Mental Health Chapter 7-8

tangential blocking scapegoating cgnfidenWty thebry base social skills

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Group Work

P r a c e S ~ ~ Conmlt a6 Roles Role d t h e Grow Leader &DUP

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:g~ag@ a f Gronp Dmlopnrent Group h e 8 ?h2ps df Grotlp1

Foms~d Gronps Psychotherapy Gmups

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components af an interaction are content and process:

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developing in the group, and deteres of d e c t i v e group action.

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I;ommynWon smcture m e f a to the exchange of though- and messages. L ~ o katwho talks to whom, who listens to whom, aad who respomb to wkm Also be awatx of who do= not partidpate in the communication Smctuce. SocimneCriC structure & fato prefmence and intapersonal macy.Look at who refers to w h m iD the group and who sits next to whom carefuny obgewe phHiml proxbify, fadal qmssion, m e of Mice, and eye eontact The environment Mmnc& the gratqh and development of the @up. Group enpironmenf include$room s&et phydd location, type of iimimCie,, mnfkrtable chairs], seating aanganats, and educational rwmces ( i . ~blackboard, , video). 6bsex&%on &the @oup atmosphere. is imptmt, Ts the guup mngerrid and frimdly? Are unplmmt feelings expressed? Do group membem cT.imgrec.7 Are memhtem sparttaneous or WitMrawn?

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FUNCTIONS OF CRWUPS W e are two basic functions oFgrpups: task and maintenanm The task function keeps the gzoup on target and g& the jab done, Some behaviors that omm daring task are initiating artiviQ, s e w fnfarmiltian, g%ng or uking fmfee&actC, wortbat@+ surmnarizing, and evalqa&. %k functidn can be slowmoving m 6 be d e b 9 & need tobe defixed, and ~ m d n to 5 wntmt The &&ee h & m i is to stwng&en the group spidt and $a&& tbe me& of p u g members. Some behaviors dmZng maintenance are standard setting1CQnsWUstesting, en~uraghg, enmgtzing, and a m i n s a BOUD feeha functions ereate an &ec. tive g&up atmosphere among pronp members so t h y can attempt to worktogetha in a smooth and maan& If maintenance funcrions are ipadqateI nonfunctianal bef~avimssuch aS the folkmi% usuauy occur: W Blocking-resjstiug eontributiam of other group members or going off on a tangent with welated infarmation W Domibati@-manipulatiw&conwolung GXovnk+-ho~'singmom& dismpting the group, mimicking anothCr group mernba: 6 Self-confessing-telling all, using the group a s o u n b g bomd m t h d r a ~ - p u B n g away from the group althou$h remaining phsgiraIly in the group; sometimes 8to other* or wandering f r m the subject 4 &apegoating-someone bearing the Mame for o T h S

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workmg @g;@per .yetwe proRlem .summariq~~ sq~vrng:,

neVd roles

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be no break and wayone is ixpxied to remain in the mom during the session Startin$ and finishing the session on time will conti-ibute to an organized group style. Reserve time at the end of the swsion for sllmmarizing. At h t the group leader can summarize by da&kg the b e or problem discussed and focus on ideas that emerged h the group and any goals or actions decided on Later, as the group's cohesivenm and wUaboIaung spirit is in placa thegroup leader can ask for a p u p member to volunteer to summarize for thegroup what happened at the session

GROUP PHASES The group phases on be divided ioto the foUowing categories: initial or orientation, worktng, termination, and d u a t i o n In orientation phase, the p u p settles down to work The members size each other up and 1ookt;arapproval,acceptaace, aad respert Qesbons the group might ask are the following: Why are we here? What are we going to set as our goals and how are we gain$ to get this done? There is usuall-j a polite atmosphere with dependency needs being expressed toward the gfoup leader. The group discusses its purpose, and group mles are discussed to arrive at a g o r p cantract Conilktwill &ace as group members become preoccupied with wntFol and paver. During the co& phase, the group may even insist that the leader "5x it?for t h a n Carl Rogers describes this first stage as lnilling around, with group members demomfratfng a resistance to e&pressing. Pasl pason-

1

Function mslc Maintenance

1 croup Database

Phases

orlentation WOrRIng

Termination EValUatlon

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Yalom has described cuatim f a e s that occur in the p u p . Some of Yalonts cur&% factors W d e the foil* Installation and maintaunee of hope 'Others have the same problems as I do."

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UM6aliW "We are people-all in the same boat'*

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hts, feelings, coptng sl(llls,and social support.

of others above my anm ae]E8

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I Self-wldersstanding T amleambgwhpl Wnkand feeltheway1 do. I have some hang-ups from lox ago."

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Group cohesiveness T beto a group now, and I ain being accepted ?q others." Catharsis 'T gn kgbming to express my posith~andnegative feelings w a r d other group membm. I Eke being able to say what bothem me!

TYPES OF GROUPS Nurses may encounter many types-of groups. The primary parpose of a group is to be therapeufic to the gmup m e m k through supporting,educating, motiva~g,and problem solving with them. A gmup needs a purpose statement*length oftime to meet and date, time+ and place of meeting. Becoming moxe popular in outpatient settings are closed groups with specific membmhfp, specific time flames, and a set number of sessions. See F g u e 7-2 for a typical announcement of a speeiahzd gmup meetin& Following are some sample groups

group presents specific information Active partidpatian The teaby the members is- encouraged Ceg, a four-week nutritional g r o q led by the dieticianfor catdiac elients, a ~lledicationgroup m-led by a nurse and pharmacist for inpatient ps;]rchit.ricclients).

Discussion Group

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The d i s ~ ~ ~ sgroup i o n encourages communication and ' ~ bbuilding e of the indi~dual'sself-esteem. It usually had an educational and %&ha-

porthe empathy and -bing loneliness. In most cases, &mt@ must have a rea* abiiiy suitable for na~lgathgin eqfompace and hand m m b t i a nto operate a wmputes moase.

FQcuSedTask Groups Group -d occur in a wide varietg- of situations in our work env2ronment task groups? team meetings, and mmdtees. We are asslgntd themes or problenns t~ mlve through working with others,If a w om mi tree is not fuilctioningat an optfnxun l e d obsewe lowvvork behavioz sod&zhg, pbyfuhms, casual wnvezsing, attitude Boring not humesd wasting my meldand leadershir, style (no dkctiola),A $ o q fa& must look at the time avaikhleand wUt dedsions need to bemade. AUocath?g five minnw to agenda setting can save time and make cemb that each undmtands the problems to be discum?& an& h resourm needed. Setting priodtia and h e b i t s allom the p u p to be 8 d e yet have a sense of o m a t i o n List p r a b l m on a c b a l k b d or flip &art and then number according to importancepergroup comensus-Why are we-herel Vhat are w&supposed to do? How are We ping m get it all dane? Vhat is our h e fkme?What are ow go&? {ag., protocol far tbe sujcidaI p%tient,documentation guiddim~for a mental status exam, a stahdard of *ire thaf meets JCQlHD crlterial? Task p u p s are dear, wnciser and ammplished pro+ide consistency and continuiq for the patient care and intrease team-unitefficiency and overaIJ safisfaction

Psychotherapy Group AIlotbm type of group is: a psyddtlrerapy p u p led by a therapiiFt Group therapis@oul be p~ydxhtrists,pqch010gist social wmkersLor ahneed practice nurses.It is imprtant &at the p u p therapfisx have Parpert knowledge apd eqdcnce in the dynamim oaf hwnan behaviar and psy&opatholag~n The group is approached k m the theBpisVs theo'pbase. A theory base is asystematic, organized knowledge base tha~help$ m e d y n e , predia, or a p w a phenomenon leg., whatis hap* in tbe group, to the group members). This theorg base serves as a gtrtde for a h tetherapistwhen leading the goup intera&oZ3: therefore,dMng a t h e m h e is Nte different from qerimenM,g, pmrtieing, or "doing t h q y by the seat of your pan=' The Maring are mample of theurakal approache%:

Dialectical Behavioral Therapy. Dialectical behavioral t b q q is cognitive-behavioralthesapywith the addftionof psych.ciocial skills. DBT WSdeveloped by M a h a I i n w for a sueaiflc -i6:

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baddine pmnality disorder. Thwapy plus ski& mi&g den@'efnotionalre$ulato~mdindulatb~lrloo^ at the Mm&edness d b W ~ r apatwns l mtributes to interpwonaI eEecti-ese.

O ~ t a lThr: l group &mis on the i n W u a l witbin tfie goup. Roleplqhg is used to help the idvidaaI pupmember explore his o ~ h e r feeliqp, Some therapists use the hot seat approach.A person w e n mfes on his OP her pmhlem as the g r o q ohm.

trzlnsaettonal AnalYsls. ~ m mabas^ p b h v i o m and commacafian pttezm a r ~obsemd t and analyzed according to the rmdult-childparenttramaction m d e ~

I OonrmunlcaTio~Theory. The gmnp is eked far idkctive eommunication patternr;. Panems am identified and problem solved h u g h the estabhbent of feedbad channels. The therapist models gaod ~ u n i c a styles ~ nto clfminish &sfinmianal m-rion by the gmup members. In psychofhrapy groups*the grow memberis m selected for a, p u p through an interviewing pm-, and pmom&im grid b W iors ate considered. The group eq&ence W Escilitate behaviard changes and allow fur reaIiy t&stingand risk-* in as& en*ment. The goal is rhat the group membm e q m h n ~ ean . inaease in wtag and belongmg and a dewease ia IoneIinms and isdafion

pgYChodmma. A g r a q memba dr rly aefs out or reliveg a @EmasEdI& ifet rts the grow m d e s a Mfe e n m e a t for the climt tt, deal with difhd't ~ e s o issues ~ ~in%e d h w and now. The Other g m p me;mbas act a8 an interactiod audience. Mmm fl81410) OM pssrchodrama toda~itis & P F ~ F us~d 6~ O S W ked clienrgmqs. "

Clie*rtswiih ehmnic inePtaI illnesses arre fkeipently isolated and need b dweIap and wss theirsocial shtns.The he goaloft& group is to * e w e the ~m0unCof anxiety experend by clients in social interactions and provide a safe e d r ~ n m e nwhere t they can be social a d $iendly. POXa gmup of e l d e x ~ a ~ ~ c$map i n gmay be appropriate: Per$ons wfth mebltal jllnmses way enjw @amhg a barbeae With outd00T galne5 and acli@ies. Dav-hosM dienrs mau enimr =

CPOUQ Process

&-help grow for the client Wbaf infomation would the n m e garher prior to nbkmg this mwmmd&on? 5 R What grade of education the dienttbished, Q B. Characteristics ofthe dent's neigbboxhood Q C, The Jient's reading ability and band coordinatioa CI D. The &enre ability to perfom independent transfers.

F. betine the following.

: Briefly answer the following. norm as it pertains to group and give emnpIe6 ofan "-pWand impkit norm.

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Stressor8 in Adult and Teenage Pregmcy Nwsing Care of the Unwed Prepant Teenager Primary Bonding Coping with a StiIIborn or Malformed Infant Posp~.imaDepression Mother$ wiih Mental Diordw The Hospitalized Child Coping Mefhods ofthe Hoapitdbed ChiId

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postpatturn depression teratogenic

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.mESSORS IN AR@;&TH ~ DTEENAGE PI@GNANCY ,,-

"~he.p%g&nt t g w h a m e dif&cult&e x&ptingto the.q=.$OD of prqgnmcy mle 8%3.&e :muat face the admLal ghysid, and n r e t a h ~ l i c & g c ~ q f ~ ~ b ~hadtime ,~she~ adj,ustto fhe changes ~f,&olqsm ?be @ must.adaptto tbe role of parmrhoed We seill the mle &age to a8uIthowd She. mast BQwon'sstage &Wmtitymd,t:&e me-timeac~ompj&h o-ffin~ey&ns bdlaffm. She mmt disc@i+?t*vJio~&~& as :%eke she who, she 8 pipason, ~g foI %dependence is blrs&ed by t& and em&od r pJ@p&@,Em in & s0pbistr&etletl s&q6 w a g & .G-ge &m pqpmq and p m e o 6 & kcg d.knowledge:@esriseto aqggtz4 t&qe&tic fw? %.y~un$ WO* 5 a b 's@ d@&$bping and has not y& ; r w e l ! ?abiIligfl2Id& at:fhhgs4$wtiinm thep9niculmiastanee. mtho~tthis &iE$ .she has ,&tienl~+resng&ing rhe f i i t q .@,m

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ADULT PREGNANCY

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TEENAGE PREGNANCY

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,Ama,mBli& ~ e ~ s & ~ e . u j % & e n ~ f ~ ~ &&the stage ofin1-ae,yaanb sirn~ttane.~~s!~aope \ni,M'kfie stage ofg@nerafWty o+v@f@plnqgQefiqehcewijlle hcreasing aependen~:qu%ed by p.m~n,ancy

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a d s 4 finaneiaI burdenss Temagers are categorizes according to yomiddle, and late adoles&n= Pregnanq has been increasing in the youngest grmp. Thisyoung adolescent thinla in the present She g i x s little thought to the possible effects of coitus. Knowledge of her body, pregnancy, and contraception is limited and what knowledge she does haw is often imrrect There is usually no lasting relationship bethe young teen and her boy&iendShe often becomes p r w t following the first sexual experience. Denial is a common defense mechanism and she may deny the pregnancy even when it is evident to others. If she accepts the pregnancy, 6b.e often d&es responsibility This blame is placed on her sexual partner, who is then despised.Adoptionis seldom considerzd. More ofteq, thebalgr is turned over to the grandparents to raise as the mother's sibhg. The middle adolescentis a littlemore sophisticated in her knowledge.She is aw& of the possible eeects of coitus. She knows h u t contraceptives but manytimes fails to use thea There are many theories to "plain this. If the gfrl irlllses contraceptives, she is obviously planning on having s d relationships, which goes against her parentally instilled values and makes her a %ad" girl If coitus is not planned, she can save her selfconcept by blaming "the moment? or passion. Pregnancy is actually sought by some middle teens because it means maturity and independence to them It may also be a rebellious act sainst her parents. In somegroups, it is sirnpIy the *id1thing to do. TKmaWr the reason, the Zpiddle adolacent usuaUy denies responsibility forthe prepmq. She o f t a blames her paenI5, The middle teen rarely has a desire to m a ~ her y boyfj!iend,but she does need his support. Wahout his suppork she experiences increased anxiety. Even thrmgh she may have msciously or nnconsciously sought the pregnancy, she often has unrealistic fantasies and ambivalent feelings about motherhood The pregnant teen demonmates her extreme anxiety fh~oughrebellion, anger, disinterest and boredom, as well as numerous somatic complaints. She is usual& very frghtened of media care arrd seeks care late, ifat all. Because of anxietyand distrust of authority, she may be uncooperative during examinations and may not follow through on directions. TYLe baby may be raised bythe grandpments. In other cases,the teenis forced to assume complete care to the detriment of her education and s o d life. The late adolescent girl freqwnfly aims her relationship with her sexual partner as meaningM and often has planned to m a w M at some time in the future. Even if marriage is not sought when pregnancy is discovered, recognition and support ffom Yhe SeYual partner seem8 to be important Athough older adobe& males tend to ampt

: wponsibilitp for pa-

more &n than yotmgs adelescents, the wst nXi0tity still reject the g i 5 Unfortnnate& the old= a d o k c a t is also the one mest 6rejected &the W y Tkib gscl is &ie to rrcog&e fbe h h n a n o d a l , and motional p m b h to be faced as a single mother. W i m t tip needed suppopt, she is apt to bemme d-ed Bnd to fbi that no one ma.A l h u g h &ols are now , mare leniem the older adoiescent is &en &rmd to quit sdhool Ibextux of f b n e j d an$ time ConsWnB. M Q Bpregnant ~ adole5cents keep their inht3, bur abortion and a&ption are a"ept&Ie akmtives %r some,

'Uwglnsleareof thr unwed Pregn;mt:feenmf@r Xt%$ easy to stemtype all a@zed p ~ mado1wcnts, t but-&qde not b~rntl~ inti,oix cafeg~zyA I t h ~ ~ t h earma marry pmbtems,,sqme~ m&gw ltre prouddef6:ppepmeyand lmk forward w ~ae exp&m m of motkrhocrd & with any a*g cJient it 1s importsnt t W rtre n=*,get

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.Mazy Aan is Bkea ykvs old. She pwents h e r a t &e clinic b a m e she h& h a s m s s ie d8ome perfads. She:& not wtain hCMt She st@wetly f i e her blood pressure h ,takenq d 4submits telqmanty to a we&t check @he rerebels ~ t t h e m - ~ & & , g ~ & ~ ~ ~ @ sa90 not do elmP X h y Ami acted @ s& did because @hewgs~Eghtenedde& W g s &at &.e e l dd i not undmtand. She was emiboulasse& selfcon@ :& I & .anddisbtfiul of a t h e new pmple mrmd her: Before the nmse can &e&dy help &Q he or she must 3wdop.a trusting relati-hip. B ' UST takes thne; several *its may ~& ..~@eiLIt wdald bc id& if ow m s e . mw M q Ann each time she ~toth~clinicBdwelop~tthenrusgne& explainanpro. m $ W m befm they am done in terms t b t tfte r e q q mde~statldri; Magdmn is,still demloping ber aB@ytq W ing & d rather than +p&c terms. Sin@ she is weriendn$ s m , egpi-11s should,be &$bPlt ,using visual kteriBls whenmrpgssibla Developing Wt ab4 iavobw wntinuity, accepting M a q withput clific'imj ,a ppdm-, and .mm tvith.the. ti~d@l&~ent is ngt m y T& ~amse ,&.dd nut fqwW&i$akss ,M@QApn's nee& o n &~&& vfsit&&q

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to a m o n whom she has~ b & d w,'w@,@-magwc o & ~ m w , ~ a q ' &&.i => ,;~e+i&;;i& c9m a h ,be m& yVrth s.Iftile, or a , l e ~ ~ W 1~ .~ e r & ybfiaw ~. ~ ,&XI,

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Chapter 8

ana m ~ l a care

%m&nzss T& n a m@t.@ktbeinitia@ee,%uchm %fayAnn, are Scmw tkings +need@ &class." isleas e f f w kbecause @e %ddlesWt or .mq not comply. To detennfne Mmy Am-1~6nee&, the nurse shbuld g&er Mgr-

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FIGURE 8-2 pattern.

Characterrstics of tne Adolescent Communication '

the teemger will ~nrPacenonwerbally. Ho-, few a d o l e s w wiII o E e ~information without dire3 questioning. You@ and middle m a g e m && in speck& tams and respmd IftaaOyto cpe-sW11~.If the nmse ash *Canp teII me abozlt it'? the msvw is lib:& to be simply TeahhP To get tbe right the m e should say TEIIme abaut it"Teen8 also use the hngu@ge&@ermtlx

Mm5e Qtent:

Nurse: C3.t-

Nme: m e

I hew gou have a new motoxbike." Qh yeah, its wmo! *It'searn01 Wt does &at mean?" Tmlred y a squid It8 qurll, realbad" You mwn it% cool'? %ght Its sb-a-ad bikk"

To express m&m, a teen rnag say, *I don'tha= my W on sFaighr" or T ' m hung wetB A "bummd means thing.^ ate not- good Young and middle &&wmay not be ware of their ferns tw the~maynotbave the words ta enpress their feelings. meflan adolescent descrk%an expdence, shema$ start over several time%beca~se she bas a feat- of not b&g & m o d . It takes good obserpath and timing to initiate thempeufic communicationWth the adolescent. We:

Sfou lo& Me you b v e lM go- last &end Bad m M a l y h 1 "

client Nme:

CIfefi: Nurse: Client:

T\Tab'pkceofcak:aa %at L see yau have a sad face. What did the doctor tell PUP *Oh,n&g! %e cadiimed fhe ppregm~xy,didn't Be?" T s a real b-aP

may

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mt.(en &qt: B Ph.attpi+q$aancya n d , p . d o dmwn to her Her Eeuel of anxi* W effed tbe grqnancy has on kretreladionship with her W a n d her b o r n a d I oElth whatotbep Mopmental srresmrs she is dealbg . The 1 4 of her need for fuEument fo Maslm &b .W @b@idqgicaLq i low and belonging RePzds being met?? R How she sees kg & i m n 'R m a t plans she has for hemelfmd her babjr R DVhat shc?.fMs #he.needs fmm theawse The nussingm:m@then d~,&mil&thatshe;&s tbe fo&* 1

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strmgfhs and wwe9ses:

sw8n~tno

She a m p a responsibilityfor the -4 ,Shehas mnttriaed suppun h m her bofiead 71se schaaI.has a program for pptgllmtt~

I She feds she needs prepmatimfor labof md delivery

md pwnthood

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WeiIR~~ee~en 8hehas ngt .told her

m y and fearS repHer fntm plans are

ISha has an ~ 1 n r d k d c 8 i ~

sf p*@mcJ ma pmutJl~od Herphysid s a w i @ belong $ in^ l n@& are threatened

She has the ,sapportof her bogfrmdJ'spayens ~A&qArm,liks all feem&sG needs fbf: suppost o f h e r ~ M She p map neitrd el^ .@.,gainingit & , r e f e d to so&~shces or a &&ing nme might EX@& s ~ p k o when a &e s b e h her -psrents. M q Ann ma$ &$-fitt&,d* m&j ,demommw how &@!migh&& ,rn:!&..E& family nejem her,she,a need a

ref&& ma six*., ,S.~ce~h%$@~:@@&edae:nwj?m*@& -, be @ g & ~ ; h 3 m.@ ,&& q , &&. NeDa@@ or ~

individUany during her clinic visits. Preparation for labor should ihcIude relaxation exercises and some type of breathing techniques to lessen anxiety during labor: Probably the most important thing the nurse can do for Mary Am, and teenagers like her, is to provide support and be there when she needs someone. Doring labor, Mary AM has the same needs rn any other mother relief of paitt i n f o m o ~ and ~ emotional support She needs to have the person she trusts, whether it be her mother, her bqhend, or both, with ha. To help the young mother after birth, the nurse should manipulate the environment to provide sqccess experiences for her. She should provide compliments and gently wnect mistakes. If the girl decides to keep her baby, rooming-in should be encouraged so that the mother can learn to eare for her infant with the nurse's help. If she is planning on putting the baby up for adoption, she may want to see the chlld and care for it while the baby is in the hospital When the baby is adopted, she will face separation anxiety, but not seeing the baby often muses lasting anxiety. Sics the young mother is in the hospital for such a shoa time, referral for home health nursing &ce is usually indicated.

PRIMARY BONDING Primary bondingis the process of establishing an intimate interdependent attachment a m o ~ gmother, fkther, and infant @gwe 8-31. Research on bondmg, which began to surface in the 1960s indicates that bonding is impurtant to the child's future interpmonal relatianships. It also shows that infirm not bonded to their mothem h the criticaI immediate postparhnn period were more apt to be abused and neglected. Children who were not bonded expeximxd more anxiety and wereless able to cope with s m s . The bonded person is the child's P m support Bonding nomdly begins in the prenatal period when the mother feels quickening (the Grst movemeats of the baby,) The mother then can be seen massaging her growing abdomen, delighting in fetal movements, and taIking to the fetus. The immediate postpartum period seems to be most mcial Some mothers who have had negative feelings about being pregnant have effeaiveIy bonded ta the infant during the time just after birth. Although bonding may occur late, it seems to be mare diBcult and intervention is usually essential Natural bonding is initiatd by either the parent or the infant through behavior to which the other person responds. The baby aies and the mother picks the baby up and cuddles him or h a The baby stops crying and molds himself or herself to the moth& body The

Flburr: u-5 some oonalng Denavlon are eye-to-eyecontact and holding the baby no more than 17 Inches from the parent'sface.

mother fuaher responds by smiling. Eye contact, skin-to* contact, and touchmg seem to be essential to the proIpigure 8-41. If not intedmxl with bonding occurs automatidy The p r o w can be enhanced premtaDy and postnatally Bondmg is enrnuraged prenatally by allowing parents to Iisten to fetal heart tones, teachkg them to massage the mother's abdomen and showing them how to feel and recognize fetal parts. In the postnatal period, the parent is taught to hold the infant no more than seventeen inches flom the &GZ The infant cannot see clearly beyond sm enteen inches Eye-to-eye contact is important Talking to the infant should be encouraged. Some mothers feel ulcomfortabletalking to an infant They may feelas ifthey are taIking to a dolLor a wall. The nurse can help by pointing out the babys responses.

FIGURE 8-4 Factors that enhance bonding.

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l?&q A - ?* '4 Chapter 8

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mowing the mother to care for the bab, hduding feeding, w g i n g diapers, and bathing, abo enwurages bonding. The young

mothet in particular shodd be encouraged to pro* physicaI cate for her infirrrt Eooming-in helps the bonding process. The nurse supervbing the infads care should compliment the mother and correctians. It" the mother is having drffculty with the baby's cate and becomes upset, it is important that the nurse not take over.The. mother sometimes believe6 the baby evaluates her agaiwlt the more skiUed nurse and her sdf-concept is lowered. OE course this is not tme,but it is nonetheless a real c o r n to the mother. Instead*fo m,the nurse should help the mother to relax and then assist her with mggestions. If the environment is manipulated to give €he mother suceess, her self
COPING WITH A STILLBORN OR MALFORMED INFANT Whenever a problem m delivery occm or is anticipated, at times the father is banned or banished h m the scene. The infkt is Then taken quickly to the nursq, and bonding with both parents is intermpted If the mother is awake, she quiekty becomes aware that something is wrong and anxiety results. Ifshe is a n a t h e w , amdegris only delqed. Parents dream of having a perfect child. When a malformed or saiously ill infant is born the parent9 must grieye for the loss of the dream child before they can even begin to aecept the real child Denial is offen the mechanism used. Denialis &ested by a refusal to name the baby, by refusing to see, touch,or talk to the babs The psents may withdram They may accuse the hospitd of changing bahies or of not doing what they could to s m the infant The parents often feel guilv about malformations and wonder what rhey have done to cause it They are embarrassed and feel inadequate as people. Having a malformed child can be a blow to fhe self-concept Sometimes the motha is given a tran@er to help calm her. Rather rhmdelay the grief p e e s , tt is better to handle it with the 8Uppok of the nwsing st&. Denial may Issen anxieq, but the problem st3l rernains. The parents should see the child as early as possible No matter how deformed the child is, reality is usuallyless disturbingthan the paxents' imagination. The mother skouId be +.he one to mske the choice of movlog to a private room or off the flool: If she decides to leave the m a f e w

The nurse should point out the baby%healthy a s p If the ehild has a name, it should be used and the child should ah3ys be referred to by the correct sex As they care for the child nurses should be alert for s i p of anxi* in the mother and &ow her to withdraw from the child if the mother feels the need If the infant dies or was born dead, allowing the parents m see the child prevents deniaL The infant may have been deformed and the death anticipated, but the event is stressfuI.This parent too, needs to have time with the baby to wmpIete the gnef process. Crying should be enwuraged Nurses may also feel like crying. By doing so, they share the sadness with the m ts.

POSTPARTUM DEPRESSION As previously stated, pregnruyr i s a -cant strPsscn. with normal mood flucflations.Repressive s y m m mqy o m or,ifaIready present, map worsen The continuing stigma ofmenfd ilhess contrhtes to the undeneporhg of depressive symptoms by p m t and lactating women. Some contributing fadom to depression during precy and lactation are: r chronic f i ~ ~ dsaain al Everyday life hassles EI Disrupted or abusive relatiomhips Unstable housing -gemen& S SocialisoIation Homonal influences and fluctnations W H f t q of depression or medical problems r Lack of community resources postdel&my,some women may have a brief period ofthe "blues: d e other women are dinically depressed or psychotic It is imporcant to rewgnize the symptom of posdepression: Letdown feeling r IlTitabiity Loss of appetite IInsomnia Wety The mather cria easily and may complain of discomfort and an inabilityto concentrate. It is impor€antto diffkntiate the symptom ofpostparnun blues and postpartum depression in terms of the number of episodes, intensity, and *ten= of symptoms.

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in a foster home, or the parental rights of the parent have been temu

nated Due to the complexity ofthese issue,women's mental h e m is a major issue of the millennium. Continued reseveh is needed in the area@of pregnancy and kcfation and their relationship to a woman' mental health and women's rights.

THE HOSPITALIZED CHILD The child's response to hospitakation depends in part on his or hedevelopmenral stage. Very young children do not understand wby the must be hospitalized and often see it as punishment If the d 3 d ha., any concept af illness, it is thought to be due to &obedience. Although r e p s f o n is a defense mechanism obsmed in aU age groups, it is most common in the verqi young child One who h a been drhki.ng from a cup may seek comfort in a bottle during hospitalization When the hospitalized child is removed from all that is familia he or she Iwks to the bonded pason for support If that person is misslng, anxiety increases. This is h o r n as separation anxiety, which is normally seenin children between seven months and threeyears of age. In the hospital, sepaation an~ietymay be seen m children up to hur or tke years of age and occasionally in oJda children W e n the parent leaves, the child exhibiting separation anxiety responds with temper t;lntrums, crying,md atfempts at clingkg to the parent It is important to the child that at least one parent remain and participate m his or her care if at all possibl~Ifboth parents must leave, theybeed to understand that separation anxiety is a n m a l reaction The child who is old enough to uadmtaad should be toId that the parent is leaving but will return. It is best that the par& not sne& am The nurse should be sure that the child has his or her securlty blanket or a favorite toy nearby Although preschoolers sdfl see hospitalization as punishment thae is an increased awareness of the hospital experience. Fantasies me c o m m a intrusive procedures can be d e veIy f?tghWg through fantasy. The preschooler knows the missing parent will return However, he or she worries that the parent wiII not be able to find him or her, particularly ifthe child is moved Bleeding is extremefrightming as children think all their blood may wme outA small bandage o h lessens m e t y as efTectnrely as a kiss. The school-age child's hospiiahtion causes anxi* mainly because of immobility, a possibility of bodily ham, and a loss of friends and parents. This child may be embarrassed w h n forced to sullrenderprivacy. Though he or she is not expect& to have separation anxi*, the child sees the loss of parents as a stress and is relieved when the parent is around This child's concept 0fiUms-s is dependent

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stregs. H m and why are common words in the preschooI grdup. At other time,&klreX~ display dependenceby saying '?XiiIlyou stay with me?" or hostility with '"Iwill ha flu.' Regression to a more secure stage &devebpent i8 most comm0.n in this age grou Denial is the mosr c o m m o n mechanismseen in children and adolescents, but the agial is usually temparkuy. Children who use denial do not a m the extent of their illness. They may be m m o p erative, overfflmpllaisaut, or even stoic about painful pr0cedm'~S. Another ~i~eehanism is inte7leohlakation. Cbildren who fhts method disassociate themselves from the i1lnes.s and view it objectively. They display an inter~stin factual @pacts; it is as if they were disoussing someone else, exhibit Some children cape by acting out Children who itct a@mSOn and uicaopefativeness. Theae Mdrm may disconnect N &om their m,hide their medications, or refuse to Stay in bed Children who are depressed often act om Almost all ehildren use mauipulation, which e f f e w lessens anxiety. ChiMre~need ,to know what procednm win. be done and fore warned about dismmfort The infarmation needs to be presented in a w q the ehild undefstwds. Pupp&, stmyteying, gatilw,. a d riddling equipment are ways of preparing children for proeedureS. Presdhool children need ta follow their usual routine. School-age children heed to knowfhat their thiilgs at home wilI not be @sturbedvvbilethey W away: An duldren need to have their He rourines changed as little as possible for a s e w of senuity.

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pffer to move the mether & the matsmiQ flwon Th- mofher shauld be the one to make the &oice of moving to a m t e mom or to another department Ethe mother d d e s to move, she should be cited by the riming ST& sb she does not feel forgotten. Parents need to have trutlfd information about their childJs condition and be e n m a g d to talk together regarding their feelings. The nurse canbest help b y w the parent know it is & right to about the event and by followingthe parents cues. The nurse can point out the baby's healthy aspm. The child's name and sex should be used. The nurse needs to be alat to signs of &eQ in the P-t Mild deprmion occurs in a large percentage of p o s r p m clients. It lasts only one to two weeks and requires no treatment "I% mother, however, needs support ~ndetstandingmt and nutrition S m depression oceurs in 1 to 2 percent of p o s t p a m dknts and requires immediate detection and treatmeflt When a woman with a &om mental &order bpre$nsnt the risk versus benefit of wnGnuing me$ication must be msidered. Collaboration between all provkh lobstetria, primary care, and mental health) must o m as a pmtection to both mother and child. The child'$ response to hospidkation depends on the developmental l e d ofthe child and the parents' concept of iIks. Other factors are previous h o s p i ~ t i o n sthe , child's support system and the Ehild's &ping methods. The h o a v i W child has beenmoved f?om all that is fam& lat He or shiis sometimes subjected to embarrassing procedurRs and strict d e s . There is often an inteauption in his or her dardopmental needs. The hospitalized child should have a parent near and be told what is going to happen and why His m her routine should be a g e d as M e as possible. Children cope d t h stress in diffmt ways. The vay young child cries, has tantrums, and ehgs to the w e n t Olda chiIdren may use denjaI,intelleczualization,aacting 0U4

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SUGGESTED RCTlVltlES Attend a prenatal class in wbich preparation for Iabor and delivery is discrussed B Voluntee~time in a home for upwed mothers, if one is able in your area

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id a d q w i t h a play thempist Observe the therapist's onses to and &em on children an agescppropri;ne a* far a pediauic client haalte a list of bonding behaviors observed while visiting or carjng fm a mother and her newborn. With a small group of classmates, discuss feehgs towards the birth of a malformed child.

F

OW AND COMPREHEND ' Multiple choice. Select the one best answer L DPhieh factor wntributes to ¬ional W e s t a t i o m of pregnancy?

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Q A. psychotic disorders Q B. somatic disorders Q C neurotic disorders

O D. normal physiological dlanges 3. which developmentaltasks must the pregnant teen

a~omp~7 R autonomy and generati* O B. trust and initiative a C. identity and intimacy P D. autmomy and identity 3. S e l e the ~ factor commonly present when a middle adolescent becomes pregnant Q

PGipmee LI B. failure of birth-wntml methods Q C. owwhelming pasgion P D. rebeDon againsf her parents % Boading should be encouraged because it P A. assmes that the child will not be abused GI B. pxwnts postnatal complicatiom and depression. Q C, aids in involution and hoflllonal *ability, 0 D. is impo-t in the chilchild'sfuture interpersonal

relationships.

5. When teadung parents to bold th& inf&S, whkh -&on wonld the n m indude to promote bonding? "Hold fhe infant P d no more than 17 inches from the fabe!' O B. only when the chdd is wmpped securely." P C, in the football hold for safety dw e in baadIingfl a D,m y -from the face to avoid disease miss^." 6. Which &&me mechanfstn would the nurse expect &omparents of a maEo111led child? P k rationalimpion 0 B. i n t e f l a l i z a t i a 0 C. deniai 0 D, reattion f o r m a h il The mother of a malfonaed child can be& be helped by U A. giving atmnqUfllzer m allmiare &eQ. B. being transferred Emm the s&tssful matem* depart-

ment 0 C. w&im her face mliw an&for&g her m touch the *t0 D. allowing her to talk about hex feelin@if she des$es. 8. Whl& defense meohmbm is most wmnody seen the pug hospttakd ehild? 0 tl denial 0 B. r a p s i o n a Gf w y 0 D. identification

9. Sel& the moat common defense mechanism seen in y5ungepregnant adolseent P A denirzl P B.reg~ssion P GfantaSy 0 D. identifieation 10. Which stressor is most likdyto mme anxiety in a hospital-

k d , school-age child? P R immobiliy 13B. lack of opponunity Em cratbit)i

a Cmi&ngschoal

D. loss of independence