN 9780803660540 | ISBN 0803660545
Subjects: | MESH: Psychiatric Nursing—methods | Mental Disorders—nursing |

Evidence-Based Nursing
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6054_FM_i-xx 16/08/17 2:42 pm Page vii

THIS BOOK IS DEDICATED TO:

FRANCIE

God made sisters for sharing laughter

and wiping tears

–Mary Townsend

To my friend and mentor, Chaplain (Colonel) Thomas W. Elsey

He was dearly loved and will be deeply missed

October 26, 1942–November 10, 2015

–Karyn Morgan
6054_FM_i-xx 16/08/17 2:42 pm Page viii

Reviewers

Theresa Aldelman Ruth Burkhart

Bradley University New Mexico State University/Dona Ana Community
Peoria, Illinois College
Las Cruces, New Mexico
Fredrick Astle
University of South Carolina Annette Cannon
Columbia, South Carolina Platt College
Aurora, Colorado
Carol Backstedt
Baton Rouge Community College Deena Collins
Baton Rouge, Louisiana Huron School of Nursing
Cleveland, Ohio
Elizabeth Bailey
Clinton Community College Martha Colvin
Pittsburgh, New York Georgia College & State University
Milledgeville, Georgia
Sheryl Banak
Baptist Health Schools – Little Rock Mary Jean Croft
Little Rock, Arkansas St. Joseph School of Nursing
Providence, Rhode Island
Joy A. Barham
Northwestern State University Connie Cupples
Shreveport, Louisiana Union University
Germantown, Tennessee
Barbara Barry
Cape Fear Community College Karen Curlis
Wilmington, North Carolina State University of New York Adirondack
Queensbury, New York
Carole Bomba
Harper College Nancy Cyr
Palatine, Illinois North Georgia College and State University
Dahlonega, Georgia
Judy Bourrand
Samford University Carol Danner
Birmingham, Alabama Baptist Health Schools Little Rock – School of Nursing
Little Rock, Arkansas
Susan Bowles
Barton Community College Carolyn DeCicco
Great Bend, Kansas Our Lady of Lourdes School of Nursing
Camden, New Jersey
Wayne Boyer
College of the Desert Leona Dempsey, PhD, APNP (ret.), PMHCS-BC
Palm Desert, California University of Wisconsin Oshkosh
Oshkosh, Wisconsin
Joyce Briggs
Ivy Tech Community College Debra J. DeVoe
Columbus, Indiana Our Lady of Lourdes School of Nursing
Camden, New Jersey
Toni Bromley
Rogue Community College Victoria T. Durkee, PhD, APRN
Grants Pass, Oregon University of Louisiana at Monroe
Monroe, Louisiana
Terrall Bryan
North Carolina A & T State University J. Carol Elliott
Greensboro, North Carolina St. Anselm College
Fairfield, California

viii
6054_FM_i-xx 16/08/17 2:42 pm Page ix

Reviewers ix

Sandra Farmer Eleanor J. Jefferson

Capital University Community College of Denver
Columbus, Ohio Platt College
Metropolitan St. College
Patricia Freed Denver, Colorado
Saint Louis University
St. Louis, Missouri Dana Johnson
Mesa State College/Grand Junction Regional Center
Diane Gardner Grand Junction, Colorado
University of West Florida
Pensacola, Florida Janet Johnson
Fort Berthold Community College
Maureen Gaynor New Town, North Dakota
Saint Anselm College
Manchester, New Hampshire Nancy Kostin
Madonna University
Denise Glenore Livonia, Michigan
West Coast University
Riverside, California Linda Lamberson
University of Southern Maine
Sheilia R. Goodwin Portland, Maine
Winston Salem State University
Salem, North Carolina Irene Lang
Bristol Community College
Janine Graf-Kirk Fall River, Massachusetts
Trinitas School of Nursing
Elizabeth, New Jersey Rhonda Lansdell
Northeast MS Community College
Susan B. Grubbs Baldwyn, Mississippi
Francis Marion University
Florence, South Carolina Jacqueline Leonard
Franciscan University of Steubenville
Elizabeth Gulledge Steubenville, Ohio
Jacksonville State University
Jacksonville, Alabama Judith Lynch-Sauer
University of Michigan
Kim Gurcan Ann Arbor, Michigan
Columbus Practical School of Nursing
Columbus, Ohio Glenna Mahoney
University of Saint Mary
Patricia Jean Hedrick Young Leavenworth, Kansas
Washington Hospital School of Nursing
Washington, Pennsylvania Jacqueline Mangnall
Jamestown College
Melinda Hermanns Jamestown, North Dakota
University of Texas at Tyler
Tyler, Texas Lori A. Manilla
Hagerstown Community College
Alison Hewig Hagerstown, Maryland
Victoria College
Victoria, Texas Patricia Martin
West Kentucky Community and Technical College
Cheryl Hilgenberg Paducah, Kentucky
Millikin University
Decatur, Illinois Christine Massey
Barton College
Lori Hill Wilson, North Carolina
Gadsden State Community College
Gadsden, Alabama Joanne Matthews
University of Kentucky
Ruby Houldson Lexington, Kentucky
Illinois Eastern Community College
Olney, Illinois
6054_FM_i-xx 16/08/17 2:42 pm Page x

x Reviewers

Joanne McClave JoAnne M. Pearce, MS, RN

Wayne Community College Idaho State University
Goldsboro, North Carolina Pocatello, Idaho

Mary McClay Karen Peterson

Walla Walla University DeSales University
Portland, Oregon Center Valley, Pennsylvania

Susan McCormick Carol Pool

Brazosport College South Texas College
Lake Jackson, Texas McAllen, Texas

Shawn McGill William S. Pope

Clovis Community College Barton College
Clovis, New Mexico Wilson, North Carolina

Margaret McIlwain Karen Pounds

Gordon College Northeastern University
Barnesville, Georgia Boston, Massachusetts

Nancy Miller Konnie Prince

Minneapolis Community and Technical College Victoria College
Minneapolis, Minnesota Victoria, Texas

Vanessa Miller Cheryl Puntil

California State University Fullerton Hawaii Community College
Fullerton, California Hilo, Hawaii

Mary Mitsui Larry Purnell

Emporia State University University of Delaware
Emporia, Kansas Newark, Delaware

Cheryl Moreland, MS, RN Susan Reeves

Western Nevada College Tennessee Technological University
Carson City, Nevada Cookeville, Tennessee

Daniel Nanguang Debra Riendeau

El Paso Community College Saint Joseph’s College of Maine
El Paso, Texas Lewiston, Maine

Susan Newfield Sharon Romer

West Virginia University South Texas College
Morgantown, West Virginia McAllen, Texas

Dorothy Oakley Lisa Romero

Jamestown Community College Solano Community College
Olean, New York Fairfield, California

Christie Obritsch Donna S. Sachse

University of Mary Union University
Bismarck, North Dakota Germantown, Tennessee

Sharon Opsahl Betty Salas

Western Technical College Otero Junior College
La Crosse, Wisconsin La Junta, Colorado

Vicki Paris Sheryl Samuelson, PhD, RN

Jackson State Community College Millikin University
Jackson, Tennessee Decatur, Illinois

Lillian Parker John D. Schaeffer

Clayton State University San Joaquin Delta College
Morrow, Georgia Stockton, California
6054_FM_i-xx 16/08/17 2:42 pm Page xi

Reviewers xi

Mindy Schaffner Dorothy Varchol

Pacific Lutheran University Cincinnati State
Tacoma, Washington Cincinnati, Ohio

Becky Scott Connie M. Wallace

Mercy College of Northwest Ohio Nebraska Methodist College
Toledo, Ohio Omaha, Nebraska

Janie Shaw Sandra Wardell

Clayton State University Orange County Community College
Morrow, Georgia Middletown, New York

Lori Shaw Susan Warmuskerken

Nebraska Methodist College West Shore Community College
Omaha, Nebraska Scottville, Michigan

Joyce Shea Roberta Weseman

Fairfield University East Central College
Fairfield, Connecticut Union, Missouri

Judith Shindul-Rothschild Margaret A. Wheatley

Boston College Case Western Reserve University, FPB School
Chestnut Hill, Massachusetts of Nursing
Cleveland, Ohio
Audrey Silveri
UMass Worcester Graduate School of Nursing Jeana Wilcox
Worcester, Massachusetts Graceland University
Independence, Missouri
Brenda Smith, MSN, RN
North Georgia College and State University Jackie E. Williams
Dahlonega, Georgia Georgia Perimeter College
Clarkston, Georgia
Janet Somlyay
University of Wyoming Rita L. Williams, MSN, RN, CCM
Laramie, Wyoming Langston University School of Nursing & Health
Professions
Charlotte Strahm, DNSc, RN, CNS-PMH Langston, Oklahoma
Purdue North Central
Westville, Indiana Rodney A. White
Lewis and Clark Community College
Jo Sullivan Godfrey, Illinois
Centralia College
Centralia, Washington Vita Wolinsky
Dominican College
Kathleen Sullivan Orangeburg, New York
Boise State University
Boise, Idaho Marguerite Wordell
Kentucky State University
Judy Traynor Frankfort, Kentucky
Jefferson Community College
Watertown, New York Jan Zlotnick
City College of San Francisco
Claudia Turner San Francisco, California
Temple College
Temple, Texas

Suzanne C. Urban
Mansfield University
Mansfield, Pennsylvania
6054_FM_i-xx 16/08/17 2:42 pm Page xii
Acknowledgments
Amy M. Romano, Content Project Manager, Nursing,
F.A. Davis Company, for all your help and support in
preparing the manuscript for publication.
Sharon Y. Lee, Production Editor, for your support
and competence in the final editing and production
of the manuscript.
The nursing educators, students, and clinicians, who
provide critical information about the usability of the
textbook and offer suggestions for improvements.
Many changes have been made on the basis of your
input.
To those individuals who critiqued the manuscript for
this edition and shared your ideas, opinions, and sug-
gestions for enhancement. I sincerely appreciate your
contributions to the final product.
My husband, Jim, and children and grandchildren,
Kerry and Ryan, Tina and Jonathan, Meghan,
Matthew, and Catherine for showing me what life is
truly all about.
Mary C. Townsend
xii
First of all, sincere thanks to Mary Townsend for hav-
ing the confidence in me to be included in authoring
this exceptional text. I have the utmost respect for
what you have created and for your foresight in rec-
ognizing the most relevant issues in the changing face
of psychiatric mental health nursing care.
My thanks also to Susan Rhyner for the encourage-
ment, humor, and passion that have made this work
enjoyable. Thanks to Amy Romano, Andrea Miller,
and Christine Becker for your expertise and accessi-
bility in preparing the manuscript. I, too, appreciate
all the reviewers who have offered feedback and their
unique expertise. Thanks to Jennifer Feldman, MLIS,
AHIP, for sharing your skills and research assistance.
I have learned just how true it is that it “takes a village”
and I am grateful for each of you.
Special thanks to Erin Barnard, Alan Brunner, Fred
Frese, Emmy Strong, and the others who coura-
geously allowed their stories to be told. Your contri-
butions to student learning and to breaking down the
barriers of stigmatization are immeasurable.
I appreciate each of you more than I can say.
Karyn I. Morgan
6054_FM_i-xx 16/08/17 2:42 pm Page xiii

Contents

UNIT 1 Summary and Key Points 82

Review Questions 83
Basic Concepts in Psychiatric-Mental
Health Nursing 1 Chapter 5 Ethical and Legal Issues 86
Objectives 86
Chapter 1 The Concept of Stress Adaptation 2 Homework Assignment 86
Ethical Considerations 88
Objectives 2 Legal Considerations 92
Homework Assignment 2 Summary and Key Points 101
Stress as a Biological Response 3 Review Questions 102
Stress as an Environmental Event 5
Stress as a Transaction Between the Chapter 6 Cultural and Spiritual Concepts
Individual and the Environment 7 Relevant to Psychiatric-Mental
Stress Management 8
Summary and Key Points 9 Health Nursing 105
Review Questions 10 Objectives 105
Homework Assignment 105
Chapter 2 Mental Health and Mental Illness: Cultural Concepts 106
Historical and Theoretical Concepts 12 How Do Cultures Differ? 106
Objectives 12 Application of the Nursing Process 108
Homework Assignment 12 Spiritual Concepts 120
Historical Overview of Psychiatric Care 13 Addressing Spiritual and Religious Needs
Mental Health 14 Through the Nursing Process 123
Mental Illness 15 Summary and Key Points 128
Psychological Adaptation to Stress 16 Review Questions 129
Mental Health/Mental Illness
Continuum 22 UNIT 3
Summary and Key Points 23 Therapeutic Approaches in Psychiatric
Review Questions 23
Nursing Care 133
UNIT 2
Chapter 7 Relationship Development 134
Foundations for Psychiatric-Mental
Objectives 134
Health Nursing 27 Homework Assignment 134
Role of the Psychiatric Nurse 135
Chapter 3 Concepts of Psychobiology 28 Dynamics of a Therapeutic Nurse-Client
Objectives 28 Relationship 136
Homework Assignment 28 Conditions Essential to Development
The Nervous System: An Anatomical of a Therapeutic Relationship 139
Review 29 Phases of a Therapeutic Nurse-Client
Neuroendocrinology 39 Relationship 141
Genetics 45 Boundaries in the Nurse-Client
Psychoneuroimmunology 48 Relationship 143
Psychopharmacology and the Brain 49 Summary and Key Points 144
Implications for Nursing 49 Review Questions 145
Summary and Key Points 50 Chapter 8 Therapeutic Communication 147
Review Questions 51
Objectives 147
Chapter 4 Psychopharmacology 54 Homework Assignment 147
Objectives 54 What Is Communication? 148
Homework Assignment 54 The Impact of Preexisting Conditions 148
Historical Perspectives 55 Nonverbal Communication 150
The Role of the Nurse in Therapeutic Communication Techniques 152
Psychopharmacology 55 Nontherapeutic Communication Techniques 154
How Do Psychotropics Work? 57 Active Listening 154
Applying the Nursing Process in Motivational Interviewing 156
Psychopharmacological Therapy 57 Process Recordings 157
Feedback 160

xiii
6054_FM_i-xx 16/08/17 2:42 pm Page xiv

xiv Contents

Summary and Key Points 160 Phases of Crisis Intervention: The Role
Review Questions 161 of the Nurse 239
Disaster Nursing 241
Chapter 9 The Nursing Process in Application of the Nursing Process to
Psychiatric-Mental Health Nursing 164 Disaster Nursing 242
Objectives 164 Summary and Key Points 249
Homework Assignment 164 Review Questions 250
The Nursing Process 165
Why Nursing Diagnosis? 175 Chapter 14 Assertiveness Training 253
Nursing Case Management 176 Objectives 253
Applying the Nursing Process in Homework Assignment 253
the Psychiatric Setting 178 Assertive Communication 254
Concept Mapping 179 Basic Human Rights 254
Documentation of the Nursing Process 179 Response Patterns 254
Summary and Key Points 185 Behavioral Components of Assertive
Review Questions 185 Behavior 256
Techniques That Promote Assertive
Chapter 10 Therapeutic Groups 188 Behavior 257
Objectives 188 Thought-Stopping Techniques 258
Homework Assignment 188 Role of the Nurse in Assertiveness
Functions of a Group 189 Training 259
Types of Groups 189 Summary and Key Points 262
Physical Conditions That Influence Group Review Questions 263
Dynamics 190
Therapeutic Factors 191 Chapter 15 Promoting Self-Esteem 266
Phases of Group Development 191 Objectives 266
Leadership Styles 192 Homework Assignment 266
Member Roles 193 Components of Self-Concept 267
Psychodrama 193 Development of Self-Esteem 268
The Role of the Nurse in Therapeutic Groups 194 Manifestations of Low Self-Esteem 270
Summary and Key Points 195 Boundaries 271
Review Questions 196 The Nursing Process 273
Summary and Key Points 277
Chapter 11 Intervention With Families 199 Review Questions 277
Objectives 199
Homework Assignment 199 Chapter 16 Anger and Aggression Management 280
Stages of Family Development 200 Objectives 280
Major Variations 202 Homework Assignment 280
Family Functioning 204 Anger and Aggression, Defined 281
Therapeutic Modalities With Families 208 Predisposing Factors to Anger and
The Nursing Process—A Case Study 214 Aggression 281
Summary and Key Points 219 The Nursing Process 283
Review Questions 220 Summary and Key Points 289
Review Questions 290
Chapter 12 Milieu Therapy—The Therapeutic
Community 223 Chapter 17 Suicide Prevention 293
Objectives 223 Objectives 293
Homework Assignment 223 Homework Assignment 293
Milieu, Defined 224 Historical Perspectives 294
Current Status of the Therapeutic Epidemiological Factors 294
Community 224 Risk Factors 296
Basic Assumptions 224 Predisposing Factors: Theories of Suicide 298
Conditions That Promote a Therapeutic Application of the Nursing Process
Community 225 With the Suicidal Client 299
The Program of Therapeutic Community 226 Summary and Key Points 312
The Role of the Nurse in Milieu Therapy 229 Review Questions 313
Summary and Key Points 230 Chapter 18 Behavior Therapy 318
Review Questions 231
Objectives 318
Chapter 13 Crisis Intervention 234 Homework Assignment 318
Objectives 234 Classical Conditioning 319
Homework Assignment 234 Operant Conditioning 320
Characteristics of a Crisis 235 Techniques for Modifying Client Behavior 320
Phases in the Development of a Crisis 235 Role of the Nurse in Behavior Therapy 322
Types of Crises 237 Summary and Key Points 324
Crisis Intervention 239 Review Questions 325
6054_FM_i-xx 16/08/17 2:42 pm Page xv

Contents xv

Chapter 19 Cognitive Therapy 327 The Chemically Impaired Nurse 440

Objectives 327 Codependency 441
Homework Assignment 327 Treatment Modalities for Substance-Related
Historical Background 328 Disorders 442
Indications for Cognitive Therapy 328 Non-Substance Addictions 447
Goals and Principles of Cognitive Therapy 328 Summary and Key Points 450
Basic Concepts 329 Review Questions 451
Techniques of Cognitive Therapy 331
Role of the Nurse in Cognitive Therapy 333
Chapter 24 Schizophrenia Spectrum and Other
Summary and Key Points 336 Psychotic Disorders 456
Review Questions 337 Objectives 456
Homework Assignment 456
Chapter 20 Electroconvulsive Therapy 340 Nature of the Disorder 457
Objectives 340 Predisposing Factors 458
Homework Assignment 340 Other Schizophrenia Spectrum
Electroconvulsive Therapy, Defined 341 and Psychotic Disorders 463
Historical Perspectives 341 Application of the Nursing Process 467
Indications 342 Treatment Modalities for Schizophrenia
Contraindications 342 and Other Psychotic Disorders 479
Mechanism of Action 343 Summary and Key Points 488
Side Effects 343 Review Questions 489
Risks Associated With Electroconvulsive
Therapy 343 Chapter 25 Depressive Disorders 494
The Role of the Nurse in Electroconvulsive Objectives 494
Therapy 344 Homework Assignment 494
Summary and Key Points 346 Historical Perspective 495
Review Questions 347 Epidemiology 495
Types of Depressive Disorders 497
Chapter 21 The Recovery Model 350 Predisposing Factors 500
Objectives 350 Developmental Implications 504
Homework Assignment 350 Application of the Nursing Process 509
What Is Recovery? 351 Treatment Modalities for Depression 519
Guiding Principles of Recovery 351 Summary and Key Points 527
Models of Recovery 353 Review Questions 527
Nursing Interventions That Assist
With Recovery 359 Chapter 26 Bipolar and Related Disorders 533
Summary and Key Points 360 Objectives 533
Review Questions 361 Homework Assignment 533
Historical Perspective 534
UNIT 4 Epidemiology 534
Types of Bipolar Disorders 534
Nursing Care of Clients With Alterations Predisposing Factors 537
in Psychosocial Adaptation 363 Developmental Implications 538
Application of the Nursing Process
to Bipolar Disorder (Mania) 540
Chapter 22 Neurocognitive Disorders 364 Treatment Modalities for Bipolar
Objectives 364 Disorder (Mania) 547
Homework Assignment 364 Summary and Key Points 555
Delirium 365 Review Questions 555
Neurocognitive Disorder 366
Application of the Nursing Process 374 Chapter 27 Anxiety, Obsessive-Compulsive,
Medical Treatment Modalities 386 and Related Disorders 559
Summary and Key Points 393 Objectives 559
Review Questions 394 Homework Assignment 559
Chapter 23 Substance-Related and Historical Aspects 560
Epidemiological Statistics 560
Addictive Disorders 399 How Much Is Too Much? 562
Objectives 399 Application of the Nursing Process—
Homework Assignment 400 Assessment 562
Substance Use Disorder, Defined 400 Diagnosis and Outcome Identification 571
Substance-Induced Disorders, Defined 401 Planning and Implementation 574
Predisposing Factors to Substance- Evaluation 578
Related Disorders 401 Treatment Modalities 580
The Dynamics of Substance-Related Summary and Key Points 586
Disorders 403 Review Questions 587
Application of the Nursing Process 425
6054_FM_i-xx 16/08/17 2:42 pm Page xvi

xvi Contents

Chapter 28 Trauma- and Stressor-Related UNIT 5

Disorders 591
Psychiatric Mental Health Nursing
Objectives 591
Homework Assignment 591 of Special Populations 731
Historical and Epidemiological Data 592
Application of the Nursing Process— Chapter 33 Children and Adolescents 732
Trauma-Related Disorders 592 Objectives 732
Application of the Nursing Process— Homework Assignment 732
Stressor-Related Disorders 600 Neurodevelopmental Disorders 733
Treatment Modalities 606 Disruptive Behavior Disorders 754
Summary and Key Points 610 Anxiety Disorders 763
Review Questions 611 Quality and Safety Education for
Chapter 29 Somatic Symptom and Dissociative Nurses (QSEN) 765
General Therapeutic Approaches 767
Disorders 614 Summary and Key Points 768
Objectives 614 Review Questions 769
Homework Assignment 614
Historical Aspects 615 Chapter 34 The Aging Individual 773
Epidemiological Statistics 616 Objectives 773
Application of the Nursing Process 616 Homework Assignment 773
Treatment Modalities 632 How Old is Old? 774
Summary and Key Points 637 Epidemiological Statistics 775
Review Questions 638 Theories of Aging 776
The Normal Aging Process 779
Chapter 30 Issues Related to Human Special Concerns of the Elderly Population 785
Sexuality and Gender Dysphoria 641 Application of the Nursing Process 791
Objectives 641 Summary and Key Points 798
Homework Assignment 641 Review Questions 801
Development of Human Sexuality 642
Variations in Sexual Orientation 644 Chapter 35 Survivors of Abuse or Neglect 806
Gender Dysphoria 646 Objectives 806
Application of the Nursing Process Homework Assignment 806
to Gender Dysphoria in Children 647 Predisposing Factors 807
Gender Dysphoria in Adolescents Application of the Nursing Process 809
and Adults 650 Treatment Modalities 822
Sexual Disorders 652 Summary and Key Points 824
Application of the Nursing Process Review Questions 825
to Sexual Disorders 659
Summary and Key Points 668 Chapter 36 Community Mental Health Nursing 831
Review Questions 668 Objectives 831
Homework Assignment 831
Chapter 31 Eating Disorders 673 The Changing Focus of Care 832
Objectives 673 The Public Health Model 833
Homework Assignment 673 The Community as Client 834
Epidemiological Factors 674 Summary and Key Points 858
Application of the Nursing Process 676 Review Questions 858
Treatment Modalities 690
Summary and Key Points 693 Chapter 37 The Bereaved Individual 862
Review Questions 693 Objectives 862
Homework Assignment 862
Chapter 32 Personality Disorders 697 Theoretical Perspectives on Loss and
Objectives 697 Bereavement 863
Homework Assignment 697 Length of the Grief Response 867
Historical Aspects 699 Anticipatory Grief 867
Types of Personality Disorders 700 Maladaptive Responses to Loss 868
Application of the Nursing Process 707 Application of the Nursing Process 869
Treatment Modalities 721 Additional Assistance 875
Summary and Key Points 725 Summary and Key Points 878
Review Questions 726 Review Questions 879
6054_FM_i-xx 16/08/17 2:42 pm Page xvii

Contents xvii

Chapter 38 Military Families 883 Appendix E Assigning NANDA International

Objectives 883 Nursing Diagnoses to Client
Homework Assignment 883 Behaviors Appendix-26
Historical Aspects 884 Glossary Glossary-1
Epidemiological Statistics 884
Application of the Nursing Process 884 Index Index-1
Treatment Modalities 894
Summary and Key Points 897 Ebook Bonus Chapters
Review Questions 898
Chapter 39 Complementary and Psychosocial
Appendix A Answers to Chapter Review Therapies 903

Questions Appendix-1 Chapter 40 Relaxation Therapy 929

Appendix B Examples of Answers to Chapter 41 Theoretical Models of Personality
Communication Exercises Appendix-3 Development 940
Appendix C Mental Status Assessment Appendix-6 Chapter 42 Forensic Nursing 959
Appendix D DSM-5 Classification: Categories
and Codes Appendix-10
6054_FM_i-xx 16/08/17 2:42 pm Page xviii
To the Instructor
Currently in progress, implementation of the recom-
mendations set forth by the New Freedom Commis-
sion on Mental Health has given enhanced priority
to mental health care in the United States. Moreover,
at the 65th meeting of the World Health Assembly
(WHA) in May 2012, India, Switzerland, and the
United States cosponsored a resolution requesting
that the World Health Organization, in collaboration
with member countries, develop a global mental
health action plan. This resolution was passed at the
66th WHA in May 2013. By their support of this res-
olution, member countries have expressed their
commitment for “promotion of mental health, pre-
vention of mental disorders, and early identification,
care, support, treatment, and recovery of persons
with mental disorders.” With the passage of this res-
olution, mental health services may now be available
for millions who have been without this type of care.
More recently, national initiatives have sought to
address the growing crises of deaths related to sui-
cide and opiate overdoses. Mental health and mental
illness continue to gain attention globally in the wake
of these and other critical issues but much still needs
to be done to reduce stigmatization and premature
loss of life in this population.
Many nurse leaders see this period of mental health-
care reform as an opportunity for nurses to expand
their roles and assume key positions in education, pre-
vention, assessment, and referral. Nurses are, and will
continue to be, in key positions to assist individuals to
attain, maintain, or regain optimal emotional wellness.
As it has been with each new edition of Psychiatric
Mental Health Nursing: Concepts of Care in Evidence-Based
Nursing, the goal of this ninth edition is to bring to prac-
ticing nurses and nursing students the most up-to-date
information related to neurobiology, psychopharmacol-
ogy, and evidence-based nursing interventions. This edi-
tion includes changes associated with the latest( fifth)
edition of the American Psychiatric Association’s Diag-
nostic and Statistical Manual of Mental Disorders (DSM-5).
Content and Features New to the Ninth
Edition
All content has been updated to reflect the current
state of the discipline of nursing.
All nursing diagnoses are current with the
NANDA-I 2015–2017 Nursing Diagnoses Definitions
and Classifications.
xviii
Communication Exercises are included in Chapters
13, Crisis Intervention; 17, Suicide Prevention; 21, The
Recovery Model; 22, Neurocognitive Disorders; 23, Sub-
stance Use and Addictive Disorders; 24, Schizophrenia
Spectrum and Other Psychotic Disorders; 25, Depres-
sive Disorders; 26, Bipolar and Related Disorders; 27,
Anxiety, Obsessive-Compulsive, and Related Disor-
ders; 30, Issues Related to Human Sexuality; 31, Eating
Disorders; 32, Personality Disorders; 35, Survivors of
Abuse or Neglect; and 37, The Bereaved Individual.
These exercises portray clinical scenarios that allow the
student to practice communication skills with clients.
Examples of answers appear in an appendix at the back
of the book.
A new feature, “Real People, Real Stories,” in-
cludes interviews conducted by one of the authors,
Karyn Morgan, in which individuals discuss their
experience of living with a mental illness and their
thoughts on important information for nurses to
know. These discussions can be used with students
to explore communication issues and interventions
to combat stigmatization and to build empathy
through understanding individuals’ unique experi-
ences. “Real People, Real Stories” interviews are in
Chapters 8, Therapeutic Communication; 17, Sui-
cide Prevention; 23, Substance Use and Addictive
Disorders; 24, Schizophrenia Spectrum and Other
Psychotic Disorders; 25, Depressive Disorders; 30, Issues
Related to Human Sexuality and Gender Dysphoria;
and 38, Military Families.
New QSEN icons (in addition to the existing QSEN
Teaching Strategy boxes) have been added selectively
throughout chapters to highlight content that reflects
application of one or more of the six QSEN compe-
tencies (patient-centered care, evidence-based prac-
tice, teamwork and collaboration, maintaining safety,
quality improvement, and informatics).
Chapter 4, Psychopharmacology, has been moved
from DavisPlus to the textbook. While each class of
psychoactive substances is discussed in this chapter,
lists of commonly used agents have been retained in
the chapters that discuss specific disorders. For exam-
ple, a list of commonly used antipsychotic agents
(along with dosage ranges, half-life, and pregnancy
categories) appears in Chapter 24, Schizophrenia
Spectrum and Other Psychotic Disorders. These lists
also appear online at DavisPlus.
New content on motivational interviewing appears
in Chapters 8 and 23.
6054_FM_i-xx 16/08/17 2:42 pm Page xix
New content describing the concept of emotional
intelligence is included in Chapter 14, Assertiveness
Training.
New content on RAISE (Recovery After an Initial
Schizophrenia Episode), based on the NIMH initia-
tive is included in Chapter 24.
New content on gender dysphoria and transgender
issues appears in Chapter 21.
Updated and new psychotropic drugs approved
since the publication of the eighth edition are included
in the specific diagnostic chapters to which they apply.
Features That Have Been Retained
in the Ninth Edition
The concept of holistic nursing is retained in the
ninth edition. An attempt has been made to ensure
that the physical aspects of psychiatric-mental health
nursing are not overlooked. In all relevant situations,
the mind/body connection is addressed.
Nursing process is retained in the ninth edition as
the tool for delivery of care to the individual with a psy-
chiatric disorder or to assist in the primary prevention
or exacerbation of mental illness symptoms. The six
steps of the nursing process, as described in the
American Nurses Association Standards of Clinical Nurs-
ing Practice, are used to provide guidelines for the nurse.
These standards of care are included for the DSM-5
diagnoses, as well as those on the aging individual, the
bereaved individual, survivors of abuse and neglect, and
military families, and as examples in several of the ther-
apeutic approaches. The six steps include:
Assessment: Background assessment data, including
a description of symptomatology, provides an ex-
tensive knowledge base from which the nurse may
draw when performing an assessment. Several
assessment tools are also included.
Diagnosis: Nursing diagnoses common to specific
psychiatric disorders are derived from analysis of
assessment data.
Outcome Identification: Outcomes are derived from
the nursing diagnoses and stated as measurable
goals.
Planning: A plan of care is presented with selected
nursing diagnoses for the DSM-5 diagnoses, as well
as for the elderly client, the bereaved individual,
victims of abuse and neglect, military veterans and
their families, the elderly homebound client, and
the primary caregiver of the client with a chronic
mental illness. The planning standard also includes
tables that list topics for educating clients and fam-
ilies about mental illness. Concept map care plans
are included for all major psychiatric diagnoses.
Implementation: The interventions that have been
identified in the plan of care are included along with
To the Instructor xix
rationales for each. Case studies at the end of each
DSM-5 chapter assist the student in the practical
application of theoretical material. Also included as
a part of this particular standard is Unit 3, Therapeu-
tic Approaches in Psychiatric Nursing Care. This
section of the textbook addresses psychiatric nursing
intervention in depth and frequently speaks to the
differentiation in scope of practice between the basic-
level psychiatric nurse and the advanced practice–
level psychiatric nurse.
Evaluation: The evaluation standard includes a set of
questions that the nurse may use to assess whether
the nursing actions have been successful in achiev-
ing the objectives of care.
Following are additional features of this ninth
edition:
■ Internet references for each DSM-5 diagnosis, with
website listings for information related to the
disorder.
■ Tables that list topics for client/family education
(in the clinical chapters).
■ Boxes that include current research studies with
implications for evidence-based nursing practice
(in the clinical chapters).
■ Assigning nursing diagnoses to client behaviors
(diagnostic chapters).
■ Taxonomy and diagnostic criteria from the DSM-5
(2013). Used throughout the text.
■ All references have been updated throughout the
text. Classical references are distinguished from
general references.
■ Boxes with definitions of core concepts appear
throughout the text.
■ Comprehensive glossary.
■ Answers to end-of-chapter review questions
(Appendix A).
■ Answers to communication exercises (Appendix B).
■ Sample client teaching guides (online at www
.davisplus.com).
■ Website. An F.A. Davis/Townsend website that con-
tains additional nursing care plans that do not ap-
pear in the text, links to psychotropic medications,
concept map care plans, and neurobiological con-
tent and illustrations, as well as student resources
including practice test questions, learning activities,
concept map care plans, and client teaching guides.
Additional Educational Resources
Faculty may also find the teaching aids that accompany
this textbook helpful. These Instructor Resources are
located at www.davisplus.com:
■ Multiple choice questions (including new format
questions reflecting the latest NCLEX blueprint).
■ Lecture outlines for all chapters
6054_FM_i-xx 16/08/17 2:42 pm Page xx
xx To the Instructor
■ Learning activities for all chapters (including
answer key)
■ Answers to the Critical Thinking Exercises from the
textbook
■ PowerPoint Presentation to accompany all chapters
in the textbook
■ Answers to the Homework Assignment Questions
from the textbook
■ Case studies for use with student teaching
Additional chapters on Theories of Personality
Development, Relaxation Therapy, Complementary
and Psychosocial Therapies, and Forensic Nursing are
presented online at www.davisplus.com.
It is hoped that the revisions and additions to
this ninth edition continue to satisfy a need within
psychiatric-mental health nursing practice. The mis-
sion of this textbook has been, and continues to be, to
provide both students and clinicians with up-to-date
information about psychiatric-mental health nursing.
The user-friendly format and easy-to-understand lan-
guage, for which we have received many positive com-
ments, have been retained in this edition. We hope that
this ninth edition continues to promote and advance
the commitment to psychiatric/mental health nursing.
Mary C. Townsend
Karyn I. Morgan
6054_Ch01_001-011 27/07/17 5:24 PM Page 1

UNIT 1
Basic Concepts in
Psychiatric-Mental
Health Nursing
6054_Ch01_001-011 27/07/17 5:24 PM Page 2

CORE CONCEPTS
Adaptation
1 The Concept of Stress
Adaptation
CHAPTER OUTLINE
Objectives Stress Management
Maladaptation Homework Assignment Summary and Key Points
Stressor Stress as a Biological Response Review Questions
Stress as an Environmental Event
Stress as a Transaction Between the Individual
and the Environment

K EY T E R M S
adaptive responses maladaptive responses
fight-or-flight syndrome precipitating event
general adaptation syndrome predisposing factors

O B J EC T I V E S
After reading this chapter, the student will be able to:

1. Define adaptation and maladaptation. 5. Explain the concept of stress as a transaction

2. Identify physiological responses to stress.
3. Explain the relationship between stress and
“diseases of adaptation.”
4. Describe the concept of stress as an environ-
mental event.
between the individual and the environment.
6. Discuss adaptive coping strategies in the
management of stress.

HOMEWORK ASSIGNMENT
Please read the chapter and answer the following questions:

1. How are the body’s physiological defenses
affected when under sustained stress? Why?
2. In the view of stress as an environmental
event, what aspects are missing when
considering an individual’s response to a
stressful situation?
3. In their study, what event did Miller and
Rahe (1997) find produced the highest
level of stress reaction in their participants?
4. What is the initial step in stress
management?

Psychologists and others have struggled for many
years to establish an effective definition of the term
stress. This term is used loosely today and still lacks
a definitive explanation. Stress may be viewed as an
individual’s reaction to any change that requires an
adjustment or response, which can be physical, men-
tal, or emotional. Responses directed at stabilizing
internal biological processes and preserving self-
esteem can be viewed as healthy adaptations to
stress.
Roy (1976), a nursing theorist, defined an adaptive
response as behavior that maintains the integrity of
the individual. Adaptation is viewed as positive and is
correlated with a healthy response. When behavior

2
6054_Ch01_001-011 27/07/17 5:24 PM Page 3

CHAPTER 1 ■ The Concept of Stress Adaptation 3

disrupts the integrity of the individual, it is perceived Stress as a Biological Response

as maladaptive. Maladaptive responses by the individ-
ual are considered to be negative or unhealthy.
Various 20th-century researchers contributed to
several different concepts of stress. Three of these
concepts include stress as a biological response,
stress as an environmental event, and stress as a
transaction between the individual and the environ-
ment. This chapter includes an explanation of each
of these concepts.
CORE CONCEPT
Stressor
A biological, psychological, social, or chemical factor
that causes physical or emotional tension and may con-
tribute to the development of certain illnesses.
In 1956, Hans Selye published the results of his re-
search on the physiological response of a biological
system to an imposed change on the system. Since his
initial publication, his definition of stress has evolved
to “the state manifested by a specific syndrome which
consists of all the nonspecifically induced changes
within a biologic system” (Selye, 1976). This combi-
nation of symptoms has come to be known as the
fight-or-flight syndrome. Schematics of these biologi-
cal responses, both initially and with sustained stress,
are presented in Figures 1–1 and 1–2. Selye called this
phenomenon the general adaptation syndrome. He
described three distinct stages of the reaction:
1. Alarm reaction stage: During this stage, the physi-
ological responses of the fight-or-flight syndrome
are initiated.

HYPOTHALAMUS

Stimulates

Sympathetic Nervous System

Innervates

Adrenal Eye Lacrimal Respiratory Cardiovascular GI system Liver Urinary Sweat Fat
medulla glands system system system glands cells

Pupils Bronchioles Gastric and Ureter Lipolysis

dilated dilated intestinal motility
Respiration motility Bladder
rate increased Secretions muscle
Sphincters contracts
contract Sphincter
relaxes

Norepinephrine Secretion Force of cardiac Glycogenolysis Secretion

and epinephrine increased contraction and
released Cardiac output gluconeogenesis
Heart rate Glycogen
Blood pressure synthesis

FIGURE 1–1 The fight-or-flight syndrome: The initial stress response.

Another random document with
no related content on Scribd:
been so much approved, that we can recommend it with some
confidence, as it stands. Modern taste would perhaps be rather in
favour of rich brown gravy and thick tomata sauce, or sauce
poivrade.
82. A deep oblong dish of suitable size seems better adapted to this purpose.
In dishing the pig lay the body flat in the middle, and the head and
ears at the ends and sides. When very pure oil can be obtained, it is
preferable to butter for the basting: it should be laid on with a bunch
of feathers. A pig of three weeks old is considered as best suited to
the table, and it should always be dressed if possible the day it is
killed.
1-1/4 to 1-3/4 hour.
 BAKED PIG.

Prepare the pig exactly as for roasting; truss, and place it in the
dish in which it is to be sent to the oven, and anoint it thickly in every
part with white of egg which has been slightly beaten; it will require
no basting, nor further attention of any kind, and will be well crisped
by this process.
 PIG À LA TARTARE

When the shoulders of a cold roast pig are left entire, take them off
with care, remove the skin, trim them into good form, dip them into
clarified butter or very pure salad oil, then into fine crumbs highly
seasoned with cayenne and mixed with about a half-teaspoonful of
salt. Broil them over a clear brisk fire, and send them quickly to table,
as soon as they are heated through and equally browned, with
tomata sauce, or sauce Robert. Curried crumbs and a currie-sauce
will give an excellent variety of this dish; and savoury herbs with two
or three eschalots chopped small together, and mixed with the
bread-crumbs, and brown eschalot sauce to accompany the broil,
will likewise be an acceptable one to many tastes.
 SUCKING PIG EN BLANQUETTE. (ENTRÉE.)

Raise the flesh from the bones of a cold roast pig, free it from the
crisp outer skin or crackling, and cut it down into small handsome
slices. Dissolve a bit of butter the size of an egg, and throw in a
handful of button-mushrooms, cleaned and sliced; shake these over
the fire for three or four minutes, then stir to them a dessertspoonful
of flour and continue to shake or toss them gently, but do not allow
them to brown. Add a small bunch of parsley, a bay-leaf, a middling-
sized blade of mace, some salt, a small quantity of cayenne or white
pepper, half a pint of good veal or beef broth, and from two to three
glasses of light white wine. Let these boil gently until reduced nearly
one third; take out the parsley and mace, lay in the meat, and bring it
slowly to the point of simmering; stir to it the beaten yolks of three
fresh eggs, and the strained juice of half a lemon Serve the
blanquette very hot.
 TO ROAST PORK.

When the skin is left on the joint which is to be roasted, it must be

scored in narrow strips of equal width, before it is put to the fire, and
laid at a considerable distance from it at first, that the meat may be
heated through before the skin hardens or begins to brown; it must
never stand still for an instant, and the basting should be constant.
Pork is not at the present day much served at very good tables,
particularly in this form; and it is so still less with the old savoury
stuffing of sage and onions, though some eaters like it always with
the leg: when it is ordered for this joint, therefore prepare it as
directed for a goose, at page 160, and after having loosened the skin
from the knuckle, insert as much as can well be secured in it. A little
clarified butter or salad oil may be brushed over the skin quite at first,
particularly should the meat not be very fat, but unless remarkably
lean, it will speedily yield sufficient dripping to baste it with. Joints
from which the fat has been pared, will require of course far less
roasting than those on which the crackling is retained. Brown gravy,
and apple or tomata sauce, are the usual accompaniments to all
roasts of pork except a sucking pig; they should always be
thoroughly cooked.
Leg of pork of 8 lbs., 3 hours; loin of from 5 to 6 lbs., with the skin
on, 2 to 2-1/2 hours; spare rib of 6 to 7 lbs., 1-1/2 hour.
 TO ROAST A SADDLE OF PORK.

The skin of this joint may be removed entirely, but if left on it must
be scored lengthwise, or in the direction in which it will be carved.
The pork should be young, of fine quality, and of moderate size.
Roast it very carefully, either by the directions given in the preceding
receipt, or when the skin is taken off, by those for a saddle of mutton,
allowing in the latter case from three quarters of an hour to a full
hour more of the fire for it in proportion to its weight. Serve it with
good brown gravy and tomata sauce, or sauce Robert; or with apple
sauce should it be preferred. 20 minutes to the pound, quite [TN: text
missing.]
 TO BROIL OR FRY PORK CUTLETS.

Cut them about half an inch thick from a delicate loin of pork, trim
them into neat form, and take off part of the fat, or the whole of it
when it is not liked; dredge a little pepper or cayenne upon them,
and broil them over a clear and moderate fire from fifteen to eighteen
minutes: sprinkle a little fine salt upon them just before they are
dished. They may be dipped into egg and then into bread-crumbs
mixed with minced sage, and finished in the usual way.[83] When
fried, flour them well, and season them with salt and pepper first.
Serve them with gravy in the pan, or with sauce Robert.
83. If broiled, with the addition of these a little clarified butter must be added to
the egg, or sprinkled on the cutlets.
 COBBETT’S RECEIPT FOR CURING BACON.

“All other parts being taken away, the two sides that remain, and
which are called flitches, are to be cured for bacon. They are first
rubbed with salt on their inside, or flesh sides, then placed one on
the other, the flesh sides uppermost in a salting trough, which has a
gutter round its edges to drain away the brine; for to have sweet and
fine bacon, the flitches must not be sopping in brine, which gives it
the sort of taste that barrel-pork and sea-junk have, and than which
is nothing more villainous. Everyone knows how different is the taste
of fresh dry salt from that of salt in a dissolved state. Therefore,
change the salt often; once in four or five days. Let it melt and sink
in, but let it not lie too long. Change the flitches, put that at the
bottom which was first on the top. Do this a couple of times. This
mode will cost you a great deal more in salt than the sopping mode;
but without it your bacon will not be so sweet and fine, nor keep so
well. As to the time required for making the flitches sufficiently salt, it
depends on circumstances; the thickness of the flitch, the state of
the weather, the place wherein the salting is going on. It takes a
longer time for a thick than for a thin flitch; it takes longer in dry than
in damp weather, it takes longer in a dry than in a damp place. But
for the flitches of a hog of five score, in weather not very dry or very
damp, about six weeks may do; and as yours is to be fat, which
receives little injury from over-salting, give time enough; for you are
to have bacon till Christmas comes again. The place for salting
should, like a dairy, always be cool, but always admit of a free
circulation of air; confined air, though cool, will taint meat sooner
than the midday sun accompanied with a breeze. With regard to
smoking the bacon, two precautions are necessary: first to hang the
flitches where no rain comes down upon them, and next, that the
smoke must proceed from wood, not peat, turf, nor coal. As to the
time that it requires to smoke a flitch, it must depend a good deal
upon whether there be a constant fire beneath, and whether the fire
be large or small. A month will do if the fire be pretty constant, and
such as a farm house fire usually is. But oversmoking, or rather, too
long hanging in the air, makes the bacon rust. Great attention
should, therefore, be paid to this matter. The flitch ought not to be
dried up to the hardness of a board, and yet it ought to be perfectly
dry. Before you hang it up, lay it on the floor, scatter the flesh-side
pretty thickly over with bran or with some fine saw-dust, not of deal
or fir. Rub it on the flesh, or pat it well down upon it. This keeps the
smoke from getting into the little openings, and makes a sort of crust
to be dried on.
“To keep the bacon sweet and good, and free from hoppers, sift
fine some clean and dry wood-ashes. Put some at the bottom of a
box or chest long enough to hold a flitch of bacon. Lay in one flitch;
and then put in more ashes, then another flitch, and cover this with
six or eight inches of the ashes. The place where the box or chest is
kept ought to be dry, and should the ashes become damp they
should be put in the fire-place to dry, and when cold, put back again.
With these precautions the bacon will be as good at the end of the
year as on the first day.”
Obs.—Although the preceding directions for curing the bacon are
a little vague as regards the proportions of salt and pork, we think
those for its after-management will be acceptable to many of our
readers, as in our damp climate it is often a matter of great difficulty
to preserve hams and bacon through the year from rust.
 A GENUINE YORKSHIRE RECEIPT FOR CURING HAMS AND
BACON.

“Let the swine be put up to fast for twenty-four hours before they
are killed (and observe that neither a time of severe frost, nor very
damp weather, is favourable for curing bacon). After a pig has been
killed and scalded, let it hang twelve hours before it is cut up, then
for every stone or fourteen pounds’ weight of the meat, take one
pound of salt, an ounce and a quarter of saltpeter, and half an ounce
of coarse sugar. Rub the sugar and saltpetre first into the fleshy
parts of the pork, and remove carefully with a fork any extravasated
blood that may appear on it, together with the broken vessels
adjoining; apply the salt especially to those parts, as well as to the
shank-ends of the hams, and any other portions of the flesh that are
more particularly exposed. Before the salt is added to the meat,
warm it a little before the fire, and use only a part of it in the first
instance; then, as it dissolves, or is absorbed by the meat, add the
remainder at several different times. Let the meat in the meanwhile
lie either on clean straw, or on a cold brick or stone floor: it will
require from a fortnight to three weeks’ curing, according to the state
of the atmosphere. When done, hang it in a cool dry place, where
there is a thorough current of air, and let it remain there until it is
perfectly dry, when the salt will be found to have crystallized upon
the surface. The meat may then be removed to your store, and kept
in a close chest, surrounded with clean outer straw. If very large, the
hams will not be in perfection in less than twelve months from the
time of their being stored.”
Pork 20 stone; salt, 20 lbs.; saltpetre, 20 oz.; sugar, 10 oz.; 14 to
21 days.
 KENTISH MODE OF CUTTING UP AND CURING A PIG.

To a porker of sixteen stone Kentish weight (that is to say, eight

pounds to the stone, or nine stone two pounds of common weight),
allow two gallons of salt, two pounds of saltpetre, one pound of
coarse sugar, and two pounds of bay-salt well dried and reduced to
powder. Put aside the hams and cheeks to be cured by themselves;
let the feet, ears, tail, and eye-parts of the head be salted for
immediate eating; the blade-bones, and ends of the loins and ribs
reserved for sausage-meat should it be wanted, and the loin and
spare-ribs for roasting. Divide and salt the remainder thus: Mix well
together the saltpetre, sugar, and bay-salt, and rub the pork gently
with them in every part; cover the bottom of the pickling tub with salt,
and pack in the pork as closely as possible, with a portion of the
remaining salt between each layer. A very little water is sometimes
sprinkled in to facilitate the dissolving of the salt into a brine, but this
is always better avoided, and in damp weather will not be needed. If
in a fortnight it should not have risen, so as almost entirely to cover
the meat, boil a strong brine of salt, saltpetre, sugar, and bay-salt; let
it remain until perfectly cold, and then pour it over the pork. A board,
with a heavy stone weight upon it, should be kept upon the meat to
force it down under the brine. In from three to four months it will be fit
for table, and will be delicate and excellent pickled pork.
The pickling parts of a porker of sixteen stone (Kentish weight, or
nine stone two pounds of common weight, or fourteen pounds to the
stone); common salt, 2 gallons; saltpetre, 2 lbs.; coarse sugar, 1 lb.:
bay-salt, 2 lbs.
 FRENCH BACON FOR LARDING.

Cut the bacon from the pig with as little lean to it as possible. Rub
it well in every part with salt which has been dried, reduced to
powder, and sifted; put the layers of bacon close against and upon
each other, in a shallow wooden trough, and set in a cool, but not a
damp cellar; add more salt all round the bacon, and lay a board, with
a very heavy weight upon it. Let it remain for six weeks, then hang it
up in a dry and airy place.
Pork, 14 lbs.; salt, 14 oz.: 6 weeks.
 TO PICKLE CHEEKS OF BACON AND HAMS.

One pound of common salt, one pound of the coarsest sugar, and
one ounce of saltpetre, in fine powder, to each stone (fourteen
pounds) of the meat will answer this purpose extremely well. An
ounce of black pepper can be added, if liked, and when less sugar is
preferred, the proportion can be diminished one half, and the
quantity of salt as much increased. Bacon also may be cured by this
receipt, or by the Bordyke one for hams. A month is sufficient time
for the salting, unless the pork be very large, when five weeks must
be allowed for a ham. The ingredients should be well mixed, and all
applied at the same time.
To each 14 lbs. of pork, salt, 1 lb.; coarse sugar, 1 lb.; saltpetre, 1
oz.; pepper (if used), 1 oz.: 4 to 5 weeks.
 MONSIEUR UDE’s RECEIPT, HAMS SUPERIOR TO
WESTPHALIA.

(Excellent.)
“Take the hams as soon as the pig is sufficiently cold to be cut up,
rub them well with common salt, and leave them for three days to
drain; throw away the brine, and for a couple of hams of from fifteen
to eighteen pounds weight, mix together two ounces of saltpetre, a
pound of coarse sugar, and a pound of common salt; rub the hams in
every part with these, lay them into deep pickling-pans with the rind
downwards, and keep them for three days well covered with the salt
and sugar; then pour over them a bottle of good vinegar, and turn
them in the brine, and baste them with it daily for a month; drain
them well, rub them with bran, and let them be hung for a month high
in a chimney over a wood-fire to be smoked.”
Hams, of from 15 to 18 lbs. each, 2; to drain 3 days. Common salt,
and coarse sugar, each 1 lb.; saltpetre, 2 oz.: 3 days. Vinegar, 1
bottle: 1 month. To be smoked 1 month.
Obs.—Such of our readers as shall make trial of this admirable
receipt, will acknowledge, we doubt not, that the hams thus cured
are in reality superior to those of Westphalia. It was originally given
to the public by the celebrated French cook, Monsieur Ude. He
directs that the hams when smoked should be hung as high as
possible from the fire, that the fat may not be melted; a very
necessary precaution, as the mode of their being cured renders it
peculiarly liable to do so. This, indeed, is somewhat perceptible in
the cooking, which ought, therefore, to be conducted with especial
care. The hams should be very softly simmered,[84] and not over-
done. They should be large, and of finely-fed pork, or the receipt will
not answer. We give the result of our first trial of it, which was
perfectly successful, the ham cured by it being of the finest possible
flavour.
84. We have not had the trial made ourselves, but we think they would be even
finer baked than boiled.
 Leg of Suffolk farm-house pork, 14 to 15 lbs.; saltpetre, 1-1/4 oz.;
strong coarse salt, 6 oz.; coarse sugar, 8 oz.: 3 days. Fine whitewine
vinegar, 1 pint. In pickle, turned daily, 1 month. Smoked over wood, 1
month.
Obs.—“When two hams are pickled together, a smaller proportion
of the ingredients is required for each, than for one which is cured by
itself.”
 SUPER-EXCELLENT BACON.

For several successive years, after first testing the above receipt,
we had it adopted for curing bacon, with even more highly
satisfactory results, as it was of incomparable flavour, and remained
good for a great length of time, the vinegar preserving it entirely from
becoming rusted. Well-fed pork of delicate size was always used for
it, and excellent vinegar. The ingredients were added in the
proportions given in the receipt for the Suffolk ham which preceeds
this, and the same time was allowed for the salting and smoking.
 HAMS.

(Bordyke Receipt.)
After the hams have been rubbed with salt, and well drained from
the brine, according to our previous directions, take, for each
fourteen pounds weight of the pork, one ounce of saltpetre in fine
powder mixed with three ounces of very brown sugar; rub the meat
in every part with these, and let it remain some hours, then cover it
well with eight ounces of bay-salt, dried and pounded, and mixed
with four ounces of common salt: in four days add one pound of
treacle, and keep the hams turned daily, and well basted with the
pickle for a month. Hang them up to drain for a night, fold them in
brown paper, and send them to be smoked for a month. An ounce of
ground black pepper is often mixed with the saltpetre in this receipt,
and three ounces of bruised juniper-berries are rubbed on to the
meat before the salt is added, when hams of a very high flavour are
desired.
Ham, 14 lbs.; saltpetre, 1 oz.; coarse sugar, 3 oz.: 8 to 12 hours.
Bay-salt, 1/2 lb.; common salt, 4 oz.: 4 days. Treacle, 1 lb.: 1 month.
To heighten flavour, black pepper, 1 oz; juniper-berries, 3 oz.
 TO BOIL A HAM.

The degree of soaking which must be given to a ham before it is

boiled, must depend both on the manner in which it has been cured,
and on its age. If highly salted, hard, and old, a day and night, or
even longer, may be requisite to dilate the pores sufficiently, and to
extract a portion of the salt. To do either effectually the water must
be several times changed during the steeping. We generally find
hams cured by any of the receipts which we have given in this
chapter quite enough soaked in twelve hours; and they are more
frequently laid into water only early in the morning of the day on
which they are boiled. Those pickled by Monsieur Ude’s receipt need
much less steeping than any others. After the ham has been
scraped, or brushed, as clean as possible, pare away lightly any part
which, from being blackened or rusty, would disfigure it; though it is
better not to cut the flesh at all unless it be really requisite for the
good appearance of the joint. Lay it into a ham-kettle, or into any
other vessel of a similar form, and cover it plentifully with cold water;
bring it very slowly to boil, and clear off carefully the scum which will
be thrown up in great abundance. So soon as the water has been
cleared from this, draw back the pan quite to the edge of the stove,
that the ham may be simmered softly but steadily, until it is tender.
On no account allow it to boil fast. A bunch of herbs and three or four
carrots, thrown in directly after the water has been skimmed, will
improve it. When it can be probed very easily with a sharp skewer, or
larding-pin, lift it out, strip off the skin, and should there be an oven
at hand, set it in for a few minutes after having laid it on a drainer;
strew fine raspings over it, or grate a hard-toasted crust, or sift upon
it the prepared bread of Chapter V., unless it is to be glazed, when
neither of these must be used.
Small ham, 3-1/2 to 4 hours; moderate sized, 4 to 4-1/2 hours;
very large, 5 to 5-1/2 hours.
Obs.—We have seen the following manner of boiling a ham
recommended, but we have not tried it:—“Put into the water in which
it is to be boiled, a quart of old cider and a pint of vinegar, a large
bunch of sweet herbs, and a bay leaf. When it is two-thirds done,
skin, cover it with raspings, and set it in an oven until it is done
enough: it will prove incomparably superior to a ham boiled in the
usual way.”
 TO GARNISH AND ORNAMENT HAMS IN VARIOUS WAYS.

When a ham has been carefully and delicately boiled, the rind
while it is still warm, may be carved in various fanciful shapes to
decorate it; and a portion of it left round the knuckle in a semi-
circular form of four or five inches deep, may at all times be easily
scollopped at the edge or cut into points (vandykes). This, while
preserving a character of complete simplicity for the dish, will give it
an air of neatness and finish at a slight cost of time and trouble. A
paper frill should be placed round the bone.
The Germans cut the ham-rind after it has been stripped from the
joint, into small leaves and similar “prettinesses,”[85] and arrange
them in a garland, or other approved device, upon its surface. In
Ireland and elsewhere, bread evenly sliced, and stamped out with
cutters much smaller than a fourpenny-piece, then carefully fried or
coloured in the oven, is used to form designs upon hams after they
are glazed. Large dice of clear firm savoury jelly form their most
appropriate garnish, because they are intended to be eaten with
them. For the manner of making this, and glaze also see Chapter IV.
85. This should be done with a confectionary or paste cutter.
The ham shown in Plate V., which follows the directions for
“Carving,” is of very good appearance; but in common English
kitchens generally, even the degree of artistic skill required to form
its decorations well, is not often to be met with.