Section 10.2: Care for Clients with Maladaptive Behaviors and Mental Health Disorders

Anxiety and Obsessive-Compulsive Disorders

Anxiety is a universal human experience, but when it becomes disproportionate to the stimulus or impairs functioning, it manifests as a disorder. Levels of anxiety range from mild (which can be motivating and enhances learning) to moderate, severe, and panic. During severe and panic-level anxiety, the client's perceptual field is severely narrowed, and learning is impossible.

Nursing Interventions for Severe/Panic Anxiety:

• Prioritize Safety: Remain with the client. Leaving them alone can exacerbate panic.
• Environment: Move the client to a quiet environment with minimal stimulation.
• Communication: Use clear, short, and simple sentences. Speak in a calm, firm, and reassuring voice.
• Pharmacology: Administer short-acting benzodiazepines (e.g., lorazepam, alprazolam) as prescribed for acute relief.

In Obsessive-Compulsive Disorder (OCD), clients experience intrusive thoughts (obsessions) that cause severe anxiety, leading to repetitive behaviors (compulsions) performed to alleviate that anxiety. The initial nursing approach is to allow time for the compulsion to prevent a severe panic attack, while gradually working with the client to implement a schedule that limits the behavior, coupled with Cognitive Behavioral Therapy (CBT).

Depressive Disorders

Major Depressive Disorder (MDD) is characterized by a persistently depressed mood, anhedonia (loss of interest in pleasurable activities), sleep disturbances, psychomotor retardation, and potential suicidal ideation.

Nursing Management for MDD:

• Suicide Assessment: Continuously assess for suicidal ideation, specifically asking if they have a plan and the means to carry it out. This is the highest priority.
• Basic Needs: Clients may neglect hygiene and nutrition. Offer small, frequent, high-calorie meals. Assist with ADLs without doing everything for them, to promote independence.
• Pharmacology: SSRIs (e.g., fluoxetine, sertraline) are first-line. Educate clients that antidepressants take 2 to 4 weeks to achieve therapeutic effect. Watch for Serotonin Syndrome (agitation, hyperthermia, rigidity) and explicitly warn against abruptly stopping the medication. If the client is on MAOIs, provide strict dietary education to avoid tyramine-rich foods (aged cheese, cured meats, wine) to prevent hypertensive crisis.

Bipolar Disorder

Bipolar disorder is characterized by extreme mood swings spanning from deep depression to extreme euphoria and hyperactivity (mania). During an acute manic episode, clients exhibit flight of ideas, grandiosity, impulsivity, hypersexuality, and severely decreased need for sleep.

Nursing Management for Acute Mania:

• Safety and Environment: Provide a safe, low-stimulus environment. Remove hazardous objects, as clients are highly impulsive.
• Nutrition: Manic clients cannot sit still long enough to eat. Provide high-calorie, nutritious "finger foods" and drinks they can consume while moving.
• Communication: Use a firm, calm approach with concise explanations. Set strict, consistent limits on inappropriate behaviors.
• Pharmacology: Lithium carbonate is the gold standard mood stabilizer. The therapeutic index is extremely narrow (0.6 to 1.2 mEq/L). Educate the client on maintaining adequate fluid and sodium intake, as sodium depletion can lead to lithium toxicity (manifesting as ataxia, severe diarrhea, blurred vision, and tinnitus).

Schizophrenia and Psychotic Disorders

Schizophrenia is a severe mental disorder that profoundly disrupts perception, thought processes, and emotional responsiveness. Symptoms are categorized into positive (presence of abnormal behaviors) and negative (absence of normal behaviors).

• Positive Symptoms: Hallucinations (mostly auditory), delusions (fixed, false beliefs), disorganized speech (word salad, neologisms), and bizarre behavior.
• Negative Symptoms: Flat affect, alogia (poverty of speech), avolition (lack of motivation), and anhedonia.

Nursing Interventions for Psychosis:

• Managing Delusions: Do not argue with or validate the delusion. Instead, validate the feeling behind the delusion (e.g., "I understand you believe the food is poisoned and that makes you fearful, but the food is safe.").
• Managing Hallucinations: Observe for behavioral cues (talking to oneself, tilting the head). Ask the client directly what the voices are saying to assess for command hallucinations that may instruct the client to harm themselves or others.
• Pharmacology: Administer typical (e.g., haloperidol) or atypical (e.g., clozapine, risperidone) antipsychotics. Monitor aggressively for Extrapyramidal Symptoms (EPS) such as acute dystonia, akathisia, and tardive dyskinesia, as well as the life-threatening Neuroleptic Malignant Syndrome (NMS - characterized by severe muscle rigidity, high fever, altered mental status, and autonomic instability).

Personality Disorders

Clients with personality disorders possess rigid, maladaptive traits that cause significant functional impairment. Borderline Personality Disorder (BPD) and Antisocial Personality Disorder are highly tested.

• Borderline Personality Disorder: Characterized by severe emotional instability, fear of abandonment, impulsivity, self-harming behaviors, and splitting (viewing people as entirely good or entirely bad). The primary nursing intervention is maintaining strict consistency among all staff members to prevent the client from manipulating and turning staff against one another.
• Antisocial Personality Disorder: Characterized by a pervasive disregard for the rights of others, deceitfulness, and a profound lack of remorse. Nursing care involves setting clear, firm limits, detailing the specific consequences of rule violations, and enforcing these consequences without argument or negotiation.