Varcarolis' Foundations of Psychiatric-Mental Health
Nursing
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Table of Contents
Cover image
Title page
Copyright
Dedication
Acknowledgments
Contributor List
Reviewers
To the Instructor
To the Student
Unit I. Foundations in Theory
1. Mental Health and Mental Illness
Mental Health and Mental Illness
Mental Health Continuum
Risk and Protective Factors
Legislation and Mental Health Funding
Epidemiology of Mental Disorders
Psychiatric-Mental Health Nursing
Future Issues for Psychiatric-Mental Health Nurses
Advocacy and Legislative Involvement
Key Points to Remember
Critical Thinking
2. Theories and Therapies
Psychoanalytic Theories and Therapies
Interpersonal Theories and Therapies
Behavioral Theories and Therapies
Cognitive Theories and Therapies
3
Humanistic Theories
Biological Theories and Therapies
Developmental Theories
Conclusion
Key Points to Remember
Critical Thinking
3. Psychobiology and Psychopharmacology
Structure and Function of the Brain
Action of Psychotropic Drugs
Key Points to Remember
Critical Thinking
Unit II. Foundations for Practice
4. Treatment Settings
Background
Continuum of Care
Outpatient Care Settings
Prevention in Outpatient Care
Outpatient Psychiatric Nursing Care
Inpatient Care Settings
Considerations for Inpatient Care
Inpatient Psychiatric Nursing Care
Specialty Treatment Settings
Key Points to Remember
Critical Thinking
5. Cultural Implications
Minority Status, Race, Ethnicity, and Culture
Demographic Shifts in the United States
Basic Worldviews
Impact of Culture
Cultural Barriers to Mental Health Services
Populations at Risk for Mental Illness and Inadequate Care
Culturally Competent Care
Key Points to Remember
Critical Thinking
6. Legal and Ethical Considerations
Ethical Concepts
Mental Health Laws
Admission and Discharge Procedures
4
Patients’ Rights Under the Law
Laws Relevant to Psychiatric Nursing
Standards for Nursing Care
Acting on Questionable Practice
Documentation of Care
Forensic Nursing
Violence in the Psychiatric Setting
Key Points to Remember
Critical Thinking
Unit III. Psychosocial Nursing Tools
7. The Nursing Process and Standards of Care
Standards of Practice for Psychiatric-Mental Health Nursing: Standard 1: Assessment
Standards of Practice for Psychiatric-Mental Health Nursing: Standard 2: Diagnosis
Standards of Practice for Psychiatric-Mental Health Nursing: Standard 3: Outcomes Identification
Standards of Practice for Psychiatric-Mental Health Nursing: Standard 4: Planning
Standards of Practice for Psychiatric-Mental Health Nursing: Standard 5: Implementation
Standards of Practice for Psychiatric-Mental Health Nursing: Standard 6: Evaluation
Documentation
Key Points To Remember
Critical Thinking
8. Therapeutic Relationships
Concepts of the Nurse-Patient Relationship
A Focus on Self-Awareness
Peplau’s Model of the Nurse-Patient Relationship
Factors that Promote Patients’ Growth
Key Points to Remember
Critical Thinking
9. Therapeutic Communication
Introduction
The Communication Process
Factors that Affect Communication
Verbal and Nonverbal Communication
Communication Skills for Nurses
The Clinical Interview
Key Points to Remember
Critical Thinking
10. Stress Responses and Stress Management
Responses to and Effects of Stress
5
Mediators of the Stress Response
Nursing Management of Stress Responses
Other Ways to Relax
Key Points to Remember
Critical Thinking
Unit IV. Psychobiological Disorders
11. Childhood and Neurodevelopmental Disorders
Risk Factors
Health Policy
Child and Adolescent Psychiatric-Mental Health Nursing
Application of the Nursing Process
Neurodevelopmental Disorders: Clinical Picture
Communication Disorders
Motor Disorders
TIC Disorders
Specific Learning Disorder
Intellectual Disability
Application of the Nursing Process
Diagnosis
Outcomes Identification
Implementation
Evaluation
Autism Spectrum Disorder
Application of the Nursing Process
Diagnosis
Outcomes Identification
Implementation
Evaluation
Attention-Deficit/Hyperactivity Disorder
Application of the Nursing Process
Diagnosis
Outcomes Identification
Implementation
Evaluation
Quality Improvement
Key Points to Remember
Critical Thinking
12. Schizophrenia Spectrum Disorders
Delusional Disorder
Brief Psychotic Disorder
6
Schizophreniform Disorder
Schizoaffective Disorder
Substance Induced Psychotic Disorder and Psychotic Disorder Due to Another Medical Condition
Schizophrenia
Epidemiology
Comorbidity
Risk Factors
Application of the Nursing Process
Diagnosis
Outcomes Identification
Planning
Implementation
Evaluation
Quality Improvement
Key Points to Remember
Critical Thinking
13. Bipolar and Related Disorders
Clinical Picture
Epidemiology
Comorbidity
Risk Factors
Application of the Nursing Process
Diagnosis
Outcomes Identification
Planning
Implementation
Psychopharmacological Interventions
Evaluation
Quality Improvement
Key Points to Remember
Critical Thinking
14. Depressive Disorders
Major Depressive Disorder
Epidemiology
Comorbidity
Risk Factors
Application of the Nursing Process
Diagnosis
Outcomes Identification
Planning
7
Implementation
Psychobiolocial Interventions
Biological Interventions
Evaluation
Quality Improvement
Key Points to Remember
Critical Thinking
15. Anxiety and Obsessive-Compulsive Disorders
Anxiety
Levels of Anxiety
Defenses Against Anxiety
Anxiety Disorders
Clinical Picture
Obsessive-Compulsive Disorders
Risk Factors
Application of the Nursing Process
Diagnosis
Outcomes Identification
Planning
Implementation
Evaluation
Quality Improvement
Key Points to Remember
Critical Thinking
16. Trauma, Stressor-Related, and Dissociative Disorders
Trauma-Related Disorders in Children
Clinical Picture
Epidemiology
Comorbidity
Risk Factors
Application of the Nursing Process
Diagnosis
Outcomes Identification
Implementation
Evaluation
Attachment Disorders
Trauma-Related Disorders in Adults
Epidemiology
Comorbidity
Risk Factors
8
Application of the Nursing Process
Diagnosis
Outcomes Identification
Implementation
Evaluation
Acute Stress Disorder
Diagnosis
Outcomes Identification
Implementation
Evaluation
Adjustment Disorder
Dissociative Disorders
Depersonalization/Derealization Disorder
Dissociative Amnesia
Dissociative Identity Disorder
Epidemiology
Comorbidity
Risk Factors
Application of the Nursing Process
Diagnosis
Outcomes Identification
Planning
Implementation
Evaluation
Key Points to Remember
Critical Thinking Exercises
17. Somatic Symptom Disorders
Clinical Picture
Epidemiology
Risk Factors
Application of the Nursing Process
Nursing Diagnosis
Outcomes Identification
Implementation
Evaluation
Factitious Disorder
Clinical Picture
Epidemiology
Comorbidity
Risk Factors
Application of the Nursing Process
9
Planning and Implementation
Evaluation
Key Points to Remember
Critical Thinking
18. Eating and Feeding Disorders
Anorexia Nervosa
Epidemiology
Comorbidity
Risk Factors
Application of the Nursing Process
Diagnosis
Outcomes Identification
Planning
Implementation
Evaluation
Bulimia Nervosa
Epidemiology
Comorbidty
Risk Factors
Application of the Nursing Process
Diagnosis
Outcomes Identification
Planning
Implementation
Evaluation
Binge-Eating Disorder
Epidemiology
Comorbidity
Application of the Nursing Process
Diagnosis
Outcomes Identification
Planning
Implementation
Evaluation
Feeding Disorders
Key Points to Remember
Critical Thinking
19. Sleep-Wake Disorders
Sleep
Sleep Disorders
10
Clinical Picture
Comorbidity
Application of the Nursing Process
Assessment
Diagnosis
Outcomes Identification
Planning
Implementation
Evaluation
Key Points to Remember
Critical Thinking
20. Sexual Dysfunction, Gender Dysphoria, and Paraphilias
Sexuality
Sexual Dysfunction
Clinical Picture
Epidemiology
Comorbidity
Risk Factors
Application of the Nursing Process
Diagnosis
Outcomes Identification
Planning
Implementation
Evaluation
Gender Dysphoria
Epidemiology
Comorbidity
Risk Factors
Nursing Care for Gender Dysphoria
Paraphilic Disorders
Exhibitionistic Disorder
Fetishistic Disorder
Frotteuristic Disorder
Pedophilic Disorder
Sexual Sadism Disorder and Sexual Masochism Disorder
Transvestic Disorder
Voyeuristic Disorder
Paraphilic Disorder Not Otherwise Specified
Epidemiology
Comorbidity
Risk Factors
11
Application of the Nursing Process
Diagnosis
Outcomes Identification
Planning
Implementation
Evaluation
Key Points to Remember
Critical Thinking
21. Impulse Control Disorders
Oppositional Defiant Disorder
Risk Factors
Treatment Approaches
Intermittent Explosive Disorder
Risk Factors
Treatment Approaches
Conduct Disorder
Risk Factors
Treatment Approaches
Application of the Nursing Process
Diagnosis
Outcomes Identification
Implementation
Evaluation
Key Points to Remember
Critical Thinking
22. Substance-Related and Addictive Disorders
Substance Use Disorders
Epidemiology
Comorbidity
Risk Factors
Clinical Picture
Alcohol Use Disorder
Application of the Nursing Process
Assessment
Diagnosis
Outcomes Identification
Planning
Implementation
Evaluation
Key Points to Remember
12
Critical Thinking
23. Neurocognitive Disorders
Delirium
Risk Factors
Clinical Picture
Application of the Nursing Process
Nursing Diagnosis
Outcomes Criteria
Planning
Intervention
Evaluation
Mild and Major Neurocognitve Disorders
Alzheimer’s Disease
Risk Factors
Clinical Picture
Application of the Nursing Process
Nursing Diagnosis
Outcomes Criteria
Planning
Intervention
Evaluation
Key Points to Remember
Critical Thinking
24. Personality Disorders
Clinical Picture
Epidemiology and Comorbidity
Risk Factors
Cluster A Personality Disorders
Cluster B Personality Disorders
Cluster C Personality Disorders
Antisocial Personality Disorder
Epidemiology
Etiology
Application of the Nursing Process
Diagnosis
Outcomes Identification
Planning
Implementation
Evaluation
Borderline Personality Disorder
13
Epidemiology and Comorbidity
Etiology
Application of the Nursing Process
Diagnosis
Outcomes Identification
Planning
Implementation
Evaluation
Key Points to Remember
Critical Thinking
Unit V. Trauma Interventions
25. Suicide and Nonsuicidal Self-Injury
Epidemiology
Risk Factors
Clinical Picture
Application of the Nursing Process
Assessment
Diagnosis
Outcomes Criteria
Planning
Intervention
Psychosocial Interventions
Psychobiological Interventions
Evaluation
Nonsuicidal Self-Injury
Clinical Picture
Application of the Nursing Process
Assessment
Diagnosis
Outcomes Criteria
Planning
Interventions
Evaluation
Key Points to Remember
Critical Thinking
26. Crisis and Disaster
Crisis Characteristics
Crisis Theory
Types of Crisis
Phases of Crisis
14
Application of the Nursing Process
Assessment
Diagnosis
Outcomes Identification
Planning
Implementation
Evaluation
Key Points to Remember
Critical Thinking
27. Anger, Aggression, and Violence
Clinical Picture
Epidemiology
Comorbidity
Etiology
Application of the Nursing Process
Diagnosis
Outcomes Identification
Planning
Implementation
Evaluation
Key Points to Remember
Critical Thinking
28. Child, Older Adult, and Intimate Partner Violence
Child Abuse
Intimate Partner Violence
Older Adult Abuse
Application of the Nursing Process
Diagnosis
Outcomes Identification
Planning
Implementation
Evaluation
Key Points to Remember
Critical Thinking
29. Sexual Assault
Sexual Assault and Sexual Violence
Epidemiology
Clinical Picture
Application of the Nursing Process
15
Diagnosis
Outcomes Identification
Planning
Implementation
Evaluation
Conclusion
Key Points to Remember
Critical Thinking
Unit VI. Interventions for Special Populations
30. Dying, Death, and Grieving
Death and Dying
Facilitating Death
Advance Care Planning
Nursing Care at the End of Life
The Dying Process
Grieving
Self-Care
Key Points to Remember
Critical Thinking
31. Older Adults
Mental Health Issues Related to Aging
Healthcare Concerns of Older Adults
Healthcare Decision Making
Nursing Care of Older Adults
Key Points to Remember
Critical Thinking
32. Serious Mental Illness
Serious Mental Illness Across the Lifespan
Development of Serious Mental Illness
Rehabilitation Versus Recovery: Two Models of Care
Issues Confronting Those with Serious Mental Illness
Serious Mental Illness Resources
Evidence-Based Treatment Approaches
Other Treatment Approaches
Nursing Care of Patients with Serious Mental Illness
Current Issues Affecting Those with SMI
Key Points to Remember
Critical Thinking
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33. Forensic Nursing
Forensic Nursing
Forensic Psychiatric Nursing
Correctional Nursing
Key Points to Remember
Critical Thinking
Unit VII. Other Intervention Modalities
34. Therapeutic Groups
From Group to Therapeutic Group
Concepts Common to All Groups
Phases of Group Development
Group Participant Roles
Therapeutic Framework for Groups
Nurse as a Group Leader
Ethical Issues in Group Therapy
Dealing with Challenging Member Behaviors
Expected Outcomes
Key Points to Remember
Critical Thinking
35. Family Interventions
Family Structure
Family Functions
Overview of Family Therapy
Concepts Central to Family Therapy
Application of the Nursing Process
Assessment
Nursing Diagnosis
Outcomes Identification
Planning
Intervention
Evaluation
Key Points to Remember
Critical Thinking
36. Integrative Care
Integrative Care in the United States
Classification of Integrative Care
Key Points to Remember
Critical Thinking
17
Appendix. NANDA-Approved Nursing Diagnoses 2015–2017
Index
18
Copyright
3251 Riverport Lane
St. Louis, Missouri 63043
VARCAROLIS’ FOUNDATIONS OF PSYCHIATRIC-MENTAL HEALTH NURSING: A CLINICAL
APPROACH, EIGHTH EDITION ISBN: 978-0-323-38967-9
Copyright © 2018, Elsevier Inc.
Previous editions copyrighted 2014, 2010, 2006, 2002, 1998, 1994, 1990.
All rights reserved. No part of this publication may be reproduced or transmitted in any form or by
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This book and the individual contributions contained in it are protected under copyright by the
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Notices
Knowledge and best practice in this field are constantly changing. As new research and
experience broaden our understanding, changes in research methods, professional practices, or
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Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds, or experiments described herein. In
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Library of Congress Cataloging-in-Publication Data
Names: Halter, Margaret J. (Margaret Jordan), editor.
Title: Varcarolis’ foundations of psychiatric mental health nursing : a clinical approach / [edited by]
19
Margaret Jordan Halter.
Other titles: Foundations of psychiatric mental health nursing
Description: Eighth edition. | St. Louis, Missouri : Elsevier, [2018] | Preceded by Varcarolis’
foundations of psychiatric mental health nursing.
7th ed. / [edited by] Margaret Jordan Halter. c2014. | Includes bibliographical references and index.
Identifiers: LCCN 2017015075 | ISBN 9780323389679 (pbk. : alk. paper)
Subjects: | MESH: Mental Disorders--nursing | Psychiatric Nursing
Classification: LCC RC440 | NLM WY 160 | DDC 616.89/0231--dc23 LC record available at
https://lccn.loc.gov/2017015075
Senior Content Strategist: Yvonne Alexopoulos
Content Development Manager: Lisa P. Newton
Publishing Services Manager: Jeff Patterson
Senior Project Manager: Tracey Schriefer
Design Direction: Paula Catalano
Printed in Canada
Last digit is the print number: 9 8 7 6 5 4 3 2 1
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Dedication
This book is dedicated to people who are living with and recovering from mental illness and to the
future registered nurses who will focus on supporting their recovery.
My dream is that scientific understanding and advances will not only provide even better
treatments, but will also prevent, and even cure, psychiatric disorders.
Dedicated to my husband, Paul. Your kindness and love of life shine through your daughters and
granddaughters.
I miss you every day.
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Acknowledgments
My ancestors were storytellers. Boxes of diaries, articles, and books fill an unused closet and detail
many of their moves and thoughts. The family tree includes a newspaper editor, a historian, a poet,
and a nonfiction writer. One great aunt, Ella Chalfant, published a book titled A Goodly Heritage in
1955. Her book centered on inheritance laws in the 1800s and featured copies of wills demonstrating
the disenfranchisement of women (e.g., a husband needed to will a wife her own clothing on his
death). She was likely an early feminist.
As a registered nurse, I did have the opportunity to write some non-fiction in the form of nurses
notes. As a tenure-track faculty member, I was required to write some stories in the form of
presentations, research, and publications.
A 2004 phone call finally put me on the path to join my ancestors in their vocation. A pleasant
voice with a slight New York accent says, “Peggy? Hi, this is Betsy Varcarolis.” I knew the name at
once—my undergraduates used her book. She went on, “The reason I’m calling is that I very much
enjoyed your article, ‘Stigma and help seeking related to depression: A study of nursing students.’ I
would like to feature it as an Evidence-Based Practice box in the fifth edition of my book.” I was
thrilled—what an honor!
This was the beginning. After that call, my work progressed from chapter reviewer to chapter
writer to textbook editor. I spent several years as an apprentice of Elizabeth Varcarolis, the creative
power who conceived of Foundations of Psychiatric Mental Health Nursing in 1990. She went on to
make this textbook a leader in the specialty of psychiatric nursing. Betsy has the rare gift of making
the complex understandable and of making impersonal learning a joint process in which the experts
talk with the students rather than just providing information.
In this 8th edition of the book, Elizabeth Varcarolis continues to be honored for her work with her
name in the title. Sincere thanks and gratitude go out to Betsy for enriching my life. The profession
of psychiatric nursing, countless students, and recipients of psychiatric-mental health care have
benefited from her wisdom. I wish for Betsy all the best as she enjoys her retirement hand-in-hand
with her husband, Paul.
My heartfelt appreciation also goes out to the talented group of writers who contributed to the
8th edition. We have a talented pool of veteran writers, and their knowledge and passion continue
to influence psychiatric nursing. A few new writers whose expertise was both recognized and
sought after agreed to join us in this edition. It has truly been a joy working with each of you.
Thanks for the countless hours you spent researching, writing, and rewriting!
A huge debt of gratitude goes to the many educators and clinicians who reviewed the manuscript
and offered valuable suggestions, ideas, opinions, and criticisms. All comments were appreciated
and helped refine and strengthen the individual chapters.
Throughout this project, a number of people at Elsevier provided superb support. I am grateful
for Tracey Schriefer, our Senior Project Manager, who nudged me to meet deadlines, and Paula
Catalano, a talented and creative designer. Yvonne Alexopoulos, Senior Content Strategist, kept me
on a straight path and helped me work through some thorny issues. Lisa Newton, Content
Development Manager, was my ever-optimistic colleague who celebrated each milestone with a
smiley emoji and an exclamation mark! My sincere thanks go out to my whole Elsevier family.
Peggy Halter
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Contributor List
Lois Angelo, APRN, Case Manager, Newton-Wellesley Hospital, Newton, Massachusetts
Natalie K. Boysen, BSN, RN, Genesis East Medical Center, Emergency Services, Davenport, Iowa
Leslie A. Briscoe, MSN, RN, PMHCNP
Psychiatric Nurse Practitioner, Louis Stokes Cleveland VA Medical Center, Geriatric Psychiatry:
Outpatient and Consultation/Liaison Service, Cleveland, Ohio
Nursing Editorial Advisory Panel, Wolters Kluwer Publishing, Clinical Drug Information / Nursing
division, Hudson, Ohio
Alison M. Colbert, PhD, APRN, BC, Assistant Professor, Duquesne University School of
Nursing, Pittsburgh, Pennsylvania
Carissa Enright, MSN, RN, PMHNP BC, Associate Clinical Professor, Texas Woman’s
University, Dallas, Texas
Jill Espelin, DNP, PMHNP-BC, CNE, APRN, Assistant Professor, Central Connecticut State
University, New Britain, Connecticut
Jodie A. Flynn, MSN, RN, SANE-A, SANE-P, D-ABMDI, Instructor, Capital University,
Columbus, Ohio
Christina Fratena, MSN, PMHCNS-BC, Clinical Instructor of Nursing, Malone University,
Canton, Ohio
Faye J. Grund, PhD, APRN, PMHNP-BC, Dean, Dwight Schar College of Nursing and Health
Sciences, Ashland University, Mansfield, Ohio
Mary A. Gutierrez, PharmD, BCPP, Professor of Pharmacy Practice (Psychiatry), Chapman
University School of Pharmacy, Irvine, California
Monica J. Halter, APRN, PMHNP-BC, Psychiatric Nurse Practitioner, Psychological and
Behavioral Consultants, Cleveland, Ohio
Edward A. Herzog, APRN-CNS, Senior Lecturer, College of Nursing, Kent State University,
Kent, Ohio
Jerika T. Lam, PharmD, AAHIVP, FCSHP, Assistant Professor of Pharmacy Practice, Chapman
University School of Pharmacy, Irvine, California
Laura G. Leahy, DrNP, APN, PMH-CNS/FNP, BC, Family Psychiatric Advanced Practice Nurse,
APN Solutions, LLC, Sewell, New Jersey
Lorann Murphy, MSN, PsychBC, Clinical Nurse Specialist, Lutheran Hospital, Cleveland, Ohio
Cindy Parsons, DNP, PMHNP-BC, FAANP, Associate Professor of Nursing, University of
Tampa, Tampa, Florida
Donna Rolin, PhD, APRN, PMHCNS-BC, PMHNP-BC, Assistant Professor, Director of Family
Psychiatric Mental Health Nurse Practitioner Graduate Program, University of Texas at Austin,
School of Nursing, Austin, Texas
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