A disturbance of mood, characterized by a full or partial depressive syndrome, or loss of interest or pleasure in usual activities and pastimes with evidence of interference in social/occupational functioning.

DSM-IV
DEPRESSIVE DISORDERS
296.xx Major depressive disorder
296.2x Single episode
296.3x Recurrent
300.4 Dysthymic disorder
311 Depressive disorder NOS
ETIOLOGICAL THEORIES
Psychodynamics
Psychoanalytical theory focuses on an early unsatisfactory parent/child relationship, with an unresolved grieving process. This results in the individual remaining fixed in the anger stage of the grieving process and turning it inward on the self. The ego remains weak, while the superego expands and becomes punitive.

Cognitive theory projects a belief that depression occurs as a result of impaired cognition, fostering a negative evaluation of self through disturbed thought processes. The individual is pessimistic and views self as inadequate and worthless and life as hopeless.

Learning theorists propose that depressive illness arises out of the individual’s having experienced numerous failures (either real or perceived). A feeling of inability to succeed at any endeavor ensues. This “learned helplessness” is viewed as a predisposition to depressive illness. The behavioral model states that the cause of depression is in the person-behavior-environment interaction. Although people are seen as capable of exercising control over their behavior, they are not totally free of environmental influence.

Biological
A family history of major affective disorders may exist in individuals with depressive disorders. Recently it has been found that the disease has a genetic marker, as shown by numerous studies that support the involvement of heredity in depressive illness.

Biochemical factors (e.g., electrolyte imbalances) appear to play a role in depressive illness. An error in metabolism results in the transposition of sodium and potassium within the neuron. Another theory implicates the biogenic amines norepinephrine, dopamine, and serotonin. The levels of these chemicals are deficient in individuals with depressive disorders. Controversy remains as to whether these biochemical changes cause the depression or whether they are caused by the illness. In recent years, a common form of major depression called seasonal affective disorder (SAD) has been identified. Recurring each year, starting in fall or winter and ending in spring, the symptoms are largely typical of depression, with some atypical symptoms (excessive sleep, increased appetite, and weight gain). This disorder is believed to be caused by the decreased availability of sunlight and is related to circadian cycles, which are set by each individual’s internal biological clock. Circadian cycles are more precisely adjusted and coordinated by the alternation of darkness and light.

Impaired seratonergic transmission has also been investigated as a cause of depression (indolamine hypothesis). It has been shown that multiple regions of the brain in depressed clients lack metabolic responsivity, suggesting a generalized subresponsivity of the serotonergic system. Additionally, current research suggests that infection with the Borna disease virus (BDV) may be linked to some cases of major depression and other severe mood disorders.

Family Dynamics
Object loss theory suggests that depressive illness occurs if the person is separated from or abandoned by a significant other during the first 6 months of life. The bonding process is thereby interrupted, and the child withdraws from people and the environment.

NURSING PRIORITIES
1. Promote physical safety with special focus on suicide prevention.
2. Provide for client’s basic needs, promoting highest possible level of independent functioning.

3. Provide experience/interactions that enhance self-esteem, sense of personal power.
4. Support client/family participation in follow-up care/community treatment.
5. Provide information about condition, prognosis, and treatment needs.

DISCHARGE GOALS
1. Suicidal ideation/self-violent behaviors absent.
2. Physiological stability achieved with responsibility for self demonstrated.
3. Client expressing feelings appropriately with some optimism and hope for the future.
4. Client/family participating in follow-up care/community treatment.
5. Condition, prognosis, and therapeutic regimen understood.
6. Plan in place to meet needs after discharge.

Nursing diagnosis for Dysthymic Disorder: Risk for Violence, Directed to Self may be related to Depressed mood; and Feelings of worthlessness and hopelessness possibly evidenced by Verbalization of suicidal ideation/plan or futility of trying (e.g., “What’s the use?”); Giving possessions away/making a will; Sudden mood elevation/appearing more energized or displaying calmer, more peaceful manner; and Refusal/reluctance to sign a “no harm” contract.

Desired Outcomes:
1. Voluntarily comply with suicide precautions, sign “no harm” contract.
2. Verbalize a decrease/absence of suicidal ideas.
3. State 2 reasons for not harming self.
4. Commit no acts of self-violence.

Nursing intervention with rationale:
1. Identify degree of risk/potential for suicide through direct questions (e.g., “Have you thought about killing yourself?”). Assess seriousness of suicidal tendency, noting behaviors such as gestures, threats, giving away possessions, previous attempts, presence of hallucinations or delusions. (Use scale of 1–10 and prioritize care according to severity of threat, availability of means.)
Rationale: Degree of hopelessness expressed by client is important indicator of severity of depression and suicide risk. Eight of 10 clients who state an intention to commit suicide do so. The more thought-out the plan, the higher the chances of completing it. The chances of suicide increase if there was a previous suicide attempt or if a family history of suicide and depression is present. Impulsive clients are more likely to attempt suicide without giving clues, including those with psychotic thinking who are especially at risk when hallucinations or delusions encourage self-harm. Note: Individuals with untreated depression have a suicide rate of 15%.

2. Reevaluate potential for suicide periodically at key times (e.g., during mood changes, at initiation of/ changes in medication regimen, when increasing withdrawal occurs, when discharge planning becomes active, before sending out on pass, before discharge from program).
Rationale: Suicide risk is the greatest during the first few weeks following admission to treatment. More than half of suicides by hospitalized clients occur out of the hospital, while they are on leave or during an unauthorized absence. The highest risk is when the client has both suicidal ideation and sufficient energy with which to act (e.g., at the point when the client begins to feel better).

3. Implement suicide precautions. For example, explain to client that you are concerned for his or her safety and that you will be helping client to stay “safe.”
Rationale: Communicates caring and provides sense of protection.

4. Create a time-specific contract with client on what client and nurse will do to provide for client’s safety. Renew contract as appropriate. Place a copy of the “contract,” signed by client and staff, in the chart/ file and give a copy to the client to keep.
Rationale: Documents actions taken to prevent suicide and client response. It also promotes communication and can help client realize that others care what happens. Short-term contracts encourage client to deal with the here-and-now and provide opportunity to reassess situation.

When patient is hospitalized
1.  Provide close observation (1:1 or random checks every 10 to 15 minutes for most acute risk). Place in room close to nurse’s station; do not assign to a single room. Accompany to off-ward activities if attendance is indicated. Ask client to stay in view of staff member at all times.
Rationale: Being alert for suicidal and escape attempts facilitates being able to prevent or interrupt harmful behavior.

2. Be alert to use of hazardous equipment; remove hazardous personal items (e.g., scarves, belts, razor blades, scissors).
Rationale: Provides environmental safety; removes objects that may prompt suicidal thoughts/attempts.

3. Check all items brought in to or by the client as indicated. Ask family and other visitors to avoid bringing hazardous items.
Rationale: Suicidal clients may bring harmful items back from a pass or may ask family for items, with a suicide plan in mind.

4. Routinely check environment for hazards. Provide for environmental safety (e.g., lock doors/windows when not supervised; block access to stairways, roof, and construction areas; monitor cleaning chemicals /repair supplies).
Rationale: Minimizing opportunities for self-harm is an ongoing issue requiring constant attention and consideration of the unusual.

5. Administer medications as indicated, e.g.: SSRIs: fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil), sertraline (Zoloft); tricyclics, e.g., amitriptyline (Elavil), desipramine (Norpramin), doxepin (Sinequan), imipramine (Tofranil); heterocyclics, e.g., amoxapine (Asendin), bupropion (Wellbutrin), maprotiline (Ludiomil), trazodone (Desyrel); monoamine oxidase inhibitors (MAOIs), e.g., phenelzine (Nardil), isocarboxazid (Marplan), tranylcypromine (Parnate).
Rationale: Selective serotonic reuptake inhibitors and cyclic antidepressants are generally considered the safest and easiest to manage of the antidepressants and so are started first. If response is not noted in 4 to 6 weeks, an MAOI may be the drug of choice. These drugs act by blocking enzyme degradation of neurotransmitters (norepinephrine, serotonin). Note: Medications inhibiting reuptake of serotonin, or heterocyclic drugs (e.g., Wellbutrin), are usually preferred for treating depression in bipolar disorders, whereas tricyclics and MAOIs may increase possibility of switch to manic behavior. (Tricyclics use a “shotgun approach,” whereas newer generations of drugs usually target a specific neurotransmitter. TCAs also can cause toxicity before therapeutic levels are achieved, and MAOIs can cause fatal central serotonin syndrome if administered within 2 weeks of SSRI therapy).

6. Prepare for/assist with ECT as indicated.
Rationale: ECT becomes essential and in some cases life saving when depression does not respond to other treatments and suicide is a major risk. (Of clients with major depression, 80% to 90% show marked improvement after ECT.)

Hallucinogenic substances can distort an individual’s perception of reality, altering sensory perception, and inducing hallucinations. For this reason, these substances are referred to as “mind expanding.” They are highly unpredictable in the effects they may induce each time they are used, and adverse reactions, including “flashbacks,” can recur at any time, even without current use of the drug. Hallucinogens have been used as part of religious ceremonies and at social gatherings by Native Americans for more than 2000 years. Therapeutic uses for LSD have been proposed; however, more research is required. At this time, no real evidence speaks to the safety and efficacy of LSD in humans.

Of the drugs that produce mood and perceptual changes varying from sensory illusions to hallucinations, the most popular and well-known are ergot and related compounds (LSD, morning glory seeds), phenyl alkylamines (mescaline, “STP,” and MDMA or “Ecstasy”), and indole alkaloids (DMT).

A separate classification of drugs includes phencyclidine (PCP, “angel dust,” HOG) and similarly acting compounds such as ketamine (Ketalar) and the thiophene analogue of phencyclidine (TCP). Although these drugs have an entirely different chemical structure, they can have similar hallucinogenic effects and therefore are included here.

Additionally, cannabis (marijuana, hashish, synthetic THC) also produces an altered state of awareness accompanied by feelings of relaxation and mild euphoria and is often used in conjunction with other substances.

This plan of care addresses acute intoxication/withdrawal and is to be used in conjunction with CP: Substance Dependence/Abuse Rehabilitation.

DSM-IV
HALLUCINOGEN-RELATED/INDUCED DISORDERS
292.89 Hallucinogen intoxication
292.81 Intoxication delirium
292.89 Hallucinogen persisting perception disorder (flashbacks)
292.89 Hallucinogen-induced anxiety disorder
292.84 Hallucinogen-induced mood disorder

PHENCYCLIDINE (OR PHENCYCLIDINE-LIKE)/INDUCED DISORDERS
292.89 Phencyclidine intoxication
292.81 Intoxication delirium
292.11 Induced psychotic disorder with delusions
292.12 Induced psychotic disorder with hallucinations

CANNABIS-RELATED/INDUCED DISORDERS
292.89 Cannabis intoxication
292.81 Intoxication delirium
292.89 Cannabis-induced anxiety disorder

ETIOLOGICAL THEORIES
Psychodynamics
Individuals who abuse substances fail to complete tasks of separation-individuation, resulting in underdeveloped egos. The person is thought to have a highly dependent nature, with characteristics of poor impulse control, low frustration tolerance, and low self-esteem. The superego is weak, resulting in absence of guilt feelings for behavior.

Certain personality traits may play an important part in the development and maintenance of dependence. Characteristics that have been identified include impulsivity, negative self-concept, weak ego, low social conformity, neuroticism, and introversion. Substance abuse has also been associated with antisocial personality and depressive response styles.

Biological
A genetic link is thought to be involved in the development of substance abuse disorders. Although statistics are currently inconclusive, hereditary factors are generally accepted to be a factor in the abuse of substances. Research is currently being done into the role biochemical factors play in the problems of substance abuse.

Family Dynamics
A predisposition to substance use disorders is found in the dysfunctional family system. Often one parent is absent or is an overpowering tyrant, and/or another parent is weak and ineffectual. Substance abuse may be evident as the primary method of relieving stress. The child has negative role models and learns to respond to stressful situations in like manner. However, parents may be average, normal individuals with children who succumb to overwhelming peer pressure and become involved with drugs.

In the family the effects of modeling, imitation, and identification on behavior can be observed from early childhood onward. Peer influence may exert a great deal of influence also. Cultural factors may help to establish patterns of substance use by attitudes of acceptance of such use as a part of daily or recreational life.

NURSING PRIORITIES
1. Protect client/others from injury.
2. Promote physiological/psychological stability.
3. Provide appropriate referral and follow-up.
4. Support client/family in Intervention (confrontation) process for decision to stop using drugs.

DISCHARGE GOALS
1. Homeostasis achieved.
2. Complications prevented/resolved.
3. Abstinence from drug(s) maintained on a day-to-day basis.
4. Participation in drug rehabilitation program.
5. Plan in place to meet needs after discharge.

Nursing diagnosis for Hallucinogen, Phencyclidine, and Cannabis Related Disorders: Risk for Violence, directed at self/others may be related to Chemical alteration, exogenous (CNS stimulants/mind-altering drug), toxic reactions to drug(s); Organic brain syndrome (drug anesthetizes mind and body); and Psychological state (narrowed perceptual field) possibly evidenced by Synesthesias, hallucinations, illusions, visual/auditory distortions; panic state; suspiciousness of others, paranoid ideation, delusions; Hostile, threatening verbalizations; exaggerated emotional response; increased motor activity, pacing, excitement, irritability, agitation; Change in behavior pattern; unpredictable behavior; increasing anxiety, fear, and feelings of loss of control; Overt and aggressive acts; self-destructive behavior; and Decreased response to pain.

Desired Outcomes:

1. Demonstrate self-control, as evidenced by relaxed posture, free of violent behavior.
2. Acknowledge reality of situation and understanding of relationship of behavior to drug use.
3. Participate in treatment program.

Nursing intervention with rationale:
1. Place in darkened, quiet, nonthreatening environment with a nonintrusive observer.
Rationale: Lowered stimulation decreases the likelihood of confusion and fear; thus, there is less chance of violent behavior. Use of an observer promotes safety. Note: PCP users seek help only after the situation has gotten out of hand, and it is therefore important to take safe action immediately.

2. Speak in a soft, nonthreatening voice. Use “Talk- downs” when LSD has been taken. If technique is tried with other drugs (particularly PCP) and agitation increases, stop immediately.
Rationale: Nonthreatening communication may have a calming effect. However, “Talk-downs” (the use of orientation, support, and reassuring words/touch) may be deleterious in the presence of PCP intoxication, resulting in an increase in the client’s agitation level.

3. Observe for escalating anxiety, fear, irritability, and agitation.
Rationale: May indicate potential for progression to violent behavior. Note: Client is not in complete control of self because of drug use.

4. Accept and deal with client’s anger without reacting on an emotional basis.
Rationale: Responding emotionally on a personal level is not constructive and may escalate reactions.

5. Provide protection within the environment via constant observation and removal of objects that may be used to hurt self or others.
Rationale: Reduces risk of injury to client and/or staff. Client may not feel pain and may not be able to follow directions because of use of the drug.

6. Observe behavior without administering medications.
Rationale: A period of drug-free observation should precede any decision to administer medications (e.g., antianxiety agents), so that a clear clinical picture can develop. In addition, because it is not known what other drugs may also have been taken, it is not generally advisable to add another drug.

7. Administer medications as necessary, e.g.: diazepam (Valium)
Rationale: Used to reduce muscle spasms and/or restlessness in PCP user.

8. Administer haloperidol (Haldol).
Rationale: Preferred to control psychosis and assaultive behavior.

9. Avoid use of phenothiazine neuroleptics.
Rationale: Drugs such as chlorpromazine (Thorazine) are generally avoided because of the possibility of potentiating PCP anticholinergic effects.

10. Apply restraints, if needed, and document reason(s) for use.
Rationale: Restraints should be avoided in a frightened, hallucinating client but may be necessary because of potential injury to self or others, or when other dangerous drugs have been taken. PCP users are
unpredictable, so it is best to err on the side of safety (using restraints with sufficient documentation) rather than to risk injury.

Although some degree of anxiety is normal in life’s stresses, anxiety can be adaptive or maladaptive. Problems arise when the client has coping mechanisms that are inadequate to deal with the danger, which may be recognized or unrecognized. The essential feature of this inadequacy is unrealistic or excessive anxiety and worries about life circumstances. Anxiety disorders are the most common of all major groups of mental disorders in the United States, sharing comorbidity with major depression and substance abuse, increasing the client’s risk of suicide.

DSM-IV
300.02 Generalized anxiety disorder
ETIOLOGICAL THEORIES
Psychodynamics
The Freudian view involves conflict between demands of the id and superego, with the ego serving as mediator. Anxiety occurs when the ego is not strong enough to resolve the conflict. Sullivanian theory states that fear of disapproval from the mothering figure is the basis for anxiety. Conditional love results in a fragile ego and lack of self-confidence. The individual with anxiety disorder has low self-esteem, fears failure, and is easily threatened.

Dollard and Miller (1950) believe anxiety is a learned response based on an innate drive to avoid pain. Anxiety results from being faced with two competing drives or goals.

Cognitive theory suggests that there is a disturbance in the central mechanism of cognition or information processing with the consequent disturbance in feeling and behavior. Anxiety is maintained by this distorted thinking with mistaken or dysfunctional appraisal of a situation. The individual feels vulnerable, and the distorted thinking results in a negative outcome.

Biological
Although biological and neurophysiological influences in the etiology of anxiety disorders have been investigated, no relationship has yet been established. However, there does seem to be a genetic influence with a high family incidence.

The autonomic nervous system discharge that occurs in response to a frightening impulse and/or emotion is mediated by the limbic system, resulting in the peripheral effects of the autonomic nervous system seen in the presence of anxiety.

Some medical conditions have been associated with anxiety and panic disorders, such as abnormalities in the hypothalamic-pituitary-adrenal and hypothalamic-pituitary-thyroid axes, acute myocardial infarction, pheochromocytomas, substance intoxication and withdrawal, hypoglycemia, caffeine intoxication, mitral valve prolapse, and complex partial seizures.

Family Dynamics
The individual exhibiting dysfunctional behavior is seen as the representation of family system problems. The “identified patient” (IP) is carrying the problems of the other members of the family, which are seen as the result of the interrelationships (disequilibrium) between family members rather than as isolated individual problems.

It is recognized that multiple factors contribute to anxiety disorders.

NURSING PRIORITIES
1. Assist client to recognize own anxiety.
2. Promote insight into anxiety and related factors.
3. Provide opportunity for learning new, adaptive coping responses.
4. Involve client and family in educational/support activities.

DISCHARGE GOALS
1. Feelings of anxiety recognized and handled appropriately.
2. Coping skills developed to manage anxiety-provoking situations.
3. Resources identified and used effectively.
4. Client/family participating in ongoing therapy program.
5. Plan in place to meet needs after discharge.

Nursing diagnosis for generalized anxiety disorder: Severe Anxiety may be related to Real or perceived threat to physical integrity or self-concept (may or may not be able to identify the threat); Unconscious conflict about essential values (beliefs) and goals of life; unmet needs; Negative self-talk possibly evidenced by Persistent feelings of apprehension and uneasiness (related to unidentified stressor or stimulus) that client has difficulty alleviating; Sympathetic stimulation; restlessness; extraneous movements (foot shuffling, hand/arm fidgeting, rocking movements); Poor eye contact; focus on self; Impaired functioning; verbal expressions of having no control or influence over situation, outcome, or self-care; Free-floating anxiety; Nonparticipation in care or decision-making when opportunities are provided.

Desired Outcomes:
1. Verbalize awareness of feelings of anxiety.
2. Identify effective coping mechanisms to successfully deal with stress.
3. Report anxiety is reduced to a manageable level.
4. Demonstrate problem-solving skills/lifestyle changes as indicated for individual situation.

Nursing intervention with rationale:
1. Establish and maintain a trusting relationship through the use of warmth, empathy, and respect. Provide adequate time for response. Communicate support of the client’s self-expression.
Rationale: The client may perceive the nurse as a threat, which may increase the client’s anxiety. Attending behaviors can increase the degree of comfort the client experiences with the nurse.

2. Be aware of any negative or anxious feelings nurse may have because of client’s conscious or unconscious resistance of nurse’s helpful efforts.
Rationale: Negative reactions to the client will block future progress. Anxiety is “contagious,” and nurse needs to recognize and control own anxiety.

3. Identify behaviors of the client that produce anxiety in the nurse. Explore these behaviors with the client once relationship is established.
Rationale: Promotes growth and change and helps client realize how own behavior affects others.

4. Use supportive confrontation as indicated.
Rationale: Confrontation can be useful when client’s progress is blocked but may heighten anxiety to a level that is detrimental to the therapy process. Therefore, it should be used with caution.

5. Have client identify and describe the sensations of emotional and physical feelings. Assist the client to link behavior and feelings. Validate all inferences and assumptions with the client.
Rationale: To adopt new coping responses, the “5 R’s” of anxiety reduction are used. The client first needs to RECOGNIZE anxiety and be aware of feelings, how they link to certain maladaptive coping responses, and own responsibility in learning to control behavior.

6. Help to explore conflictual issues by beginning with nonthreatening topics and progressing to more conflict-laden ones.
Rationale: Anxious client does not think clearly, and beginning with simple topics promotes comfort level, increasing sense of success and progress.

7. Monitor the anxiety level of the nurse/client interaction on an ongoing basis.
Rationale: Moderate anxiety may be productive for/motivate client, but too high a level of anxiety can interfere with the interaction and ability to attend to information.

8. Assist the client to identify the situations and interactions that immediately precede the anxiety. Suggest that the client keep an “anxiety notebook” that focuses on feelings and what is going on in the environment when anxious feelings begin.
Rationale: After the client recognizes feelings of anxiety, examination of the development of the anxiety (e.g., what precipitates it, the strength of the stressor[s]) and what resources are available can help the client develop new coping skills. Therapeutic writing serves to decrease the anxiety while the client is learning about it, making it more tangible/controllable.

9. Encourage client to use relaxation techniques (e.g., meditation, massage, breathing techniques, exercises, guided imagery, and biofeedback).
Rationale: RELAXATION is the ultimate stress management technique because it brings about a decreased heart rate, lowers metabolism, and decreases respiration rate. The relaxation response is the physiological opposite of the anxiety response.

10. Administer medication as indicated, e.g., buspirone (BuSpar), benzodiazepines, e.g., alprazolam (Xanax), clonazepam (Klonopin), clorazepate (Tranxene), chloridiazepoxide (Librium), diazepam (Valium), oxazepam (Serax).
Rationale: Anxiolytics provide relief from the immobilizing effects of anxiety. BZDs have few side effects, are generally well tolerated, have a fairly rapid rate of onset, and do not impair sleep. Note: When anxiety is associated with depression, antidepressant agents alone may provide relief of symptoms. Unlike BZDs, BuSpar is nonaddicting, has a delayed onset of action (10 days–2 weeks), and must be taken on a regular basis (not PRN).

Sexuality is a product of one’s genetic identity, gender identity, gender role and sexual orientation. As all of these are independent components, there is a 4 3 4 interaction that can result in 16 distinct possibilities of sexual identity. In a society in which clear differences between the sexes is the expected norm, any individual challenging this dichotomy is deemed problematic. However, in the mental health arena, sexual orientation is a concern only when the individual experiences persistent and marked distress regarding uncertainty about issues relating to personal identity—in this case, sexual orientation and behavior.

Consensual homosexuality in adults is no longer viewed as a mental disturbance. Homosexual individuals in general have no more psychopathology than heterosexuals, and when they do seek treatment it is for the same reasons as heterosexuals—psychiatric disorders (e.g., bipolar disorder, borderline personality), relationship problems, and stress. Therefore, it is important to avoid mistakenly attributing psychiatric symptoms to the individual’s sexual orientation.

In gender identity disorder, the individual does not view himself or herself as homosexual; rather, there is a strong and persistent cross-gender identification and discomfort with one’s gender or a sense of inappropriateness in the assigned gender role exists (e.g., a male “trapped” in a female’s body). This perception results in clinically significant distress/functional impairments (e.g., social, occupational).

In addition, this plan of care also addresses the diagnosis of Identity Problem for homosexuals who are uncertain about multiple issues relating to their identity, such as sexual orientation and behavior, moral values, friendship patterns, and group loyalties.

to fully understand about gender identity disorder you may read my previous post: http://www.enurse-careplan.com/2012/01/sexual-and-gender-identity-disorders.html

DSM-IV
GENDER IDENTITY DISORDERS
302.6 Gender identity disorder in children
302.85 Gender identity disorder in adolescents and adults (specify: sexually attracted to males/females/both/neither)
302.6 Gender identity disorder not otherwise specified (intersex conditions, androgen insensitivity syndrome, or congenital adrenal hyperplasia and gender dysphoria)
313.82 Identity problem (specific to sexual orientation and behavior)

ETIOLOGICAL THEORIES
Psychodynamics
The libido is seen as the force that expresses sexual instinct and develops gradually during the oral stage, which focuses on the mouth and lips. The central concern of the anal stage is the anus and the elimination/retention of feces. During the phallic stage, the male is concerned with love of his mother, is jealous of his father, and has castration anxiety (Oedipus complex). The female has penis envy, loves her father, and rejects her mother (Electra complex). This theory focuses on the biological inferiority of women because they do not have penises, with subsequent envy of the male.

Developmental theories suggest that sexuality develops throughout life and especially during the formative years. Confusion about one’s individual personality and sexual identity affects the ability to be intimate, interfering with sexual development.

Biological
Although adult endocrine levels are usually normal in individuals who are homosexual, a “hormonal wash” may have occurred at a critical time of embryonic development, sensitizing brain cells in as yet immeasurable ways. Androgen is necessary for masculinization in the fetal male, with the fetus developing as female without the addition of this hormone. When androgenic influences in the fetal hypothalamus are decreased in the male or increased in the female, homosexuality may occur. Some research sources report that there is a neuroendocrine factor (e.g., that the fetus was exposed to large amounts of androgenic hormones or that the mother may have received synthetic hormones at a crucial fetal developmental period, preventing adequate stimulation for neural differentiation).

Current research allows monitoring of normal fetal exposure to testosterone in utero. When subsequent behavior is linked to this information, we will understand more than has been previously available from studies of abnormal exposure of the fetus to high levels of androgen, overdoses due to drugs, or adrenal malfunction. Research continues into the effect of prenatal brain-sexing on homosexual development. We know that lack of male hormone at a crucial state of male fetal development can lead to a feminine brain in a male body. It is clear that, as with other aspects of behavior, sexual orientation is crucially mediated by
hormonal influences on the developing brain in utero. It is believed that abnormal hormones interact with
neurotransmitters, the chemicals that direct the construction of the brain, affecting the sex centers, mating
centers, and the so-called gender-role centers, which assume their structure at different times of brain
development (Moir & Jessel, 1991).

Family Dynamics
Role-modeling of gender-specific behaviors is believed to play a part in the development of these disorders as well as the negative effect of a disturbed relationship with one or both parents. Imprinting and classic conditioning may affect the development of gender identity.

In males with gender identity disorders, a symbiotic relationship appears to exist between mother and child. The father is usually absent, ineffectual, or hostile and is perceived as weak and distant, with the mother seen as strong and protective.

In females with these disorders, the child may not be valued as a girl, or the mother may be absent, depressed, or suffer from other illness, resulting in inadequate mothering. The father may treat the daughter as his little boy, expecting “masculine” behavior.

NURSING PRIORITIES
1. Help client reduce level of anxiety.
2. Promote sense of self-worth.
3. Encourage development of social skills /comfort level with own sexual identity/preference.
4. Provide opportunities for client/family to participate in group therapy/other support systems.

DISCHARGE GOALS
1. Anxiety reduced/managed effectively.
2. Self-esteem/image enhanced.
3. Accepts and is comfortable with identity as established.
4. Client/family are participating in ongoing treatment/support programs.
5. Plan in place to meet needs after discharge.

Nursing diagnosis for gender identity disorder: Severe Anxiety may be related to Ego-dystonic gender identification; Unconscious conflicts about essential values/beliefs; Threat to self-concept; unmet needs possibly evidenced by Increased tension/helplessness (hopelessness); Feelings of inadequacy, apprehension, uncertainty; Increased wariness; insomnia; and Focus on self; impaired daily functioning.

Desired Outcome:
1. Verbalize awareness of feelings of anxiety and healthy ways to deal with them.
2. Appear relaxed and report anxiety is reduced to a manageable level.
3. Demonstrate problem-solving skills and use resources effectively.

Nursing intervention with rationale:
1. Assess level of anxiety and degree of interference with daily activities/life.
Rationale: Necessary information to identify the extent of problem for the individual and plan appropriate interventions.

2. Review drug/substance use history (e.g., prescription/illicit), familial/physiological factors (e.g., mental/physical illness, family disorganization).
Rationale: Drugs (including alcohol) may have been used to handle anxious feelings in the past. Other factors contribute to anxiety and may affect individual’s ability to handle stress of dealing with own identity problems.

3. Help client identify feelings, conveying empathy and unconditional positive regard. Encourage free expression of feelings in appropriate ways.
Rationale: Identification of feelings within a safe, therapeutic environment can help the client begin to explore causes of anxiety and begin to move toward acceptance of self as a worthwhile person.

4. Acknowledge reality of anxiety/fear. (Do not deny or reassure client that everything will be all right.)
Rationale: Helps client accept own feeling(s) and learn trust in self. Denial of these feelings contributes to increased anxiety. Platitudes lack factual basis, and providing false reassurance can damage trust and may increase client’s anxiety.

5. Provide accurate information to assist client to clarify reality base, reframe sexuality, and delineate boundaries.
Rationale: Anxiety may be the result of misinterpretation or lack of knowledge about sexuality/gender identity, and client may fantasize unrealistic ideation.

6. Accept the client as he or she is.
Rationale:Lack of self-acceptance is the basis of much anxiety, and other’s unacceptance increases anxiety.

7. Identify things client has done previously when feeling nervous/anxious.
Rationale: Helps client see which previous actions have been beneficial and can be used in this situation, increasing sense of control/capability and allaying anxiety.

8. Assist with developing program of exercise (e.g., brisk walking, aerobic class).
Rationlae: Strenuous activity releases opiate-like endorphins, which create sense of well-being and decrease anxiety. However, exercise therapy need not be aerobic or intensive to achieve the desired effect.

The DSM-IV defines enuresis/encopresis as repeated involuntary (or, much more rarely, intentional) voiding/passage of feces into places not appropriate for that purpose, after attaining the developmental level at which continence is expected. If continence has not been achieved, the condition can be termed “functional” or “primary.” The period of continence necessary to differentiate between primary and secondary enuresis/encopresis is now considered to be 1 year. There does seem to be a significant relationship between enuresis and encopresis, although neither condition can be the direct effect of a general medical condition (e.g., diabetes, spina bifida, seizure activity) to be included in this category.

DSM-IV
307.6 Enuresis (not due to a general medical condition)
307.7 Encopresis without constipation and overflow incontinence
787.6 Encopresis with constipation and overflow incontinence
ETIOLOGICAL FACTORS
Psychodynamics
Numerous psychological interpretations exist speculating on the dynamics of toilet training and the significance of flushing bodily fluids down the toilet. Freudian theory places the fixation at the anal stage of development whereby the child fails to neutralize libidinal urges, and the aggressive impulses are fused with the pleasure of controlling bodily functions. Expulsion of feces or urination and untimed feces or urination or intentionally placing the feces in inappropriate places elicits hostility from parents. Loss of bodily functions leads to loss of self-respect, loss of friends, and feelings of shame and isolation.

Biological
Learning to control urination/defecation is a developmental task most likely achieved by age 4 or 5 and requires a mechanically effective anatomy. In some enuretic children, abnormalities in regulation of vasopressor/antidiuretic hormone (ADH) have been evidenced, with ADH regulation being linked to both the dopaminergic and serotonergic systems. A theory of developmental delay suggests there is a common underlying maturational factor that predisposes children to manifest both enuresis and behavioral disturbances. Enuresis and encopresis are normal responses to environmental stresses that occur in certain situations (e.g., when a child is separated from his or her family or is abused). In either case, as the child matures and the environmental stressors are alleviated, normal bodily control is resumed. Children who are hyperactive may have occasional accidents, as they do not attend to the sensory stimuli until it is too late.

Enuresis and its relationship to bladder capacity and urinary tract infections has been explored, as has nocturnal enuresis occurring during deep sleep with no response to arousal signals. In addition, research has been conducted to investigate the physiological basis for encopresis. These studies indicate that the act of bearing down led to decreased anal sphincter control in almost all cases.

Soiling may result from excessive fluid buildup caused by diarrhea, anxiety, or the retention overflow process, whereby leakage occurs around a retentive fecal mass. This mechanism is responsible for 75% of encopretic children.

Genetically, a child is at risk for enuresis if the parent has a history of enuresis after the age of 4. Recent research suggests a genetic mutation on chromosome 13.

Family Dynamics
As mentioned previously, the parental attitude toward cleanliness and the rigidity with which this behavior is controlled may perpetuate the fear associated with loss of bodily control. Parents often get caught up in the volitional aspects, blaming the child for “acting like a baby.” Further social embarrassment ensues when school personnel target the problem in terms of “the dirty child from a dirty family.” Attempts to deny the problem lead to covert behaviors such as hiding soiled clothing in lockers, under the bed, or in the trash. The child may in fact be using the only weapon available, as in the case of severe neglect and/or sexual assault.

NURSING PRIORITIES
1. Promote understanding of condition.
2. Identify and support change in parent/child patterns of interaction.
3. Enhance self-esteem.
4. Assist client in achieving continence.

DISCHARGE GOALS
1. Condition/therapy needs are understood.
2. All parties are participating in therapeutic regimen.
3. Achieves as near a normal pattern of bowel/bladder functioning as individually possible.
4. Plan in place to meet needs after discharge.

Nursing diagnosis for elimination disorders: Altered Urinary Elimination/Bowel Incontinence may be related to Situational/maturational crisis; Psychogenic factors: predisposing vulnerability; threat to physical integrity (child/sexual abuse); Constipation possibly evidenced by Nocturnal and/or diurnal enuresis; Involuntary passage of stool at least once monthly; Strong odor of urine/feces on client; Hiding fecal material/soiled clothing in inappropriate places.

Desired Outcome:
1. Verbalize understanding of contributing factors and appropriate interventions.
2. Participate in appropriate toileting program.
3. Achieve continence.

Nursing intervention with rationale:
1. Identify times of occurrence, preceding/precipitating events, amounts of oral fluids, and family/client response to incontinence.
Rationale: Baseline data will help identify patterns and document improvement after treatment begins

2. Check for fecal impaction.
Rationale: This may be a contributing factor.

3. Discuss measures client/family have tried and successes/failures to date.
Rationale: Typically, parents/caregivers have tried various methods, usually getting child up periodically at night, limiting fluids before bedtime, and having older children change soiled bed linens. These methods are not very effective and usually lead to frustration, power struggles/battles.

4. Suggest use of bladder-stretching exercises (e.g., ask child to drink favorite beverage and wait to urinate until the urge becomes very strong, then measure the amount of urine voided). Gradually increase amount of liquid and waiting period.
Rationale: Although this method can have good results, the length of time needed may be discouraging and result in the family discontinuing the program.

5. Active-listen and involve client in developing the plan for remaining dry/clean. Institute a system of positive reinforcement. Use rewards that the child would like or agrees to. Use the previously determined baseline data to determine parameters of the reward system and when to increase schedule.
Rationale: Establishing a plan to which the client agrees has more chance of success than using aversive operant behavioral interventions (e.g., bell alarm) alone. Behavioral therapy may be useful when client is included in the planning, with rewards, such as tokens having value, if client agrees to their use. Note: If client is not involved in planning/vested in behavioral program, then therapy becomes an external control manipulating the client rather than promoting internal control and growth.

6. Establish toileting routine with positive reinforcement for “sitting time” and depositing urine/feces in lavatory appropriately.
Rationale: Client may begin to establish bowel/bladder habits often missing prior to treatment.

7. Treat occasional relapses with matter-of-fact attitude and follow through with procedures for self-hygiene.
Rationale: Relapse (whether intentional or not) is to be expected but may be minimized when the client does not feel pressured/blamed for lack of cooperation.

8. Discuss length of treatment with parents/client and make plans for maintaining dry/clean status.
Rationale: Knowing that treatment is ongoing prevents becoming discouraged and giving up treatment.

9. Administer medications as appropriate, e.g: Imipramine (Tofranil).
Rationale: May be used after age 7 for enuresis. However, drug therapy is only a temporary treatment, not a cure, as condition recurs within 3 months after medication is discontinued. Pharmacological studies indicate improvement in encopresis with relatively low doses over 2-week period. Note: Factors such as child’s age, duration of problem, and child’s motivation to change are factors that affect decision to include pharmacological agents in combination with behavioral interventions.

10. Refer for evaluation of other therapies (e.g., hypnotherapy).
Rationale: Used alone or in conjunction with conditioning, the use of hypnosis can help the child access the subconscious mind allowing the child to work through emotional conflicts and develop positive suggestions t hat he or she has good muscle control and will be dry in the morning. Note: This technique is contraindicated in the presence of child abuse.