00Shives(F)-FM 12/7/06 10:44 AM Page i Basic Concepts of Psychiatric–Mental Health Nursing S E EVENTH DITION Louise Rebraca Shives, MSN, ARNP, CNS Psychiatric–Mental Health Nurse Practitioner and Clinical Nurse Specialist Consultant in Long-Term Care Legal Nurse Consultant Orlando,Florida Health Ministry Cabinet,St.Stephen Lutheran Church Co-Director C.A.R.E.Team Ministry,St.Stephen Lutheran Church Longwood,Florida 00Shives(F)-FM 12/7/06 10:44 AM Page ii Senior Acquisitions Editor:Peter Darcy Managing Editor:Michelle Clarke Senior Production Editor:Debra Schiff Director of Nursing Production:Helen Ewan Senior Managing Editor/Production:Erika Kors Design Coordinator:Holly Reid McLaughlin Interior/Cover Designer:Candice Carta-Myers Manufacturing Coordinator:Karin Duffield Indexer:Kathy Pitcoff Compositor:Spearhead Printer:RR Donnelley-Crawfordville Seventh Edition Copyright © 2008 by Lippincott Williams & Wilkins,a Wolters Kluwer business. Copyright © 2005, 2002 by Lippincott Williams & Wilkins. Copyright © 1998 by Lippincott-Raven Publishers.All rights reserved.This book is protected by copyright.No part of this book may be reproduced or transmitted in any form or by any means,including as photocopies or scanned-in or other electronic copies,or utilized by any information storage and retrieval system without written permission from the copyright owner,except for brief quotations embodied in critical articles and reviews.Materials appearing in this book prepared by individuals as part of their official duties as U.S.government employees are not covered by the above-mentioned copyright.To request permission,please contact Lippincott Williams & Wilkins at 530 Walnut Street,Philadelphia,PA 19016,via email at [email protected],or via our web- site at lww.com (products and services). 9 8 7 6 5 4 3 2 1 LCCN 98643499 ISBN 978-0-7817-9707-8 Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices.However,the author,editors,and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty,expressed or implied,with respect to the currency,completeness,or accuracy of the contents of the publication. Application of this information in a particular situation remains the professional responsibility of the prac- titioner;the clinical treatments described and recommended may not be considered absolute and univer- sal recommendations. The author,editors,and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with the current recommendations and practice at the time of pub- lication.However,in view of ongoing research,changes in government regulations,and the constant flow of information relating to drug therapy and drug reactions,the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions.This is par- ticularly important when the recommended agent is a new or infrequently employed drug. Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings.It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned for use in his or her clinical practice. LWW.com 00Shives(F)-FM 12/7/06 10:44 AM Page iii This book is dedicated to my daughters, Terri Spence, Lorrie Shives, and Debbie Moore;to my grandchildren, Jeffray, Jennifer, and Zachary;and to the memory of my parents, Pete and Christine Rebraca. 00Shives(F)-FM 12/7/06 10:44 AM Page iv R EVIEWERS Tamera L. Althoff, MSN, RN Jane S. Hopson, MSN, RN Associate Professor Coordinator,Practical Nursing Program North Dakota State College of Science Northeast Alabama Community College Wahpeton,North Dakota Rainsville,Alabama Kathleen C. Banks, MSN Leanna Huscher, MSN, RN Assistant Professor AD Nursing Associate Professor Kent State University,East Liverpool Campus Kansas Wesleyan University East Liverpool,Ohio Salina,Kansas Catherine Batscha, MSN Linda Kisker, MSN, BSN, RN Clinical Instructor Professor of Nursing University of Illinois,Chicago College of Nursing Kansas City Kansas Community College Chicago,Illinois Kansas City,Kansas Terry Broda, BSN, RN, CDDN Kathryn Kornegay, PhD, RN, CARN-AP Nursing Instructor Professor of Nursing John Abbott College Southeast Missouri State University Montreal,Québec,Canada Cape Girardeau,Missouri Denise Doliveira, MSN, RN Dimitra Loukissa, PhD, RN Assistant Professor Assistant Professor Community College of Allegheny County,Boyce Campus Rush University Monroeville,Pennsylvania Chicago,Illinois Florencetta Hayes Gibson, PhD, APRN, LMFT Tamar Jones Lucas, MSN, BSN, RN, BC Director,Associate Professor,School of Nursing Associate Degree Nursing Instructor University of Louisiana at Monroe Itawamba Community College Monroe,Louisiana Fulton,Mississippi Jessica Greni, MSN, RN Jane S. Mahoney, DSN, APRN, BC ADN Director/Faculty Assistant Professor Howard College University of Texas Health Science Center at Houston Big Spring,Texas Houston,Texas Leslie E. Guthrie, MS, BSN, RN, CLC, NRP Sherri Melrose, PhD, RN Assistant Professor of Nursing Assistant Professor Bacone College Centre for Nursing and Health Studies,Athabasca University Muskogee,Oklahoma Calgary,Alberta,Canada Pamela Gwin, BSN, RN,C Norma Ponzoni, PhD (c), RN Director,Vocational Nursing Program Nursing Professor Brazosport College John Abbott College Lake Jackson,Texas Ste Anne de Bellevue,Québec,Canada iv 00Shives(F)-FM 12/7/06 10:44 AM Page v REVIEWERS v Nancy E. Reilly, PhD, RN B. J. Taylor, MSN, RN, CS Associate Professor Assistant Professor Armstrong Atlantic State University Raymond Walters College Savannah,Georgia University of Cincinnati Cincinnati,Ohio Janell Sample, MSN, RN Assistant Professor Ann-Marie Urba, MSN, RN Del Mar College Faculty,Nursing Education Program Corpus Christi,Texas Saskatchewan (NEPS)–Wascana Campus Saskatchewan Institute of Applied Science and Technology Barbara Scheirer, MSN, RN (SIAST) Assistant Professor Regina,Saskatchewan,Canada Grambling State University Grambling,Louisiana Linda Wood, MSN, RN Director of Practical Nursing Nicole Snow, MSN(c), BSN, RN Massanutten Technical Center Faculty Harrisonburg,Virginia Centre for Nursing Studies St.John’s,New Brunswick,Canada 00Shives(F)-FM 12/7/06 10:44 AM Page vi P REFACE S ince its inception,the goal has been to produce a • Expanding content regarding historical perspec- textbook that addresses the current concepts used in tives of the various psychiatric–mental health psychiatric–mental health nursing to foster compe- disorders tency in practicing nurses and other mental health • Adding content about forensic nursing practice,the professionals.Several nursing journals were reviewed psychiatric–mental health nurse’s role in disaster to obtain information relevant to the content included intervention,and the identification and treatment of in this text:ADVANCE for Nurses,ADVANCE for Nurse the impaired nurse Practitioners, American Journal for Nurse • Expanding content about spirituality,schizophrenia, Practitioners,American Journal of Nursing,Clinical substance-related disorders,and disorders of child- Advisor:A Forum for Nurse Practitioners, and the hood and adolescence Journal of Psychosocial and Mental Health Nursing. • Adding current information regarding psychiatric Additional journals utilized were Clinical Psychiatry research that focuses on genetic,biologic,and psy- News, Current Psychiatry, and Neuropsychiatry chosocial theories News.Information regarding psychotropic medication • Discussing current technological advances used in was obtained from several sources including current the delivery of care editions of the Nurse Practitioners’ Prescribing • Reorganizing the lengthy chapter on psychophar- Reference. Several Internet resources, including the macology World Health Organization and Centers for Disease • Adding current content on clinical psychopharma- Control and Prevention,were utilized to obtain rele- cology in the disorder chapters,including the prac- vant information and current statistics related to vari- tice of “off-label prescribing,” the identification of ous psychiatric–mental health disorders. target symptoms for specific drugs,the assessment Comments by reviewers helped this author to iden- and treatment of metabolic syndrome, and the tify specific content that should be included in this importance of recognizing FDA black box warnings seventh edition of Basic Concepts of Psychiatric– as they relate to nursing interventions Mental Health Nursing. Consideration was given to • Retaining information related to nursing specialties the limited amount of time and various clinical set- such as legal,holistic,parish,and addictions nursing tings in which nurse educators are able to present psy- • Retaining content regarding clients who are seri- chiatric–mental health nursing content. Reviewers ously and persistently mentally ill, including the recommended: homeless and incarcerated • Retaining, and expanding when indicated, peda- • Retaining the following threads throughout the gogic content such as key terms, learning objec- text:psychobiological and developmental theories tives,nursing research,NCLEX-style multiple-choice related to specific disorders;economic,spiritual,and questions,critical thinking questions,and Internet religious factors affecting mental health; cultural resources and ethnic diversity;loss and grief;the nurse’s role in clinical psychopharmacology; management of As noted in the 6th edition, understanding the pain and sleep disturbances;client empowerment; neuropathology or pathophysiology of a psychi- and the utilization of behavior therapy as a nursing atric–mental health disorder presents a challenge to intervention when appropriate student nurses as they enter a new phase of nursing vi 00Shives(F)-FM 12/7/06 10:44 AM Page vii PREFACE vii education. Clinical psychopharmacology, which health maintenance, misconceptions about mental includes a working knowledge of the pharmacody- illness, different levels of communication used by namics and pharmacokinetics of psychoactive drugs clients and health care providers,the use of defense and the potential for drug–drug interactions,is an inte- mechanisms,and the ANA standards of practice.The gral part of psychiatric–mental health nursing care. current state of psychiatric nursing,including career Furthermore,students must be given the opportunity opportunities and the expanded role of the nurse,is to feel competent using crisis and disaster interven- addressed. Chapter 3 addresses the development of tion techniques because both have become topics psychiatric–mental health nursing theory and its appli- affecting the mental health of all age groups. cation to practice. The availability of settings for student nurse clinical Unit II,Special Issues Related to Psychiatric– experiences continues to be limited due to changes in Mental Health Nursing, consists of five chapters. Medicaid and Medicare reimbursement,limited insur- Chapter 4 discusses spiritual, cultural, and ethnic ance coverage for both outpatient and inpatient psy- issues psychiatric–mental health nurses face as they chiatric care, and the decentralization of settings provide care to various diverse clients in the clinical where mental health care is provided (eg,private prac- setting.Nursing implications derived from research on tice,community mental health centers,mobile mental ethnopharmacology are also addressed.Chapter 5 dis- health units,and school systems).For example,insur- cusses the major ethical and legal issues that occur in ance carriers require health care providers to obtain psychiatric–mental health nursing. precertification prior to an initial consult for clients Chapter 6,a new chapter,focuses on the history with mental health concerns. This precertification of forensic nursing,the scope and standards of foren- process often delays or may deny treatment.If precer- sic nursing practice, the forensic nurse’s code of tification is obtained, the insurance carriers then ethics, and forensic nursing education. Chapter 7 require the health care providers to complete a treat- provides information to familiarize the student with ment plan stating the number of estimated visits the the concepts of loss, grief, and end-of-life care as client will require,what type of treatment will be ini- they are experienced by individuals,families,or their tiated,and where the treatment will occur.Finally,the significant others.Chapter 8 discusses the continuum out-of-pocket expenses or co-payments imposed on of care available to clients as they progress from clients may affect their decision to continue or dis- the most restrictive clinical setting (inpatient) to continue treatment.As a result of these changes and the least restrictive clinical setting in which they limitations in the delivery of psychiatric–mental health may reside. care,student nurses are now challenged to apply the Unit III, Components of the Nurse–Client basic concepts of psychiatric–mental health nursing in Relationship,includes four chapters.Chapters 9 and diverse settings. 10 discuss the application of the six steps of the nurs- ing process and the use of the Diagnostic and Text Organization Statistical Manual of Mental Disorders, Fourth Edition,Text Revision (DSM-IV-TR) in the psychiatric The text is organized into seven units.An in-depth setting.Chapters 11 and 12 address therapeutic com- review of chapter content and a detailed literature munication and relationships and the therapeutic search were conducted to provide the student with milieu. the most current information available. Suggestions Unit IV,Interactive Therapies,consists of three by reviewers were considered and added to enhance chapters. They describe the different therapeutic content. approaches used by psychiatric–mental health nurses Unit I, Psychiatric–Mental Health Nursing, to meet the needs of clients and their families and sig- includes three chapters. Chapter 1 focuses on the nificant others. The approaches include Crisis and development of self-awareness and addresses student Disaster Intervention (Chapter 13), Individual issues and concerns regarding psychiatric clinical Psychotherapy (Chapter 14),and Family,Couple,and experiences. Chapter 2 discusses the history and Group Therapy (Chapter 15). trends of psychiatric–mental health nursing from 1773 Unit V, Special Treatment Modalities, includes to present.It describes basic concepts such as mental three chapters.Chapter 16 addresses the science of health and mental illness, factors affecting mental psychopharmacology and the rationale for the use of 00Shives(F)-FM 12/7/06 10:44 AM Page viii viii PREFACE various psychoactive agents, including the newest • Disorders of infancy,childhood,and adolescence agents available at the time of publication.Generic and • Ineffective coping with the psychosocial aspects of trade names,as well as daily dose ranges of various aging agents,are listed.Chapter 17,Somatic Therapies,dis- • Suicidal ideation or behavior or who request physi- cusses the history of ECT,its indications for use in the cian-assisted suicide psychiatric clinical setting,contraindications,adverse • Dual diagnosis effects,advances in the technique,and nursing inter- • Abuse and violence ventions.A discussion of recent advances in somatic • Ineffective coping associated with AIDS therapies (e.g.,VNS,TMS,and MST) is also included. • Serious and persistent mental illness Chapter 18 describes the concept of holistic nursing and discusses the common complementary and alter- Pedagogic Features native (CAM) therapies classified by the National Reviewers recommended that several pedagogic fea- Institute of Health that are used in the treatment of tures introduced in the sixth edition be retained in insomnia,pain,stress and anxiety,depression,and cog- this edition’s text. Revisions in each of the features nitive decline. were made when appropriate to reflect changes in or Unit VI, Clients With Psychiatric Disorders, expansion of content.Pedagogic features include: contains 10 chapters (Chapters 19 through 28). The chapter order has been reorganized to introduce • Learning objectives at the beginning of each the more common psychiatric disorders first, chapter focusing on: • Key terms at the beginning of each chapter linked to the expanded glossary • Anxiety disorders • Self-awareness prompts • Somatoform and dissociative disorders • Clinical examples of clients with specific psychi- • Mood disorders atric–mental health disorders • Schizophrenia and schizophrenic-like disorders • Boxes to highlight features such as med alerts, • Eating disorders assessment or screening tools,subtypes of a specific • Personality development and personality dis- disorder,and nursing interventions orders • Recurring boxes that address supporting evidence • Substance-related disorders for practice • Sexuality and sexual disorders • Drug summary tables in clinical disorder chapters • Cognitive disorders that include generic/trade name, dosage range, • Delusional and shared psychotic disorders adverse effects,and nursing interventions • Recurring boxes summarizing the major clinical Each chapter describes the historical perspective symptoms and diagnostic characteristics associated of a disorder,if applicable;discusses the etiology of with specific psychiatric mental health disorders specific disorders,including the discussion of specific incorporating the DSM-IV-TRcriteria theories if appropriate;presents the clinical symptoms • Recurring boxes highlighting examples of North and diagnostic characteristics of each disorder incor- American Nursing Diagnosis Association (NANDA) porating the DSM-IV-TR criteria when applicable; nursing diagnoses for specific disorders focuses on the application of the nursing process; • Recurring boxes providing examples of client out- and explains the continuum of care. Most of these comes for specific disorders chapters contain a drug summary table listing the • Key concepts summarized at the end of each generic name and trade name of the more common chapter drugs used,the daily dosage range,adverse effects,and New and Expanded Features nursing implications.Specific target symptoms of cer- tain drugs are listed if the drug is used for stabilization and Content of more than one symptom or is used in off-label The seventh edition now provides: prescribing. Unit VII, Special Populations, includes seven • Examples of unique pilot or outreach intervention chapters (Chapters 29 through 35) that address the programs such as In Shape (Chapter 12), Project needs of clients who exhibit clinical symptoms of: SMART (Chapter 20),community- and school-based 00Shives(F)-FM 12/7/06 10:44 AM Page ix PREFACE ix interventions (Chapter 29), and Signs of Suicide Commission on Complementary and Alternative Prevention Programs (Chapter 31) Medicine Policy and the establishment of safety clas- • Examples of current research and surveys pertain- sifications of medical herbs by the American Herb ing to specific psychiatric mental health disorders Products Association including schizophrenia,eating disorders,substance • New and expanded content in Chapter 20 related to abuse,dementia,and autism somatoform and dissociative disorders • Expanded content in Chapter 2 describing events • New and expanded content in Chapter 21 including during the 21st century that have influenced history an historical perspective of mood disorder,biologic and trends in psychiatric–mental health nursing theories related to mood disorder, clinical symp- • New content in Chapter 4 addressing spiritual,cul- toms and characteristics of mood disorder with tural,and ethnic issues postpartum onset,and pain management of clients • New content in Chapter 5 focusing on ethical with a mood disorder and legal issues such as advance psychiatric direc- • New and expanded content in Chapter 22 including tives history of schizophrenia, clinical symptoms of • One new chapter, Chapter 6, describing forensic metabolic syndrome, Phase I of the Clinical nursing practice Antipsychotic Trials Intervention Effectiveness • New content in Chapter 7 describing the use of a (CATIE) in Schizophrenia, and application of the legal document,5 Wishes,that enables a dying client nursing process to plan his or her end-of-life care • New and expanded content in Chapter 23 focusing • New and expanded content in Chapter 9 regarding on the history of eating disorders, research, and the assessment of supporters or caregivers of application of the nursing process clients,cultural assessment of diverse client popula- • Expanded content in Chapter 24 regarding individ- tions,and assessment of clients exhibiting impaired uals at risk for the development of personality dis- communication and thought process orders, clinical symptoms and diagnostic • New content in Chapter 10 regarding the concept characteristics, and application of the nursing of evidence-based nursing practice process • New content in Chapter 11 discussing therapeutic • New content in Chapter 25 including the history of interaction with difficult clients who exhibit angry, substance use and abuse,prescription drug abuse, manipulative, suspicious, demanding, uncoopera- Internet addiction,Stages of Change Model,detoxi- tive,or escalating behavior fication,and the impaired nurse • Expanded content in Chapter 12 focusing on inter- • New and expanded content in Chapter 26 dis- ventions related to personal and sleep hygiene,pain cussing sexual aggression in adolescents,new diag- management,restraint and seclusion standards for nostic labels regarding women’s sexual problems, protective care, and therapeutic lifestyle change medical management of clients with sexual disor- counseling ders,and treatment of children with sexually abu- • New content in Chapter 13 discussing disaster inter- sive behavioral problems vention • New and expanded content in Chapter 27 address- • New content in Chapter 14 focusing on nur- ing the history of dementia, dementia with Lewy sing diagnosis for individuals,including children and bodies,behavioral intervention techniques and pro- adolescents,participating in individual psychother- grams,medication management of clients with cog- apy nitive disorders, and research related to cognitive • Expanded content in Chapter 15 including the addi- disorders tion of couple therapy • New content in Chapter 28 describing the • Expanded content in Chapter 16 describing the sci- history of delusional and shared psychotic dis- ence of psychopharmacology orders • New and expanded content in Chapter 17 describ- • New and expanded content in Chapter 29 including ing the history of ECT,recent advances in somatic history of child and adolescent psychiatry, recent therapies,and nursing diagnoses related to clients research regarding autism, clinical symptoms of utilizing somatic therapies ADHD in adults,attachment theory,child and ado- • New and expanded content in Chapter 18 describ- lescent psychosis,and community- and school-based ing practice recommendations by the White House interventions 00Shives(F)-FM 12/7/06 10:44 AM Page x x PREFACE • New and expanded content in Chapter 30 focusing Ancillary Package on the history of geriatric psychiatry; assessment of elderly clients,with specific content addressing An Instructor’s Resource CD-ROM is available to fac- the treatment of Native American,African American, ulty adopting this text and a back-of-book CD-ROM Hispanic, and Asian American elderly clients; pain is available for students.There is also a companion management;and stabilization of sleep–rest activity website at thePoint*. The Instructor’s Resource • New and expanded content in Chapter 31 including CD-ROMincludes: new theories,assessment tools for adolescents,sui- • PowerPoint lectures intended to provide significant cide prevention programs, and empowerment of lecture,classroom,and/or online teaching support. survivors of suicide • Testbank containing approximately 350 multiple- • Expanded content in Chapter 32 focusing on the choice NCLEX-style question application of the nursing process during the treat- • Answers to the NCLEX-style questions found at the ment of clients with dual diagnosis end of each chapter • New and expanded content in Chapter 33 dis- • An Image Bank cussing child abduction,groups at risk for domestic • Answers to the movie viewing guides or intimate partner violence,etiology of youth vio- lence,and hate crimes Student Resource CD-ROM • New and expanded content in Chapter 34 related to the history and etiology of HIV/AIDS A back-of-book CD-ROM is an invaluable learning tool • Expanded content in Chapter 35 related to special that provides an NCLEX alternate format tutorial,clin- populations of the homeless,hate crimes against the ical simulations, and movie viewing guides, as indi- homeless, and the application of the nursing cated by the icon in the text.Also process including assessment,medication manage- included are a Glossary,updated Internet Resources, ment and education, continuum of care, and and a Spanish-English Audio Glossary. empowerment of clients with SPMI • Updated selected references and suggested readings *thePoint is a trademark of WKHealth