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Chapter 14 Personality Disorders

Epidemiology

Types of Personality Disorders

Cluster A Personality Disorders

Cluster B Personality Disorders

Cluster C Personality Disorders

Assessment

Nurse, Patient, and Family Resources

Part III Psychiatric Crises

Chapter 15 Grieving

Theory

Anticipatory Grief

Grieving

Complicated Grieving

Nurse, Patient, and Family Resources

Chapter 16 Suicide

Epidemiology

Risk Factors

Assessment

Nurse, Patient, And Family Resources

Chapter 17 Crisis Intervention

Types of Crises

Phases of Crisis

Assessment

Nurse, Patient, and Family Resources

Chapter 18 Anger, Aggression, and Violence

Responses to Anger, Aggression, and Violent Behavior

Nurse, Patient, and Family Resources

Chapter 19 Family Violence

Assessment

Self-Assessment

Nurse, Patient, and Family Resources

Chapter 20 Sexual Violence

Assessment

Nurse, Patient, and Family Resources

Part IV Psychopharmacology

Chapter 21 Attention-Deficit/Hyperactivity Disorder Medications

Stimulants

Nonstimulants

Managing Aggressive Behaviors in Attention-Deficit/Hyperactivity Disorder

Chapter 22 Antipsychotic Medications

First-Generation Antipsychotics

Second-Generation Antipsychotics

Injectable Antipsychotics

Chapter 23 Mood Stabilizers

Lithium

Anticonvulsants

Second-Generation Antipsychotics

Bipolar Depression

Chapter 24 Antidepressants

Antidepressant Drugs

Choosing an Antidepressant

Discontinuing an Antidepressant

Antidepressant Classification

Antidepressant Use in Special Populations

Chapter 25 Antianxiety Medications

Antidepressants

Antianxiety Drugs

Other Classes of Medications

Herbal Therapy and Integrative Approaches

Anxiety Treatment use in Special Populations

Chapter 26 Sleep-Promoting Medications

Benzodiazepines

Nonbenzodiazepine Receptor Agonists

Melatonin Receptor Agonist

Orexin Receptor Agonist

Tricyclic Antidepressant

Over-the-Counter Sleep Aids

Herbal and Dietary Supplements for Insomnia

Chapter 27 Substance Use Disorder Medications

Alcohol Cannabis

Opioids

Hallucinogens

Inhalants

Sedatives, Hypnotics, and Benzodiazepines

Amphetamines

Nicotine

Chapter 28 Neurocognitive Medications

Cholinesterase Inhibitors

N-Methyl-D-Aspartate Receptor Antagonist

Medications for Behavioral Symptoms of Alzheimer's Disease

Part V Nonpharmacological Approaches

Chapter 29 Psychotherapeutic Models

Cognitive–Behavioral Therapy

Dialectical Behavior Therapy

Eye Movement Desensitization and Reprocessing Therapy

Interpersonal Therapy

Behavioral Therapy

Milieu Therapy

Group Therapy

Chapter 30 Brain Stimulation Therapies

Electroconvulsive Therapy

Repetitive Transcranial Magnetic Stimulation

Magnetic Seizure Therapy

Vagus Nerve Stimulation

Deep Brain Stimulation

Light Therapy

References

Appendix A Patient-Centered Assessment

General Information

Presenting Problem, Strengths, Goals, and Coping

Relevant History

Psychiatric History

Medication (Including Over-the-Counter)

Alcohol/Substance Use

Sleep Pattern

Appearance

Attitude

Behavior

Mood

Affect

Speech

Thought Processes

Thought Content

Perceptions

Cognition

Insight

Judgment

Appendix B DSM-5 Classification

Neurodevelopmental Disorders (31)

Schizophrenia Spectrum and Other Psychotic Disorders (87)

Bipolar and Related Disorders (123)

Depressive Disorders (155)

Anxiety Disorders (189)

Obsessive–Compulsive and Related Disorders (235)

Trauma- and Stressor-Related Disorders (265)

Dissociative Disorders (291)

Somatic Symptom and Related Disorders (309)

Feeding and Eating Disorders (329)

Elimination Disorders (355)

Sleep–Wake Disorders (361)

Sexual Dysfunctions (423)

Gender Dysphoria (451)

Disruptive, Impulse-Control, and Conduct Disorders (461)

Substance-Related and Addictive Disorders (481)

Neurocognitive Disorders (591)

Personality Disorders (645)

Paraphilic Disorders (685)

Other Mental Disorders (707)

Medication-Induced Movement Disorders and Other Adverse Effects of Medication (709)

Other Conditions That May Be a Focus of Clinical Attention (715)

Index

Patient Problems by Chapter

Copyright

3251 Riverport Lane

St. Louis, Missouri 63043

Varcarolis' Manual of Psychiatric Nursing Care Planning, Edition 6

ISBN: 978-0-323-47949-3

Copyright © 2019 by Elsevier, Inc. All rights reserved.

All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission and further information about the Publisher's permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Although for mechanical reasons all pages of this publication are perforated, only those pages imprinted with an Elsevier Inc. copyright notice are intended for removal.

Notices

Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds or experiments described herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.

Previous editions copyrighted 2015, 2011, 2006, 2004, 2000

International Standard Book Number: 978-0-323-47949-3

Senior Content Strategist: Yvonne Alexopoulos

Content Development Manager: Lisa Newton

Senior Content Development Specialist: Danielle M. Frazier

Publishing Services Manager: Julie Eddy

Project Manager: Mike Sheets

Design Direction: Patrick Ferguson

Printed in the United States of America

Dedication

This book is dedicated to people who are living with and recovering from mental illness and to the nursing students and registered nurses who focus on supporting this recovery.

Reviewers

Leslie A. Folds Ed D.; PMHCNS-BC; CNE

Associate Professor of Nursing School of Nursing

Belmont University

Nashville, TN

Phyllis M. Jacobs RN, MSN

Assistant Professor Emeritus School of Nursing

Wichita State University

Wichita, Kansas

Susan Justice MSN, RN, CNS

Clinical Assistant Professor

College of Nursing

University of Texas at Arlington College of Nursing and Health

Innovation Arlington, Texas

Chris Paxos PharmD, BCPP, BCPS, BCGP

Pharmacotherapy Specialist

Department of Pharmacy

Cleveland Clinic Akron General Akron, Ohio

Associate Professor of Pharmacy Practice

Department of Pharmacy Practice

Northeast Ohio Medical University, College of Pharmacy

Rootstown, Ohio

Northeast Ohio Medical University, College of Medicine

Rootstown, Ohio

Preface

As with previous editions, the sixth edition of the Varcarolis' Manual of Psychiatric Nursing Care Planning supports students and practitioners in planning realistic, evidence-based, and individualized nursing care for their patients. This thoroughly updated edition of the Manual provides readers with a foundation for clinical work in contemporary psychiatric settings. The chapters are logically and intuitively arranged in five parts:

• Part I provides a snapshot of basic psychiatric concepts and tools. These chapters focus on the nursing process, therapeutic relationships, and therapeutic communication.

• Part II explores specific diagnostic groups, an overview of major disorders within these groups, and guidelines for developing and providing psychiatric nursing care.

• Part III discusses psychiatric crises such as suicide and family violence and outlines the nursing process as it pertains to these crises.

• Part IV is devoted to psychopharmacology. Eight chapters provide essential information regarding specific classifications of drugs such

as antipsychotics and antidepressants.

• Part V provides a summary of nonpharmacological approaches. Whereas psychotherapeutic models are mentioned in the clinical chapters, Chapter 29 provides an overview of evidence-based therapies such as cognitive–behavioral therapy. Chapter 30 introduces the increasingly common brain stimulation therapies, such as electroconvulsive therapy and vagus nerve stimulation.

Overall, the format of the Manual has been streamlined and blank space reduced. The organization of the clinical chapters now mirrors the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Although some classical references remain, citations are thoroughly updated.

In this edition, we have moved toward a terminology that more accurately reflects the way healthcare professionals describe patient problems in the real world. This move eliminates the use of NANDA-I nursing diagnoses, which requires nurses to learn a second language in addition to the primary terms that are used by other healthcare providers. We hope that this approach will promote and support interprofessional collaboration for nursing students and nurses.

Acknowledgments

Thanks to my Elsevier family for coordinating and completing another successful project. Kudos go out to Yvonne Alexopoulos, senior content strategist, for providing feedback and supporting my ideas for this sixth edition. Yvonne is a brilliant person with thoughtprovoking comments along with a humorous take on thorny issues. As always, cheers go out to Lisa Newton, our content development manager. This is a woman who responds to emails within an hour, sends positive greetings, and adds a personal touch to nearly all of our communications.

As a senior content development specialist, Danielle Frazier moved the publishing process along while tirelessly re-uploading files to the electronic management system. Big thanks to Mike Sheets, project manager, for pulling all the details together, ensuring consistency, and producing a reader-friendly edition for students and clinical nurses.

Moving from NANDA-I based nursing care plans to a patient problem approach was a big move. Other nurse editors have pioneered and already adopted this method in their popular textbooks. I am especially grateful to editors Donna Ignatavicius and Pamela Swearingen for taking the lead in this endeavor and helping me through the process.

Finally, I'd like to acknowledge Elizabeth (Betsy - the real wizard) Varcarolis. Betsy developed a leading undergraduate psychiatric nursing textbook, Foundations of Psychiatric-Mental Health Nursing, and later added the Manual of Psychiatric Nursing Care Planning. Together, Betsy and I went on to introduce the popular Essentials of Psychiatric Mental Health Nursing, a more condensed version of Foundations. Countless psychiatric nursing students have read her words and been

prepared for the NCLEX based on her knowledge of this discipline. I am sincerely grateful to have been (and still am) Betsy's apprentice. I will always be indebted to her.

PART I

Foundations for Psychiatric Nursing Care

OUTLINE

Chapter

Chapter

Chapter

CHAPTER 1

The Nursing Process

The basis of psychiatric–mental health nursing is the therapeutic relationship. It is within this relationship that care is provided to address healthcare problems, both actual or potential. These problems occur in the context of or as the result of psychiatric disorders, also known as mental illness or mental disorders. A common language for nurses, physicians, social workers, psychologists, and other professionals who work in the mental health system facilitates patient care.

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the official publication of the American Psychiatric Association (APA) for categorizing medical diagnoses in the United States. The DSM provides clinicians, researchers, insurance companies, pharmaceutical firms, and policy makers with standard criteria for the classification of psychiatric disorders. Clinicians use this publication as a guide for planning care and evaluating patients' treatments.

First published in 1952, the current manual is the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) (APA, 2013). The Manual of Psychiatric-Mental Health Nursing Care Planning uses the DSM-5 for organizing the order of clinical chapters and for describing psychiatric disorders.

The Nursing Process

The nursing process is a problem-solving process. It is the basic framework for nursing practice with patients who are experiencing psychiatric disorders or conditions. The National Council of State Boards of Nursing ([NCSBN] 2015, p. 3) defines the nursing process as “a scientific, clinical reasoning approach to client care that includes assessment, analysis, planning, implementation and evaluation.” The nursing process is fundamental to patient care and is the basis for this textbook.

Safety and quality care for patients are also prime directives for nurses and nursing education. The national initiative that is centered on patient safety and quality of care is known as Quality and Safety Education for Nurses (QSEN). QSEN competencies are integrated throughout this manual, and specific examples are highlighted along with each standard of practice. Box 1.1 provides a summary of the competencies.

Box 1.1

Quality and Safety Education for Nurses (QSEN) Competencies

Patient-centered care: Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for the patient's preferences, values, and needs.

Teamwork and collaboration: Function effectively within nursing and interprofessional teams, fostering open communication, mutual respect, and shared decision making to achieve quality patient care.

Evidence-based practice: Integrate best current evidence with

clinical expertise and patient/family preferences and values for delivery of optimal health care.

Quality improvement: Use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems.

Safety: Minimizes risk of harm to patients and providers through both system effectiveness and individual performance.

Informatics: Use information and technology to communicate, manage knowledge, mitigate error, and support decisionmaking.

QSEN Institute. (n.d.). QSEN competencies. Retrieved from http://qsen.org/competencies/pre-licensure-ksas

Assessment

Psychiatric–mental health registered nurses collect information that guides the plan of care. Assessment is an essential initial activity and it is also ongoing. The focus and type of information that is gathered is based on the patient's specific condition and by anticipating future needs.

Quality and Safety Standards (QSEN) Related to Assessment

• Patient-centered care: Elicit preferences, values, and expressed needs as part of the clinical interview.

• Informatics: Identify essential information that must be available in a common database to support patient care.

Patients with psychiatric disorders are not only found on behavioral health units. Symptoms such as depression, suicidal thoughts, anger, disorientation, delusions, and hallucinations are encountered in all settings. These settings include medical-surgical wards, obstetrical units, intensive care units, outpatient settings, extended-care facilities, emergency departments, and community centers. Psychiatric symptoms can also be the result of chemical imbalances, substance use, and disease. The assessment helps to identify and clearly articulate specific problems in the individual's life that are causing distress.

The assessment has several primary goals:

• Establish rapport.

• Elicit the patient's chief complaint (i.e., the

perception of the problem in the patient's own words).

• Review physical status and obtain baseline vital signs.

• Determine the impact of the disorder and symptoms on the patient's life (self-esteem, loss of intimacy, role functioning, change in family dynamics, lifestyle change, and employment issues).

• Identify risk factors that may affect safety (e.g., confusion, suicidal thoughts, or homicidal thoughts).

• Gather information related to previous illnesses, treatment, and hospitalizations.

• Identify psychosocial status (family relationships, social patterns, interests and abilities, stress factors, substance use, social supports).

• Complete a mental status examination.

It is helpful if the patient's family members, friends, and relatives participate during the data collection whenever possible. If a law enforcement agent brought the patient into the emergency department or crisis intervention unit, it is important for the nurse to understand what situation warranted police intervention.

Past medical and psychiatric history can supply valuable information. This is particularly important if the patient is experiencing psychosis, is withdrawn and mute, or is too agitated to

provide a history. Charts from previous hospitalizations or electronic medical records are extremely helpful. Laboratory reports also provide important information.

The use of a standardized nursing assessment tool facilitates the assessment process. Appendix A contains a patient-centered assessment tool. Most healthcare facilities provide patient assessments in either paper or electronic form. Although these tools are integral for gathering essential data, they can feel impersonal. With practice, nurses become proficient in gathering information in a less formal fashion, with the nurse clarifying, focusing, and exploring pertinent data with the patient. This method allows patients to state their perceptions in their own words and enables the nurse to observe a wide range of nonverbal behaviors. A personal style of interviewing congruent with the nurse's personality develops as comfort and experience increase. Box 1.2 presents the factors that are typically assessed.

Box 1.2

Common Assessment Areas

Previous psychiatric treatment

Educational background

Occupational background

Employed? Where? How long?

Special skills

Social patterns

Describe family.

Describe friends.

With whom does the patient live?

To whom does the patient go in times of crisis?

Describe a typical day.

Sexual patterns

Sexually active? Practices safe sex? Practices birth

control?

Sexual orientation

Sexual difficulties

Interests and abilities

What does the patient do in his or her spare time?

What sport, hobby, or leisure activity is the patient good at?

Medications

What medications does the patient take? How often? How much?

What herbal or over-the-counter drugs does the patient take? How often? How much?

What psychotropic drugs does the patient take or use? How often? How much?

How many drinks of alcohol does the patient take per day? Per week?

What recreational drugs does the patient take or use? How often? How much?

Does the patient identify the use of drugs as a problem?

Coping abilities

What does the patient do when he or she gets upset?

To whom can the patient talk?

What usually helps to relieve stress?

What did the patient try this time?

Issues for Which Referral May Be Indicated

Patients may be referred to social services and might need further investigation when planning long-term care. This is especially important in the case of severe mental illness, if any of the following issues are noted:

• Problems

with

primary support (death, illness, divorce, sexual or physical abuse,

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