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A. Elder abuse

  • May entail physical, emotional or sexual abuse
  • May mean neglect that is the omission of basic needs such as not providing nutrient to the elderly
  • May also include depleting the elder of his/her financial resources.
  • Nurses must report to proper authority.
  • Provide safety and physical needs to the elder.

B. Child Abuse

  • Watch for any injuries (bruises, burns, fractures) that are not consistent with the history on how the injuries occurred.
  • May entail physical, emotional or sexual abuse
  • May mean neglect that is the omission of basic needs such as not feeding the child.
  • Nurses are mandated to report any suspected case of abuse.
  • Provide emotional support to the child and play therapy (dolls, drawings) to allow child to express feelings.

C.. Sexual Abuse

1. Sexually Abused Child

  • May develop development problems and sleep or eating disturbances
  • May use defense mechanism (denial, dissociation)
  • May become self destructive

2. Adult Victims

  • May experience reaction similar to Postraumatic Stress Disorder (PTSD)
  • May have difficulty with relationship and intimacy issues
  • May experience nightmares, flashbacks
  • May use defense mechanism (denial, dissociation) or be self-destructive.

D. Nonalcoholic Substance Abuse (see below)


Addictions – Non-alcoholic Substance Abuse

  • Generally substance abusers get frustrated easily and need immediate gratification.
  • Observe for general signs of withdrawal, sweating, agitation, panic, hallucinations. Thus, be ready to keep airway open, be ready for seizure precautions, detoxify gradually, decrease the stimuli and provide a calm environment.
  • Stimulants

    A. Cocaine, Uppers

    May experience a lot of hallucinations (see Hallucination topic); may cause tachycardia, increased BP, seizures
    May have to give activated charcoal for gastric lavage.
    Withdrawal can lead to long periods of sleep, irritability, depression.


B. Barbiturate


Phenobarbital, downers
May cause nystagmus, poor muscle coordination, decreased mental alertness
One may need to give sodium bicarbonate to promote excretion and to give activated charcoal for gastric lavage.


C. Narcotics

Morphine, Heroin, Codeine, Dilaudid, Meperidine, Methadone
May cause respiratory distress, one may need to give Narcan to reverse respiratory depression
May cause seizures, euphoria, pinpoint pupils,

D. Hallucinogens.

May cause hallucinations, nystagmus, confusion

E. Cannabis also referred to as pot, weed, grass, joint, mary jane. .

Marijuana, Hashish
May cause nystagmus, hallucinations, incoherence, mania, hypertension,


Aggressive / Violent Behavior

  • Tends to be physically or verbally abusive to staff or other patients.
  • Assess the anger at a distance while allowing patient to ventilate and make sure you have are not blocking the exit.
  • Need to contract with individual to use nonviolent methods to control anger and to consider displacing anger
  • Always speak calmly and try to use non threatening body language (i.e. arms at side, avoid body contact)
  • Restraint should only be used after all other option have failed. Restraints also include chemical restraints (i.e.medications). If physically tied, makes sure to check for proper use of restraints and for circulation.

Alcohol Addiction

  • Patient may exhibit slurred speech, tremors, diminished reflexes, impaired thinking, loss of inhibitions, elevated respiration, nystagmus, hypoglycemia
  • Monitor vital signs, particularly respiration and the need to protect the airway
  • Check glucose
  • Check for signs of withdrawal, which may include tremors, hallucinations, insomnia, anxiety, easily startled.
  • If withdrawal is exhibited, nurse should be ready to administer sedation as needed, do seizure precautions and the possibility of giving anti-convulsants, provide a quite environment, may have to give Thiamine IV or IM, may have the necessity to give IV glucose
  • To maintain a person’s sobriety, a patient may be given Antabuse, a drug that interacts with alcohol when sufficient alcohol blood level is reached and causes a sever reaction
  • Disorders associated with Chronic Alcoholic Dependence
      • Dementia – personality changes, depression, confusion, loss of memory of recent events
      • Wernicke Syndrome – confusion , nystagmus, ataxia, disorientation
      • Korsakoff Pychosis – memory disturbance with confabulation, loss of memory of recent events, learning problem.
  • Remember that a high percentage of children of alcoholics become alcoholics also.
  • Incidence of violence increases with the use of alcohol.
  • A common support group for alcoholics is Alcoholic Anonymous, where peers share experiences and organization for support for spouses of alcoholics is Al Anon, a self help group of spouses and relatives. Alateen is an organization that provide support for teenagers of alcoholic parents, similar to Al-Anon



  • An individual feels fear in the absence of an actual threat or when the level of fear is disproportionate3 from the nature of the threat.
  • The person may exhibit a defense mechanism (see below) to compensate or help in dealing with the feared situation.
  • An individual having an anxiety will exhibit the following physical changes:  increased in heart rate, elevated blood pressure, palpitation, cold feet/ hands, headache, constant heartburn (belching), cramps, muscle tension, tremors, inability to comprehend, poor concentration,
  • Nurses can try to keep the environmental stressors low. For example, keep the immediate environment uncluttered and pleasant looking.
  • Nurses can acknowledge the anxious behavior and remain with the client. Be aware of any defense mechanism the individual is attempting to “use” to make the situation tolerable for him.
  • Nurses should be aware of their own anxiety while with a patient and be prepared to administer any anti-anxiety medications as needed. p



  • Defined as a defective muscular coordination.

Behavior Modification

  • Use of positive (rewards) or negative (punishments) reinforcements

Bi-Polar Disorder

  • Characterized by having a mood changes from depression to mania / highly hyperactive or agitated.
  • Patient maybe taking Lithium to control the manic phase. In so doing, patient must limit salt intake since salt can cause the Lithium to be excreted.
  • A manic patient may not be getting enough nutrition so make sure the patient gets the highest amount of calories when the patient eats.
  • During mania, the nurse can do the following:
  • Decrease environmental stimuli – soft lighting, keep noise level low to avoid overstimulating the patient.
  •  Do no encourage patient – avoid laughing at jokes
  • Watch for any signs of suicide
  • Deal with patient’s manipulativeness – limit phone calls, refuse unreasonable demands, explain restrictions, never threaten but give firm and consistent rules


Occipital lobe – vision
Temporal lobe – speech and hearing
  Frontal lobe – could have impaired judgement

Common Defense Mechanisms

A. Denial

  • An individual is unable to accept or acknowledge a feeling, a thought or a fact.
  • For instance, an alcoholic may deny the fact that he or she has any drinking problem.

B. Displacement

  • Redirecting an emotion or feeling to an object or situation that is acceptable and less threatening.
  • For instance, Squeezing at a sponge ball rather when angry and feels like punching an individual.

C. Projection

  • When a individual attributes one’s feelings, thoughts, impulses or wishes to others.
  • For instance, a person, who is mad at someone, will say that the other person does not like him.

D. Reaction Formation

  • When a patient reacts or says something that is totally the opposite of what is really felt.

F. Delusions of Grandeur

  • Belief that the patient is someone famou

G. Conversion Reaction

  • It’s similar to  REPRESSION; an accompanying anxiety is repressed and converted into physical symptom

H. Repression

  • An individual is unable to remember thoughts that are unacceptable because those thoughts have been kept from awareness.
  • For instance, the inability to remember a tragic event.

I. Regression

  • Returning to an earlier stage of development, usually due to stress.
  • For instance bed wetting

J. Suppresion

  • An individual consciously aware of disturbing thought or incident and ecides not to deal with it until the next day or whenever he or she feels she is able to deal with the situation

K. Dissociative Disorder

  • Formerly called multiple personality disorder. If a patient turns when another name is called it is an indication that the personalities are not in control.

L. Compensation

  • An individual attempting to overcome shortcoming whether it is an imagined one or real
  • For instance, excelling in basketball when one is physically short.



  • Defined as a behavioral reaction to memory loss in which person fill in gap with inappropriate words or fabricated ideas.


  • Allow verbalization of delusions
  • Do not argue with patient
  • Provide activities to divert attention for the delusion
  • Don’t validate the delusion


  1. Grandeur – belief that one is special such as being a Monarch or President.
  2. Persecutory – belief that one is being plotted against
  3. Ideas of reference – belief that people are talking and discussing about him


  • Always maintain an optimal level of function;  keep  patient healthy as possible


  • A patient may have self esteem feeling helpless or hopeless, a sense of failure, may have a regressed behavior of immaturity (demanding and whining a lot)
  • Individual may be physically unkempt, lacks energy and fell unrested (lack of sleep)
  • Be aware of certain signs: loss of weight, lack of appetite, lack of sexual desire, withdrawn from normal activities, agitation, restlessness, loss of concentration or decreases attention span.
  • Watch for self destructive behaviors / suicidal tendencies (see Suicide also).
  • Patient taking Trycyclic medications should be monitored up until 6 months to determine the effect of the medication.
  • Dexamethasone-suppression test is used to determine if a patient will benefit from an anti-depressant and electroconclusive (ECT) therapy
  • Kava-kava increase the effect of antidepressants
  • Those on MAO antidepressant mediations should avoid foods containing tyramine, (see Diet / Nutrition section) since it can cause hypertension 
  • Combining MAO and SSRI antidepressants can lead to serotonin syndrome.
  • Do not overwhelm Patient; activities should be structured.
  • ECT (Electroconclusive therapy) is used for severe Depression and catatonic conditions.


Domestic Violence

  • Injuries usually do not match the history of how the injuries were obtained.
  • Women and children are the most common victim and is usually accompanied by brainwashing where the victims are blamed themselves; that they are unworthy and that no one will help them.
  • Nurses should provide privacy during interview and make the perpetrator is not present in the room  Tell the perpetrator that the interview is done in private.
  • Carefully document all injuries and photograph is possible and with consent.
  • Determine safety of patient from weapons (knives, guns) at home.



  • Stages according to Kubler-Ross
    • a. Anger
    • b. Bargaining
    • c. Depression
    • d. Acceptance
  • Nurses should be attentive to the need to provide privacy and provide a comforting environment.
  • Respect patient’s wishes.


Eating Disorder

  • A. Anorexia Nervosa – common in females of 12 – 18 years of age; fear of getting fat; characterized by weight loss with distorted body image
      • May engage in excessive exercise,
      • May induce vomiting and purging
      • Watch for electrolyte imbalance, monitor hydration and electrolytes
      • May use ipecac or laxatives often.
      • May need behavior modification and support.
  • B. Bulimia – same characteristics as Anorexia, along with binge eating, that is eating high calorie food in a short period of time.
      • May be normal weight or overweight.



  • An individual experiencing a loss of deceased or separation from a family member or close one or the loss of a body part after undergoing a surgery
  • Nurses can provide family privacy and to encourage verbalization of feelings.
  • Encourage how realistic patient deals with the situation and make sure to emphasize the strengths particularly the ability to cope and adjust to the illness or loss of loved one or of body part.
  • Avoid blaming the client or blaming others.


  • False sensory perception since there is no external stimuli
  • It can be auditory (hearing things) visual (seeing things) olfactory (smelling things) tactile (sense that one is being touched)


Level of Consciousness

  • First signs of altered level of consciousness are restlessness and irritability of the patient.
  • For a patient with neurological impairment, the patients Level of Consciousness is the best indicator not pupil reaction.


Obsessive Compulsive

  • Obsession is the repetitive and uncontrolled thoughts and Compulsion is the repetitive and uncontrolled action of an individual.
  • Nurses should accept the ritualistic behavior and try to offer an alternative activity to the behavior.
  • Another way and an effective way to deal with individuals with Obsessive Compulsive behavior is to provide a contract with the patient to limit time in performing certain tasks.


Manic Depressive

  • Manic patients would have be very active and have difficulty sitting for a long period. So it is good to give patient food high in calorie.


Personality Disorders

A. Paranoid – very suspicious of others, Very sensitive, easily angered and holds grudges,

  • Nurse should try to establish trust, be honest and not intrusive
  • May have to give phenothiazine for anxiety

B. Schizoid – Cold and detached, little verbalization, shy and introverted, tends to daydream

  • Nurses can do the same actions as with paranoid patients.

C. Antisocial – Disregards rights of others; tends to lye cheat, steal and be promiscuous; may appear charming, lacks guilt or remorse; more common in males.

  • May need to be confronted with inappropriate behavior and be firm in setting limits.

D. Borderline – Exhibits labile mood; blames others for own problems; can get into tantrums and physical fights; tend to overspend with compulsive eating; 75% are women and have been sexually abused;

  • Enforce unit rules. Encourage to verbalize or write feelings, do not be confrontational

E. Narcissistic – arrogant, sense of entitlement, use others to own needs, displays grandiosity; sees others as inferior to self; expects special treatment; has shallow relationships.

  • Emphasize that mistakes and imperfections are acceptable, supportive confrontation.

F. Histrionic – tends to draw attention to self / likes center of attention; easily influenced by others.

  • Encourage unselfishness

G. Avoidant – shy , socially uncomfortable; hypersensitive to criticism; avoid situations where one may feel rejected; fears intimate relationship. Lacks self confidence

  • Gradually confront fears, discuss feelings before and after accomplishing a goal

H. Obsessive-Compulsive – see Obsessive Compulsive topic.



  • Feeling of anxiety or apprehension when an individual is confronted with an object or a situation that is feared.
  • For instance, Claustrophobia – the fear of closed spaces. A person may start hyperventilate upon entering a crowded elevator. 
  • Nurses should not confront the individual and have that person be forced in stopping the feared situation and eventually feel humiliated.
  • Systematic dysensitization may work – slowly introducing the individual to the feared object or situation.

Post Traumatic Stress Disease (PTSD)

  • Needs a supportive environment
  • Syndrome make re-occur months or years after the traumatic event.
  • Flooding may help, that is to have the client recall as much detail and images about the traumatic event.

Rape Victims

  • Dont let rape victims left seated waiting for a long time.
  • If presented in ER, makes sure to put clothings in a paper bag to avoid moisture. May need to get hair samples and have the individual NPO. Be alert of any internal injuries.
  • Be ready to give the individual referrals for legal assistance, along with written treatment and appointments since client may forget because of anxiety.
  • Individual may undergo a series of responses
    • Self blame
    • Phobias or fear of violence and injury
    • Anxiety coupled with insomnia
    • Psychosomatic problems.



  • Individual tends to withdraw from any type of relationship and from the world
  • Tend to be suspicious of others
  • Unable to test reality
  • Inappropriate display of feelings


a. Catatonic – sudden onset of bizarre mannerism or suddenly remaining in an particular position; may have periods of agitation

b. Disorganized – exhibiting inappropriate behavior such as laughing silly or having hallucinations

c. Paranoid – having ideas or thoughts or persecution and delusions

d. Undifferentiated – having more than one type of schizophrenia

      1. Hallucinations

        • False sensory perception since there is no external stimuli.
        • It can be auditory (hearing things) visual (seeing things) olfactory (smelling things) tactile (sense that one is being touched)

      2. Delusions


        • Grandeur – belief that one is special such as being a Monarch or President.
        • Persecutory – belief that one is being plotted against
        • Ideas of reference – belief that people are talking and discussing about him
            • Allow verbalization of delusions
            • Do not argue with patient.
            • Provide activities to divert attention for the delusion
            • Don't validate the delusion
            • When experiencing hallucinations, do not agree with patient about reality of hallucination; encourage discussion of reality based interests; provide diversional activity (i.e. playing cards)
            • During patients agitated state, allow physical distance, maintain attentiveness to patient withouth being intrusive, decrease physcial contact.
            • If patient is catatonic, be ready to tolerate silences, position or provide skin care.

Stress Reducers (see Anxiety)

  • Use of distractors to avoid the patient from thinking of focusing on what’s causing the stress. Example is music or increase in activity.
  • Demand on the body may be physical or psychological and the patient may use avoidance and blame self.
  • Use of Biofeedback (use of electrical instruments to identify muscle and skin surface activity) and Medication are ways to relieve stress.


  • Similar symptoms to depression.
  • Certain individuals may be predisposed to suicide:
  • Those who may have previously attempted
  • Male over 50 years of age and teenagers from 15 – 20 years of age
  • Those who have poor social attachment
  • Those experiencing hallucinations or with personality disorders.
  • Those who has recently experienced an overwhelming event such as knowing to have a terminal diseases (i.e. cancer), loss of job, death of love one, divorce
  • Watch for clues of impending suicide
  • Patient become very energetic after a period of depression
  • Improved mood after taking an anti-depressant. Patient may have the energy to pull of plan of suicide.
  • Gives away personal possessions
  • Finalizes business or personal affairs.
  • Leaves a note /  presence of weapon
  • May make indirect statements (i.e. I may be gone for an indefinite period)
  • Remove any harmful objects
  • Stay with patient and not leave them alone
  • A “no suicide” “no harm” “No self injury” contract may be made by Psychiatric health professionals with the patient and have the patient agree and abide with the contract.

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