Chp 11,12,13,18,21

Describe personality disorders in terms of the client's difficulty in perceiving, relating to, and thinking about self, others, and the environment.

People with personality disorders have traits that are inflexible and maladaptive and cause either significant functional impairment or subjective distress. Personality disorders are relatively common and diagnosed in early adulthood, though some behaviors are evident in childhood or adolescence. Rapid or substantial changes in personality are unlikely. This can be a primary source of frustration for family members, friends, and health care professionals. Schizotypal personality disorder is characterized by social and interpersonal deficits, cognitive and perceptual distortions, and eccentric behavior. People with antisocial personality disorder often appear glib and charming, but they are suspicious, insensitive, and uncaring and often exploit others for their own gain. People with BPD have markedly unstable mood, affect, self-image, interpersonal relationships, and impulsivity; they often engage in self-harm behavior. People with obsessive-compulsive personality disorder are preoccupied with orderliness, perfection, and interpersonal control at the expense of flexibility, openness, and efficiency. Narcissistic personality disorder is characterized by grandiosity, need for admiration, lack of empathy for others, and a sense of entitlement. Avoidant personality disorder is characterized by social discomfort and reticence in all situations, low self-esteem, and hypersensitivity to negative evaluation.

Describe behavioral and emotional responses to abuse.

Rape is a crime of violence and humiliation through sexual means. Half of reported cases are perpetrated by someone the victim knows. Child abuse includes neglect and physical, emotional, and sexual abuse. It affects three million children in the United States. Elder abuse may include physical and sexual abuse, psychological abuse, neglect, exploitation, and medical abuse. Rape is most often perpetrated by someone known to the victim and is an act of aggression and violence.

Apply the nursing process to the care of clients with personality disorders.

Several therapeutic strategies are effective when working with clients with personality disorders. Cognitive restructuring techniques such as thought stopping, positive self-talk, and decatastrophizing are useful; self-help skills aid the client in functioning better in the community. Psychotropic medications are prescribed for clients with personality disorders based on the type and severity of symptoms the client experiences in aggression and impulsivity, mood dysregulation, anxiety, and psychotic symptoms.

Examine the incidences of and trends in domestic violence, child and elder abuse, and rape.

Spousal abuse can be emotional, physical, sexual, or all three. Women have difficulty leaving abusive relationships because of financial and emotional dependence on the abusers and because of the risk of suffering increased violence or death.

Describe important issues for nurses to be aware of when working with angry, hostile, or aggressive clients

The nurse must be aware of how he or she deals with anger before helping clients do so . The nurse who is afraid of an gry feelings may avoid a client's anger , which allows the cli ents behavior to escalate . If the nurse's response is angry , the situation can escalate into a power struggle , and the nurse loses the opportunity to "talk down " the clients anger .

Discuss factors thought to influence the development of personality disorders.

The therapeutic relationship is crucial in caring for clients with personality disorders. Nurses can help clients identify their feelings and dysfunctional behaviors and develop appropriate coping skills and positive behaviors. Therapeutic communication and role modeling help promote appropriate social interactions, which help improve interpersonal relationships.

Describe somatic symptom illnesses and identify their three central features.

The three central features of somatic symptom illnesses are physical complaints that suggest major medical illness but have no demonstrable organic basis; psychological factors and conflicts that seem important in initiating, exacerbating, and maintaining the symptoms; and symptoms or magnified health concerns that are not under the client's conscious control. Somatic symptom illnesses include somatic symptom disorder, conversion disorder, illness anxiety disorder, and pain disorder.

Describe responses to trauma and stressors, specifically posttraumatic stress disorder (PTSD) and dissociative identity disorder.

Treatment for PTSD includes individual and group therapy, self-help groups, and medication, usually SSRI antidepressants, venlafaxine, or risperidone. Counseling offered immediately after a traumatic event can help people process what has happened and perhaps avoid PTSD.

Apply the nursing process to the care of clients experiencing abuse and violence

Victims of rape do best when they receive immediate support and can express fear and rage to family, friends, health care providers, and law enforcement officials who believe and will listen to them.

Explain what is meant by "psychosomatic illness."

transforming mental experiences and states into bodily symptoms.

Discuss the characteristics, risk factors, and dynamics of immediate- and longer-term individual responses to trauma and stressors.

traumatic events that disrupt peoples' lives can lead to an acute stress disorder from 2 days to 4 weeks following the trauma. Autism spectrum disorders can be a precursor to PTSD.

Discuss the characteristics,risk factors, and family dynamics of abusive and violent behavior

violence and abusive behavior as national health concerns. Women and children are the most likely victims of abuse and violence. Characteristics of violent families include an intergenerational transmission process, social isolation, power and control, and the use of alcohol and other drugs.

Describe psychiatric disorders that may be associated with an increased risk of hostility and physical aggression in clients

-Paranoid delusions -Auditory hallucinations (Schizophrenia) -Dementia, delirium, head injuries -Intoxication with alcohol or other drugs -Antisocial, borderline personality disorders -Depression -Intermittent explosive disorder -Acting out behaviors

Describe the signs, symptoms, and behaviors associated with the five phases of aggression

-Triggering: Restlessness , anxiety , irritability , pacing , muscle tension, rapid breathing, perspiration, loud voice , anger -Escalation: Pale or flushed face, yelling, swearing, agitation, threatening, demanding , clenched fists, threatening gestures, hostility, loss of ability to solve the problem or think clearly -Crisis: Loss of emotional and physical control, throwing objects , kicking, hitting, spitting, biting, scratching, shrieking, screaming, inability to communicate clearly -Recovery: Lowering of voice ; decreased muscle tension; clearer, more rational communication; physical relaxation -Postcrisis: Remorse; apologies; crying; quiet, withdrawn behavior

Discuss anger, hostility, and aggression

Anger: Normal human emotion -Handled appropriately, a positive force for resolving conflicts, solving problems, making decisions -Body physically energized for self-defense ("fight-or-flight" response) -Expression inappropriate or suppressed: negative force -Physical or emotional problems; interference with relationships -Possible hostility, aggression -Catharsis: alleviate or increase feeling of anger -Hostility = verbal aggression, usually when feeling threatened or powerless -Physical aggression: attack on or injury to another person; destruction of property -Both to harm or punish another person or force into compliance -Sudden, unexpected -Identifiable stages or phases

In Chapter 12

Chapter 12

Provide education to clients, families, and community members to increase their knowledge and understanding of personality disorders

Clients with BPD often have self-harm urges that they enact by cutting, burning, or punching themselves; this behavior sometimes causes permanent physical damage. The nurse can encourage the client to enter into a no-self-harm contract in which the client promises to try to keep from harming him or herself and to report to the nurse when he or she is having self-harm urges.

Provide education to clients, families, and the community to increase knowledge and understanding of somatic symptom disorders.

Clients with somatic symptom disorder actually experience symptoms and the associated discomfort and pain. The nurse should never try to confront the client about the origin of these symptoms until the client has learned other coping strategies. Somatic symptom illnesses are chronic or recurrent, so progress toward treatment outcomes can be slow and difficult.

Provide education to clients, families, and communities to promote prevention and early intervention of abuse and violence.

Community violence in schools, including bullying, is increasing and represents a major public health concern. Early intervention and effective treatment are key to dealing with victims of violence. The longer the identification and treatment are delayed, the poorer the long-term outcomes for the individual.

Apply the nursing process to the care of clients with somatic symptom illnesses.

Coping strategies that are helpful to clients with somatic symptom illnesses include relaxation techniques such as guided imagery and deep breathing; distractions such as music; and problem-solving strategies such as identifying stressful situations, learning new methods of managing them, and role-playing social interactions.

Provide education to clients, families, and communities to promote prevention and early intervention for trauma and stressor-related responses.

Dissociation is a defense mechanism that protects the emotional self from the full reality of abusive or traumatic events during and after those events. Individuals with a history of childhood physical and/or sexual abuse may develop dissociative disorders. Dissociative disorders have the essential feature of disruption in the usually integrated functions of consciousness, memory, identity, and environmental perception. Survivors of trauma and abuse may be admitted to the hospital for safety concerns or stabilization of intense symptoms such as flashbacks or dissociative episodes. The nurse can help the client minimize dissociative episodes or flashbacks through grounding techniques and reality orientation.

Apply the nursing process to the care of clients with trauma or stressor- related diagnoses.

Important nursing interventions for survivors of abuse and trauma include protecting the client's safety, helping the client learn to manage stress and emotions, and working with the client to build a network of community support.

Evaluate your own experiences, feelings, attitudes, and beliefs about abusive and violent behavior.

Important self-awareness issues for the nurse include managing his or her own feelings and reactions about abuse, being willing to ask about abuse, and recognizing and dealing with any abuse issues he or she may have experienced personally.

Evaluate your own experiences, feelings, attitudes, and beliefs about responses to trauma and stress.

Important self-awareness issues for the nurse include managing his or her own feelings and reactions about traumatic events, remaining nonjudgmental regardless of circumstances, and listening to clients' expressions of despair or distress.

Discuss appropriate nursing interventions for the client during the five phases of aggression

In the triggering phase, the nurse should approach the client in a nonthreatening , calm manner in order to de-escalate the client's emotion and behavior. Convey ing empathy for the client's anger or frustration is im portant. The nurse can encourage the client to express his or her angry feelings verbally , suggesting that the client is still in control and can maintain that control escalation phase (period when cli ent builds toward loss of control ), the nurse must take control of the situation . The nurse should provide di rections to the client in a calm, firm voice. The client should be directed to take a time- out for cooling off in a quiet area or his or her room. The nurse should tell the client that aggressive behavior is not acceptable and that the nurse is there to help the client regain control. (crisis phase), the staff must take charge of the situa tion for the safety of the client, staff, and other clients. Psychiatric facilities offer training and practice in safe techniques for managing behavioral emergencies , and only staff with such training should participate in the restraint of a physically aggressive client. The nurse's decision to use seclusion or restraint should be based on the facility's protocols and standards for restraint and seclusion. The nurse should obtain a physician's order as soon as possible after deciding to use restraint or seclusion . As the client regains control (recovery phase), he or she is encouraged to talk about the situation or triggers that led to the aggressive behavior . The nurse should help the client relax, perhaps sleep , and return to a calmer state . It is important to help the client explore alternatives to aggressive behavior by asking what the client or staff can do next time to avoid an aggressive episode . In the posterisis phase , the client is removed from restraint or seclusion as soon as he or she meets the behavioral criteria. The nurse should not lecture or chastise the client for the aggressive behavior but should discuss the behavior in a calm, rational man ner. The client can be given feedback for regaining control, with the expectation that he or she will be able to handle feelings or events in a nonaggressive manner in the future. The client should be reinte grated into the milieu and its activities as soon as he or she can participate .

Discuss the etiologic theories related to somatic symptom illnesses

MUS and functional somatic syndromes are terms used in general medical practice settings when patients have physical symptoms and/or limitations unexplained by a medical diagnosis. Internalization and somatization are the chief defense mechanisms seen in clients with somatoform disorders. Clients with somatic symptom disorder and conversion reactions eventually may be treated in mental health settings. Clients with other somatic symptom illnesses are typically seen in medical settings. Clients who cope with stress through somatizing are reluctant or unable to identify emotional feelings and interpersonal issues and have few coping abilities unrelated to physical symptoms. Nursing interventions that may be effective with clients who somatize involve providing health teaching, identifying emotional feelings and stress, and using alternative coping strategies

Distinguish somatic symptom illnesses from factitious disorders and malingering.

Malingering means feigning physical symptoms for some external gain, such as avoiding work. Factitious disorders are characterized by physical symptoms that are feigned or inflicted for the sole purpose of drawing attention to oneself and gaining the emotional benefits of assuming the sick role.

Evaluate your feelings, beliefs, and attitudes regarding clients with somatic symptom disorders.

Nurses caring for clients with somatic symptom illnesses must show patience and understanding toward them as they struggle through years of recurrent somatic complaints and attempts to learn new emotion- and problem-focused coping strategies.

Evaluate personal feelings, attitudes, and responses to clients with personality disorders.

Nurses must use self-awareness skills to minimize client manipulation and deal with feelings of frustration.

Examine the occurrence of various longer-term responses to trauma and stress.

PTSD is a pattern of behavior following a major trauma beginning at least 3 months after the event or even months or years later. Symptoms include feelings of guilt and shame, low self-esteem, reexperiencing events, hyperarousal, and insomnia. Clients with PTSD may also develop depression, anxiety disorders, or alcohol and drug abuse. PTSD can affect children, adolescents, adults, or the elderly. PTSD occurs in countries around the world. People who flee their native countries for asylum benefit from remaining connected to their cultures.