Varcarolis Manual of Psychiatric Nursing Care Planning An
Varcarolis Manual of Psychiatric Nursing Care Planning An
Varcarolis Manual of Psychiatric Nursing Care Planning An
Assessment
Chapter 15 Grieving
Theory
Anticipatory Grief
Grieving
Complicated Grieving
Chapter 16 Suicide
Epidemiology
Risk Factors
Assessment
Phases of Crisis
Assessment
Self-Assessment
Part IV Psychopharmacology
Nonstimulants
Second-Generation Antipsychotics
Injectable Antipsychotics
Chapter 23 Mood Stabilizers
Lithium
Anticonvulsants
Second-Generation Antipsychotics
Bipolar Depression
Chapter 24 Antidepressants
Antidepressant Drugs
Choosing an Antidepressant
Discontinuing an Antidepressant
Antidepressant Classification
Antianxiety Drugs
Tricyclic Antidepressant
Over-the-Counter Sleep Aids
Cannabis
Opioids
Hallucinogens
Inhalants
Amphetamines
Nicotine
Interpersonal Therapy
Behavioral Therapy
Milieu Therapy
Group Therapy
Light Therapy
References
Relevant History
Psychiatric History
Alcohol/Substance Use
Sleep Pattern
Appearance
Attitude
Behavior
Mood
Affect
Speech
Thought Processes
Thought Content
Perceptions
Cognition
Insight
Judgment
Index
Notices
Practitioners and researchers must always rely on their own
experience and knowledge in evaluating and using any information,
methods, compounds or experiments described herein. Because of
rapid advances in the medical sciences, in particular, independent
verification of diagnoses and drug dosages should be made. To the
fullest extent of the law, no responsibility is assumed by Elsevier,
authors, editors or contributors for any injury and/or damage to
persons or property as a matter of products liability, negligence or
otherwise, or from any use or operation of any methods, products,
instructions, or ideas contained in the material herein.
This book is dedicated to people who are living with and recovering
from mental illness and to the nursing students and registered
nurses who focus on supporting this recovery.
Reviewers
Leslie A. Folds Ed D.; PMHCNS-BC; CNE
Associate Professor of Nursing
School of Nursing
Belmont University
Nashville, TN
Box 1.1
Quality and Safety Education for Nurses
(QSEN) Competencies
Patient-centered care: Recognize the patient or designee as the
source of control and full partner in providing compassionate
and coordinated care based on respect for the patient's
preferences, values, and needs.
Teamwork and collaboration: Function effectively within nursing
and interprofessional teams, fostering open communication,
mutual respect, and shared decision making to achieve quality
patient care.
Evidence-based practice: Integrate best current evidence with
clinical expertise and patient/family preferences and values for
delivery of optimal health care.
Quality improvement: Use data to monitor the outcomes of care
processes and use improvement methods to design and test
changes to continuously improve the quality and safety of
health care systems.
Safety: Minimizes risk of harm to patients and providers through
both system effectiveness and individual performance.
Informatics: Use information and technology to communicate,
manage knowledge, mitigate error, and support decision-
making.
• Establish rapport.
• Elicit the patient's chief complaint (i.e., the
perception of the problem in the patient's own
words).
• Review physical status and obtain baseline
vital signs.
• Determine the impact of the disorder and
symptoms on the patient's life (self-esteem,
loss of intimacy, role functioning, change in
family dynamics, lifestyle change, and
employment issues).
• Identify risk factors that may affect safety
(e.g., confusion, suicidal thoughts, or
homicidal thoughts).
• Gather information related to previous
illnesses, treatment, and hospitalizations.
• Identify psychosocial status (family
relationships, social patterns, interests and
abilities, stress factors, substance use, social
supports).
• Complete a mental status examination.
It is helpful if the patient's family members, friends, and relatives
participate during the data collection whenever possible. If a law
enforcement agent brought the patient into the emergency department
or crisis intervention unit, it is important for the nurse to understand
what situation warranted police intervention.
Past medical and psychiatric history can supply valuable
information. This is particularly important if the patient is
experiencing psychosis, is withdrawn and mute, or is too agitated to
provide a history. Charts from previous hospitalizations or electronic
medical records are extremely helpful. Laboratory reports also
provide important information.
The use of a standardized nursing assessment tool facilitates the
assessment process. Appendix A contains a patient-centered
assessment tool. Most healthcare facilities provide patient assessments
in either paper or electronic form. Although these tools are integral for
gathering essential data, they can feel impersonal. With practice,
nurses become proficient in gathering information in a less formal
fashion, with the nurse clarifying, focusing, and exploring pertinent
data with the patient. This method allows patients to state their
perceptions in their own words and enables the nurse to observe a
wide range of nonverbal behaviors. A personal style of interviewing
congruent with the nurse's personality develops as comfort and
experience increase. Box 1.2 presents the factors that are typically
assessed.
Box 1.2
Common Assessment Areas
Previous psychiatric treatment
Educational background
Occupational background
Employed? Where? How long?
Special skills
Social patterns
Describe family.
Describe friends.
With whom does the patient live?
To whom does the patient go in times of crisis?
Describe a typical day.
Sexual patterns
Sexually active? Practices safe sex? Practices birth
control?
Sexual orientation
Sexual difficulties
Interests and abilities
What does the patient do in his or her spare time?
What sport, hobby, or leisure activity is the patient good
at?
Medications
What medications does the patient take? How often?
How much?
What herbal or over-the-counter drugs does the patient
take? How often? How much?
What psychotropic drugs does the patient take or use?
How often? How much?
How many drinks of alcohol does the patient take per
day? Per week?
What recreational drugs does the patient take or use?
How often? How much?
Does the patient identify the use of drugs as a problem?
Coping abilities
What does the patient do when he or she gets upset?
To whom can the patient talk?
What usually helps to relieve stress?
What did the patient try this time?
Box 1.3
Brief Cultural, Social, and Spiritual and
Religious Assessment
Cultural Assessment
Language
What is your primary spoken language?
How would you rate your fluency in English?
Would you like an interpreter?
Communication style
Observe nonverbal communication (gesture, posture,
eye movement).
What are your feelings about touch?
Observe how much eye contact the patient is
comfortable with.
How much or little do people make eye contact in your
culture?
Family group
Describe the members of your family.
Who makes the decisions in your family?
Which family members can you confide in?
Health and illness beliefs
When you become ill, what is the first thing you do to take care
of the illness?
How is this condition (medical or mental) viewed by your
culture?
Are there special health care practices within your culture that
address your medical or mental problem?
Are there any restrictions on diet or medical interventions
within your religious, spiritual, or cultural beliefs?
What are the attitudes of mental illness in your culture?
Social Supports
Are there people outside the family (friends, neighbors) that
you are close to and feel free to confide in?
Is there a place where you can go for support (church, school,
work, club)?
Spiritual and Religious Beliefs and Practices
What importance does religion or spirituality have in the
patient's life?
Do the patient's religious or spiritual beliefs relate to the
way the patient takes care of himself or herself or of
the patient's illness? How?
Does the patient's faith help the patient in stressful
situations?
Whom does the patient see when he or she is medically
ill? Mentally upset?
Are there special healthcare practices within the patient's
culture that address his or her particular mental
problems?
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DANCE ON STILTS AT THE GIRLS’ UNYAGO, NIUCHI
I see increasing reason to believe that the view formed some time
back as to the origin of the Makonde bush is the correct one. I have
no doubt that it is not a natural product, but the result of human
occupation. Those parts of the high country where man—as a very
slight amount of practice enables the eye to perceive at once—has not
yet penetrated with axe and hoe, are still occupied by a splendid
timber forest quite able to sustain a comparison with our mixed
forests in Germany. But wherever man has once built his hut or tilled
his field, this horrible bush springs up. Every phase of this process
may be seen in the course of a couple of hours’ walk along the main
road. From the bush to right or left, one hears the sound of the axe—
not from one spot only, but from several directions at once. A few
steps further on, we can see what is taking place. The brush has been
cut down and piled up in heaps to the height of a yard or more,
between which the trunks of the large trees stand up like the last
pillars of a magnificent ruined building. These, too, present a
melancholy spectacle: the destructive Makonde have ringed them—
cut a broad strip of bark all round to ensure their dying off—and also
piled up pyramids of brush round them. Father and son, mother and
son-in-law, are chopping away perseveringly in the background—too
busy, almost, to look round at the white stranger, who usually excites
so much interest. If you pass by the same place a week later, the piles
of brushwood have disappeared and a thick layer of ashes has taken
the place of the green forest. The large trees stretch their
smouldering trunks and branches in dumb accusation to heaven—if
they have not already fallen and been more or less reduced to ashes,
perhaps only showing as a white stripe on the dark ground.
This work of destruction is carried out by the Makonde alike on the
virgin forest and on the bush which has sprung up on sites already
cultivated and deserted. In the second case they are saved the trouble
of burning the large trees, these being entirely absent in the
secondary bush.
After burning this piece of forest ground and loosening it with the
hoe, the native sows his corn and plants his vegetables. All over the
country, he goes in for bed-culture, which requires, and, in fact,
receives, the most careful attention. Weeds are nowhere tolerated in
the south of German East Africa. The crops may fail on the plains,
where droughts are frequent, but never on the plateau with its
abundant rains and heavy dews. Its fortunate inhabitants even have
the satisfaction of seeing the proud Wayao and Wamakua working
for them as labourers, driven by hunger to serve where they were
accustomed to rule.
But the light, sandy soil is soon exhausted, and would yield no
harvest the second year if cultivated twice running. This fact has
been familiar to the native for ages; consequently he provides in
time, and, while his crop is growing, prepares the next plot with axe
and firebrand. Next year he plants this with his various crops and
lets the first piece lie fallow. For a short time it remains waste and
desolate; then nature steps in to repair the destruction wrought by
man; a thousand new growths spring out of the exhausted soil, and
even the old stumps put forth fresh shoots. Next year the new growth
is up to one’s knees, and in a few years more it is that terrible,
impenetrable bush, which maintains its position till the black
occupier of the land has made the round of all the available sites and
come back to his starting point.
The Makonde are, body and soul, so to speak, one with this bush.
According to my Yao informants, indeed, their name means nothing
else but “bush people.” Their own tradition says that they have been
settled up here for a very long time, but to my surprise they laid great
stress on an original immigration. Their old homes were in the
south-east, near Mikindani and the mouth of the Rovuma, whence
their peaceful forefathers were driven by the continual raids of the
Sakalavas from Madagascar and the warlike Shirazis[47] of the coast,
to take refuge on the almost inaccessible plateau. I have studied
African ethnology for twenty years, but the fact that changes of
population in this apparently quiet and peaceable corner of the earth
could have been occasioned by outside enterprises taking place on
the high seas, was completely new to me. It is, no doubt, however,
correct.
The charming tribal legend of the Makonde—besides informing us
of other interesting matters—explains why they have to live in the
thickest of the bush and a long way from the edge of the plateau,
instead of making their permanent homes beside the purling brooks
and springs of the low country.
“The place where the tribe originated is Mahuta, on the southern
side of the plateau towards the Rovuma, where of old time there was
nothing but thick bush. Out of this bush came a man who never
washed himself or shaved his head, and who ate and drank but little.
He went out and made a human figure from the wood of a tree
growing in the open country, which he took home to his abode in the
bush and there set it upright. In the night this image came to life and
was a woman. The man and woman went down together to the
Rovuma to wash themselves. Here the woman gave birth to a still-
born child. They left that place and passed over the high land into the
valley of the Mbemkuru, where the woman had another child, which
was also born dead. Then they returned to the high bush country of
Mahuta, where the third child was born, which lived and grew up. In
course of time, the couple had many more children, and called
themselves Wamatanda. These were the ancestral stock of the
Makonde, also called Wamakonde,[48] i.e., aborigines. Their
forefather, the man from the bush, gave his children the command to
bury their dead upright, in memory of the mother of their race who
was cut out of wood and awoke to life when standing upright. He also
warned them against settling in the valleys and near large streams,
for sickness and death dwelt there. They were to make it a rule to
have their huts at least an hour’s walk from the nearest watering-
place; then their children would thrive and escape illness.”
The explanation of the name Makonde given by my informants is
somewhat different from that contained in the above legend, which I
extract from a little book (small, but packed with information), by
Pater Adams, entitled Lindi und sein Hinterland. Otherwise, my
results agree exactly with the statements of the legend. Washing?
Hapana—there is no such thing. Why should they do so? As it is, the
supply of water scarcely suffices for cooking and drinking; other
people do not wash, so why should the Makonde distinguish himself
by such needless eccentricity? As for shaving the head, the short,
woolly crop scarcely needs it,[49] so the second ancestral precept is
likewise easy enough to follow. Beyond this, however, there is
nothing ridiculous in the ancestor’s advice. I have obtained from
various local artists a fairly large number of figures carved in wood,
ranging from fifteen to twenty-three inches in height, and
representing women belonging to the great group of the Mavia,
Makonde, and Matambwe tribes. The carving is remarkably well
done and renders the female type with great accuracy, especially the
keloid ornamentation, to be described later on. As to the object and
meaning of their works the sculptors either could or (more probably)
would tell me nothing, and I was forced to content myself with the
scanty information vouchsafed by one man, who said that the figures
were merely intended to represent the nembo—the artificial
deformations of pelele, ear-discs, and keloids. The legend recorded
by Pater Adams places these figures in a new light. They must surely
be more than mere dolls; and we may even venture to assume that
they are—though the majority of present-day Makonde are probably
unaware of the fact—representations of the tribal ancestress.
The references in the legend to the descent from Mahuta to the
Rovuma, and to a journey across the highlands into the Mbekuru
valley, undoubtedly indicate the previous history of the tribe, the
travels of the ancestral pair typifying the migrations of their
descendants. The descent to the neighbouring Rovuma valley, with
its extraordinary fertility and great abundance of game, is intelligible
at a glance—but the crossing of the Lukuledi depression, the ascent
to the Rondo Plateau and the descent to the Mbemkuru, also lie
within the bounds of probability, for all these districts have exactly
the same character as the extreme south. Now, however, comes a
point of especial interest for our bacteriological age. The primitive
Makonde did not enjoy their lives in the marshy river-valleys.
Disease raged among them, and many died. It was only after they
had returned to their original home near Mahuta, that the health
conditions of these people improved. We are very apt to think of the
African as a stupid person whose ignorance of nature is only equalled
by his fear of it, and who looks on all mishaps as caused by evil
spirits and malignant natural powers. It is much more correct to
assume in this case that the people very early learnt to distinguish
districts infested with malaria from those where it is absent.
This knowledge is crystallized in the
ancestral warning against settling in the
valleys and near the great waters, the
dwelling-places of disease and death. At the
same time, for security against the hostile
Mavia south of the Rovuma, it was enacted
that every settlement must be not less than a
certain distance from the southern edge of the
plateau. Such in fact is their mode of life at the
present day. It is not such a bad one, and
certainly they are both safer and more
comfortable than the Makua, the recent
intruders from the south, who have made USUAL METHOD OF
good their footing on the western edge of the CLOSING HUT-DOOR
plateau, extending over a fairly wide belt of
country. Neither Makua nor Makonde show in their dwellings
anything of the size and comeliness of the Yao houses in the plain,
especially at Masasi, Chingulungulu and Zuza’s. Jumbe Chauro, a
Makonde hamlet not far from Newala, on the road to Mahuta, is the
most important settlement of the tribe I have yet seen, and has fairly
spacious huts. But how slovenly is their construction compared with
the palatial residences of the elephant-hunters living in the plain.
The roofs are still more untidy than in the general run of huts during
the dry season, the walls show here and there the scanty beginnings
or the lamentable remains of the mud plastering, and the interior is a
veritable dog-kennel; dirt, dust and disorder everywhere. A few huts
only show any attempt at division into rooms, and this consists
merely of very roughly-made bamboo partitions. In one point alone
have I noticed any indication of progress—in the method of fastening
the door. Houses all over the south are secured in a simple but
ingenious manner. The door consists of a set of stout pieces of wood
or bamboo, tied with bark-string to two cross-pieces, and moving in
two grooves round one of the door-posts, so as to open inwards. If
the owner wishes to leave home, he takes two logs as thick as a man’s
upper arm and about a yard long. One of these is placed obliquely
against the middle of the door from the inside, so as to form an angle
of from 60° to 75° with the ground. He then places the second piece
horizontally across the first, pressing it downward with all his might.
It is kept in place by two strong posts planted in the ground a few
inches inside the door. This fastening is absolutely safe, but of course
cannot be applied to both doors at once, otherwise how could the
owner leave or enter his house? I have not yet succeeded in finding
out how the back door is fastened.