Copyright © 2008 Delmar Learning. All rights reserved. Unit 30 Caring for the Emotionally Stressed Patient

Copyright © 2008 Delmar Learning. All rights reserved.

Unit 30

Caring for the

Emotionally Stressed Patient


Objectives

• Spell and define terms.• Define mental health.• Explain the interrelatedness of physical

and mental health.• Understand mental health as a process

of adaptations.


Objectives

• Identify commonly used defense mechanisms.

• Define anxiety disorder, affective disorder, eating disorder, and substance abuse and give examples of each.

• Describe ways to help patients cope with stressful situations.


Objectives

• Identify the signs and symptoms of maladaptive behaviors that should be documented and reported.

• List nursing assistant measures in providing care for patients with adaptive and maladaptive reactions.


Objectives

• Identify professional boundaries in relationships with patients and families.


Introduction

• Varying degrees and differing aspects of health

• A person in poor physical health may be mentally healthy– Self-reliant– Able to make decisions – Live an effective, productive life


Introduction

• In contrast:– A person with good physical health may

not be able to cope with and adapt to changes

– This inability limits the person’s chances to participate successfully in society


Mental Health

• Mental health– Exhibiting behaviors that reflect a person’s

adaptation, or adjustment, to the multiple stresses of life


Mental Health

• Some multiple stresses include:– Illness – Hospitalization– Loss of a loved one– Loss of a job– Loss of status– Relationships


Relationships

• Patients with mental disorders – Have an increased risk for substance

abuse disorders

• Patients with substance abuse disorders– Have an increased risk for mental

disorders


Defense Mechanisms

• A person acts in protective ways when he or she is:– Unable to cope with stress – Feels that a situation threatens self-esteem


Defense Mechanisms

• Some of the commonly used defense mechanisms include:– Repression– Suppression– Projection– Denial– Reaction formation


Defense Mechanisms

• Other adaptive behaviors include:– Displacement– Identification– Compensation– Conversion– Fantasy– Undoing


The Demanding Patient

• In every nursing care situation– You will meet patients who are very

demanding– This can be a difficult experience for

everyone if it is not handled correctly


Maladaptive Behaviors

• Mental illness or maladaptive behavior– Occurs when behaviors and responses

disrupt a person’s ability to function smoothly within the family, environment, or community


Anxiety Disorder

• Anxiety is fear, apprehension, or sense of impending doom– Physical symptoms may also be present

• Anxiety disorder – Part of a group of mental illnesses

involving anxiety as a response to stress


Types of Anxiety Disorders

• Generalized anxiety (most common)• Panic disorder

– Panic attacks

• Obsessive-compulsive disorder (OCD)• Post-traumatic stress disorder (PTSD)

– Most common in combat veterans or survivors of major trauma



• Phobias– Different types of fears

• Snakes, rats, spiders• Crowds, fear of flying, etc.



• Phobias– Some people try to conceal their fears by

using humor– They make comments such as, “If God

wanted me to fly, He would have given me wings.”


Affective Disorders

• Characterized by a disturbance in mood• Called mood disorders

– Usually marked by a profound and persistent sadness


Affective Disorders

• Common affective disorders are:– Bipolar affective disorder– Seasonal affective disorder (SAD)– Borderline personality disorder– Schizoaffective disorder


Depression

• Most affective disorder• It is also common in older people, but

younger people also may experience depression– Ranging from mild to severe


Depression

• Often masked by symptoms that make it seem as though the patient is physically ill– Such as sleeping much of the time


Borderline Personality Disorder

• Borderline Personality Disorder (BPD)– Sometimes considered a controversial

diagnosis– Cause is not definitely known



• Patients usually feel very unstable and:– Often impulsive– Fear abandonment– Prone to self‑injurious behavior and self-

mutilation– Sometimes suicidal– Often feel empty or bored



• Patients usually feel very unstable and:– Are usually very manipulative– Have difficulty maintaining stable

relationships– Usually have concrete opinions– May have difficulty with emotional

reasoning



• Patients usually feel very unstable and:– Often have relationship problems– May have difficulty functioning according to

society’s rules



• Considered very difficult to treat• Characterized by unstable mood and

self-image• Unstable intense, interpersonal

relationships



• Patient may abuse drugs to:– Diminish symptoms– Enhance low self-esteem– Decrease feelings of guilt– Amplify feelings of diminished individuality

• Avoid confrontations with the patient


Eating Disorders

• Group of disorders – Characterized by disturbances in appetite

or food intake and body self image

• Conditions overlap– Patients try to conceal the problem, making

these conditions difficult to identify


Eating Disorders

• Common eating disorder– Anorexia nervosa

• Person fears obesity and believes he or she is fat, despite having a skeletal appearance

• Person limits food through diet, exercise, purging, and taking laxatives ad diuretics


Eating Disorders

• Common eating disorder– Bulimia nervosa

• Person binge eats huge amounts, then vomits (purges) to undo the binge

• Binge eating causes feelings of guilt, depression, and self‑condemnation


Eating Disorders

• People with bulimia also use:- Laxatives, diuretics, and vigorous exercise

to lose weight - To be diagnosed with bulimia:

• Behavior must occur at least twice a week for three months in a row


Agitation

• Inappropriate verbal, vocal, or motor activity – Due to causes other than disorientation or

real need


Disorientation(Disordered Consciousness)

• Condition in which a person shows a lack of reality awareness with regard to:– Time– Person– Place


Disorientation(Disordered Consciousness)

• Disorientation may be mild or severe, temporary or prolonged

• It is important to report patient behavior, actions, and responses


Hypochondriasis

• Patient imagines or magnifies each physical ailment– Some authorities believe that

hypochondriasis is an expression of depression

– One way some individuals reduce stress


Paranoia

• Extreme maladaptive response to stress– Characterized by a heightened, false

sense of self-importance and delusions of being persecuted

– Believe that everyone is against them– Refer to Nonpharmacologic Approaches to

Care


Nonpharmacologic Approaches to Care

• Psychotherapy• Cognitive therapy• Behavioral therapy • Relaxation skills• Meditation• Biofeedback

• Acupuncture• Hypnotherapy• Self-help groups• Support groups• Exercise• Education


Mental Health versus Substance Abuse

• Treatment needs of patients who have a psychiatric disorder in combination with a substance abuse disorder:– Differ significantly from the treatment

needs of patient with either a substance abuse disorder or a psychiatric disorder by itself


Mental Health versus Substance Abuse

• Clinicians and other workers– Must differentiate between psychiatry and

substance abuse disorders• By obtaining a thorough history of symptoms

and disorders


Substance Abuse

• Characterized by the use of one or more substances– Alcohol or drugs– Alter mood or behavior– Resulting in impairment


Substance Abuse

• Use of the substance(s) results in:– Maladaptive pattern of behavior– Strained finances– Irresponsibility– Inability to fulfill social or occupational

obligations


Substance Abuse

• Substance abuser– Uses despite knowing it is dangerous or

illegal – Uses illegal (street) drugs or misuses

prescription drugs without proper physician knowledge or oversight

• Refer to Signs and Symptoms of Dependency/Addiction


Similarities of Mental Health and Addiction Treatment Systems• Variety of treatment settings and

program types• Public and private settings• Multiple levels of care• Biopsychosocial models• Increasing use of case and care

management


Signs and Symptoms of Dependency/Addiction

• Pathologic, often progressive and chronic process

• Compulsion and preoccupation with obtaining a drug or drugs

• Loss of control over use or substance abuse-induced behavior


Signs and Symptoms of Dependency/Addiction

• Continued use despite adverse consequences

• Tendency for relapse after period of abstinence

• Increased tolerance and characteristic withdrawal


Components of Drug Dependence1

• Psychologic dependence:– Centers on the user’s need of a drug to

reach a level of functioning or feeling of well-being

1 American Society of Addiction Medicine.


Components of Drug Dependence1

• Physical dependence:– Physiologic dependence– Establishment of tolerance– Evidence of an abstinence syndrome– Withdrawal upon cessation of substance

abuse

1 American Society of Addiction Medicine.


Symptoms: Substance Abuse

• Significant impairment or distress • Failure to fulfill roles at work, home, or

school• Persistent use in physically hazardous

situations


Symptoms: Substance Abuse

• Recurrent legal problems related to use• Continued use despite interpersonal

problems


Medication Misuse

• Describes the use of prescription medications outside of medical supervision or advice

• Not an abuse problem– High-risk behavior

• May or may not involve or lead to substance abuse


Medication Misuse

• May promote the reemergence of psychiatric symptoms

• May cause toxic effects and psychiatric symptoms if it involved overdose


Mental Health and Addiction Treatment Systems

• Potential pitfall – Prescribing psychoactive medications to

psychiatric patient without first determining if the individual has a substance abuse disorder


Mental Health and Addiction Treatment Systems

• In treating dual disorders– Balance must be made between behavioral

interventions and psychiatric medications as needed for the recovery process


Alcoholism

• Some people use alcohol as a means of coping with stress

• The National Institute for Alcohol Abuse– Reports that two-thirds of the senior

population uses alcohol– Fifteen percent of them become alcoholics

• Alcoholism is regarded as a disease


Delirium Tremens

• Patients who are withdrawing from alcohol may have delirium tremens (DTs)

• DTs signify withdrawal– Begin about 48 to 96 hours after the last

drink


Delirium Tremens

• Signs and symptoms are:– Severe confusion– Tremors– Hallucinations– Overactivity of the nervous system– Seizures


Delirium Tremens

• DTs can become life threatening– Require immediate treatment– Refer to Psychotic Disorders


Psychotic Disorders

• Stimulant-Induced symptoms– Acute stimulant intoxication (chronic) can

cause symptoms of psychosis– Delirium, delusions, prominent

hallucinations, incoherence, and loosening of associations


Psychotic Disorders

• Stimulant-Induced symptoms– Stimulant delirium often includes formication

(a tactile hallucination of bugs crawling on or under the skin)


Psychotic Disorders

• Depressant-Induced symptoms– Acute withdrawal from alcohol, barbiturates,

and benzodiazepines • Can produce a withdrawal delirium, especially

with heavy use and high tolerance due to a concomitant physical illness


Psychotic Disorders

• Psychedelic- and Hallucinogen-induced symptoms– Psychotic symptoms are possible in

chronic, high-dose patterns due to virtue of drugs’ stimulant properties


Psychotic Disorders

• Psychedelic- and Hallucinogen-induced symptoms– Can cause hallucinogenic hallucinosis

• Perceptual distortions• Maladaptive behavioral changes• Impaired judgment


Acute Treatment Strategies

• Management of intoxication and withdrawal

• Medical treatment• Psychiatric treatment


Assessing the Patient’s Behavior

• An initial assessment of a patient’s mental and emotional state– Made by a licensed care provider– Refer to Stages of Assessment


Assessing the Patient’s Behavior

• Because you make frequent contact with the patient– You can make a valuable contribution to

the nursing assessment process by making careful and sensitive objective observations


Stages of Assessment

• Assessing danger to self or others• Medical assessment• Initial addiction assessment• Social assessment• Violence towards others


Stages of Assessment

• Assessing mood symptomatology• Medical assessment• Psychiatric and addiction screening• Assessment instruments• Psychosocial assessment


Key Issues and Concerns

• Patient contracting– May involve a patient’s promise to avoid

certain self-harm or high-risk behavior



• Transference and countertransference – Both rely on the mechanism of projection

• Combination of personal past experiences along with feelings experienced during course of therapy



• Clear boundaries – Ethical and practical ground rules that help

a therapist to be therapeutically helpful to patients



• Changing roles – People with personality disorders may

include: • Victim• Persecutor• Rescuer



• Resistance– Patients with personality disorders often

exhibit acting-out behaviors – These were developed as psychological

defenses and survival techniques



• Subacute withdrawal may include:– Mood swings– Irritability– Impairment in cognitive functioning– Short- and long-term memory problems– Intense craving for substances



• Symptom substitutions– Compulsive behaviors – Eating disorders– Compulsive spending, gambling, and sex



• Somatic complaints• Therapists should watch for use of:

– Prescription and over-the-counter drugs – Drug-seeking behaviors



• Staff well-being can be compromised– When working with patients with

personality disorders

• Therapists – Should join or develop support systems

with others in the field


Professional Boundaries

• As a nursing assistant:– You must stay within certain professional

boundaries while caring for each patient

• Boundaries – Unspoken limits on the physical and

emotional relationships with patients


Ethical Behavior with Patients and Families

• Patients expect you, as the nursing assistant, to act in their best interests and treat them with dignity


Ethical Behavior with Patients and Families

• You do this by:– Not taking advantage of a patient’s

situation– Avoiding inappropriate involvement in each

patient’s personal and family relationships


Consequences of Boundary Violations

• Boundary violations – Lead to inappropriate relationships with

patients and/or their families– Cloud your clinical judgment – May lead to serious consequences

• Such as inappropriate sexual relationships


Enabling Behavior

• Reacting to a patient in a way that shields the person from the full impact of his or her behavior

• Enabling differs from helping– It allows (and often encourages) the

person to be irresponsible


Enabling Behavior

• By learning and respecting professional boundaries– You will avoid helping others

inappropriately

• Enabling behavior creates dependency– Rather than moving the patient toward

independence and good mental health


Enabling Behavior

• Examples of enabling behaviors that you should avoid are:– Keeping secrets about a patient’s behavior

from others– Making excuses for a patient’s behavior– Acting to get a patient out of personal

trouble


Enabling Behavior

• Examples of enabling behaviors that you should avoid are:– Attempting to control patients’ lives and

activities– Doing things for the patient that he or she

should do


Zone of Helpfulness

• Keep your behavior in the zone of helpfulness– This avoids crossing professional

boundaries and enabling patients

• Refer to Figure 30-20


Zone of Helpfulness


Assisting with Behavior Problems

• Follow the care plan • Control your responses and reactions• Be a good communicator• Avoid lying to the patient or making

promises you cannot keep



• Never discuss facility or staff problems with patients

• If a patient complains, inform the nurse



• Attempt to learn the cause of the behavior– Remove cause (or trigger), if known

• If the care plan states to respond to a specific behavior– Apply approaches when behavior starts



• Do not wait until the patient loses control

• Practice empathy• Modify your own behavior in response

to the patient’s behavior



• Watch how the patient responds to you– Adjust approaches, equipment, routines,

etc., if necessary

• Discuss pleasant information– Provides a source of strength, comfort, and

support



• Look for unmet needs and meet them– If possible



• Give patients as much control as possible– Offer choices and encourage patients to

direct their care

• Smile– Make sure your body language sends a

positive message


Long-Term Treatment Goals

• Addiction treatment• Psychiatric treatment• Long-term treatment needs• Family issues• Eating disorders and gambling

Documents

Copyright © 2008 Delmar Learning. All rights reserved. Unit 30 Caring for the Emotionally Stressed Patient