Psychiatric Mental Health Nursing by Videbeck

380 Unit 4 NURSINGPRACTICE FORPSYCHIATRICDISORDERS

threatening meanings. Clients often feel attacked by
others and may devise elaborate plans or fantasies for
protection.
These clients use the defense mechanism of pro-
jection,which is blaming other people, institutions, or
events for their own difficulties. It is common for such
clients to blame the government for personal prob-
lems. For example, a client who gets a parking ticket
may say it is part of a plot by the police to drive him
out of the neighborhood. He may engage in fantasies
of retribution or devise elaborate and sometimes vio-
lent plans to get even. Although most clients do not
carry out such plans, there is a potential danger.
Conflict with authority figures on the job is com-
mon; clients may even resent being given directions
from a supervisor. Paranoia may extend to feelings of
being singled out for menial tasks, treated as stupid,
or more closely monitored than other employees.

Nursing Interventions

Forming an effective working relationship with para-

noid or suspicious clients is difficult. The nurse must

remember that these clients take everything seriously

and are particularly sensitive to the reactions and

motivations of others. Therefore, the nurse must ap-

proach these clients in a formal, business-like manner

and refrain from social chitchat or jokes. Being on

time, keeping commitments, and being particularly

straightforward are essential to the success of the

nurse–client relationship.

Because these clients need to feel in control, it is

important to involve them in formulating their plans

of care. The nurse asks what the client would like to

accomplish in concrete terms such as minimizing

problems at work or getting along with others. Clients

are more likely to engage in the therapeutic process if

Table 16-2

SUMMARY OFSYMPTOMS ANDNURSINGINTERVENTIONS FORPERSONALITYDISORDERS

Personality Disorder Symptoms/Characteristics Nursing Interventions

Paranoid

Schizoid

Schizotypal

Antisocial

Borderline

Histrionic

Narcissistic

Avoidant

Dependent

Obsessive-compulsive

Depressive

Passive-aggressive

Serious, straightforward approach; teach client

to validate ideas before taking action; involve

client in treatment planning

Improve client’s functioning in the community;

assist client to find case manager

Develop self-care skills; improve community

functioning; social skills training

Limit-setting; confrontation; teach client to

solve problems effectively and manage

emotions of anger or frustration

Promote safety; help client to cope and control

emotions; cognitive restructuring tech-

niques; structure time; teach social skills

Teach social skills; provide factual feedback

about behavior

Matter-of-fact approach; gain cooperation with

needed treatment; teach client any needed

self-care skills

Support and reassurance; cognitive restructur-

ing techniques; promote self-esteem

Foster client’s self-reliance and autonomy;

teach problem-solving and decision-making

skills; cognitive restructuring techniques

Encourage negotiation with others; assist client

to make timely decisions and complete work;

cognitive restructuring techniques

Assess self-harm risk; provide factual feed-

back; promote self-esteem; increase involve-

ment in activities

Help client to identify feelings and express

them directly; assist client to examine own

feelings and behavior realistically

Mistrust and suspicions of others;

guarded, restricted affect

Detached from social relationships;

restricted affect; involved with

things more than people

Acute discomfort in relationships;

cognitive or perceptual distortions;

eccentric behavior

Disregard for rights of others, rules,

and laws

Unstable relationships, self-image,

and affect; impulsivity; self-

mutilation

Excessive emotionality and attention-

seeking

Grandiose; lack of empathy; need

for admiration

Social inhibitions; feelings of inade-

quacy; hypersensitive to negative

evaluation

Submissive and clinging behavior;

excessive need to be taken care of

Preoccupation with orderliness,

perfectionism, and control

Pattern of depressive cognitions and

behaviors in a variety of contexts

Pattern of negative attitudes and

passive resistance to demands for

adequate performance in social

and occupational situations