NCP Problems related to Abuse or Neglect

PROBLEMS RELATED TO ABUSE OR NEGLECT

DSM-IV

IF FOCUS OF ATTENTION IS ON THE VICTIM [SURVIVOR]:

995.52 Neglect of child
995.53 Sexual abuse of child
995.54 Physical abuse of child
995.81 Physical abuse of adult
995.83 Sexual abuse of adult

IF FOCUS OF ATTENTION IS ON THE PERPETRATOR [OFFENDER] OR ON THE RELATIONAL UNIT IN WHICH BEHAVIOR OCCURS:

V61.21 Neglect; physical or sexual abuse of child (specify)
V61.12 (Physical or sexual abuse of adult by partner)
V62.83 (Physical or sexual abuse of adult by person other than partner)

Abuse affects all populations and is not restricted to specific socioeconomic or ethnic/cultural groups. Although “violence” means the use of force or physical compulsion to abuse or damage, the term “abuse” is much broader and includes physical or mental maltreatment and neglect that result in emotional, physical, or sexual injury. In the case of children, the disabled, or elderly, abuse can result from direct actions or omissions by those responsible for the individual’s care. Additionally, one’s perception of abuse is affected by cultural and religious practices, values, and biological predispositions. The problem can be generational, with victimizers often being victims of abuse themselves as children.

Violence is not a new problem; in fact, it is probably as old as humankind. However, in the United States, medicine has focused on these issues only since 1946. Therefore, the parameters of abuse are being identified and redefined on what seems to be an almost daily basis. For example, until recently women and children were considered the personal property of men and they did not own property or have rights of their own. Women viewed themselves as sexual objects and were expected to subjugate themselves/defer to the will of men. Harsh treatment of children was justified by the belief that corporal and/or excessive punishment was necessary to maintain discipline and instill values. Changes in societal beliefs and the enactment of new laws have done little to curb abuse. Today, battering is the single most common cause of injury to women, and there has been an increase in the incidence of child abuse and neglect-related fatalities reported to child protection service agencies in the United States. Whether these statistics represent an increase in incidents or are the result of changing attitudes and/or better reporting is much debated. The Centers for Disease Control and Prevention has declared violence to be a public health problem.

This plan of care addresses the problems of abuse and neglect in both adults and children and includes both the person who offends and the survivor of the offense.

ETIOLOGICAL THEORIES

Psychodynamics

Psychoanalytical theory suggests that unmet needs for satisfaction and security result in an underdeveloped ego and a poor self-concept in the individuals involved in violent episodes. Aggression and violence supply the offender with a sense of power and prestige that boosts the self-image and provides a significance or purpose to the individual’s life that is lacking. Some theorists have supported the hypothesis that aggression and violence are the overt expressions of powerlessness and low self-esteem. The same dynamics promote acceptance in the person who is the victim of violence.

Biological

Various components of the neurological system have been implicated in both the facilitation and inhibition of aggressive impulses. The limbic system in particular appears to be involved. In addition, higher brain centers play an important role by constantly interacting with the aggression centers. Various neurotransmitters, such as epinephrine, norepinephrine, dopamine, acetylcholine, and serotonin, may also play a role in facilitation and inhibition of aggressive impulses. This theory is consistent with the “fight-or-flight” arousal in response to stress.

Some studies suggest the possibility of a direct genetic link; however, the evidence for this has not been firmly established. Organic brain syndromes associated with various cerebral disorders have been linked to violent behavior. Particularly, areas of the limbic system and temporal lobes, brain trauma, and diseases such as encephalitis and disorders such as epilepsy have been implicated in aggressive behavior.

Family Dynamics

Child abuse is often the consequence of the interactions of parental vulnerabilities (e.g., mental illness, substance abuse); child vulnerabilities (e.g., low birth weight, difficult temperament); a particular developmental stage, such as toddler, adolescence; and social stressors (e.g., lack of social supports, young parental age, single parenthood, poverty, minority ethnicity, lack of acculturation, exposure to family violence).

Learning theory states that children learn to behave by imitating their role models, usually parents, although as they mature they are influenced by teachers, friends, and others. Individuals who were abused as children or whose parents disciplined them with physical punishment are more likely to behave in a violent manner as adults. Television and movies are believed to have an influence on developing both adaptive and maladaptive behavior. Some theorists believe that individuals who have a biological influence toward aggressive behavior are more likely to be affected by external models than those without this predisposition.

The influence of culture and social structure cannot be discounted. Difficulty in negotiating interpersonal conflict has led to a general acceptance of violence as a means of solving problems. When individuals/groups of people discover they cannot meet their needs through conventional methods, they are more likely to resort to delinquent behaviors. This may contribute to a subculture of violence within society.

CLIENT ASSESSMENT DATA BASE

Activity/Rest

Sleep problems (e.g., sleeplessness or oversleeping, nightmares, sleepwalking, sleeping in strange place [avoiding offender])

Fatigue

Ego Integrity

Negative self-appraisal, acceptance of self-blame/making excuses for the actions of others

Low self-esteem (offender/survivor)

Feelings of guilt, anger, fear and shame, helplessness, and/or powerlessness

Minimization or denial of significance of behaviors (most prominent defense mechanism)

Avoidance or fear of certain people, places, objects; submissive, fearful manner (particularly in presence of offender)

Report of stress factors (e.g., family unemployment; financial, lifestyle changes; marital discord)

Hostility toward/mistrust of others

Threatened when partner shows signs of independence or shares self/time with others (offender)

Elimination

Enuresis, encopresis

Recurrent urinary infections

Changes in tone of sphincter

Food/Fluid

Frequent vomiting; changes in appetite: anorexia, overeating (survivor)

Changes in weight; failure to gain weight appropriately/signs of malnutrition, repeated pica (neglect)

Hygiene

Wearing clothing that covers body in a manner inappropriate for weather conditions (abuse), or that is inadequate to provide protection (neglect)

Excessive/anxiety about bathing (abuse); dirty/unkempt appearance (neglect)

Neurosensory

Behavioral extremes (very aggressive/demanding conduct); extreme rage or passivity and withdrawal; age-inappropriate behavior

Mental Status:

Memory: Blackouts, periods of amnesia; reports of flashbacks

Disorganized thinking; difficulty concentrating/making decisions

Inappropriate affect; may be hypervigilant, anxious, depressed

Mood swing—“dual personality,” extremely loving, kind, contrite after battering episode (offender)

Pathological jealousy; poor impulse control; limited coping skills; lacks empathy (offender)

Rocking, thumb sucking, or other habitual behavior; restlessness (survivor)

Psychiatric manifestations (e.g., dissociative phenomena including multiple personalities (sexual abuse); borderline personality disorder [adult incest survivors])

Presence of neurological deficits/CNS damage without external injuries evident (may indicate “shaken baby” syndrome)

Pain/Discomfort

Dependent on specific injuries/form of abuse

Multiple somatic complaints (e.g., stomach pain, chronic pelvic pain, spastic colon, headache)

Safety

Bruises, bite marks, skin welts, burns (e.g., scalding, cigarette), bald spots, lacerations, unusual bleeding, rashes/itching in the genital area; anal fissures, skin tags, hemorrhoids, scar tissue, changes in tone of sphincter

Recurrent injuries; history of multiple accidents, fractures/internal injuries

Description of incident incongruent with injury, delay in seeking treatment

Lack of age-appropriate supervision, inattention to avoidable hazards in the home (neglect)

Intense episodes of rage directed at self or others

Self-injurious/suicidal behavior; involvement in high-risk activities

History of suicidal behavior of family members

Sexuality

Changes in sexual awareness or activity, including compulsive masturbation, precocious sex play, tendency to repeat or reenact incest/abuse experience; excessive curiosity about sex; sexually abusing another child; promiscuity; overly anxious/ inhibited about sexual anatomy or behavior

May display feminine sex-role stereotypes; confusion about sexuality (male survivors); may have unconscious homosexual tendencies (male offenders of incest)

Reports of decreased sexual desire (as adult), erectile dysfunction, premature ejaculation, and/or anorgasmia; dyspareunia, vaginismus; flashbacks during intercourse; inability to engage in sex without anxiety

Episodes of marital rape or forced intercourse

Impaired sexual relationship between parents (incest)

Parent/female careprovider aware or strongly suspects incestual behavior, may be grateful not to be focus of partner’s sexual demands

Obstetrical history of preterm labor, abruptio placentae, spontaneous abortions, low birth weight, fetal injury/death (1 in 6 pregnant women are battered during pregnancy); lack of prenatal care until 3rd trimester (abused women twice as likely to delay care)

Vaginal bleeding; linear laceration of hymen, vaginal mucosa

Presence of STDs, vaginitis, genital warts, or pregnancy (especially child)

Social Interactions

Multiple family/relationship stressors reported

Household members may include step-relatives or a paramour

History of frequent moves/relocation

Few/no support systems

Lacks knowledge of appropriate child-rearing practices (child abusers)

Inability to form satisfactory peer relationships; withdrawal in social settings; inappropriate attachment to imaginary companion

Very possessive, perceives partner as a possession; repeatedly insults/humiliates partner, strives to isolate partner from others/keeps partner totally dependent, challenges partners honesty, uses intimidation to achieve power/control over partner (offender)

Lack of assertive communication skills; difficulty negotiating interpersonal conflicts

Cheating, lying; low achievement or drop in school performance

Running away from home/relationship

Parent may interfere with child’s normal peer relationships to prevent exposure (incest)

Memories of childhood may contain blank periods, excessive fantasizing/daydreaming; report of violence/neglect in family of origin

Family Interaction Pattern: Less verbally responsive, increased use of direct commands and critical statements, decreased verbal praise or acknowledgment, belittling, denigrating, scapegoating, ignoring; significant imbalance of power/use of hitting as control measure, patterns of enmeshment, closed family system; one parent domineering, impulsive; other partner passive, submissive

Teaching/Learning

May be any age, race, religion/culture, or educational level; from all socioeconomic groups (usual child profile is under age 3 or perceived as different due to temperamental traits, congenital abnormalities, chronic illness)

Learning disabilities include attention-deficit disorders, conduct disorders

Delay in achieving developmental tasks, declines on cognitive testing; brain damage, habitual truancy/absence from school for nonlegitimate reasons (neglect)

Substance abuse by individuals involved in abuse/neglect, or other family member(s) (most often cocaine, crack, amphetamines, alcohol)

Use of multiple healthcare providers/resources (limits awareness of repeated nature of problem); lack of age-appropriate health screening/immunization, dental care, absence of necessary prostheses, such as eyeglasses, hearing aid (neglect)

DIAGNOSTIC STUDIES

Physical and Psychological Testing

dependent on individual situation/needs

Screening Tests (e.g., Child Behavior Checklist): Elevated scores on the internalization scale reveal behaviors described as fearful, inhibited, depressed, overcontrolled or undercontrolled, aggressive, antisocial.

NURSING PRIORITIES

1. Provide physical/emotional safety.
2. Develop a trusting therapeutic relationship.
3. Enhance sense of self-esteem.
4. Improve problem-solving ability.
5. Involve family/partner in therapeutic program.

DISCHARGE GOALS

1. Physical/emotional safety maintained.
2. Trusting relationship with one person established.
3. Self-growth and positive approaches to problems evident.
4. Client/SOs participating in ongoing therapy.
5. Plan in place to meet needs after discharge.

NCP Borderline Personality Disorder

BORDERLINE PERSONALITY DISORDER

DSM-IV

301.83 Borderline personality disorder

“Borderline” has been used to identify clients who seem to fall on the border between the standard categories of neuroses or psychoses. The term has been refined to indicate a client with a pervasive pattern of instability of interpersonal relationships, self-image, affect, and control over impulses beginning in early adulthood, and includes such factors as feelings of abandonment, impulsivity, reactivity of mood, chronic feelings of emptiness, and problems with anger.

ETIOLOGICAL THEORIES

Psychodynamics

Unconscious processes that are believed to shape personality are set in motion by drives or instincts that are then influenced by conflicts among them as well as instinctual wishes and demands of reality. Defensive maneuvers are unconsciously developed to protect against anxiety arising from this conflict. This personality is seen as a painstaking but poorly constructed defense.

It is also seen as resulting from a fixation of libido at stages of psychosexual development associated with certain body parts. Although it is difficult to agree on how personality is formed, severe personality disorders are believed to begin early in childhood and milder forms are thought to be influenced by factors during later development.

Biological

Personality is believed to have a hereditary basis known as “temperament” and biological dispositions that affect mood and level of activity (e.g., cranky, placid, self-contained, outgoing, impulsive, cautious). There is little agreement about how this affects the development of personality disorders.

Family Dynamics

The child’s social environment, particularly that within the family, is assumed to be the main force that shapes personality. The theory of object relations provides a basis for personality development and an explanation of the dynamics that manifest the borderline characteristics. The individual with borderline personality may be fixed in the rapprochement phase of development (18–25 months of age). In this phase, the child is experiencing increasing autonomy, while still requiring “emotional refueling” from the mothering figure. Because the mother feels threatened by the child’s efforts at independence, she strives to keep the child dependent. Nurturing and emotional support become bargaining tools. They are withheld when the child exhibits independent behaviors and are used as rewards for clinging, dependent behaviors. This engenders a deep fear of abandonment in the child that persists into adulthood as the child continues to view objects (people) as parts—either good or bad. This is called “splitting,” which is the primary dynamic of borderline personality.

Current studies suggest that borderline personality disorders are strongly associated with a history of physical or sexual abuse by family members, and incest may be a major reason for the disproportionate ratio (2:1) of female clients.

CLIENT ASSESSMENT DATA BASE

Ego Integrity

Markedly disturbed/distorted sense of self

Experiences ambivalence toward being independent; does not like to be alone (frantic attempts to avoid real or imagined abandonment)

Reports feelings of emptiness and boredom; depression, sadness

May conform to current companions, sharing beliefs and values based on imitation

Food/Fluid

Binge eating may be reported (impulsivity)

Neurosensory

Mental Status:

  Behavior: May be erratic, impulsive, intense, clinging; may indulge in unpredictable/impulsive behaviors (e.g., irresponsible spending, reckless driving, gambling, substance abuse)

  Mood: Marked reactivity of mood (e.g., intense episodes of anxiety, irritability, dysphoria)

  Emotions: Intense emotions with rapid, unpredictable, strong mood swings; quick to anger (may be intense, inappropriate), lacks ability to control; may exhibit hostile attitude

  Affect: May appear genuine but not necessarily be appropriate to the situation

  Thought Processes: Displays overall poor reality base with difficulty making decisions; engages in concrete “all-or-nothing”/black-or-white thinking; lacks insight and does not learn from past experience; unable to form long-term goals or values

Magical thinking, difficulty in identifying the self; severely impaired self-concept

Lying and fabrication habitual, almost delusional

Self-centered, often to the point of narcissism, inordinantly hypersensitive, and inflexible; relationships may be transient, shallow, and/or demanding, with little flexibility and unstable interpersonal behavior; may use and exploit others; lacks empathy for others

Major defense mechanism used is projection (seeing in others those attitudes one fails to see in self)

May border on neuroses and psychoses, exhibiting transient psychotic symptoms when experiencing extreme stress; transient episodes of paranoid ideation or severe dissociative symptoms

May be associated with other personality disorders that have histrionic, narcissistic, schizotypal, or antisocial features

Safety

May reveal evidence of self-mutilative acts, usually nonlethal actions (e.g., cutting, burning)

History of recurrent suicidal behavior, gestures, threats

Sexuality

May present a profound disturbance in gender identity

Sexual promiscuity

Possible history of incest/sexual abuse

Social Interactions

Significant impairment in social, marital, and occupational functioning

Interpersonal relationships unstable and intense, alternating between extremes of overidealization and devaluation

Frequently attempts to provoke guilt in others, making endless demands

History of recurrent physical fights

Teaching/Learning

More prevalent in females

Substance abuse (especially alcohol) may be reported

Higher incidence found in families with history of both chronic schizophrenia and major affective disorders

DIAGNOSTIC STUDIES

P-300: A change in brain electrical activity that occurs in most people about 300 milliseconds after they perceive a tone, light, or other signal indicating that they have to perform a task; may be abnormal, smaller than average, and slightly delayed.

CSF5-HIAA (5-hydroxyindoleacetic acid): Decreased in some clients.

Prolacting Response: Diminished response to serotonin-releaser fenfuramine.

Drug Screen: Identifies substance use.

NURSING PRIORITIES

1. Limit aggressive behavior; promote socially acceptable responses.
2. Encourage assertive behaviors to attain sense of control.
3. Assist client to learn healthy ways of controlling anxiety/developing positive self-concept.
4. Promote development of effective coping skills.
5. Help client learn alternate, constructive methods of interacting with others.

DISCHARGE GOALS

1. Impulsive behavior(s) recognized and controlled.
2. Establishes goals and asserts control over own life.
3. Problem-solving techniques used constructively to resolve conflicts.
4. Interacts with others in socially appropriate manner.
5. Client/family involved in behavioral therapy/support programs.
6. Plan in place to meet needs after discharge.

NCP Adjustment Disorders

ADJUSTMENT DISORDERS

DSM-IV

ADJUSTMENT DISORDERs (SPECIFY if ACUTE/CHRONIC)

309.24 With anxiety
309.0 With depressed mood
309.3 With disturbance of conduct
309.4 With mixed disturbance of emotions and conduct
309.28 With mixed anxiety and depressed mood

The essential feature of adjustment disorders is a maladaptive reaction to an identifiable psychosocial stressor that occurs within 3 months of the onset of the stressor. (The reaction to the death of a loved one is not included here, as it is generally diagnosed as bereavement.) The stressor also does not meet the criteria for any specific Axis I disorder or represent an exacerbation of a preexisting Axis I or Axis II disorder.

The response is considered maladaptive because social or occupational functioning is impaired or because the behaviors are exaggerated beyond the usual expected response to such a stressor. Duration of the symptoms for more than 6 months indicates a chronic state. By definition, an adjustment disorder must resolve within 6 months of the termination of the stressor or its consequences. If the stressor/consequences persist (e.g., a chronic disabling medical condition, emotional difficulties following a divorce, financial reversals resulting from termination of employment, or a developmental event such as leaving one’s parental home, retirement), the adjustment disorder may also persist.

ETIOLOGICAL THEORIES

Psychodynamics

Factors implicated in the predisposition to this disorder include unmet dependency needs, fixation in an earlier level of development, and underdeveloped ego.
The client with predisposition to adjustment disorder is seen as having an inability to complete the grieving process in response to a painful life change. The presumed cause of this inability to adapt is believed to be psychic overload—a level of intrapsychic strain exceeding the individual’s ability to cope. Normal functioning is disrupted, and psychological or somatic symptoms occur.

Biological

The presence of chronic disorders is thought to limit an individual’s general adaptive capacity. The normal process of adaptation to stressful life experiences is impaired, causing increased vulnerability to adjustment disorders. A high family incidence suggests a possible hereditary influence.

The autonomic nervous system discharge that occurs in response to a frightening impulse and/or emotion is mediated by the limbic system, resulting in the peripheral effects of the autonomic nervous system seen in the presence of anxiety.
Some medical conditions have been associated with anxiety and panic disorders, such as abnormalities in the hypothalamic-pituitary-adrenal and hypothalamic-pituitary-thyroid axes; acute myocardial infarction; pheochromocytomas; substance intoxication and withdrawal; hypoglycemia; caffeine intoxication; mitral valve prolapse; and complex partial seizures.

Family Dynamics

The individual’s ability to respond to stress is influenced by the role of the primary caregiver (her or his ability to adapt to the infant’s needs) and the child-rearing environment (allowing the child gradually to gain independence and control over own life). Difficulty allowing the child to become independent leads to the child having adjustment problems in later life.
Individuals with adjustment difficulties have experienced negative learning through
inadequate role-modeling in dysfunctional family systems. These dysfunctional patterns impede the development of self-esteem and adequate coping skills, which also contribute to maladaptive adjustment responses.

CLIENT ASSESSMENT DATA BASE

(Symptoms of affective, depressive, and anxiety disorders are manifested dependent on the individual’s specific response to a stressful situation.)

Activity/Rest

Fatigue

Insomnia

Ego Integrity

Reports occurrence of personal stressor/loss (e.g., job, financial, relationship) within past 3 months
May appear depressed and tearful and/or nervous and jittery
Feelings of hopelessness

Neurosensory

Mental Status: Depressed mood, tearful, anxious, nervous, jittery
Attention and memory span may be impaired (depends on presence of depression, level of anxiety, and/or substance use)
Communication and thought patterns may reveal negative ruminations of depressed mood or flight of ideas/loose associations of severely anxious condition

Pain/Discomfort
Various physical symptoms such as headache, backache, other aches and pains (maladaptive response to a stressful situation)

Safety

Anger expressed inappropriately
Involvement in high-risk behaviors (e.g., fighting, reckless driving)
Suicidal ideations may be present

Social Interactions

Difficulties with performance in work/social setting, when no difficulties had been experienced prior to the occurrence of the stressor
Socially withdrawn/refuses to interact with others (e.g., isolates self in own room)
Reports of vandalism, reckless driving, fighting, defaulting on legal responsibilities, violation of the rights of others or age-appropriate norms and rules
May display manipulative behavior (e.g., testing limits, playing individuals/family members against each other)

Teaching/Learning

Academic difficulties, failure to attend class/complete course work
Substance use/abuse possibly present

DIAGNOSTIC STUDIES

Diagnostic studies and psychological testing as indicated to rule out conditions that may mimic or coexist (e.g., endocrine imbalance, cardiac involvement, epilepsy, or a differential diagnosis with affective, anxiety, conduct, or antisocial personality disorders).
Drug Screen: Determine substance use.

NURSING PRIORITIES

1. Provide safe environment/protect client from self-harm.
2. Assist client to identify precipitating stressor.
3. Promote development of effective problem-solving techniques.
4. Provide information and support for necessary lifestyle changes.
5. Promote involvement of client/family in therapy process/planning for the future.

DISCHARGE GOALS

1. Relief from feelings of depression and/or anxiety noted, with suicidal ideation reduced.
2. Anger expressed in an appropriate manner.
3. Maladaptive behaviors recognized and rechanneled into socially accepted actions.
4. Client involved in social situations/interacting with others.
5. Ability and willingness to manage life situations displayed.
6. Plan in place to meet needs after discharge.

NCP Obesity

OBESITY

DSM-IV

316.00 Psychological factors affecting medical condition—maladaptive health behaviors

Obesity is defined as an excess accumulation of body fat at least 20% over average weight for age, sex, and height. Although considered to be a type of eating disorder, obesity is a general medical condition coded on Axis III, with psychological factors that adversely affect the course and treatment of the medical condition, creating additional health risks for the individual.

ETIOLOGICAL THEORIES

Psychodynamics

Food is substituted by the parent for affection and love. The child harbors repressed feelings of hostility toward the parent, which may be expressed inward on the self. Because of a poor self-concept, the person has difficulty with other relationships. Eating is associated with a feeling of satisfaction and becomes the primary defense.

Biological

These disorders may arise from neuroendocrine abnormalities within the hypothalamus, which cause various chemical disturbances. Familial tendencies have been identified, but obesity is not clearly identified as being hereditary. People who are overweight have more fat cells than thin people and are known to be less active. Although overeating has long been believed to be the cause of obesity, research has not borne this out. Another popular theory has identified carbohydrates as the fattening substance. Currently, a high intake of fat in the diet is being identified as the reason for weight gain/inability to lose weight. The set-point theory proposes that people are programmed to maintain a certain level of weight to protect fat stores. Studies reveal that leptin regulates body weight by telling the body how much fat is being stored. Obese individuals often have higher leptin levels, suggesting a failure of the body to respond to leptin. This may represent a deficiency of receptor sites or inadequate amounts of glucagon-like peptide-1 (GPL-1), which may impair the leptin signaling pathway.

In recent research, genetics, metabolic changes placing some people at risk, and the way the body stores fat all play a part in the problems of obesity. Rather than a single, simple cause, obesity appears to be the result of a complex system reflecting all these factors.

Family Dynamics

Parents act as role models for the child. Maladaptive coping patterns (overeating) are learned within the family system and are supported through positive (or even negative) reinforcement. Family systems may sabotage efforts at changing any part of the system to maintain the status quo.

CLIENT ASSESSMENT DATA BASE

Activity/Rest

Fatigue, constant drowsiness

Inability/lack of desire to be active or engage in regular exercise

Increased heart rate/respirations with activity; dyspnea with exertion

Circulation

Hypertension, edema

Ego Integrity

Weight may/may not be perceived as a problem

Perception of body image as undesirable

Cultural/lifestyle factors affecting food choices; value for thinness/weight

Eating relieves unpleasant feelings (e.g., loneliness, frustration, boredom)

Reports of SO’s resistance/demands regarding weight loss (may sabotage client’s efforts)

Food/Fluid

Normal/excessive ingestion of food

History of recurrent weight loss and gain

Experimentation with numerous types of diets (yo-yo dieting) with varied/short-lived results

Weight disproportionate to height; endomorphic body type (soft/round)

Failure to adjust food intake to diminishing requirements (e.g., change in lifestyle from active to sedentary, aging)

Pain/Discomfort

Pain/discomfort on weight-bearing joints or spine

Respiration

Dyspnea with exertion

Cyanosis, respiratory distress (sleep apnea, pickwickian syndrome)

Sexuality

Menstrual disturbances, amenorrhea

Social Interactions

Family/significant other(s) may be supportive or resistant to weight loss (sabotage client’s efforts)

Teaching/Learning

Problem may be lifelong or related to life event

Family history of obesity

Concomitant health problems may include hypertension, diabetes, gallbladder and cardiovascular disease, hypothyroidism

DIAGNOSTIC STUDIES

Metabolic/Endocrine Studies: May reveal abnormalities (e.g., hypothyroidism, hypopituitarism, hypogonadism, Cushing’s syndrome [increased cortisol or glucose levels], hyperglycemia, hyperlipidemia, hyperuricemia, hyperbilirubinemia). The cause of these disorders may arise out of neuroendocrine abnormalities within the hypothalamus, which result in various chemical disturbances.

Anthropometric measurements: Measures fat-to-muscle ratio.

NURSING PRIORITIES

1. Help client identify a workable method of weight control incorporating needed nutrients/healthful foods.
2. Promote improved self-concept, including body image, self-esteem.
3. Encourage health practices to provide for weight control throughout life.

DISCHARGE GOALS

1. Healthy pattern for eating and weight control identified.
2. Weight loss toward desired goal established.
3. Positive perception of self verbalized.
4. Plan in place to meet needs for future weight-control.

NCP Sexual Dysfunctions and Paraphilias

SEXUAL DYSFUNCTIONS AND PARAPHILIAS

DSM-IV

SEXUAL DESIRE DISORDERS

302.71 Hypoactive sexual desire disorder
302.79 Sexual aversion disorder

SEXUAL AROUSAL DISORDERS

302.72 Female sexual arousal disorder
302.72 Male erectile disorder

ORGASMIC DISORDERS

302.73 Female orgasmic disorder
302.74 Male orgasmic disorder
302.75 Premature ejaculation

SEXUAL PAIN DISORDERS

302.76 Dyspareunia (not due to a general medical condition)
306.51 Vaginismus (not due to a general medical condition)

(Refer to DSM-IV manual for sexual dysfunctions due to a general medical condition)

PARAPHILIAS

302.4 Exhibitionism
302.81 Fetishism
302.89 Frotteurism
302.2 Pedophilia
302.83 Sexual masochism
302.84 Sexual sadism
302.82 Voyeurism
302.3 Transvestic fetishism

Sexual disorders include sexual dysfunctions and paraphilias. Sexual dysfunction is defined as persistent impairment/disturbance of a normal or desired pattern in any phase of the sexual response cycle. Paraphilias are more specific disorders in which unusual or bizarre imagery or acts are necessary for realization of sexual excitement. Because many paraphiliac behaviors are illegal in most states, individuals usually come for psychiatric treatment because of pressure from others, partners, or the authorities/judicial system.

ETIOLOGICAL FACTORS

Psychodynamics

Individual causes of sexual desire disorders may include religious beliefs, obsessive-compulsive personality, conflicts with gender identity or sexual preference, sexual phobias, fear of losing control over sexual urges, secret sexual deviations, fear of pregnancy, inadequate grieving following the death of a spouse, depression, and aging-related concerns. Psychological factors may also be involved in arousal disorders.

Psychoanalytical theories state that paraphilias are the product of childhood desires that survive into adulthood in their immature forms because emotional development has been inhibited, distorted, and diverted. These wishes are believed to be universal and are used to achieve arousal and release when ordinary forms of sexual activity are not available. Deviations arise when these immature forms of libido dominate adult sexual life. Fixation is thought to occur in Freud’s oral, anal, and phallic phases when corresponding body parts provide sources of instinctual gratification. Conflict arises when an imperfect compromise occurs between these impulses and reality, resulting in fear, which the unconscious perceives as castration.

Behavioral theorists believe any paraphilia/sexual dysfunction can be acquired through conditioning, in which an initial pairing of an object is accidentally associated with/then becomes necessary for sexual release. This need may become generalized to other situations of tension/anxiety.

Biological

Sometimes the cause is clearly biological (e.g., temporal lobe epilepsy that may cause changes in sexual behavior between seizures). It has also been suggested that the problem arises out of interference with brain pathways governing rage and sexual arousal. Sex hormones have been studied. Rat studies have demonstrated that small, properly timed doses of androgens (male hormones) or estrogens (female hormones) in the fetus or newborn can influence sexual behavior. Various organic reasons, medication and other drug use, physical illnesses (most notably diabetes mellitus), surgery (such as prostatectomy), and degenerative neural disorders (e.g., multiple sclerosis) may be involved in sexual desire, arousal, and pain disorders.

It is generally accepted that abnormal hormonal activity and biological (genetic) predisposition interacting with social and family factors influence the development of these fantasies/sexual acts. Although these behaviors may occur in normal sexual activity, when they become the primary source of sexual satisfaction they may result in problems for the individual/others.

Family Dynamics

There appears to be some evidence that paraphilias run in families and may be the result of dysfunctional family interactions and social learning.

Sexual dysfunctions are believed to be influenced by what the individual has learned/not learned as a child within the family system and by values and beliefs that may be based on myths and misconceptions.

CLIENT ASSESSMENT DATA BASE

SEXUAL DYSFUNCTIONS

Neurosensory

Mental Status: Findings may indicate intense distress about situation/condition or coexisting psychiatric disorders

Mood and affect may reveal evidence of increased anxiety and depression

Sexuality

Problems may be lifelong or acquired after a period of normal sexual functioning

May report inhibition or interference with some part of the human response cycle (e.g., low sexual desire, aversion to genital sexual contact, arousal/erectile/orgasmic disturbances, premature ejaculation, genital pain during or after sexual intercourse, and involuntary spasm of the outer third of the vagina interfering with coitus)

May display negative attitude(s) toward sexuality

Social Interactions

Impairment may be noted in marital/conjugal relations but rarely affects job performance

Teaching/Learning

Most commonly occur in early adulthood, although male erectile disorder may surface later in life

PARAPHILIAS

Ego Integrity

May express shame or guilt about behavior

May or may not act on fantasies

Neurosensory

Personality disturbances frequently accompany sexual disorder(s)

Safety

Physical injury may be seen following episodes of sadomasochistic activity

Sexuality

Recurrent, intense sexual urges and fantasies involving the exposure of one’s genitals to a stranger that have been acted on, cause severe distress, and may be accompanied by masturbation (exhibitionism)

Use of nonliving object(s) to stimulate recurrent intense sexual urges and sexually arousing fantasies (e.g., female undergarments [fetishism])

Rubbing and touching against a nonconsenting person to invoke recurrent, intense sexual urges and fantasies, with the touching, not the coercive nature of the act, causing sexual excitement (frotteurism)

Sexual activity with a prepubescent child or children (pedophilia)

Participation in the act (real, not simulated) of being humiliated, beaten, bound, or otherwise made to suffer (sexual masochism)

Participation in acts (real, not simulated) in which the psychological or physical suffering (including humiliation) of the victim is sexually exciting to the person (sexual sadism)

Cross-dressing activities (transvestic fetishism)

Observing unsuspecting person(s), usually a stranger, who is naked, in the process of disrobing or engaging in sexual activity (voyeurism)

Social Interactions

May not view self as ill; however, behavior may cause distress for the individual or may bring suffering to others

May be in conflict with partner or society because of behavior

Possible interference with interpersonal/occupational functioning

Teaching/Learning

Occurs mostly in males

Some evidence of occurrence in families of paraphiliacs and of depressed individual; high correlation between pedophiles and family history of pedophilic activity

DIAGNOSTIC STUDIES

As indicated, to rule out physical causes of sexual dysfunction.

Screening for sexually transmitted diseases (STDs) including HIV/AIDS.

NURSING PRIORITIES

1. Assist client to understand the nature of the behavior (disorder/dysfunction).
2. Encourage use of acceptable methods for reduction of anxiety.
3. Help to recognize the legal/interpersonal consequences of paraphilic behaviors.
4. Explore options for change.
5. Encourage involvement of client/family (significant other) in treatment regimen.

DISCHARGE GOALS

1. The nature of the problem and consequences for the individual/family understood.
2. Anxiety reduced/managed in acceptable ways.
3. Options explored and appropriate one(s) chosen.
4. Confidence in own capabilities/sense of self-worth expressed.
5. Participating in treatment program and using community/treatment resources effectively.
6. Plan in place to meet needs after discharge.

NCP Dissociative Disorders

DISSOCIATIVE DISORDERS

DSM-IV

300.12  Dissociative amnesia
300.13  Dissociative fugue
300.14  Dissociative identity disorder
300.15  Dissociative disorder NOS
300.6  Depersonalization disorder

In these disorders a disturbance or alteration exists in the normally integrative functions of identity, memory, or consciousness. The individual blocks off part of his or her life from consciousness during periods of intolerable stress. The stressful emotion becomes a separate entity, as the individual “splits” from it and mentally drifts into a fantasy state.

ETIOLOGICAL THEORIES

Psychodynamics

Selective repression of distressing mental contents from conscious awareness is used as a mechanism for protecting the individual from emotional pain or expressing self in dangerous ways. The stressor(s) may arise from external circumstances or internal sources with onset of symptoms sudden or gradual and of transient or chronic nature. Intrapsychic conflict thus uses denial and “ego splitting” to decrease anxiety.

Physical sensations seen in these disorders may represent forbidden wishes that have been somatized. The use of the defense mechanism of displacement allows the feeling(s) to be directed away from the ego-threatening object toward one less threatening. In psychoanalytic terms, dissociation is a form of denial in which the object denied is part of the self or ego.

Biological

Research on the biological basis of these disorders is increasing as more recognition of the mind-body connection is accepted. It is difficult to determine whether the biological changes (fight-or-flight mechanism) that accompany severe anxiety precede or precipitate the emotional state. Biochemical, physiological, and endocrine systems have an intimate connection with actual physical changes occurring in all body systems via the autonomic nervous system. Some studies have shown EEG abnormalities associated with cerebral mechanisms in the temporal and limbic regions of the brain, which mediate identity formation and a sense of personal boundaries and may affect development of gender and generation boundaries.

Organic causes of pathological dissociative experiences that are known or suspected include temporal lobe epilepsy, sensory deprivation, sleep loss, strokes, encephalitis, and Alzheimer’s disease. Drugs may also induce amnesia or depersonalization directly or indirectly in some incidences. However, most dissociative states are not associated with any obvious organic conditions and the diagnosis of dissociative disorder requires that the condition is not due to the direct effects of a substance or a general medical condition.

Family Dynamics

In Systems theory, the family is viewed as a system in which the process (interactions between/among family members) is the prime determinant. Level of differentiation and level of anxiety determine the degree of pathology.

Psychosocial theory states that individuals who develop dissociative disorders have often experienced severe physical, sexual, and/or emotional abuse early in life—stress so severe that the only way to cope with the painful emotions is to detach from them. The child learns to respond to stressful situations in this manner. One parent may be abusive, with the other being a passive participant, not taking care of or protecting the child. Psychiatric diagnoses (especially alcoholism) in close relatives are common, although multiple personality diagnosis is not.

Certain behaviors observed in childhood, though considered normal, may be identified as dissociative, including construction of imaginary playmates, use of different names or ages for themselves, taking on the role of an animal, imagining self as having been adopted or coming from another family, separation from the past, gender confusion, and regressive behavior. Responding to stressful situations with dissociative behaviors then becomes a method of coping for some individuals into adulthood, when there is less control over the dissociative states. The response becomes maladaptive in that the individual escapes from the stressful situation rather than facing it.

CLIENT ASSESSMENT DATA BASE

Activity/Rest

Insomnia

Ego Integrity

Confusion about personal identity, may have assumed a new identity either partial or complete (fugue)

Anxiety responses, report of phobias; fears of going crazy

Neurosensory

Memory lapses/amnesia; disorientation; inability to recall important personal information/specific incidents not due to direct effects of a substance, general medical condition, or ordinary forgetfulness

May report hallucinations, delusions

Mood swings; psychological conflicts; family/peers may describe client’s behavior as erratic, unpredictable, or unreliable

Sudden, unexpected travel away from familiar surroundings of work and home, with inability to recall past (fugue)

Persistent/recurrent experiences of feeling detached from own mental processes or body, although reality testing remains intact (depersonalization)

Presence of 2 or more distinct identities or personality states (mean average of 13), with each a fully integrated, complex unit with unique memories, behaviors, and relationships (or may be a personality state that does not have as wide a range of patterns) recurrently taking control of client’s behavior, with transition from one personality to another being sudden/associated with psychosocial stress. Alternate personalities vary in their awareness of each other, may be of opposite genders, and are commonly children, although some may be stated to be older than the individual (dissociative identity disorder)

Transient changes in facial expression, voice, and posture; tastes/habits that seem to change quickly or often

Safety

Suicidal feelings/behaviors

Evidence of self-mutilation

Sexuality

History of severe childhood incest, sexual/physical/psychological abuse

Sexually inhibited or promiscuous

Social Interactions

Significant distress or impairment in social, occupation, or other important areas of functioning

Teaching/Learning

More common in women than in men, in persons with some higher education, and in white-collar workers

Age of onset is early childhood, although often not diagnosed until the third decade

Seldom diagnosed upon initial clinical contact (accurate diagnosis may be delayed by a period of months to years)

Substance abuse may be reported (but is not cause of disorder)

Absence of organic brain disorders (e.g., temporal lobe epilepsy)

History of major depression greater than 90% (dissociative identity disorder)

DIAGNOSTIC STUDIES

(Evaluations to rule out an underlying or concurrent disease process are based on individual symptoms.)

Neurological Testing (e.g., EEG and CT/MRI Scans): To rule out organic brain conditions related to trauma, tumor, congenital defects, and temporal lobe epilepsy, symptoms of which often parallel manifestations of dissociative identity disorder.

Psychosocial Assessment, such as Rorschach, Thematic Apperception Test (TAT), Minnesota Multiphasic Personality Inventory (MMPI), Weschler Adult Intelligence Scale (WAIS), Dissociative Experiences Scale (DES), Dissociative Disorders Interview Schedule (DDIS), and Hypnosis or Amobarbital Interviews: As indicated to provide behavioral observation and documentation describing the character, duration, frequency, and precipitation of behavioral changes and client comments or complaints essential to the diagnostic process, as these clients are frequently misdiagnosed initially because of blurring of symptoms that parallel other psychiatric problems—commonly depression, neuroses, personality disorders, and schizophrenia.

Drug Screen: Assess for concomitant substance use.

NURSING PRIORITIES

1. Provide safe environment; protect client/others from injury.
2. Assist client to recognize anxiety.
3. Promote insight into relationship between anxiety and development of dissociative state/other personalities.
4. Support client/family in developing effective coping skills and participating in therapeutic activities.

DISCHARGE GOALS

1. Recognizes potentially dangerous behaviors/personalities and contracts for safety.
2. Client/family are participating in therapeutic regimen.
3. Effective coping skills, understanding of underlying dynamics of condition are demonstrated.
4. Recovers deficits in memory.
5. Major/emerging personality has been chosen and accepted (dissociative identity disorder) or client is managing stress without resorting to dissociation.
6. Plan in place to meet needs after discharge.

NCP Somatoform Disorders

SOMATOFORM DISORDERS

DSM-IV

300.81 Somatization disorder
300.11 Conversion disorder
300.7 Hypochondriasis
300.7 Body dysmorphic disorder
307.xx Pain disorder
307.80 Associated with psychological factors
307.89 Associated with both psychological factors and a general medical condition
300.82 Undifferentiated somatoform disorder
300.82 Somatoform disorder NOS

Somatization refers to all those mechanisms by which anxiety is translated into physical illness or bodily complaints. The expression of physical symptoms suggests the presence of physiological disorder, but there are no demonstrable organic findings/known pathological mechanisms, or the symptoms are not fully explained by any physical disorder. That is, the symptoms are in excess of what would be expected from the history, physical examination, or laboratory findings. There does exist, however, positive evidence, or a strong presumption, that the symptoms are linked to psychological factors or conflicts. These disorders are more common in women than in men, with somatization disorder rare in men.

ETIOLOGICAL THEORIES

Psychodynamics

This disorder may represent an unconscious transformation of internal conflicts into physical symptoms that can be explained in terms of the ego’s ability to control the sensory and motor apparatus, which may have specific meaning for the client.

Dependency is common in individuals with somatoform disorders, and fixation in an earlier level of development may be evident. Repression is the primary defense mechanism, as severe anxiety is repressed and manifested by the presence of physical symptoms.

Biological

Although biological and neurophysiological influences in the etiology of anxiety have been investigated, no relationship has yet been established. However, there does seem to be a genetic influence with a high family incidence.

The autonomic nervous system discharge that occurs in response to a frightening impulse and/or emotion is mediated by the limbic system, resulting in the peripheral effects of the autonomic nervous system seen in the presence of anxiety. These manifestations of anxiety may be related to physiological abnormalities.

Family Dynamics

The family contributes to these conditions by initiating, reinforcing, and perpetuating the behavior patterns. The children learn (overtly or covertly) that physical complaints are acceptable ways of coping with stress and obtaining attention, care, and gratification of dependency needs. The client may gain attention and meet these needs by overdramatization of the symptoms, resulting in overinvolvement of other family members in enmeshed behavior patterns. In the beginning, the client may exaggerate minor symptoms to prove she or he is really ill when others ignore reports of illness.

CLIENT ASSESSMENT DATA BASE

Activity/Rest

Fatigue

General weakness

Circulation

Heart rate may be elevated if symptoms mimic those of cardiopulmonary disease (similar to those experienced during panic attack)

Ego Integrity

Preoccupation with imagined defect in appearance or markedly excessive concern with slight physical anomaly not better accounted for by another mental disorder (e.g., dissatisfaction with body shape/size in anorexia nervosa [body dysmorphic disorder])

Evidence of severe psychological stress preceding onset/exacerbation of the physical symptoms (e.g., death of a loved one [conversion])

Preoccupation with fear of having a serious disease (hypochondriasis)

Use of denial; evidence that presence of the symptoms alleviates or promotes avoidance of the psychological conflict

Feelings of anger, helplessness, powerlessness

Report of issues suggesting unconscious secondary gain (e.g., attention of others, financial reimbursement, change in role expectations/responsibilities)

Elimination

Urinary retention

Constipation, diarrhea

Food/Fluid

Two or more GI symptoms (e.g., nausea, vomiting, bloating, intolerance of several different foods, difficulty swallowing [somatization])

Changes in eating patterns (loss of appetite/excessive intake)

Weight loss/gain

Hygiene

May neglect and/or report inability to perform basic ADLs

Excessive concern/preoccupation with/or more imagined defects in appearance (body dysmorphic disorder)

Neurosensory

Mental Status Exam:

  Fearfulness; preoccupation with belief of having serious disease; anxiety (symptoms associated with moderate to severe level) or la belle indifférence (lack of concern about loss of physical functioning)

  Depressed mood

  Amnesia

  Communication patterns: ruminating about physical symptoms

May display loss of consciousness other than fainting (somatization)

Apparent loss of or alteration in voluntary motor or sensory functioning that suggests neurological disease (e.g., blindness, double vision, deafness, paralysis, anosmia, aphonia, episodic seizure activity, and coordination disturbances [especially common in conversion disorder])

Pain/Discomfort

Pain in 1 or more anatomical sites of at least 6 months’ duration and of sufficient severity to warrant clinical attention (pain disorder); involving 4 different sites of function (e.g., head, abdomen, back, joints, chest, during urination/menstruation/sexual intercourse [somatization])

Excessive use of analgesics with minimal relief of pain

Respiration

Respiratory rate may be increased

Shortness of breath without exertion

Safety

May report suicidal ideations, inability to continue in current situation

Social Interactions

Observed/reported impairment in social, occupational, or other areas of functioning

Acute withdrawal from life activities, fear of being seen/scrutinized by others in public setting (body dysmorphic disorder)

Sexuality

One or more sexual/reproductive symptoms other than pain, e.g., decreased libido/sexual indifference, irregular menses/excessive menstrual bleeding, erectile/ejaculatory difficulties, pseudocyesis (false pregnancy), somatization

Teaching/Learning

Reports of physical symptoms of several years’ duration beginning before the age of 30 (somatization)

History of a past experience with true serious organic disease, in self or close family member (hypochondriasis)

History of frequent visits to physicians (doctor shopping) to obtain relief/requests for surgery despite medical reassurance of absence of organic pathology or need for plastic surgery (e.g., facelift, liposuction)

Failure to improve despite multiple approaches/therapies

Expression of anger and frustration toward physicians for “inability to determine cause of physical symptoms”

DIAGNOSTIC STUDIES

Virtually any diagnostic procedure (including exploratory surgery) may be performed as deemed appropriate to rule out organic pathology in light of the physical symptom(s) presented by the client.

Urine and/or Serum Toxicology Screen: Determines evidence of substance use/abuse

NURSING PRIORITIES

1. Alleviate or minimize physical symptoms/chronic pain.
2. Promote client safety.
3. Resolve potentially dysfunctional areas of client/family dynamics.
4. Promote independence in self-care activities.
5. Provide information and support for lifestyle changes.

DISCHARGE GOALS

1. Relief obtained from admitting physical symptom(s).
2. Client/family recognizes relationship between psychological stressors and onset/exacerbation of physical symptoms(s).
3. Stress management techniques used appropriately to prevent the occurrence/exacerbation of the physical symptom(s).
4. Level of function/independence increased.
5. Plan in place to meet needs after discharge.

NCP Panic Disorders / Phobias

PANIC DISORDER/PHOBIAS

DSM-IV

PANIC DISORDER/PHOBIAS
300.01 Panic disorder without agoraphobia
300.21 Panic disorder with agoraphobia
300.22 Agoraphobia without history of panic disorder
300.23 Social phobia
300.29 Specific phobia

Panic attack is a discrete period of intense fear or discomfort with onset spontaneous/unpredictable or situationally bound, peaking within 10 minutes.

ETIOLOGICAL THEORIES

Psychodynamics

Phobic object may symbolize the underlying conflict, although there is not always a clear connection. Personal perceptions, life experiences, and cultural values color the meaning of the symbol for the client.

The freudian view is that anxiety feelings stem from loss of love and support from the mothering figure, which increases the client’s dependency needs. The client combats the diffuse intolerable anxiety by an exaggerated use of displacement on a particular object or situation, which makes the anxiety more manageable.

Phobic partners may develop in the family; these are “helpers” who stand by and participate in maintaining phobic behavior, protecting phobic client from acute panic and anxiety. Participation of partner furthers the unconscious wish of phobic client to be taken care of and to be in control.

Biological

(Refer to CP: Generalized Anxiety Disorder.)

Temperament may be a factor in that some fears are innate. These fears represent a part of the overall characteristics with which one is born that influence how the individual responds to specific situations throughout his or her life. Research suggests irregularities in the synthesis and release of norepinephrine and/or hypersensitivity of receptors for neurotransmitters (including serotonin and gamma-aminobutyric acid [GABA]), or an interaction between norepinephrine transmitters. The trigger may lie in the locus coeruleus located in the brainstem. There also may be a genetic susceptibility to either an excess or deficiency of CO2 levels and a sensitivity to lactate associated with the panic attack.

Family Dynamics

(Refer to CP: Generalized Anxiety Disorder.)

CLIENT ASSESSMENT DATA BASE

Circulation

Palpitations or tachycardia

Sweating, hot flashes, or chills

Ego Integrity

A persistent fear of some object/situation that poses no actual danger or in which the danger is magnified out of proportion to its seriousness; tries to avoid or escape contact with the feared object or situation

Degree of discomfort may vary from mild anxiety to incapacitation; may be unable to move, speak, or identify ways of decreasing anxiety or may begin running about aimlessly and shouting

May express a sensation of dread and a certain knowledge that death is at hand or may fear dying, going crazy, or doing something uncontrolled

Food/Fluid

Nausea/abdominal distress

Neurosensory

May exhibit one of three types of phobias:

Agoraphobia: Fears any situation in which individual may feel helpless or humiliated if a panic attack should occur and client cannot readily escape from public view

Specific/Simple Phobia: Fear involving specific objects such as spiders or snakes or situations such as heights, darkness, or closed spaces

Social Phobia: Fear of talking or writing in public and/or eating, blushing, urinating, etc.; fear of these behaviors resulting in public scorn

Preoccupied with bodily symptoms and feelings of terror

Feelings of faintness, dizziness, or lightheadedness; trembling/shaking; paresthesias (numbness or tingling sensations)

May experience brief periods of delusional thinking, hallucinations, inability to test reality

Depersonalization or derealization

Pain/Discomfort

Chest pain or discomfort

Respiratory

Shortness of breath (dyspnea); smothering sensations, choking; hyperventiliation, labored breathing

Sexuality

Occurs more frequently in women than in men

May avoid sexual involvement because of fear of arousal, particular sexual acts, and/or relationships

Social Interactions

More common among people who have experienced an early traumatic loss, such as the death of a parent

Manipulates environment and depends on others to avoid confrontation with the object or situation

Some constriction of life activities present

Teaching/Learning

Usually begins in late teens or early adulthood (panic attacks rare after age 65)

Attacks may be associated with magic or witchcraft

No history of a physical disorder (e.g., hyperthyroidism, hypoglycemia), although mitral valve prolapse is common

May report other disorders such as major depression, somatization disorder, schizophrenia, personality disorder

Increased rate of alcohol abuse

DIAGNOSTIC STUDIES

Drug Screen: Identifies drugs that may be used by client to reduce anxiety, rules out drugs that may produce symptoms.

Other diagnostic studies may be conducted to rule out physical disease as a basis for individual symptoms, e.g.:

EEG: To rule out epilepsy, other neurological disorders.

EKG: In the presence of severe chest pain to rule out cardiac conditions.

Thyroid Studies: To rule out hyperthyroidism.

NURSING PRIORITIES

1. Provide for physical safety.
2. Assist client to recognize onset of anxiety.
3. Help client learn alternative responses.
4. Assist with desensitization to phobic object/situation, if present.
5. Promote involvement of client/family in group or community support activities.

DISCHARGE GOALS

1. Stays in feared situation even when discomfort is experienced.
2. Identifies techniques to lower/keep fear at manageable level.
3. Confronts the phobia and is desensitized to the stimulus.
4. Demonstrates greater independence and an increasingly freer lifestyle.
5. Plan in place to meet needs after discharge.

(Refer to CP: Generalized Anxiety Disorder for needs/concerns in addition to the following NDs.)

NCP Major Depression / Dysthymic Disorders

MAJOR DEPRESSION/DYSTHYMIC DISORDER

DSM-IV

DEPRESSIVE DISORDERS
296.xx Major depressive disorder
296.2x Single episode
296.3x Recurrent
300.4 Dysthymic disorder
311 Depressive disorder NOS

A disturbance of mood, characterized by a full or partial depressive syndrome, or loss of interest or pleasure in usual activities and pastimes with evidence of interference in social/occupational functioning.

ETIOLOGICAL THEORIES

Psychodynamics

Psychoanalytical theory focuses on an early unsatisfactory parent/child relationship, with an unresolved grieving process. This results in the individual remaining fixed in the anger stage of the grieving process and turning it inward on the self. The ego remains weak, while the superego expands and becomes punitive.

Cognitive theory projects a belief that depression occurs as a result of impaired cognition, fostering a negative evaluation of self through disturbed thought processes. The individual is pessimistic and views self as inadequate and worthless and life as hopeless.

Learning theorists propose that depressive illness arises out of the individual’s having experienced numerous failures (either real or perceived). A feeling of inability to succeed at any endeavor ensues. This “learned helplessness” is viewed as a predisposition to depressive illness. The behavioral model states that the cause of depression is in the person-behavior-environment interaction. Although people are seen as capable of exercising control over their behavior, they are not totally free of environmental influence.

Biological

A family history of major affective disorders may exist in individuals with depressive disorders. Recently it has been found that the disease has a genetic marker, as shown by numerous studies that support the involvement of heredity in depressive illness.

Biochemical factors (e.g., electrolyte imbalances) appear to play a role in depressive illness. An error in metabolism results in the transposition of sodium and potassium within the neuron. Another theory implicates the biogenic amines norepinephrine, dopamine, and serotonin. The levels of these chemicals are deficient in individuals with depressive disorders. Controversy remains as to whether these biochemical changes cause the depression or whether they are caused by the illness. In recent years, a common form of major depression called seasonal affective disorder (SAD) has been identified. Recurring each year, starting in fall or winter and ending in spring, the symptoms are largely typical of depression, with some atypical symptoms (excessive sleep, increased appetite, and weight gain). This disorder is believed to be caused by the decreased availability of sunlight and is related to circadian cycles, which are set by each individual’s internal biological clock. Circadian cycles are more precisely adjusted and coordinated by the alternation of darkness and light.

Impaired seratonergic transmission has also been investigated as a cause of depression (indolamine hypothesis). It has been shown that multiple regions of the brain in depressed clients lack metabolic responsivity, suggesting a generalized subresponsivity of the serotonergic system. Additionally, current research suggests that infection with the Borna disease virus (BDV) may be linked to some cases of major depression and other severe mood disorders.

Family Dynamics

Object loss theory suggests that depressive illness occurs if the person is separated from or abandoned by a significant other during the first 6 months of life. The bonding process is thereby interrupted, and the child withdraws from people and the environment.

CLIENT ASSESSMENT DATA BASE

Activity/Rest

Fatigue, malaise, decreased energy level, lethargy

Sleep disturbances (e.g., insomnia) occur in 90% of cases—either anxiety insomnia (with difficulty falling asleep) or depressive insomnia (with early morning awakening, accompanied by painful ruminations); also hypersomnia (with restlessness and feeling unrefreshed, particularly in SAD)

May report feeling best early in the morning, then continually feeling worse as the day progresses (dysthymia); or the opposite may be true (especially in severe depression)

Ego Integrity

Feelings of worthlessness: self-derogatory statements, expressions of guilt, or exaggeration of minor inadequacies; may assume delusional proportions with presentations of unrealistic evidence of self-worth/intense focus on self (e.g., feeling oneself responsible for major tragedies and catastrophes or persecuted for a failure)

Morbid sadness; actual loss or life stressor perceived as a loss (e.g., retirement, job loss, divorce, illness, aging); may or may not see connection between perceived losses and onset of depression

Feelings of helplessness, hopelessness, powerlessness, pessimism, irritability, excessive anger

Elimination

Constipation and urinary retention may be present

Food/Fluid

Decreased/increased appetite accompanied by significant change in weight (average gain of 10 pounds in SAD)

Hygiene

Inattention to personal care needs, unkempt appearance

Possible body odor

Posture may be bent/slouched (defeated-looking)

Neurosensory

Dejected or sad mood, with loss of interest/enjoyment in usual activities

Depressed mood for most of day, for more days than not, for at least 2 years (dysthymia), or with intermittent symptom-free periods, for at least 2 months (recurrent)

Expressed sadness, dejection, not caring about anything, not seeing any future for self; tending to sigh and be tearful

Irritability, headache

Psychotic features with prominent delusions and/or hallucinations (major depression)

Psychomotor Retardation: May present either a “slow motion” picture, with slowed speech and latencies (long pauses before responding), decreased amount of speech, and slowed body movements; or agitation, featuring constant, rapid, purposeless movements (severe depression)

Thinking characterized by poor concentration and decreased memory, indecision, suicidal ideation

Safety

Thoughts of suicide/wanting to die possibly occurring frequently throughout the illness; may range in severity from indifference about the consequences of behavior (e.g., lack of cooperation with medical treatment, or dangerous driving), to wishing it were “over” or for death, to specific suicide plans and attempts

Sexuality

Disinterest in sexual activities, and/or impotence

Women affected almost twice as often as men, primarily during the childbearing years of late 20s to early 30s and again in the postmenopausal years of late 40s to early 50s

Social Interactions

Participation diminished, difficulty starting activities, withdrawal (e.g., housebound or remains in a single room/bed)

Teaching/Learning

Family history of depression; high rates of alcoholism/other drug abuse

DIAGNOSTIC STUDIES

(The several biochemical alterations in depression are not, by themselves, indicative of depression but, combined with clinical observation, may indicate best pharmacological response.)

Thyroid-Stimulating Hormone Response to Thyrotropin-Releasing Hormone: Decreased level suggests depression.

Dexamethasone-Suppression Test (DST) (an indirect marker of melancholia): Postdexamethasone cortisol levels exceeding 5 g/dl indicate abnormal/positive result and can be used to predict effectiveness of antidepressants.

EEG Sleep Profile: This shows reduced latency of rapid eye movement (REM) sleep.

CBC, Blood Glucose, Electrolytes, Renal/Liver Function Tests: These identify abnormalities contributing to or resulting from depression.

Other medical tests that may be included:

Platelet Monoamine Oxidase Activity (MAO): Increased.

Biogenic Amines (Especially Norepinephrine and Serotonin Levels): Decreased (clients with low serotonin levels are 10 times more likely to commit suicide within a year).

a-Acid Glycoprotein: Inhibitor of serotonin transporter is elevated.

Urinary 3-Methoxy-4-Hydroxyphenylglycol (MHPG): If low, indicates decreased norepinephrine output.

Cerebrospinal Fluid Level of 5-Hydroxytryptamine (5HIAA): Reduced.

Minnesota Multiphasic Personality Inventory (MMPI): Scale 2 consistently

elevated.

Wechsler Adult Intelligence Scale-Revised (WAIS-R): Overall performance score significantly lower than verbal score.

Rorschach Test: Long reaction times, chromatic color responses diminished.

Thematic Apperception Test (TAT): Short, stereotyped responses/simple descriptions of cards.

Zung (or Similar) Depressive Scale (ADS): Self-report reflecting affective, psychic, somatic characteristics of depression.

NURSING PRIORITIES

1. Promote physical safety with special focus on suicide prevention.
2. Provide for client’s basic needs, promoting highest possible level of independent functioning.
3. Provide experience/interactions that enhance self-esteem, sense of personal power.
4. Support client/family participation in follow-up care/community treatment.
5. Provide information about condition, prognosis, and treatment needs.

DISCHARGE GOALS

1. Suicidal ideation/self-violent behaviors absent.
2. Physiological stability achieved with responsibility for self demonstrated.
3. Client expressing feelings appropriately with some optimism and hope for the future.
4. Client/family participating in follow-up care/community treatment.
5. Condition, prognosis, and therapeutic regimen understood.
6. Plan in place to meet needs after discharge.

NCP Schizophrenia

SCHIZOPHRENIA

DSM-IV

295.30 Paranoid type
295.10 Disorganized type
295.20 Catatonic type
295.90 Undifferentiated type
295.60 Residual type

(Refer to DSM-IV for other listings.)

Schizophrenia describes psychotic state that at some time is characterized by apathy, avolition, asociality, affective blunting, and alogia. The client has alterations in thoughts, percepts, mood, and behavior. Subjective experiences of disordered thought are manifested in disturbances of concept formation that sometimes lead to misinterpretations of reality, delusions (particularly delusions of influence and ideas of reference), and hallucinations. Mood changes include ambivalence, constriction or inappropriateness of feeling, and loss of empathy with others. Behavior may be withdrawn, regressive, or bizarre (Shader, 1994).

ETIOLOGICAL THEORIES

Psychodynamics

Psychosis is the result of a weak ego. The development of the ego has been inhibited by a symbiotic parent/child relationship. Because the ego is weak, the use of ego defense mechanisms in times of extreme anxiety is maladaptive, and behaviors are often representations of the id segment of the personality.

Biological

Certain genetic factors may be involved in the susceptibility to develop some forms of this psychotic disorder. Individuals are at higher risk for the disorder if there is a familial pattern of involvement (parents, siblings, other relatives). Schizophrenia has been determined to be a sporadic illness (which means genes cannot currently be followed from generation to generation). It is an autosomal dominant trait. However, most scientists agree that what is inherited is a vulnerability or predisposition, which may be due to an enzyme defect or some other biochemical abnormality, a subtle neurological deficit, or some other factor or combination of factors. This predisposition, in combination with environmental factors, results in development of the disease. Some research implies that these disorders may be a birth defect, occurring in the hippocampus region of the brain. The studies show a disordering of the pyramidal cells in the brains of schizophrenics, while the cells in the brains of nonschizophrenic individuals appear to be arranged in an orderly fashion. Ventricular brain ratio (VBR) or disproportionately small brain (or specific areas of the brain) may be inherited and/or congenital. The cause can be a virus, lack of oxygen, birth trauma, severe maternal malnutrition, or cellular damage resulting from an RhD immune response (mother negative/fetus positive).

A biochemical theory suggests the involvement of elevated levels of the neurotransmitter dopamine, which is thought to produce the symptoms of overactivity and fragmentation of associations that are commonly observed in psychoses.

Although overall occurrence is relatively equal between males and females, resources report a predominant male bias with two-thirds of young adults with serious mental illnesses being male. Boys react more strongly than girls to stress and conflicts in the family home, and are more vulnerable to infantile autism. A significantly larger number of males than females exhibit obsessive and suicidal behaviors, fetishism, and schizophrenia. Schizophrenia develops earlier in males, and they respond less well to treatment and have less chance of recovery and return to normal life than females. The incidence in females may have more familial origins. The different brain organization of men and women, and the effect of sex hormones on brain growth are likely to result in subtle differences that define the “scope and range of sex differences in the incidence, clinical presentation, and course of specific psychiatric diseases” (Moir & Jessel, 1991).

Family Dynamics

Family systems theory describes the development of schizophrenia as it evolves out of a dysfunctional family system. Conflict between spouses drives one parent to become attached to the child. This overinvestment in the child redirects the focus of anxiety in the family, and a more stable condition results. A symbiotic relationship develops between parent and child; the child remains totally dependent on the parent into adulthood and is unable to respond to the demands of adult functioning.

Interpersonal theory relates that the psychotic person is the product of a parent/child relationship fraught with intense anxiety. The child receives confusing and conflicting messages from the parent and is unable to establish trust. High levels of anxiety are maintained, and the child’s concept of self is one of ambiguity. A retreat into psychosis offers relief from anxiety and security from intimate relatedness. Some research indicates that clients who live with families high in expressed emotion (e.g., hostility, criticism, disappointment, overprotectiveness, and overinvolvement) show more frequent relapses than clients who live with families who are low in expressed emotion.

Current research of genetic and biological influences suggests that these family interactions are more likely to be contributing factors to rather than the cause of the disorder.

CLIENT ASSESSMENT DATA BASE

General

Activity/Rest

Interruption of sleep by hallucinations and delusional thoughts, early awakening, insomnia, and hyperactivity (e.g., pacing)

Hygiene

Poor personal hygiene, unkempt/disheveled appearance

Neurosensory

History of alteration in functioning for at least 6 months, including an active phase of at least 2 weeks in which psychotic symptoms were evident

Family reports of psychological symptoms (primarily in thought and perception) and deterioration from previous level of adaptive functioning

Mental Status:

Thought: Delusions, loose association

Perception: Hallucinations, illusions

Affect: Blunted, flat, inappropriate, incongruous, or silly

Volition: Cannot self-initiate or participate in goal-oriented activity

Capacity to Relate to Environment: Mental/emotional withdrawal and isolation (autism) and/or psychomotor activity ranging from marked reduction to stereotypic, purposeless activity

Speech: Frequently incoherent, echolalia may be noted/alogia (inability to speak) may occur

Delusions:

Disorganized type—Fragmentary delusions or hallucinations (disorganized,

unthematized [without theme] content) common; systematized delusions absent

Paranoid type—One or more systematized delusions with prominent persecutory or

grandiose content; delusional jealousy may occur

Undifferentiated type—Delusions prominent

Behaviors: Grimaces, mannerisms, hypochondriacal complaints, extreme social withdrawal, and other odd behaviors

Negativism: Resistance to all directions or attempts to move without apparent motive

Rigidity: Rigid posture maintained despite attempts to move client

Excitement: Purposeless motor activity not caused by external stimuli

Posturing: Voluntarily assuming inappropriate or bizarre posture

Emotions: Unfocused anxiety, anger, argumentativeness, and violence

Teaching/Learning

May have had previous acute episodes with impairment ranging from none to severe deterioration requiring institutionalization

Onset of symptoms most commonly occurring between the late teens and mid-30s

Correlations with family history of psychiatric illness; lower socioeconomic groups, higher stressors; premorbid personality described as suspicious, introverted, withdrawn, or eccentric

Disorganized

Neurosensory

Speech disorganized, communication consistently incoherent

Behavior regressive/primitive, incoherent, and grossly disorganized

Psychomotor: Stupor, markedly decreased reactivity to milieu, and/or reduced spontaneity of movement/activity or mutism

Affect: Incoherent, flat, incongruent, silly

Social Interactions

Extreme social impairment/withdrawal; odd mannersisms

Poor premorbid personality

Teaching/Learning

Chronic course with no significant remissions

Catatonic

(Although common several decades ago, incidence has decreased markedly with the advent of antipsychotic medications.)

Activity/Rest

Marked psychomotor retardation or excessive/purposeless motor activity

Exhaustion (extreme agitation)

Food/Fluid

Weight below norms; other signs of malnutrition

Neurosensory

Marked psychomotor disturbance (e.g., stupor, rigidity, mutism or excitement, negativism, waxy flexibility, and/or posturing)

Speech: Echolalia or echopraxia

Safety

Possible violence to self/others (during catatonic stupor or excitement)

Teaching/Learning

Possible hypochondriacal complaints or oddities of behavior

Paranoid

(Absence of symptoms characteristic of disorganized and catatonic types.)

Neurosensory

Systematized delusions and/or auditory hallucinations of a persecutory or grandiose nature, usually related to a single theme

Safety

Easily agitated, assaultive, and violent (if delusions are acted on)

Impairment in functioning (may be minimal), with gross disorganization of behavior (relatively rare)

Social Interactions

Significant impairment may be noted in social/marital areas

Affective responsiveness may be preserved but often with a stilted, formal quality or extreme intensity in interpersonal interactions

Sexuality

May express doubts about gender identity (e.g., fear of being thought of as, or approached by, a homosexual)

Teaching/Learning

Other family members may have history of paranoid problems

Undifferentiated

(This category is used when illness does not meet the criteria for the other specific types of schizophrenias, illness meets the criteria for more than one, or course of the last episode is unknown.)

Neurosensory

Prominent delusions/hallucinations, incoherence, and grossly disorganized behaviors

Residual

Neurosensory

Inappropriate affect

Social Interactions

Social withdrawal, eccentric behavior

Teaching/Learning

History of at least one episode of schizophrenia in which psychotic symptoms were evident, but the current clinical picture presents no psychotic symptoms

DIAGNOSTIC STUDIES

(Usually done to rule out physical illness, which may cause reversible symptoms such as: toxic/deficiency states, infections, neurological disease, endocrine/metabolic disorders.)

CT Scan: May show subtle abnormalities of brain structures in some schizophrenics (e.g., atrophy of temporal lobes); enlarged ventricles with increased ventricle-brain ratio may correlate with degree of symptoms displayed.

Positron Emission Tomography (PET) Scan: Measures the metabolic activity of specific areas of the brain and may reveal low metabolic activity in the frontal lobes, especially in the prefrontal area of the cerebral cortex.

MRI: Provides a three-dimensional image of the brain; may reveal smaller than average frontal lobes, atrophy of left temporal lobe (specifically anterior hippocampus, parahippocampogyrus, and superior temporal gyrus).

Regional Cerebral Blood Flow (RCBF): Maps blood flow and implies the intensity of activity in various brain regions.

Brain Electrical Activity Mapping (BEAM): Shows brain wave responses to various stimuli with delayed and decreased response noted, particularly in left temporal lobe and associated limbic system.

Addiction Severity Index (ASI): Determines problems of addiction (substance abuse), which may be associated with mental illness, and indicates areas of treatment

need.

Psychological Testing (e.g., MMPI): Reveals impairment in one or more areas. Note: Paranoid type usually shows little or no impairment.

NURSING PRIORITIES

1. Promote appropriate interaction between client and environment.
2. Enhance physiological stability/health maintenance.
3. Provide protection; ensure safety needs.
4. Encourage family/significant other(s) to become involved in activities to promote independent, satisfying lives.

DISCHARGE CRITERIA

1. Physiological well-being maintained with appropriate balance between rest and activity.
2. Demonstrates increasing/highest level of emotional responsiveness possible.
3. Interacts socially without decompensation.
4. Family displays effective coping skills and appropriate use of resources.
5. Plan in place to meet needs after discharge.

NCP Alcohol Related Disorders

ALCOHOL-RELATED DISORDERS

DSM-IV

ALCOHOL-INDUCED DISORDERS
303.00 Alcohol intoxication
291.81 Alcohol withdrawal
291.89 Alcohol-induced mood disorder
291.89 Alcohol-induced anxiety disorder
292.81 Intoxication delirium

Alcohol is a CNS depressant drug that is used socially in our society for many reasons (e.g., to enhance the flavor of food, to encourage relaxation and conviviality, for feelings of celebration, and as a sacred ritual in some religious ceremonies). Therapeutically, it is the major ingredient in many OTC/prescription medications. It can be harmless, enjoyable, and sometimes beneficial when used responsibly and in moderation. Like other mind-altering drugs, however, it has the potential for abuse and, in fact, is the most widely abused drug in the United States (research suggests 5% to 10% of the adult population) and is potentially fatal. Frequently, the client in a residential care setting has been using alcohol in conjunction with other drugs. It is believed that alcohol is often used by clients who have other mental illnesses to assuage the pain they feel. The term “dual diagnosis” is used to mean an association between the use/abuse of drugs (including alcohol) and other psychiatric diagnoses. It may be difficult to determine cause and effect in any given situation to determine an accurate diagnosis. However, it is important to recognize when both conditions are present so that the often-overwhelming problems of treatment are instituted for both conditions.

This plan of care addresses acute intoxication/withdrawal and is to be used in conjunction with CP: Substance Dependence/Abuse Rehabilitation.

ETIOLOGICAL THEORIES

Psychodynamics

The individual remains fixed in a lower level of development, with retarded ego and weak superego. The person retains a highly dependent nature, with characteristics of poor impulse control, low frustration tolerance, and low self-esteem.

Biological

Enzymes, genes, brain chemistry, and hormones create and contribute to an individual’s response to alcohol. The two types of alcohol-related disorders are (1) familial, which is largely inherited, and (2) acquired. A childhood history of attention-deficit disorder or conduct disorder also increases a child’s risk of becoming alcoholic. Certain physiological changes also may cause addiction to alcohol, or alcoholism.

Family Dynamics

One in 12–15 persons has serious problems from drinking. In a dysfunctional family system, alcohol may be viewed as the primary method of relieving stress. Children of alcoholics are 4 times more likely to develop alcoholism than children of nonalcoholics. The child has negative role models and learns to respond to stressful situations in like manner. The use of alcohol is cultural, and many factors influence one’s decision to drink, how much, and how often. Denial of the illness can be a major barrier to identification and treatment of alcoholism and alcohol abuse.

CLIENT ASSESSMENT DATA BASE

Data depend on the duration/extent of alcohol use, concurrent use of other drugs, degree of organ involvement, and presence of other psychiatric conditions.

Activity/Rest

Difficulty sleeping, not feeling well rested

Circulation

Peripheral pulses weak, irregular, or rapid

Hypertension common in early withdrawal stage but may become labile/progress to hypotension

Tachycardia common during acute withdrawal

Ego Integrity

Feelings of guilt/shame; defensiveness about drinking

Denial, rationalization

Reports of multiple stressors; problems with relationships

Multiple stressors/losses (relationships, employment, financial)

Use of substances to deal with life stressors, boredom, etc.

Elimination

Diarrhea

Bowel sounds varied (may reflect gastric complications [e.g., gastric hemorrhage])

Food/Fluid

Nausea/vomiting, food tolerance

Muscle wasting, dry/dull hair, swollen salivary glands, inflamed buccal cavity, capillary fragility (malnutrition)

Generalized tissue edema may be noted (protein deficiencies)

Gastric distension; ascites, liver enlargement (seen in cirrhosis)

Neurosensory

“Internal shakes”

Headache, dizziness, blurred vision, “blackouts”

Psychopathology such as paranoid schizophrenia, major depression (may indicate dual diagnosis)

Level of Consciousness/Orientation: Confusion, stupor, hyperactivity, distorted thought processes, slurred/incoherent speech

Memory loss/confabulation

Affect/Mood/Behavior: May be fearful, anxious, easily startled, inappropriate, silly, euphoric, irritable, physically/verbally abusive, depressed, and/or paranoid

Hallucinations: Visual, tactile, olfactory, and auditory (e.g., picking items out of air or responding verbally to unseen person/voices)

Nystagmus (associated with cranial nerve palsy)

Pupil constriction (may indicate CNS depression)

Arcus senilis, a ringlike opacity of the cornea (normal in aging populations, suggests alcohol-related changes in younger clients)

Fine motor tremors of face, tongue, and hands; seizure activity (commonly grand mal)

Gait unsteady/ataxia (may be due to thiamine deficiency or cerebellar degeneration [Wernicke’s encephalopathy])

Pain/Discomfort

May report constant upper abdominal pain and tenderness radiating to the back (pancreatic inflammation)

Respiration

History of tobacco use, recurrent/chronic respiratory problems

Tachypnea (hyperactive state of alcohol withdrawal)

Cheyne-Stokes respirations or respiratory depression

Breath Sounds: Diminished/adventitious sounds (suggests pulmonary complications [e.g., respiratory depression, pneumonia])

Safety

History of recurrent accidents, such as falls, fractures, lacerations, burns, blackouts, or automobile accidents

Skin: Flushed face/palms of hands, scars, ecchymotic areas, cigarette burns on fingers, spider nevi (impaired portal circulation); fissures at corners of mouth (vitamin deficiency)

Fractures, healed or new (signs of recent/recurrent trauma)

Temperature elevation (dehydration and sympathetic stimulation); flushing/diaphoresis (suggests presence of infection)

Suicidal ideation/attempts (some research suggests alcoholic suicide attempts are 30% higher than national average for general population)

Social Interactions

Frequent sick days off work/school, fighting with others, arrests (disorderly conduct, motor vehicle violations [DUIs])

Denial that alcohol intake has any significant effect on the present condition/situation

Dysfunctional family system of origin; problems in current relationships

Mood changes affecting interactions with others

Teaching/Learning

History of alcohol and/or other drug use/abuse (including tobacco)

Ignorance and/or denial of addiction to alcohol or inability to cut down or stop drinking despite repeated efforts

Large amount of alcohol consumed in last 24–48 hours, previous periods of abstinence/withdrawal

Previous hospitalizations for alcoholism/alcohol-related diseases (e.g., cirrhosis, esophageal varices)

Family history of alcoholism/substance use

DIAGNOSTIC STUDIES

Blood Alcohol/Drug Levels: Alcohol level may/may not be severely elevated depending on amount consumed and length of time between consumption and testing. In addition to alcohol, numerous controlled/illicit substances may be identified in a polydrug screen (e.g., amphetamine, cocaine, morphine, Percodan, Quaalude).

CBC: Decreased (Hb/Hct) may reflect such problems as iron-deficiency anemia or acute/chronic GI bleeding. White blood cell count may be increased with infection or decreased, if immunosuppressed.

Glucose: Hyperglycemia/hypoglycemia may be present, related to pancreatitis, malnutrition, or depletion of liver glycogen stores.

Electrolytes: Hypokalemia and hypomagnesemia are common.

Liver Function Tests: CPK, LDH, AST, ALT, and amylase may be elevated, reflecting liver or pancreatic damage.

Nutritional Tests: Albumin is low and total protein decreased. Vitamin deficiencies are usually present, reflecting malnutrition/malabsorption.

Other Screening Studies (e.g., Hepatitis, HIV, TB): Dependent on general condition, individual risk factors, and care setting.

Urinalysis: Infection may be identified; ketones may be present related to breakdown of fatty acids in malnutrition (pseudodiabetic condition).

Chest X-Ray: May reveal right lower lobe pneumonia (malnutrition, depressed immune system, aspiration) or chronic lung disorders associated with tobacco use.

ECG: Dysrhythmias, cardiomyopathies, and/or ischemia may be present owing to direct effect of alcohol on the cardiac muscle and/or conduction system, as well as effects of electrolyte imbalance.

Addiction Severity Index (ASI): An assessment tool that produces a “problem severity profile” of the client, including chemical, medical, psychological, legal, family/social, and employment/support aspects, indicating areas of treatment needs.

NURSING PRIORITIES

1. Maintain physiological stability during withdrawal phase.
2. Promote client safety.
3. Provide appropriate referral and follow-up.
4. Encourage/support SO involvement in Intervention (confrontation) process.

DISCHARGE GOALS

1. Homeostasis achieved.
2. Complications prevented/resolved.
3. Sobriety being maintained on a day-to-day basis.
4. Ongoing participation in a rehabilitation program/attendance at group therapy (e.g., Alcoholics Anonymous).
5. Plan in place to meet needs after discharge.

This plan of care is to be used in conjunction with CP: Substance Dependence/Abuse Rehabilitation.