Medical-Surgical Nursing: An
Integrated Approach, 2E
NURSING CARE OF
THE CLIENT: MENTAL
Mental illness occurs when:
an individual is not able to view self
clearly or has a distorted view of self.
is unable to maintain satisfying
is unable to adapt to the environment.
A clinically significant behavior or
psychological syndrome or pattern
Associated with present distress, disability
or with a significantly increased risk of
suffering, death, pain, disability.
The fourth edition of the Diagnostic and
Statistical Manual of Mental Disorders
(better known as the DMS-IV) is the
reference tool used to identify and
establish psychiatric disorders.
Five components necessary in the
therapeutic nurse-client relationship:
The ability to rely on an individual’s
character and ability.
A nurse promotes trust by demonstrating
consistency, respect, and honesty.
Essential Factors of Trust
CONSISTENCY RESPECT HONESTY
Follow through Call client by Ask client about
on plans. name. personal
Adhere to Provide clear Keep any
schedule. explanations. promises.
Seek out client Recognize own Maintain
for extra time to strengths and confidentiality.
Be Listen to client. Be flexible in
straightforward. responding to
A bond or connection between two people
that is based on mutual trust.
To establish rapport, the nurse must show
that the client is considered important.
The acceptance of an individual as is and
in a nonjudgmental manner.
Genuineness (sincerity) is an attribute
easily perceived by the client and can be
the most significant aspect of the nurse-
The ability to perceive and relate to
another person’s experience.
By perceiving the client’s understanding
of his own needs, the nurse is better able
to assist the client in determining what will
Through empathy, the nurse validates the
experiences of the client.
Because of the highly personal and
sensitive nature of mental disorders, it is
vitally important in psychiatric nursing to
observe confidentiality, the nondisclosure
of the identity of or personal information
about an individual.
Clients in Crisis
A crisis, in psychological terms, is a
stressor that forces an individual to
respond and/or adapt in some way.
The client experiencing crisis may be
anxious, angry, aggressive, homicidal,
suicidal, psychotic, or any combination of
Feelings of dread frequently accompanied
by physical symptoms (increased heart
and respiratory rates and elevated blood
pressure) in absence of a specific source
and reason for these emotions and
Common psychiatric diagnoses related to
anxiety are Generalized Anxiety Disorder,
Panic Disorder and Post-Traumatic Stress
Generalized Anxiety Disorder
Exhibits symptoms of excessive anxiety
Clients usually realize that their symptoms
are out of proportion to any real threat.
Symptoms include three or more of the
following: restlessness, easy fatigue,
difficulty concentrating, irritability, muscle
tension, and sleep disturbance.
A condition wherein the client experiences
periods of intense anxiety that begin
abruptly and peak within 10 minutes.
Characterized by palpitations, sweating,
trembling, shortness of breath, sensation
of choking, chest pain, nausea, dizziness,
fear of losing control, fear of dying,
numbness or tingling, chills or hot flashes,
and some sense of altered reality.
Client has experienced a serious trauma (e.g. a
severe beating or emotional, physical, or sexual
abuse or has lived through a catastrophic event
or natural disaster).
The response is fear or helplessness and the
event is persistently re-experienced through
recurrent recollections, dreams, or hallucinatory
Impairment of social functioning and a numbing
of general responsiveness are characteristic.
Psychotherapy, the treatment of mental and
emotional disorders through psychological
rather than physical methods, continues to be
widely used in the treatment of anxiety
Psychotherapy can be viewed as falling into two
general categories: those based on helping
individuals achieve insight into why they feel
anxiety and those that emphasize behavioral
means of controlling the anxiety.
Therapy focused on uncovering
unconscious memories and processes.
Among the best of the insight therapies
and has been widely employed to assist
persons with anxiety.
Assumes that clients can learn to identify
the common stimuli that give rise to their
anxiety, develop plans to respond to
those stimuli with nonanxious response,
and problem solve when unanticipated
anxiety-provoking situations arise.
The drug of choice for treating clients with
anxiety are usually the anxiolytics, or
Some of the anxiolytics include
alprazolam (Xanax) and lorazepam
Do not increase dose or frequency of
medication without consulting physician.
Tolerance develops quickly and
unsupervised used can lead to addiction.
Do not drink alcohol while on medication.
Do not take any other medications unless
prescribed by your physician.
Do not stop taking medication abruptly.
Do not drive or operate heavy machinery
while on the medication.
The state wherein an individual
experiences feeling of extreme sadness,
hopelessness, and helplessness.
Symptoms include insomnia or
hypersomnia (excessive sleeping);
changes in appetite; lethargy; decreased
libido (sexual energy); frequent crying
spells; racing thoughts; difficulty
concentrating; forgetfulness; and suicidal
ideations (thoughts of hurting or killing
Major Depressive Disorder
A person experiencing a depressive
episode may express feelings of sadness
and hopelessness or may express the
sense of feeling empty or having no
Some individuals, particularly
adolescents, may exhibit irritability rather
Major depressive episodes frequently
develop over a few days or weeks and
without treatment commonly last for
A feeling of depression that lasts nearly
all the time.
The DSM-IV criteria include “depressed
mood for most of the day, for more days
than not…for at least two years.”
Somewhat rarer than Major Depressive
Disorder, occurring during a lifetime in
approximately 6% of persons.
Some Therapies for Depression
Brief Dynamic Therapy focuses on core
conflicts that derive from personality and
living situations. The goal is to resolve
depressive symptoms by improving these
conflicts and resolving stresses.
Electroconvulsive therapy (ECT) is a
procedure wherein the client is treated
with pulses of electrical energy sufficient
to cause a brief convulsion or seizure.
Within this classification are several
The tetracyclic and atypical
The selective serotonin reuptake
The tricyclic antidepressants.
The monoamine oxidase inhibitors.
Some of the techniques used in anger
Limiting access to frustrating situations.
Providing physical outlets for
expression of anger or tension (such as
punching bags, large motor activities,
e.g. sports; and anger journals).
Ensuring that a client for whom anger is
a problem is given enough personal
Assessing for Risk of Violence
Be aware of those clients with past history of
violence or poor impulse control.
Observe the client’s body language. Notice
changes in behavior, words, or dress.
Assess for aggressive behaviors, increasing
tension, clenched fists, loud or angry tone of
voice, narrowed eyes, and pacing.
Remember that hostility tends to be contagious.
Do not reciprocate with anger and hostility!
Purposefully taking one’s own life is the ultimate
form of self-destruction.
Clients who are suicidal often feel overwhelmed
by life events and decide that the only relief will
come from ending their own lives.
Intense feelings of fear, loss, anger, or despair
can drive individuals to suicide, and the effects
of an attempted or completed suicide can be
devastating and long-lasting.
Suicide is the eighth leading cause of death in
Assessment of Risk for Suicide
Does the client have a plan to commit suicide?
The client who has a plan for committing suicide is at
How specific is the plan to commit suicide?
A specific plan increases the risk of completing a suicide.
Does the client have access to the means to commit suicide?
Easy availability of the means to kill oneself increases the risk of suicide.
How lethal is the intended means to commit suicide?
Gunshots are the most common cause of completed suicide.
Restraints and Seclusion
The client who is severely agitated,
aggressive, actively suicidal, and/or
homicidal may need to be restrained
(usually with leather straps serving as
physical restraints) or placed in seclusion
(confined to a single room that may or
may not be locked and may or may not
Ask the client whether he is able to make a promise to himself that he will
not do anything to harm himself.
If the client is unable to commit to the contract for the rest of his life, work with him on
establishing a time frame to which he can commit.
Ask the client whether he is able to maintain the No-Suicide Contract
no matter what happens.
Ask the client whether he can make a promise to himself
that if thoughts of suicide return, he will talk to someone and let them know
before taking any action.
Assist the client in developing a detailed plan of action regarding
those persons he will contact in ev ent suicidal thoughts return.
At the bottom of the list put the name an dpone number of local suicide
crisis hotline and/or local emergency number.
Assist the client in putting the No-Suicide Contract in writing and
in his own words.
Psychosis: Defined as:
A state wherein an individual loses the
ability to recognize reality.
A psychotic person may experience
hallucinations, wherein he hears voices or
sees images of persons or things others
cannot see or hear.
A psychotic person is frequently unable to
care for basic needs of safety, security,
nutrition, and so on.
Clients with schizophrenia tend to be tired
and lethargic, probably due to multiple
factors including the disease process and,
possible, the sedative properties
associated with some of the
antipsychotics, especially some of the
older ones like Thorazine and Mellaril.
Previously known as manic-depressive
disorder, it is a psychiatric diagnosis
characterized by wide fluctuations in
mood (the way an individual reports
feeling, e.g. depressed, elated, happy,
sad) and affect (the objective or outward
manifestations of the way an individual
feels, e.g. avoids eye contact, smiles,
Bipolar Disorder: Mood Swings
Individual with bipolar disorder may
experience fluctuations between
depression and mania (extremely
elevated mood with accompanying
agitated behavior), sometimes in the
The drug of choice for treatment is
The child with ADHD may exhibit
inattention, hyperactivity, and impulsivity.
Condition may continue well into
Neglect and Abuse
Neglect (a situation wherein a basic need
of the client is not being provided) and
abuse (an incident involving some type of
violation of the client) can occur among
any age group.
Abuse can be physical, emotional,
psychological, financial, or sexual in
nature, or any combination of these.
Abuse can also take the form of domestic
violence, which is aggression and
violence involving family members.
Sexual violence to dominate and degrade
victims and to express rapist’s own anger.
Three basic types of rape: (1) rape by a
person known to survivor; (2) gang rape;
(3) stranger-to-stranger rape.
Interviewing the Survivor of
Abuse or Violence
Inform the client that it is necessary to ask some very
Use language appropriate to age and developmental
level of survivor.
Use conversational or street language.
Keep questions simple, nonthreatening, and direct.
Pose questions in a manner that permits brief answers.
Indicate sensitivity to client’s state of confusion.
Avoid using leading statements that can distort the
Do not criticize the client’s family.
Do not promise to report the abuse; indicate that you
are required by law to report abuse.
Anorexia nervosa (self-imposed starvation
created by restricting caloric intake and
Bulimia nervosa (characterized by periods
of binge eating of up to 10,000 calories at
one time followed by self-induced
vomiting and others forms of purging such
as laxative and diuretic abuse).
Both syndromes affect mainly women.