Give an example in which you used strategies as listed in chapter 13 to express an opinion in an assertive way. List three criteria for the appropriate use of humor in healthcare. Can y

PSYCHOSOCIAL NURSING

FOR GENERAL PATIENT CARE 3rd Edition

Linda M. Gorman, APRN, BC, MN, CHPN, OCN Palliative Care Clinical Nurse Specialist Cedars-Sinai Medical Center Los Angeles, California

Assistant Professor University of California, Los Angeles Los Angeles, California

Donna F. Sultan, RN, MS Mental Health Counselor, RN West Valley Mental Health Center Los Angeles County Department of Mental Health Los Angeles, California

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F. A. Davis Company 1915 Arch Street Philadelphia, PA 19103 www.fadavis.com

Copyright © 2008 by F. A. Davis Company

Copyright © 2008 by F. A. Davis Company. All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher.

Printed in the United States of America

Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1

Publisher, Nursing: Joanne Patzek DaCunha, RN, MSN Director of Content Development: Darlene D. Pedersen Project Editor: Padraic Maroney Art and Design Manager: Carolyn O’Brien

As new scientific information becomes available through basic and clinical research, rec- ommended treatments and drug therapies undergo changes. The author(s) and publisher have done everything possible to make this book accurate, up to date, and in accord with accepted standards at the time of publication. The author(s), editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of the book. Any prac- tice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situ- ation. The reader is advised always to check product information (package inserts) for changes and new information regarding dose and contraindications before administering any drug. Caution is especially urged when using new or infrequently ordered drugs.

Library of Congress Cataloging-in-Publication Data Gorman, Linda M. Psychosocial nursing for general patient care / Linda M. Gorman, Donna F. Sultan. —

3rd ed. p. ; cm.

Includes bibliographical references and index. ISBN-13: 978-0-8036-1784-1 ISBN-10: 0-8036-1784-4

1. Psychiatric nursing—Handbooks, manuals, etc. 2. Nursing—Social aspects— Handbooks, manuals, etc. I. Sultan, Donna. II. Title. [DNLM: 1. Nursing Care—psychology—Handbooks. 2. Nurse-Patient Relations—

Handbooks. 3. Nursing Assessment—Handbooks. WY 49 G671p 2008] RC440.G659 2008 616.89′0231—dc22 2007040704

Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by F. A. Davis Company for users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, provided that the fee of $.10 per copy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a photocopy license by CCC, a separate sys- tem of payment has been arranged. The fee code for users of the Transactional Reporting Service is: 8036-1169-2/04 0 � $.10.

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iii

Preface

Having worked in a variety of specialty areas over the years as staff nurses, clin- ical nurse specialists, educators, therapists, and managers, we realize that nurses aspire to become highly proficient in their area of practice. But psychosocial skills are often more difficult to perfect. Very often nurses feel inadequately prepared to deal with complex behaviors and psychiatric problems on top of the demands of providing physical care for the patient and family. Even nurses who practice in the psychiatric setting find themselves dealing with unique situations that chal- lenge their level of expertise. And yet, a large percentage of a nurse’s time is spent dealing with these issues.

Psychosocial Nursing for General Patient Care bridges the gap between the information contained in the large, comprehensive psychiatric texts and the infor- mation needed to function effectively in a variety of healthcare settings. The cli- nician can refer to this book to find the information to effectively handle specific patient problems. The nursing student can use this book as a supplement to other texts and will be useful throughout nursing school curriculum.

The concise, quick reference format used throughout this book allows the nurse to easily find information on a specific psychosocial problem commonly seen in practice. In addition to common psychosocial problems, psychiatric dis- orders are explained and discussed. Each chapter is organized to provide easy access to information on etiology, assessment, age-specific implications, nursing diagnosis and interventions, patient/family education, interdisciplinary manage- ment including pharmacology, and community based care. The fast-paced health- care environment we are all experiencing demands quick assessment and treatment plans that are realistic, cost-effective, and outcome driving. The infor- mation contained in this book is readily applicable to all patient care settings.

Each psychosocial problem includes a section on common nurses’ reactions to the patient behaviors that may result from the problem. Nurses often think they should only have acceptable and “proper” emotional reactions to their patients. Nurses may deny certain feelings and have unrealistic expectations of themselves. These factors impact how the nurse then responds to the patient’s problems. The more aware the nurse becomes of how one reacts to the patient’s behaviors, the easier it will be to accept one’s own feelings and understand how these feelings affect the patient and influence interventions.

In this third edition we have added two new chapters that reflect concerns faced by many nurses. The Homeless Patient with Chronic Illness reflects the increasingly frequent encounters that nurses in all areas of the country are facing. Disaster Planning and Response–Psychosocial Impact provides the nurse with tools to prepare for the emotional impact of a natural or man-made disaster. Throughout this third edition we have updated information on patient safety, pharmacologic interventions, and psychiatric diagnoses and treatment. We con-

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tinue to include information that will apply to the inpatient hospital setting, long- term care, and outpatient care.

We wish to thank our contributors Yoshi Arai and Margaret Mitchell who revised their chapters from the second edition. We also thank our new contribu- tors Bill Whetstone and Carl Magnum. Particular thanks go to our editors Annette Ferrans and Joanne DaCunha of FA Davis. This was our third collabo- ration with Joanne and she remains a dynamic force that keeps us on track.

For those of you familiar with our earlier two editions, you will notice the name of author Marcia L. Raines, RN, PhD is missing. Marcia died in 2006 after a long illness. Marcia was the consummate nurse who strove for excellence throughout her career. She started as a psychiatric nurse, became a clinical nurse specialist, was an educator and administrator, and faculty member and chair of a university school of nursing. She inspired countless nurses over the years with her wise and gentle approach. She strove for excellence in all aspects of her career. Working with her on the previous two editions was always a joy because of her genuine love of the work and her enthusiasm to produce an outstanding book. Marcia wrote many of the original chapters from the first and second edition including chapters on anxiety, sexual dysfunction, confusion, pain, and sleep. We have strived to carry on in her memory but know the nursing world has lost a great one. This edition is dedicated to Marcia.

Linda M. Gorman Donna F. Sultan

iv Preface

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v

Contributors

Yoshinao Arai, RN, MN, CNS Senior Mental Health Counselor, RN Los Angeles County Department of Mental Health Los Angeles, California

Carl Magnum, RN, MSN, PhD(c), CHS, FF Assistant Professor of Nursing Emergency Preparedness Coordinator The University of Mississippi Medical Center Jackson, Mississippi

Margaret L. Mitchell, RN, MN, MDIV, MA, CNS Senior Mental Health Counselor, RN Los Angeles County Department of Mental Health Los Angeles, California

William R. Whetstone, RN, CNS, PhD Professor, Nursing Clinical Nurse Specialist, Adult Psychiatric Mental Health Nursing California State University, Dominguez Hills Carson, California

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vii

Reviewers

Michael Beach, MSN, APRN, BC, ACNP, PNP Instructor University of Pittsburgh Pittsburgh, Pennsylvania

Dorie V. Beres, PhD, MSN, ANP-C Associate Professor and Coordinator Vitterbo University La Crosse, Wisconsin

Earl Goldberg, EdD, APRN, BC Assistant Professor LaSalle University Philadelphia, Pennsylvania

Barbara A. Jones, RN, MSN, DNSc Professor Gwynedd-Mercy College Gwynedd Valley, Pennsylvania

Nancy L. Kostin, MSN, RN Associate Professor Madonna University Livonia, Michigan

Karen P. Petersen, RN, CCRN, MSN Nursing Instructor Chemeketa Community College Salem, Oregon

Glenda Shockley, RN, MS Director of Nursing Connors State College Warner, Oklahoma

Ellen F. Wirtz, RN, MN Faculty Chemeketa Community College Salem, Oregon

Margaret A, Wetsel, PhD, MSN Associate Professor Clemson University Clemson, South Carolina

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ix

Contents

SECTION I— Aspects of Psychosocial Nursing

1 Introduction to Psychosocial Nursing for General Patient Care ………………………………………………………….1

2 Psychosocial Response to Illness……………………………………..7 3 Psychosocial Skills ……………………………………………………………15 4 Nurses’ Responses to Difficult Patient Behaviors…………33 5 Crisis Intervention…………………………………………………………….43 6 Cultural Considerations: Implications for

Psychosocial Nursing Care………………………………………………49

SECTION II— Commonly Encountered Problems

7 Problems with Anxiety …………………………………………………….57 The Anxious Patient ………………………………………………………………….57

8 Problems with Anger ……………………………………………………….73 The Angry Patient………………………………………………………………………73

The Aggressive and Potentially Violent Patient…………………….83

9 Problems with Affect and Mood…………………………………….99 The Depressed Patient …………………………………………………………….99

The Suicidal Patient ………………………………………………………………..113

The Grieving Patient ……………………………………………………………….129

The Hyperactive or Manic Patient………………………………………..142

10 Problems with Confusion……………………………………………….157 The Confused Patient …………………………………………………………….157

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11 Problems with Psychotic Thought Processes……………….177 The Psychotic Patient……………………………………………………………..177

12 Problems Relating to Others ………………………………………….191 The Manipulative Patient ……………………………………………………….191

The Noncompliant Patient…………………………………………………….204

The Demanding, Dependent Patient…………………………………..219

13 Problems with Substance Abuse…………………………………..231 The Patient Abusing Alcohol …………………………………………………231

The Patient Abusing Other Substances ………………………………250

14 Problems with Sexual Dysfunction ……………………………….273 The Patient with Sexual Dysfunction …………………………………..273

15 Problems with Pain …………………………………………………………291 The Patient in Pain………………………………………………………………….291

16 Problems with Nutrition …………………………………………………315 The Patient with Anorexia Nervosa or Bulimia…………………..315

The Morbidly Obese Patient …………………………………………………330

17 Problems Within the Family……………………………………………341 Family Dysfunction………………………………………………………………….341

Family Violence ……………………………………………………………………….351

18 Problems with Spiritual Distress……………………………………369 The Patient with Spiritual Distress ……………………………………….369

Margaret L. Mitchell, RN, MN, MDIV, MA, CNS

SECTION III— Special Topics

19 Nursing Management of Special Populations …………….387 The Patient with Sleep Disturbances…………………………………..387

The Chronically Ill Patient………………………………………………………400

The Homeless Patient with Chronic Illness………………………..410

William R. Whetstone, RN, CNS, PhD

The Dying Patient……………………………………………………………………421

x Contents

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20 Disaster Planning and Response–Psychosocial Impact ……………………………………………………………………………..435 The Disaster Victim/Patient

The Disaster Responder/Nurse ……………………………………………435

Carl Magnum, RN, MSN, PhD(c), CHS, FF

21 Psychopharmacology: Database for Patient and Family Education on Psychiatric Medications……..451 Yoshinao Arai, RN, MN, CNS

References……………………………………………………………………………..487

Index……………………………………………………………………………………….513

Contents xi

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1

SECTION I Aspects of Psychosocial Nursing

1Introduction to Psychosocial Nursing for General Patient Care

Learning Objectives • Define psychosocial nursing care. • Describe the impact of patient behavior problems in a managed-

care setting. • Describe the role of patient education in psychosocial care. • Name the resources the nurse can use when planning for patients across

care settings.

Every day, nurses are confronted with patient problems and crises that fall in the realm of the psychosocial, and they must find a way to deal with them.

The Agency for Healthcare Research and Quality found in 2004 that one in four stays in U.S. hospitals for patients 18 and over involved depressive, bipolar, schiz- ophrenia, and other mental disorders or substance abuse. Nurses often must care for patients with:

• Intense emotional responses to illness • Personality styles that make care difficult • Psychiatric disorders • Stresses and family problems that affect patients’ reactions to illness or hos-

pitalization

Nurses can be proficient in managing patients’ physical health problems and yet be less prepared to manage emotional problems. The ability to recognize

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behaviors that suggest psychosocial problems and to develop skills to manage them effectively not only improves the patients’ chances of healing but can also reduce frustration for nurses.

Psychosocial care emphasizes interventions to assist individuals who are having difficulty coping with the emotional aspects of illness, with life crises that affect health and health care, or with psychiatric disorders. For example, problems with depression, anger, substance abuse, or grief can influence a patient’s response to illness or to the interventions of the health-care system. In psychosocial care, the nurse focuses on the effects of stress in psychological or physiological illness and on the intrapsychic and social functioning of individuals responding to stress.

The nurse has a responsibility to facilitate each patient’s adaptations to his or her unique stresses by helping and supporting the person in his or her environ- ment, level of wellness, and adjustment to the illness or condition. Identifying the patient’s coping responses, maximizing strengths, and maintaining integrity will help the nurse meet this responsibility.

NURSES’ POSSIBLE REACTIONS

A factor whose importance cannot be overlooked in psychosocial care is aware- ness of one’s own reactions to patient behaviors. These reactions will influence the nurse-patient relationship, assessment findings, and selection of potential interventions. They can help or hinder the relationship. Recognizing the influence of these reactions can help the nurse to:

• Increase awareness of the reactions that influence objectivity • Identify reactions frequently experienced by other nurses to ease feelings of

guilt and resentment • Increase understanding of colleagues’ reactions to enhance the work envi-

ronment • Facilitate self-support by reducing self-criticism and reinforcing skills • Select better assessment tools to identify patients’ dilemmas and responses • Recognize how personal reactions to patients can influence assessment,

planning, and effective interventions

In coming chapters, “Possible Nurses’ Reactions” will be presented as boxed text, so that you can easily find and refer to it.

THE ROLE OF PSYCHOSOCIAL NURSING IN MANAGED-CARE SETTINGS

Patients with psychosocial and psychiatric problems often require many more resources than patients without such problems. A patient’s emotional reactions can increase his or her length of stay in the hospital or under a nurse’s care, can con- tribute to the patient’s not complying with care, and can drain physical and emo-

2 Chapter 1 ■ Introduction to Psychosocial Nursing

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tional resources. Once these patient problems are identified, the nurse needs to use skills to meet the patient’s needs while making judicious use of available resources.

In the managed-care system, controls are exerted over access, use, quality, and effectiveness of health services. Managed care is now the dominant form of health care in the United States (Shoemaker & Varcarolis, 2006). It has led to shortened hospital stays and limitations in available resources. Outpatient programs and home health care are now being used more to address problems in place of inpa- tient care. To work within this system, the nurse must quickly identify the patient’s needs, establish a realistic plan of care, implement interventions, and evaluate out- comes, all within a predetermined length of time. Psychosocial and psychiatric patient problems complicate the demands made on the nurse in an already stretched health-care environment and can negatively affect patient outcomes. When the nurse has skills readily at hand to identify problems and intervene effec- tively, patient outcomes can be improved and nurse satisfaction will be enhanced.

Managed care has also intensified the focus on outcome-based interventions to address key problems within a shorter timeframe. Clinical pathways or clini- cal practice guidelines are often used to drive this process. These pathways are evidence-based approaches to plans of care, and their focus is on outcomes. Psy- chosocial and psychiatric problems often have to be addressed to keep on target with the pathway.

PATIENT SAFETY

The incorporation of methods to improve patient safety is an important consid- eration for all levels of patient care today. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has spearheaded a national movement, which includes avoiding the use of abbreviations that can be confused with one another, using universal protocol to prevent surgical error involving “wrong site, wrong procedure, and wrong person,” and the development of National Patient Safety Goals (JCAHO, 2007). Psychosocial care incorporates these patient safety measures as a routine part of practice by maintaining open communication with the patient and health-care team.

LIFE SPAN ISSUES

Although each individual is unique, we all share certain patterns and common links throughout the life cycle. Psychosocial development proceeds through a series of stages and crises. Each phase of the life span presents new challenges, experiences, and problems. Many psychosocial problems have their origins in developmental crises that remain unresolved or that are resolved with negative outcomes. Problems such as depression and grief affect individuals differently in each stage of life. Childhood, adolescence, and old age are times of particular vulnerability to psychosocial dysfunction. Look for this heading in the coming chapters indicating discussions of life span issues.

Chapter 1 ■ Introduction to Psychosocial Nursing 3

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Interventions in this book are geared to adults, but many of them can be adapted to the care of children. To adapt an intervention to a pediatric population, the nurse must consider children’s developmental and cognitive levels, and incor- porate them in the care plan as well as consult specialists in pediatrics, if necessary.

COLLABORATIVE MANAGEMENT

Our complex health-care system relies on a variety of health-care professionals to meet patients’ needs. Obviously, the nurse does not work in a vacuum but must participate in the interdisciplinary team and be aware of other disciplines as resources for psychosocial intervention. The nurse also needs to know when work needs to be shared or delegated through referrals. For example, social workers may be helpful because they are often familiar with psychotherapists and community support groups for emotional problems. The nurse should be aware of agency policies regarding referrals to psychotherapists. Some may require a doctor’s order.

Other resources include physicians, advanced practice nurses, pharmacists, clergy, dietitians, and others, depending on the specialty and setting. Knowing when and how to access them and work effectively with them will improve patient outcomes and enhance the working environment. Collaborative manage- ment is addressed throughout the book in terms specific to the topic discussed in each chapter.

WHEN AND WHO TO CALL FOR HELP

Many difficult, challenging situations require a number of complex skills. While continuing to gain knowledge in identifying psychosocial issues and intervening in cases in which patients require psychosocial care, nurses also need to recognize their own limitations and be able to recognize patient behaviors that may precede or currently signal a dangerous or emergency situation. Knowing when to seek out resources and who to call for help are essential factors in providing quality, cost-effective care.

When and who to call for help will also be set inside a box in coming chap- ters so that you can easily reference it.

PATIENT EDUCATION

Patient education is an important component of psychosocial care. Nurses are required to incorporate appropriate patient education in their practice. To provide adequate education, the nurse needs to be aware of how psychosocial issues influ- ence learning. For example, assessing the patient’s anxiety level or disturbed thoughts will influence the timing of teaching as well as the type of information the nurse tries to convey. Patient education can enhance the patient’s independence and control, involvement of the patient and his or her family in the treatment plan,

4 Chapter 1 ■ Introduction to Psychosocial Nursing

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and help prepare the patient for possible emotional changes, coping skills needed, and responses to medications. Patient education can be influential in reducing length of stay and helping patients to take more responsibility for their own care.

Many factors can affect effective patient education, including patients’ cultural beliefs and language, as well as knowledge of and access to computer technology.

CHARTING TIPS

Changes in patients’ emotional responses and behaviors, and their responses to interventions and education are significant and must be noted in the medical record. The increased use of computerized documentation can present new challenges to nurses who are trying to identify and record behavioral problems succinctly.

Charting tips are given in each chapter for specific situations and are identified with a chapter heading.

COMMUNITY-BASED CARE

Many patients require care that crosses settings, for instance from hospital-based care to home nursing care. In most cases, acute hospital care is now a small part of the treatment plan and eventually ends. To ensure continuity of care, planning for the next level of care should begin as early as possible. While the patient is in the acute setting, this planning needs to begin on admission. Long-term care, out- patient rehabilitation, other outpatient programs, and home health care are now used for many patients. Nurses in all these settings must also consider planning for the next level of care.

Home health agencies may have nurses with psychiatric backgrounds on staff. Box 1–1 lists possible interventions by psychiatric home care nurses. These nurses can be helpful in evaluating patients’ responses to psychotropic medications, confusion, psychotic behavior, and suicide risk. Patients may need referrals to other types of care, such as psychiatric hospitalization or convalescent care, and

Chapter 1 ■ Introduction to Psychosocial Nursing 5

BOX 1–1 Interventions by Psychiatric Home Care Nurses • Crisis intervention • Suicide risk assessment • Management of psychiatric medications and blood level monitoring • Administration of long-acting injectable psychiatric medications • Counseling and education • Assessment of patient and family coping • Safety assessment

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assistance with financial support. Other professionals such as social workers, case managers, and counselors can help ensure safe and effective home care. Other resources including support groups, hotlines, and even telemedicine increase access to care. For a patient to be eligible for psychiatric home care, usu- ally the patient has to be homebound, have a psychiatric diagnosis, and have a need for the skills of a psychiatric nurse (Shoemaker & Varcarolis, 2006).

PATIENT PRIVACY AND RIGHT TO CONFIDENTIALITY

Patient rights are becoming increasingly emphasized in all health-care settings. These rights generally include autonomy, informed consent, treatment with dig- nity and respect, and confidentiality. The Health Insurance Portability and Accountability Act (HIPAA) enacted in 2003 established a number of mechanisms to maintain privacy, including the requirement that health-care professional obtain permission from the pa

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