Module 9: Stressors Affecting Alterations Across the Lifespan

Learning Objectives:

Key Focus Areas:

Key Terms:

Stressor-Induced Alterations Across the Lifespan: Child, Adolescent, and Elderly Populations

Introduction

Mental health conditions can manifest differently across the lifespan, with unique stressors and developmental factors in childhood, adolescence, and older adulthood. Nurses play a crucial role in identifying these alterations, planning care using standardized diagnoses, and implementing evidence-based interventions tailored to the patient’s age and needs. This module reviews six key conditions – Autism Spectrum Disorder (ASD), Attention-Deficit/Hyperactivity Disorder (ADHD), youth suicide, eating disorders (anorexia nervosa and bulimia nervosa), delirium in older adults, and dementia (Alzheimer’s disease) – integrating DSM-5 diagnostic criteria, NANDA-I nursing diagnoses, therapeutic interventions (including pharmacologic management), and psychosocial, cultural, ethical, and legal considerations. Each section includes nursing care strategies (such as therapeutic communication techniques and patient/family education) and highlights current trends, statistics, and research to inform best practices.

Autism Spectrum Disorder (ASD)

Clinical Features and DSM-5 Criteria: Autism Spectrum Disorder is a neurodevelopmental disorder characterized by persistent deficits in social communication and interaction across multiple contexts, along with restricted, repetitive patterns of behaviors, interests, or activities. These symptoms emerge in early childhood and cause clinically significant impairment in functioning​autismspeaks.org​autismspeaks.org. DSM-5 criteria specify difficulties in social-emotional reciprocity (e.g. abnormal back-and-forth conversation), nonverbal communication (e.g. poor eye contact, limited gestures), and developing or maintaining relationships​autismspeaks.org​autismspeaks.org. In addition, at least two types of repetitive or ritualistic behaviors are present (such as stereotyped movements, insistence on sameness, fixated interests, or unusual sensory reactivity)​autismspeaks.org​autismspeaks.org. Symptoms must appear in the early developmental period and cannot be better explained by intellectual disability​autismspeaks.org. The severity of ASD can range widely, from mild social difficulties to severe communication deficits and behaviors requiring substantial support.

Epidemiology: ASD has become more commonly recognized in recent years. Approximately 1 in 36 children in the United States is identified with ASD, according to the CDC’s latest estimates​cdc.gov. ASD occurs in all racial and socioeconomic groups and is about four times more common in boys than in girls​cdc.gov. Increased awareness and broadened diagnostic criteria have contributed to rising prevalence. Nurses should be aware that many children with ASD also have co-occurring conditions such as intellectual disability or epilepsy, and early diagnosis is critical for accessing interventions.

Common Nursing Diagnoses: When formulating a nursing care plan for a child with autism, the nurse commonly identifies Impaired Verbal Communication related to reduced ability to interpret or use social cues, Impaired Social Interaction, and Risk for Injury (due to sensory deficits or repetitive behaviors that may cause self-harm)​ncbi.nlm.nih.gov. Deficient Knowledge (Caregiver) related to understanding ASD and its management is another important nursing diagnosis, as families often need extensive education and support​ncbi.nlm.nih.gov. Other possible NANDA-I diagnoses include Disturbed Sensory Perception (if the child has hyper- or hyposensitivity to stimuli) and Caregiver Role Strain due to the chronic demands of managing ASD at home. Each nursing diagnosis should be individualized to the child’s specific behaviors and family situation.

Evidence-Based Interventions and Management: There is no cure for ASD, but early and intensive intervention can greatly improve outcomes. The mainstay of management is behavioral and educational therapy. Applied Behavior Analysis (ABA) programs use positive reinforcement to teach communication, social, and self-care skills in a highly structured way​ncbi.nlm.nih.gov​ncbi.nlm.nih.gov. Speech therapy is used to enhance language development, and occupational therapy can help with sensory integration and fine motor skills​ncbi.nlm.nih.gov​ncbi.nlm.nih.gov. Nurses should ensure a consistent, structured routine for the child in the hospital or at home, as ASD patients do best with predictability and may become distressed by change. Family education is crucial – nurses collaborate with parents to continue behavioral strategies at home and connect them with resources such as special education services. While no medications treat the core symptoms of ASD, pharmacologic therapy is sometimes used to manage associated symptoms. For example, atypical antipsychotics (like risperidone or aripiprazole) can reduce severe irritability, aggression, or self-injurious behavior in children with autism​ncbi.nlm.nih.gov. Selective serotonin reuptake inhibitors (SSRIs) or stimulants may be tried off-label to address repetitive behaviors or attention problems, though their efficacy is variable​ncbi.nlm.nih.gov. All medications must be used cautiously in children and monitored for side effects. Importantly, the primary treatment focus remains on non-pharmacological interventions: creating an autism-friendly environment, using visual supports or communication boards for nonverbal children, and engaging the child in play therapy or social skills groups as tolerated. Early intervention programs (ideally before age 3) have strong evidence for improving language and adaptive behaviors in ASD.

Psychosocial and Cultural Considerations: Caring for a child with ASD can be stressful for families. Culturally, there may be varying levels of understanding or stigma about autism; some parents may struggle with denial or seek unproven remedies. The nurse should provide empathetic support, acknowledging the family’s emotional journey and possible grief over developmental expectations. Education rights are a key legal aspect – in the U.S., children with ASD are entitled by law to appropriate educational accommodations (Individualized Education Programs, IEPs). Nurses can advocate for the child by ensuring the family is aware of these services. Culturally sensitive care might involve providing translation for non-English-speaking caregivers or connecting families with community support groups (including groups specific to their cultural or ethnic background). Ethically, respect the child’s individuality and neurodiversity; many in the autism community emphasize acceptance. Nurses should also dispel myths (such as debunked theories linking vaccines to autism) and instead focus on evidence-based guidance.

Nursing Care Strategies: In any setting, a nurse should approach the ASD patient calmly and with patience. Therapeutic communication may require creative approaches: use simple language, concrete instructions, and allow extra time for the child to process. Nonverbal techniques (pictures, gestures, sign language) can facilitate understanding. If the child has particular fixations or routines, incorporate those into care when possible (for example, allowing a favorite object for comfort, or scheduling procedures at the same time of day to maintain routine). Ensure the environment is safe – remove potential hazards since an autistic child might wander or ingest non-food items (pica). Dimming harsh lights or minimizing loud noises can help if the child has sensory sensitivities. In the hospital, try to have the same staff care for the child for consistency, and involve parents in caregiving (they can often predict triggers and know how to soothe their child best). Teaching for parents should cover behavior management techniques, coping strategies for stress (respite care, support networks), and information on ASD support organizations.

Summary: ASD is a lifelong condition that profoundly affects socialization and communication. With early diagnosis and comprehensive intervention – including behavioral therapies, family support, and individualized educational plans – many children with ASD can achieve significant improvements in function. The nurse’s role is to advocate for appropriate resources, ensure safety, and foster the child’s development while providing compassionate support to families. By using structured routines, clear communication, and evidence-based therapies, nurses help children with ASD reach their fullest potential​ncbi.nlm.nih.gov​ncbi.nlm.nih.gov. Crucially, care must be culturally sensitive and family-centered, empowering caregivers with knowledge and coping skills to navigate the challenges of ASD.

Attention-Deficit/Hyperactivity Disorder (ADHD)

Clinical Features and DSM-5 Criteria: ADHD is one of the most common childhood psychiatric disorders, marked by developmentally inappropriate levels of inattention, impulsivity, and/or hyperactivity that interfere with functioning. The DSM-5 requires a persistent pattern of inattention and/or hyperactivity-impulsivity lasting at least 6 months, with symptoms present before age 12 and evident in at least two settings (e.g. home and school)​cdc.gov. Inattentive symptoms include difficulty sustaining attention, forgetfulness, disorganization, not listening when spoken to, and careless mistakes​cdc.gov​cdc.gov. Hyperactive-impulsive symptoms include fidgeting, inability to remain seated, excessive running or climbing, talking excessively, blurting out answers, and interrupting others​cdc.gov. Depending on which symptoms predominate, DSM-5 identifies three presentations: predominantly inattentive, predominantly hyperactive-impulsive, or combined. Importantly, the symptoms must be excessive for the child’s developmental level and cause impairment in social, academic, or occupational activities​cdc.gov​cdc.gov. Many children with ADHD first come to attention due to school difficulties or behavior problems.

Epidemiology: ADHD affects roughly 8–10% of children and adolescents in the U.S., with surveys indicating about 9.8% of youth 13–17 (approximately 6 million) have ever been diagnosed​ncbi.nlm.nih.gov. It is more frequently diagnosed in boys (about 3:1 ratio in childhood)​nurseslabs.com. The prevalence of ADHD diagnoses increased significantly in the 2000s, likely owing to greater awareness and screening; one study noted a 42% rise in U.S. children diagnosed from 2003 to 2011​nimh.nih.gov. Many children with ADHD continue to have symptoms into adolescence and adulthood, although hyperactive behavior often diminishes with age. Early identification and treatment can improve long-term academic and social outcomes. Nurses should also be aware of frequent comorbidities, such as learning disabilities, anxiety, depression, or oppositional defiant disorder, which can complicate the clinical picture.

Common Nursing Diagnoses: Caring for a child with ADHD, nurses often identify Risk for Injury related to impulsivity and hyperactivity (e.g. unable to sit still, prone to accidents)​nurseslabs.com. Impaired Social Interaction is another relevant diagnosis, as ADHD behaviors like interrupting or intruding can strain peer relationships​nurseslabs.com. Children may also experience Situational Low Self-Esteem or Ineffective Role Performance related to repeated academic failures or negative feedback (“being disruptive”)​nurseslabs.com. Family stress is common; the nursing diagnosis Compromised Family Coping may apply if the child’s behaviors cause conflict at home or caregiver fatigue​nurseslabs.com. Additionally, Deficient Knowledge (Parents) regarding ADHD management is an important problem to address – families often need education on behavior techniques, medication administration, and advocacy in school. By using NANDA-I diagnoses like these, the nurse can create a holistic plan that addresses safety, psychosocial impacts, and knowledge deficits.

Evidence-Based Interventions: Effective ADHD management typically combines behavioral interventions with pharmacotherapy. Behavioral therapy focuses on reinforcing desirable behaviors and decreasing unwanted behaviors. Nurses can coach parents in behavior management strategies – for example, using reward systems (stickers, tokens) for positive behaviors and consistent, non-punitive consequences for rule-breaking. Teaching parents to issue clear, brief instructions and to establish structured daily routines (for homework, chores, bedtime) can significantly help an ADHD child succeed​nurseslabs.com. In the classroom, accommodations like preferential seating, shortened assignments, or extra time on tests may be needed. The nurse should collaborate with teachers and school counselors to ensure an Individualized Education Plan (if eligible) or 504 plan is in place to support the child’s learning needs.

Pharmacologic Management: Stimulant medications are the first-line pharmacotherapy for ADHD. Drugs such as methylphenidate or amphetamine salts (e.g. Ritalin, Adderall) have a high success rate in reducing core symptoms of hyperactivity and inattention by increasing dopamine/norepinephrine activity in the brain. When taken as prescribed, stimulants improve focus, impulse control, and task completion for a majority of children​nurseslabs.com. Nurses should monitor for common side effects of stimulants, including insomnia, decreased appetite, weight loss, or elevated heart rate/blood pressure. Children on stimulants require growth tracking and periodic assessment of their cardiovascular status. For some children, especially if tics, anxiety, or certain side effects occur, non-stimulant medications (like atomoxetine or guanfacine) may be used. It’s important to educate families that medication is not a “standalone cure” – it works best in conjunction with behavioral strategies and environmental modifications. Adherence can be an issue in adolescents, and there is potential for stimulant misuse or diversion, so the nurse should stress taking medication strictly as directed and keep it secured.

Nursing Interventions and Patient/Family Education: Key nursing interventions include ensuring safety and a therapeutic environment. For instance, in a hospital or clinic setting, an ADHD child might need supervision to prevent climbing on furniture or wandering off. Provide positive feedback when the child exhibits self-control or completes a task – praise and encouragement bolster their confidence​nurseslabs.com. To help with organization, nurses and parents can use checklists, calendars, or visual schedules for daily activities. When giving instructions, it’s effective to first get the child’s full attention (e.g. make eye contact, say their name), then deliver one step at a time in simple language​nurseslabs.com. Breaking tasks into small, achievable steps prevents the child from feeling overwhelmed. Promoting a structured daily routine is strongly recommended; having set times for meals, homework, play, and sleep can reduce chaos and improve the child’s ability to anticipate and transition between activities​nurseslabs.com.

Educating parents is a large part of the nurse’s role. The nurse should explain the nature of ADHD – that it is a neurodevelopmental condition and not simply “bad behavior” – to help alleviate blame or guilt within the family. Parents need guidance on how to implement behavior plans consistently between home and school. The nurse might teach them strategies like using a homework notebook for daily teacher feedback, or setting up a quiet, distraction-free study area at home. Therapeutic communication with the child involves patience and redirection; if the child goes off-topic or fidgets, gently bring them back to the task at hand. Group therapy or social skills training can benefit older children or teens with ADHD by improving peer interaction skills and self-esteem. Furthermore, involving the child in sports or physical activities can be a constructive outlet for excess energy and has been associated with improved concentration.

Psychosocial and Cultural Considerations: Children with ADHD often experience negative labeling (“troublemaker,” “lazy”), which can affect their self-worth. It’s vital for the nurse to advocate against stigma. Family dynamics may be strained – siblings might feel a child with ADHD “gets all the attention” or parents may disagree on discipline approaches. Family therapy or support groups for parents can provide coping strategies and emotional support. Culturally, not all families readily accept an ADHD diagnosis or medication; some cultures may view hyperactivity as just “boyishness” or have concerns about western medications. The nurse should approach such concerns with respect, providing evidence-based information in the family’s preferred language. Emphasize that treatment plans are individualized – for example, if a family prefers to try behavioral interventions longer before medication, work with them on that plan while continuing to monitor the child’s progress. Ethical considerations include the appropriate use of medication (guarding against over-medication or use purely for academic performance enhancement in children without ADHD). Legally, schools in the U.S. must provide accommodations under disability rights laws, so nurses can guide parents in navigating the educational system to secure resources for the child (such as an evaluation for services).

Summary: ADHD is a chronic condition that, without support, can significantly impair a child’s academic achievement and social development. The nursing care plan should address immediate issues like safety and structure, as well as long-term needs for skill-building and family support. Outcomes to monitor include improved attention span, reduced disruptive incidents, and positive feedback from school. With a combination of consistent behavioral management, appropriate use of stimulant medication, and collaborative support between healthcare providers, parents, and teachers, children with ADHD can learn to manage their symptoms and thrive in their activities​nurseslabs.com​nurseslabs.com. Nurses serve as educators and advocates, ensuring families understand ADHD and have access to resources – from parent training programs to mental health services – thereby optimizing the child’s chances for success and self-esteem.

Youth Suicide

Scope and Current Trends: Suicide among youth is a critical public health issue that has escalated in recent years. In the United States, suicide now ranks as the second leading cause of death for adolescents and young adults (ages 10–24)​pmc.ncbi.nlm.nih.gov. Recent data are alarming: over the past decade the suicide rate in this age group increased by 56%, with especially steep rises observed in certain populations (for example, suicide rates among Black youth rose nearly 78%)​pmc.ncbi.nlm.nih.gov. According to the CDC’s Youth Risk Behavior Survey, approximately 20.4% of U.S. high school students seriously considered attempting suicide in the past year, and 9.5% actually attempted suicide at least once​cdc.gov​cdc.gov. Female adolescents report higher rates of suicidal ideation (in 2021, about 30% of high school females vs. 14% of males had seriously considered suicide)​cdc.gov. Sexual and gender minority youth (LGBTQ+ teens) are also at greatly increased risk of self-harm. These trends have been exacerbated by stressors such as the COVID-19 pandemic, social isolation, and cyberbullying. The statistics underscore an urgent need for prevention and early intervention. For nurses, every encounter with an adolescent includes the responsibility to assess mental health and suicide risk – catching warning signs can save lives.

Risk and Protective Factors: Youth suicide is usually the result of a complex interplay of factors. Individual risk factors include the presence of mental health disorders (especially depression, bipolar disorder, PTSD, or substance use disorder), a history of previous suicide attempts or self-harm, impulsivity or aggressive tendencies, feelings of hopelessness, and experiences of major stress or loss​cdc.gov. Many adolescents who attempt suicide have recently experienced a triggering event such as a breakup, bullying, academic failure, or family conflict. Family and relationship factors are also crucial – a family history of suicide or mental illness, exposure to violence or abuse, lack of familial support, or bullying by peers can all elevate risk​cdc.gov. Easy access to lethal means (such as firearms or large quantities of certain medications) is a critical risk factor; the presence of a gun in the home greatly increases the likelihood that an impulsive suicidal crisis will result in death​pmc.ncbi.nlm.nih.gov​pmc.ncbi.nlm.nih.gov. On a broader level, community and societal factors like stigma around mental health, barriers to accessing care, and exposure to suicide (such as contagion effects after a peer’s suicide) can influence youth suicide rates​cdc.gov.

Protective factors, conversely, can buffer against suicide risk. These include strong family and peer support, connectedness to school/community, effective coping and problem-solving skills, access to mental health care, and cultural or religious beliefs that discourage suicide. As part of psychosocial assessment, nurses should identify any protective factors to leverage (for example, involvement in sports, a trusted mentor, or future aspirations the teen values). Cultural considerations are important: different cultural groups may express distress in various ways or may have varying attitudes about suicide (in some cultures it is a taboo topic, which can hinder open discussion). Nurses must approach suicide risk assessment with sensitivity to the adolescent’s background, using interpreters or cultural liaisons if needed to ensure accurate understanding.

Common Nursing Diagnoses: In a situation of adolescent suicidal ideation or behavior, the priority nursing diagnosis is typically Risk for Suicide. NANDA-I recognizes Risk for Suicide as a nursing diagnosis indicating that the patient is at significant risk of intentionally causing self-injury or death​nurseslabs.com​ncbi.nlm.nih.gov. This risk is immediate and requires intensive intervention. Other relevant nursing diagnoses often include Hopelessness (expressed as a lack of purpose in life or belief that nothing will improve) and Social Isolation (if the youth has withdrawn from peers or family). Situational Low Self-Esteem or Disturbed Thought Processes may apply if the teen verbalizes worthlessness or has distorted cognitive outlook (e.g. “my family would be better off without me”). In some cases, Post-Trauma Syndrome or Complicated Grief could be relevant if specific traumatic events or losses precipitated the suicidal crisis. It is also important to assess the family: caregivers of a suicidal youth may have Fear or Disabled Family Coping, which nurses should address through education and support.

Assessment and Therapeutic Communication: Early identification of suicidal intent is a life-saving nursing function. All statements or signs of self-harm must be taken seriously. The nurse should conduct a thorough yet empathetic risk assessment by asking direct questions, for example: “Sometimes when people feel as upset as you do, they have thoughts of harming themselves. Are you having any thoughts like that?” Direct inquiry about suicidal ideation does not “plant” the idea; rather, it gives the youth permission to talk openly. If the adolescent acknowledges suicidal thoughts, follow-up questions determine the severity: Do they have a plan? (method, time, place), Do they have access to the means? (e.g. pills, weapons), Have they attempted before? A detailed mental status exam is needed, including assessing for depression (mood, sleep/appetite changes), anxiety, substance use, and psychotic symptoms (if any). Throughout this process, therapeutic communication is essential: the nurse must remain nonjudgmental, calm, and listen actively. Adolescents often fear betrayal of confidence or being judged; thus the nurse should convey empathy (“It sounds like you’ve been feeling unbearably sad”) and assure them that help is available. Explain confidentiality limits in an age-appropriate way – for instance, “What you share with me is private, but if I’m worried you might be in danger, we will need to involve others who can help keep you safe.” This honesty builds trust while preparing the teen for necessary interventions.

Immediate Interventions for the Suicidal Youth: If an adolescent is judged to be at high risk (e.g. has a plan and intent or is in the act of attempting self-harm), ensuring safety is the top priority. This often means not leaving the youth alone – instituting one-to-one observation (either in a hospital or calling emergency services if in the community). The nurse (in hospital or clinic) should secure or remove any accessible sharp objects, belts, shoelaces, medications, or other potential tools for self-harm from the environment. Following protocols (such as a suicide watch checklist) helps create a safe physical space. Engaging the support system is another critical step: the nurse should notify parents/guardians and, when indicated, the on-call mental health clinician or psychiatrist. In many cases, especially if a serious attempt occurred or risk remains high, the adolescent will require hospitalization (either voluntarily or via involuntary commitment for their own protection, depending on legal statutes). The nurse can explain to the teen that the hospital is a safe place to stabilize and that these measures are temporary until the crisis passes.

For youths expressing suicidal ideation without immediate intent, the nurse should develop a safety plan collaboratively. A safety plan is a prioritized written list of coping strategies and sources of support the adolescent can use before or during a suicidal crisis. It typically includes recognizing warning signs of escalating distress, listing personal coping strategies (like listening to music or journaling), identifying friends or family they can reach out to, and emergency contacts (such as the 988 Suicide & Crisis Lifeline, a 24/7 hotline). As part of the safety planning, means restriction counseling with the family is imperative – for example, advising parents to remove or securely lock up any firearms, and to store medications (both prescription and OTC) in a safe manner​pmc.ncbi.nlm.nih.gov. Research shows that reducing access to lethal means is one of the most effective suicide prevention strategies​pmc.ncbi.nlm.nih.gov.

Ongoing Care and Therapeutic Interventions: Management of suicidal youth goes beyond the acute crisis. Psychiatric evaluation and therapy are necessary to treat underlying issues. The nurse should facilitate referrals to a qualified mental health professional for therapy – evidence-based approaches for adolescent suicidality include Cognitive Behavioral Therapy (CBT) focusing on problem-solving and cognitive restructuring of hopeless thoughts, and Dialectical Behavior Therapy (DBT) which teaches emotional regulation and distress tolerance skills (originally developed for chronically self-harming patients, DBT has been adapted for adolescents). Family therapy may be recommended to address familial conflicts or improve communication, since a supportive home environment is protective. If the youth is diagnosed with a clinical depression or another treatable condition, pharmacologic treatment may be indicated (e.g. starting an SSRI antidepressant for major depression). The nurse should educate the family on the proper use of antidepressants in youth – including the FDA “black box” warning that in a minority of cases, antidepressants can initially increase suicidal thoughts in adolescents​aacap.org. This does not mean such medications are contraindicated (they can significantly help mood over time), but it underscores the need for close monitoring especially in the first few weeks. Any emergence or worsening of suicidal ideation after starting an antidepressant should be reported and evaluated immediately​aacap.org. If substance abuse is a factor, addressing it via counseling or rehabilitation programs becomes part of the care plan.

Nurses also have a role in education and support for the patient and family. Teaching adolescents coping skills – for example, using journaling, exercise, or art to handle intense emotions – can give them alternatives to suicidal behavior. Encourage healthy habits like regular sleep and avoiding alcohol or drugs (since substance use can lower inhibitions and worsen depression, raising suicide risk). Help the teen identify reasons for living, such as personal goals or relationships, to instill hope. For the family, provide resources: local support groups for parents of suicidal teens, information on warning signs of acute risk (like sudden calmness after depression, giving away belongings, or explicit statements about wanting to die), and guidance on how to talk openly yet supportively about suicide. Culturally appropriate educational materials should be used. Legal and ethical aspects include confidentiality – while teens have rights to privacy, when suicide risk is involved, safety overrides strict confidentiality. Nurses must know their state laws on involuntary commitment of minors and reporting requirements. In most jurisdictions, any healthcare provider who suspects a minor is a danger to themselves is legally permitted (and often required) to take steps to secure their safety, which may involve breaching confidentiality to inform parents and other professionals​pmc.ncbi.nlm.nih.gov. Nurses can explain to the adolescent that this is done because their life is valued and the aim is to help them, not to punish.

Prevention and Community Involvement: Beyond individual care, nurses should be aware of and involved in suicide prevention programs. School-based interventions have shown measurable success: meta-analyses indicate that comprehensive school suicide prevention programs can lead to significant reductions in suicidal ideation (~13–15% reduction) and attempts (~30% reduction) among students​pmc.ncbi.nlm.nih.gov​pmc.ncbi.nlm.nih.gov. These programs often include components like educating students about mental health, training teachers to recognize at-risk youth, establishing peer support or mentoring systems, and screening for depression. Nurses (especially school nurses or community health nurses) can implement gatekeeper training for teachers and coaches – teaching them how to identify and refer suicidal youth. Community awareness campaigns, such as those that reduce stigma and encourage help-seeking, are equally important; they create an environment where a struggling teen might feel more comfortable reaching out. The nursing profession also partners with organizations like the National Alliance on Mental Illness (NAMI) and local public health departments to advocate for resources (e.g. hotlines, counseling centers) and policies that support youth mental health.

Summary: Youth suicide is often the tragic outcome of treatable mental pain. Nurses must maintain a high index of suspicion for suicide risk in any adolescent presenting with depression, severe stress, or behavioral changes. Through prompt risk assessment, compassionate communication, and coordinated intervention, the healthcare team can interrupt the trajectory toward suicide. Nursing care focuses on protecting the patient in the acute phase and building a network of ongoing support and treatment. By engaging family, restricting lethal means, instituting safety planning, and facilitating therapy, nurses help vulnerable youth find hope and alternatives to suicide​aafp.org​ncbi.nlm.nih.gov. Suicide prevention is a multidisciplinary, community endeavor – nurses are vital advocates for proactive measures in schools and clinics to “connect” with at-risk teens before a crisis occurs. Every interaction is an opportunity to instill hope, reinforce that help is available, and ultimately, save a life.

Eating Disorders: Anorexia Nervosa and Bulimia Nervosa

Overview and Epidemiology: Eating disorders (EDs) are serious mental health conditions characterized by disturbed eating behaviors and distorted body image. They most commonly emerge during adolescence and disproportionately affect females, though individuals of any gender or age can develop an ED. Two of the most prevalent types are Anorexia Nervosa (AN) and Bulimia Nervosa (BN). According to epidemiological data, eating disorders have been on the rise worldwide – between 2000 and 2018, their prevalence more than doubled (from about 3.4% to 7.8% of the population)​ohsu.edu. In the U.S., an estimated 28 million people will experience an ED in their lifetime​ohsu.edu. Females are roughly twice as likely to be affected as males​ohsu.edu, and there are elevated rates among transgender and nonbinary individuals (possibly related to body dysphoria and societal pressures). These illnesses carry significant mortality; anorexia nervosa in particular has one of the highest mortality rates of any psychiatric disorder, due to both medical complications and suicide. Early recognition and intervention are critical to improving outcomes. Nurses should be vigilant for warning signs such as dramatic weight changes, amenorrhea (in females), gastrointestinal complaints, or evidence of purging behaviors.

Anorexia Nervosa (AN): Anorexia is characterized by extreme calorie restriction leading to significantly low body weight (below minimally normal or expected for age/height), an intense fear of gaining weight or becoming fat, and a distorted perception of body weight or shape. Despite being underweight, individuals with anorexia often believe they are “fat” or that specific body parts are too large. They may rigorously count calories, skip meals, and engage in excessive exercise. DSM-5 criteria for anorexia nervosa require: (1) restriction of energy intake relative to requirements, resulting in significantly low body weight; (2) intense fear of weight gain or persistent behavior interfering with weight gain; and (3) disturbance in self-perceived weight or shape (undue influence on self-evaluation, or lack of recognition of the seriousness of low weight)​nursetogether.com​nursetogether.com. Two subtypes are noted: a Restricting type, where weight loss is achieved primarily through dieting, fasting, or excessive exercise (no regular binge-eating or purging in the last 3 months), and a Binge-eating/Purging type, where the individual has regularly engaged in binge eating or purging (self-induced vomiting or misuse of laxatives/diuretics) during the last 3 months​nursetogether.com​nursetogether.com. Common physical findings in anorexia include bradycardia, hypotension, cold intolerance, lanugo (fine hair on skin), and, in females, loss of menstrual periods. Cognitively, many patients have obsessive thoughts about food and ritualistic eating habits.

Bulimia Nervosa (BN): Bulimia involves recurrent episodes of binge eating followed by compensatory behaviors to prevent weight gain. A binge is characterized by consuming an objectively large amount of food in a discrete period (e.g. within 2 hours) accompanied by a sense of lack of control over eating during that episode. After the binge, individuals with bulimia feel guilt, shame, or anxiety about weight gain, and thus engage in behaviors such as self-induced vomiting, misuse of laxatives or diuretics, fasting, or excessive exercise. DSM-5 criteria for bulimia include: recurrent binge eating episodes, recurrent inappropriate compensatory behaviors to prevent weight gain, both occurring on average at least once a week for 3 months, self-evaluation unduly influenced by body shape and weight, and disturbances not occurring exclusively during episodes of anorexia (meaning bulimic patients are typically of normal weight or overweight, not underweight as in anorexia)​nurseslabs.com. Unlike anorexia, patients with bulimia often maintain a weight at or above normal, which can make the disorder less obvious to observers. Physical signs of bulimia can include fluctuations in weight, dental enamel erosion and cavities (from stomach acid in vomit), swollen parotid glands (“chipmunk cheeks”), scars or calluses on the knuckles (Russell’s sign) from inducing vomiting, and electrolyte imbalances (like hypokalemia) that can lead to arrhythmias. Many bulimic individuals experience menstrual irregularities, gastrointestinal problems (bloating, constipation), and dehydration.

Common Nursing Diagnoses: For patients with anorexia or bulimia, Imbalanced Nutrition: Less than Body Requirements is a primary nursing diagnosis, reflecting inadequate intake or excessive loss of nutrients leading to weight loss and malnutrition​nurseslabs.com. In anorexia, this may be evidenced by emaciation, weakness, and lab abnormalities (e.g. anemia, low electrolytes); in bulimia, evidence may include dental erosion, parotid swelling, or metabolic alkalosis from vomiting​nurseslabs.com. Disturbed Body Image is another key nursing diagnosis, as these patients have an altered perception of their body and weight – even at 80 lbs, an anorexic patient may insist she “feels fat”​nurseslabs.com. Ineffective Coping often applies since the disordered eating behaviors (restriction, bingeing, purging) are maladaptive coping mechanisms for emotional distress​nurseslabs.com. Other relevant diagnoses include Deficient Fluid Volume (especially in anorexia or in bulimia with excessive vomiting/diuretic use leading to dehydration), Risk for Electrolyte Imbalance (due to purging behaviors, as evidenced by, for example, low potassium or chloride levels)​ncbi.nlm.nih.gov​ncbi.nlm.nih.gov, and Fatigue or Activity Intolerance related to poor energy intake. As the illness progresses, Self-Care Deficits (bathing, dressing, etc.) might emerge, especially in severe anorexia where weakness or hospitalization limits independence​ncbi.nlm.nih.gov. Psychological diagnoses such as Chronic Low Self-Esteem or Anxiety are common, given the profound self-criticism and fear of weight gain. Many patients have Interrupted Family Processes as well – families can become trapped in cycles of conflict (e.g., arguments at mealtimes) or enabling behaviors. In summary, the nurse’s care plan should address both the physiological imbalances and the psychological underpinnings of the eating disorder.

Medical Stabilization: In acute settings, particularly for anorexia nervosa, initial treatment goals center on medical stabilization. Severely malnourished patients may require hospitalization to correct dehydration, electrolyte disturbances, and vital sign abnormalities. For example, a patient with anorexia who is <75% of ideal body weight or has arrhythmias, very low blood pressure, or significant electrolyte derangements (like potassium <3 mEq/L) typically needs inpatient care​ncbi.nlm.nih.gov​ncbi.nlm.nih.gov. The nurse will implement careful monitoring: daily weights (usually done in the morning, after voiding, and in hospital gowns to ensure accuracy), intake/output, and frequent vital signs. It’s crucial to establish trust during this phase – many patients are resistant to treatment and fearful of gaining weight. The nurse should explain that medical interventions (IV fluids, nutritional support) are to ensure safety. In anorexia, refeeding syndrome is a serious risk when nutrition is reintroduced; thus, feeding must start slowly and labs (phosphate, magnesium, potassium) must be monitored closely to avoid potentially fatal shifts​ncbi.nlm.nih.gov. Small, frequent meals or specialized refeeding protocols may be used. For bulimia, hospitalization is less common unless there are severe electrolyte issues (for instance, a potassium level dangerously low causing ECG changes) or GI bleeding/tears from vomiting. Regardless, managing electrolyte imbalances is a nursing priority – this might involve IV electrolyte repletion or supplementation as ordered​nurseslabs.com. Cardiac monitoring is indicated if electrolyte levels are significantly off or if the patient has bradycardia from anorexia.

Nutritional Rehabilitation: Once medically stable, the cornerstone of treatment is nutritional rehabilitation and gradual weight restoration (for anorexia) or cessation of binge-purge cycles (for bulimia). The interdisciplinary team typically includes physicians, dietitians, and mental health professionals, but nurses play a central role in implementing and reinforcing the nutrition plan. An initial diet for a hospitalized anorexic patient might start at around 1,200–1,500 kcal/day, then increased stepwise (e.g., by 200 kcal every few days) to avoid overwhelming the patient’s metabolism​nurseslabs.com. The nurse is responsible for monitoring meals – often, sitting with the patient during meals to provide support and ensure intake. This might involve encouraging the patient to finish a nutritional supplement or coaching them through anxiety. In inpatient ED units, it’s common that after a meal or snack, patients are supervised (for about 1–2 hours) to prevent them from vomiting or disposing of food secretly​nurseslabs.com. The nurse may need to check the bathroom for any signs of purging if the patient goes shortly after eating. Establishing trust is vital; rather than taking an authoritarian stance (“you must eat”), a therapeutic nurse might say, “I understand this is very hard, but your body needs this food to get stronger. I will stay with you – we can get through this together.” For bulimic patients, a structured eating schedule (for instance, three meals and two snacks daily) is planned to break the binge-purge cycle by preventing extreme hunger. The nurse should help bulimic patients identify and interrupt triggers for binges – e.g., if loneliness after school leads to binge eating, plan a distracting activity or have them reach out to a support person at that time.

Psychotherapy and Psychosocial Interventions: The most effective treatments for eating disorders involve psychotherapy, with modalities tailored to each disorder. For adolescents with anorexia nervosa, Family-Based Therapy (FBT) (also known as the Maudsley method) is highly effective. In FBT, the parents are empowered to take charge of the adolescent’s eating in a structured way, essentially “re-feeding” their child at home with support from therapists. Studies have shown FBT leads to significant weight gain and improved eating behaviors in anorexic teens​ncbi.nlm.nih.gov​ncbi.nlm.nih.gov. The nurse should encourage family involvement in treatment planning and may help parents learn strategies to manage meals and resist giving in to the disorder’s demands (for example, not allowing the child to skip dinners and learning to remain calm yet firm). For bulimia and for adults with eating disorders, Cognitive Behavioral Therapy (CBT) is a frontline treatment. CBT helps patients identify the irrational beliefs about weight and shape, challenge all-or-nothing thinking (“I ate one cookie, I’ve ruined my diet, I might as well binge”), and develop healthier coping mechanisms for emotional distress​ncbi.nlm.nih.gov. Nurses reinforce CBT principles during care by encouraging patients to journal their food intake and feelings, then discussing patterns (e.g., “I notice you felt very anxious before you binged – what were the thoughts going through your mind?”). Group therapy and support groups (like those offered by organizations such as the National Eating Disorders Association) provide peer support and decrease isolation; nurses can provide information on these resources.

Pharmacologic Management: Medications play a adjunct role in treating eating disorders. There is no medication that can “cure” anorexia nervosa, but pharmacotherapy can target comorbid conditions or specific symptoms. In anorexia, once weight is being restored, SSRIs (such as fluoxetine or sertraline) may be prescribed to treat underlying depression or anxiety, although their efficacy in preventing relapse of anorexia is mixed. Importantly, SSRIs are less effective when the patient is very underweight (due to neurochemical changes in starvation), so restoring weight is priority before medication can work optimally. In some cases of anorexia with severe obsessive ruminations about food and weight, or where weight gain remains very difficult, low-dose second-generation antipsychotics like olanzapine have been used off-label​ncbi.nlm.nih.gov. Olanzapine can have the side effect of weight gain and may also reduce obsessive thinking; some studies show it helps increase BMI slightly in treatment-resistant anorexia​ncbi.nlm.nih.gov. Nurses should monitor for side effects like sedation or metabolic changes and remember that these patients are at higher risk for side effects (e.g., a malnourished patient may be more prone to hypotension or QT prolongation from psychotropics). Bupropion (an atypical antidepressant) is contraindicated in patients with eating disorders because it lowers the seizure threshold and bulimic patients (with electrolyte shifts) in particular are at increased risk of seizures​ncbi.nlm.nih.gov​ncbi.nlm.nih.gov. Tricyclic antidepressants are also avoided in severe EDs due to cardiotoxicity in the context of electrolyte imbalances​ncbi.nlm.nih.gov. For bulimia nervosa, fluoxetine (Prozac), an SSRI, is the only FDA-approved medication and has been shown to reduce binge-purge frequency even in patients without comorbid depression​ncbi.nlm.nih.gov. A typical therapeutic dose for bulimia is higher (e.g. 60 mg daily) than that used for depression. Other SSRIs are used off-label if fluoxetine isn’t tolerated. These medications can help by reducing impulsivity and preoccupation with shape/weight, thereby facilitating engagement in therapy. If a bulimic patient has significant anxiety or mood swings, those should be treated (e.g., SSRIs for anxiety, or mood stabilizers if co-occurring bipolar traits). Importantly, medication should always be combined with psychotherapy and nutritional rehab for best outcomes.

Nursing Interventions and Education: Nurses caring for patients with EDs must strike a balance between enforcing treatment guidelines and establishing a therapeutic alliance. Trust-building is facilitated by consistency and empathy. The nurse should acknowledge the patient’s feelings of fear and loss of control (“I know gaining weight feels scary for you”). At the same time, clear and consistent limits are set around behaviors: for instance, it might be explained that if the patient hides food or vomits, certain privileges (like walking in the hallway) might be curtailed for safety. During meals, nurses should provide support and distraction – perhaps engaging the patient in light conversation (avoiding food-related talk). Avoid power struggles around food; if the patient refuses, the nurse might reiterate the rationale and possible consequences (e.g., “Your doctor ordered this supplement because your body needs protein – if you absolutely can’t drink it now, we might need to consider tube feeding to keep you safe. Let’s try a few sips together.”). After meals, help the patient deal with guilt or anxiety through techniques like deep breathing, or have them stay engaged in a supervised activity (like a relaxation group) to prevent purge impulses​nurseslabs.com.

Another critical nursing role is to address the patient’s distorted thoughts in a gentle manner. Using cognitive techniques, the nurse can ask questions when the patient expresses distortions: e.g., patient says, “I’m so gross and fat,” nurse might respond, “I hear that you feel gross. Can we look at what the numbers say? Your BMI is actually below the healthy range, which tells me you’re underweight. It seems your mind is telling you something different than what the facts show.” This can seed doubt in the absolute certainty of their body image distortion. Body image work is often done in therapy sessions, but nurses reinforce it daily by focusing on improvements in health rather than appearance. For instance, compliment improvements in strength or mood rather than any weight or shape changes. Encourage patients to identify non-physical qualities they value in themselves.

Family education is equally important. For adolescent patients (especially with anorexia), nurses teach parents how to support nutritional rehab at home – maybe they will need to supervise all meals initially, or ensure the child is not over-exercising. Families should be cautioned to avoid comments about weight or looks and instead emphasize health and feelings. They are also taught to recognize signs of relapse (like skipping meals, resumption of secret exercise or purging) early.

Cultural and Ethical Considerations: Cultural ideals of beauty (such as a preference for thinness in many societies) undeniably contribute to eating disorders. Nurses should recognize that patients may be under pressure from social media, peer groups, or specific athletic activities (e.g. ballet, gymnastics, wrestling) that emphasize weight. In some cultures, however, fullness is valued and an eating disorder might be less recognized or even hidden due to shame. It’s essential to assess each patient’s cultural context – for example, does the family view the disorder as a medical illness or a “lifestyle choice”? Provide culturally appropriate education that frames the ED as an illness, not a vanity issue. Use of analogies (like explaining that eating disorders are not truly about food, but about coping with emotional pain or feeling in control) can help families understand the psychological nature.

Ethical dilemmas often arise in treating EDs, particularly anorexia, because of issues of autonomy vs. life-saving intervention. A competent adult with anorexia may refuse nutrition despite the risk of death, which puts healthcare providers in a difficult position. In most jurisdictions, severe malnutrition that imminently threatens life can justify temporary involuntary treatment (similar to suicidality). Still, force-feeding (e.g. via NG tube under restraint) is a last resort; it can be traumatic and erode trust. The care team, including nurses, should attempt to gain the patient’s cooperation and use the least coercive methods. Ethical practice also involves confidentiality for teens – but if a minor’s life is at risk, parents need to be involved in care decisions. Additionally, nurses must advocate for fairness and insurance coverage for ED treatment, which sometimes is limited (parity laws in mental health are intended to ensure EDs are covered as comprehensively as medical illnesses).

Current Trends and Research: Research in eating disorders is ongoing, including studies on genetics, neurobiology, and innovative treatments. Family-based approaches have strong evidence in adolescent AN, and there’s growing evidence that early intervention yields the best outcomes. The COVID-19 pandemic unfortunately correlated with a spike in adolescent eating disorder cases (referrals and hospitalizations for EDs increased during lockdown periods)​umassmed.edu, which is thought to be due to heightened anxiety and loss of routine/support. Nurses should be prepared to encounter more cases and perhaps more severe presentations post-pandemic. On a hopeful note, there is increasing advocacy and awareness; for example, many schools and colleges now have eating disorder screening programs and “body positivity” campaigns that encourage healthy body image and media literacy.

Summary: In anorexia nervosa and bulimia nervosa, the nurse’s role is pivotal in restoring physical health while also addressing the distorted thoughts and intense emotions that drive disordered eating​nurseslabs.com​nurseslabs.com. Treatment is multidisciplinary: nutritional rehabilitation and medical monitoring form the foundation, augmented by psychotherapy (CBT, family therapy) to achieve long-term behavior change. Pharmacologic therapy (like SSRIs) can aid especially in bulimia or comorbid conditions, but must be combined with counseling and nutritional support to be effective​ncbi.nlm.nih.gov. Throughout care, compassionate, nonjudgmental communication by the nurse helps patients feel understood rather than shamed. Success is measured not just in weight restoration or cessation of purging, but in the patient regaining a sense of control over their life apart from the eating disorder. Small milestones – eating a feared food, honestly reporting a lapse, expressing emotions in words instead of through food – are significant victories. With continuous support, education, and vigilance for relapse signs, patients with EDs can recover to lead healthy lives. Nurses provide the continuity and caring that encourage patients and families to trust the process of recovery, even when it feels unbearably difficult, always reinforcing that the patient is more than their disorder and deserves a life free from its grasp.

Delirium in Older Adults

Definition and Clinical Presentation: Delirium is an acute, fluctuating disturbance of consciousness and cognition – essentially, an acute brain failure. It is characterized by a reduced ability to focus or sustain attention, impaired awareness of the environment, and cognitive disturbances such as memory deficit, disorientation, or language disturbance​journals.lww.com. The onset is rapid (usually hours to days), representing a clear change from the person’s baseline mental status, and symptoms tend to fluctuate over the course of a day (e.g. worse at night, somewhat better in daytime)​journals.lww.com​journals.lww.com. DSM-5 criteria for delirium encapsulate these features, requiring: (1) disturbance in attention and awareness; (2) acute onset and fluctuating course; (3) at least one additional cognitive disturbance (memory, orientation, language, perception, etc.); (4) the disturbances are not better accounted for by an evolving dementia and do not occur in a coma; and (5) evidence that the delirium is a direct physiological consequence of a medical condition, substance intoxication or withdrawal, or exposure to a toxin​journals.lww.com​journals.lww.com. In practice, delirium often manifests as confusion, altered level of consciousness (ranging from hyperalert agitation to drowsy lethargy), disorganized thinking (the patient’s speech may be rambling or illogical), and perceptual disturbances such as hallucinations or delusions. A classic example is a hospitalized elderly patient who becomes acutely confused in the evening, not recognizing family, perhaps seeing insects on the wall that aren’t there, or believing nurses are out to harm them. This acute change (often termed “sundowning” when it worsens at night) is a hallmark of delirium and must be distinguished from baseline dementia.

Delirium is extremely common in older adults, especially in hospital and long-term care settings – studies indicate up to 10–30% of older medical patients experience delirium at some point during hospitalization​aafp.org. It is often under-recognized (hypoactive delirium, where the patient is quiet and withdrawn, is particularly easy to miss)​ncbi.nlm.nih.gov​ncbi.nlm.nih.gov. Nurses are usually the first to notice subtle changes, making routine cognitive assessment vital. Importantly, delirium is a medical emergency: it often signals an underlying life-threatening issue (such as infection, hypoxia, or metabolic derangement), and it is associated with higher mortality if not addressed​aafp.org​aafp.org.

Etiology: Delirium has a broad array of potential causes, commonly summarized by the mnemonic “DELIRIUM” (Drugs, Electrolyte imbalance, Lack of drugs (withdrawal)/pain, Infection, Reduced sensory input, Intracranial (stroke, bleed), Urinary or fecal retention, Myocardial or pulmonary issues). In older adults, polypharmacy and medication side effects are a major culprit – psychoactive drugs (benzodiazepines, opioids, anticholinergics) are notorious for precipitating delirium​ncbi.nlm.nih.gov. Common triggers include infections (urinary tract infection or pneumonia), metabolic disturbances (dehydration, hypoglycemia, electrolyte imbalances like hyponatremia), organ failures (liver or kidney failure causing toxin buildup), and environmental changes (like transfer to ICU or sleep deprivation). Often multiple factors interact to cause delirium in an elder (e.g. an 80-year-old after surgery with anesthetic effects, on opioids for pain, has sleep loss and a urinary tract infection – collectively precipitating delirium). Baseline cognitive impairment (dementia) is the biggest risk factor – patients with dementia are far more likely to develop delirium under stressors​journals.lww.com​journals.lww.com. Other risk factors include advanced age, sensory impairments (vision or hearing loss making it harder to interpret environment), history of alcohol use (risk of withdrawal delirium or less reserve), and illness severity.

Common Nursing Diagnoses: The hallmark nursing diagnosis for a patient with delirium is Acute Confusion. NANDA defines Acute Confusion as reversible disturbances of consciousness, attention, cognition and perception that develop over a short period​nurseslabs.com. Evidence might be noted as disorientation, impaired attentiveness, altered sleep-wake cycle (e.g. dozing in daytime, agitated at night), and hallucinations or delusional thinking​nurseslabs.com. Risk for Injury is an equally important diagnosis because delirious patients may fall, pull out IV lines or catheters, or inadvertently harm themselves or others due to impaired judgment. For example, a delirious patient might try to climb out of bed unassisted or wander away. Other relevant diagnoses include Disturbed Sensory Perception (if hallucinating or misinterpreting stimuli), Disturbed Thought Processes, and Disturbed Sleep Pattern. If the delirium is causing agitation or aggression, Risk for Other-Directed Violence could apply. Conversely, in hypoactive delirium, Self-Care Deficit (hygiene, feeding) may be an issue as the patient is too confused to perform ADLs. For an older adult experiencing delirium superimposed on dementia, Chronic Confusion is a background diagnosis, but the acute component is addressed by Acute Confusion. The family of a delirious patient might exhibit Fear or Anxiety seeing their loved one so altered, so supportive diagnoses like Compromised Family Coping may be considered for holistic care.

Prevention and Early Detection: The adage “an ounce of prevention is worth a pound of cure” is very true for delirium. Because delirium can often be prevented with proactive measures, nurses should implement delirium prevention protocols for high-risk patients (especially hospitalized elders). Effective non-pharmacologic interventions, such as the Hospital Elder Life Program (HELP), have been shown to significantly reduce delirium incidence in elderly inpatients​ncbi.nlm.nih.gov​ncbi.nlm.nih.gov. Key prevention strategies include: maintaining a day-night orientation (e.g. keep lights on and curtains open during the day, dark and quiet at night to promote normal sleep), providing re-orientation aids (clocks, calendars, a board with the day’s schedule, and staff introducing themselves each shift with clear communication of where the patient is and why), and ensuring the patient has their sensory aids (glasses, hearing aids) to reduce confusion​ncbi.nlm.nih.gov​ncbi.nlm.nih.gov. Other measures are to avoid or minimize deliriogenic medications – for instance, use the lowest effective dose of sedatives or avoid benzodiazepines in an elderly patient unless absolutely indicated (like for alcohol withdrawal delirium). Adequate pain control (untreated pain can precipitate delirium), encouraging early mobilization (even just sitting up in a chair or walking in hallway if possible)​aafp.org, and ensuring hydration and nutrition are all preventative steps​aafp.org. Also, preventing urinary retention and constipation (perhaps by avoiding unnecessary Foley catheters and using bowel regimens) helps, as urinary retention or fecal impaction can themselves trigger agitation in susceptible patients.

Nurses should also educate family members and involve them: a familiar voice and presence can calm a confused patient. Caregivers can be taught signs of delirium to watch for (such as new confusion or hallucinations) and to notify staff promptly​aafp.org. Many hospitals now use brief delirium screening tools each shift, like the Confusion Assessment Method (CAM) – a quick assessment where the nurse checks for acute onset, inattention, disorganized thinking, and altered consciousness​ncbi.nlm.nih.gov​ncbi.nlm.nih.gov. If the CAM is positive (indicating delirium), swift action is required.

Management of Delirium: The first step in managing delirium is to identify and treat the underlying cause(s). Delirium is a symptom of something else, so a thorough medical evaluation is essential. Physicians will often order labs (CBC, metabolic panel, urinalysis, oxygen saturation, drug levels, etc.) and studies depending on suspicion (for example, a chest X-ray if pneumonia is suspected, head CT if a stroke or bleed is possible, or checking for urinary infection)​ncbi.nlm.nih.gov​ncbi.nlm.nih.gov. Nurses contribute by gathering a history (from family or records) about baseline mental status and recent changes, reviewing medications, and noting any potential contributors (was the patient sleep-deprived? In pain? Dehydrated?). Frequently, multiple causes are addressed simultaneously: starting IV fluids for dehydration, antibiotics for infection, or correcting electrolytes.

While the medical team addresses etiology, the nursing focus is on maintaining safety and providing supportive care. For a delirious patient, create a calm, structured environment. Reduce excess stimuli that might worsen confusion (e.g. minimize loud noises or overhead pages near the patient; avoid constantly moving the patient room-to-room). Use re-orientation techniques: reintroduce yourself each interaction, call the patient by name, remind them of the hospital, and reassure them they are safe. If hallucinating or delusional, rather than arguing, respond with calm explanations or gentle reality orientation – e.g., “I know you see insects on the wall, but I don’t see any. It might be the illness causing that. You are in the hospital and we are here with you.” Ensuring the patient has their glasses/hearing aids, as mentioned, can dramatically improve orientation​ncbi.nlm.nih.gov. Continuity of care is helpful – having the same nurse or aide when possible can be more grounding for the patient. Encourage family to stay at the bedside if feasible, as familiar faces and voices can reduce anxiety and confusion (with appropriate COVID-era precautions as needed).

Safety measures are paramount: implement fall precautions (bed in low position, bed alarm or chair alarm if patient tries to get up, nonskid socks). A delirious patient should ideally be in a room near the nursing station for close observation. In some cases, assigning a 1:1 sitter or utilizing family at bedside can prevent harm. Try to avoid physical restraints, as restraints can exacerbate delirium and cause agitation or injuries​aafp.org. Restraints might only be used as a last resort if the patient is in immediate danger of pulling out a life-sustaining tube or line and less restrictive methods have failed; even then, it should be temporary and with frequent reassessment.

Attending to basic needs can help clear delirium: ensure the patient has adequate sleep (cluster nursing activities at night to allow uninterrupted sleep blocks, maybe offer a warm drink or back rub in evening). If sleep cycle is reversed (awake all night, napping in day), employ non-drug sleep hygiene strategies or low-stimulation environment at night. Maintain hydration and nutrition – delirious patients may not eat well on their own, so offer assistance with feeding or consider IV fluids/nutrition as needed. Monitor bowel and bladder: bladder scans to check retention, prompt toileting to avoid accidents (which could cause skin breakdown or infection). Treat pain – sometimes low-dose analgesia (avoiding high doses of opioids if possible) can paradoxically improve delirium if pain was the trigger. Conversely, review the medication list and remove any non-essential drugs that could be clouding cognition (e.g. anticholinergics like diphenhydramine for sleep should be stopped).

Use of Medications in Delirium: There are no FDA-approved medications specifically for delirium treatment, so the emphasis is on non-pharmacologic management​ncbi.nlm.nih.gov. However, in certain situations medications are used cautiously. If delirium is due to alcohol or benzodiazepine withdrawal, benzodiazepines (such as lorazepam) are indicated to prevent progression to seizures (delirium tremens). In the case of hyperactive delirium where the patient poses a danger to themselves or others and cannot be redirected (for example, a wildly agitated ICU patient trying to pull out a breathing tube), a low-dose antipsychotic medication is often used as a temporary measure​ncbi.nlm.nih.gov. Haloperidol (Haldol) is a common choice – it can be given IV/IM and tends to calm agitation without excessive sedation or respiratory depression. Atypical antipsychotics (like quetiapine or risperidone) are alternatives, especially in patients with Parkinson’s or Lewy Body dementia where haloperidol could worsen extrapyramidal symptoms (in such cases, quetiapine is preferred for delirium). The nurse must monitor for side effects of these medications: antipsychotics can prolong the QT interval (so check ECG), and risk extrapyramidal symptoms or neuroleptic malignant syndrome, though low, is present. Use the lowest effective dose for the shortest duration; once the patient is safer, these meds should be tapered off. Importantly, sedative medications should be reserved only for the scenarios outlined: severe agitation or end-of-life comfort​ncbi.nlm.nih.gov. They are not a substitute for treating the cause. For hypoactive delirium, meds are generally not indicated at all – these patients need stimulation and mobilization rather than sedation.

Monitoring and Reassessment: Delirium can fluctuate rapidly, so continuous reassessment is needed. Nurses should use tools like the CAM each shift or more often to track changes​ncbi.nlm.nih.gov. Vital signs and neuro status may be checked frequently. Improvement in delirium often lags behind treatment of the underlying cause by days, so do not discontinue interventions prematurely. On the other hand, if delirium signs suddenly worsen, reassess for new issues (did they develop another complication? Are they in pain? Did they receive a new medication that worsened confusion?). Communication with the healthcare team is key – nurses should update physicians on mental status changes, suggest possible causes (e.g., “Mr. J is more confused, and I noticed he hasn’t moved bowels in 4 days, could that be contributing?”). Interprofessional collaboration, including possibly involving a geriatric consult or geriatric psychiatry, can improve outcomes​ncbi.nlm.nih.gov.

Impact on Family and Discharge Planning: Delirium can be frightening for family members who may not understand why their loved one is “not themselves.” Nurses should educate the family that delirium is usually temporary and reversible with proper care​ncbi.nlm.nih.gov. Provide reassurance and explain what is being done to help. If the patient had an episode of delirium during hospitalization, they are at higher risk of subsequent delirium and functional decline. This affects discharge planning: ensure there is a safe discharge environment with perhaps home care services or rehab. Families should be educated to monitor for any return of confusion at home and to seek prompt evaluation if it happens. Also, advise on creating a delirium-prevention home setting (good lighting, maintaining routines, hydration, avoiding new sedative medications if possible).

Elder Protection and Ethical Considerations: In cases where delirium might be due to elder neglect or abuse (for instance, an elder coming from a nursing home dehydrated with medication toxicity), nurses have a legal obligation to report suspected elder abuse to Adult Protective Services​pmc.ncbi.nlm.nih.gov. A delirious patient cannot report abuse themselves, so the nurse must be their advocate if any suspicions arise. Ethically, treating delirium may involve temporary measures that infringe on autonomy (like close monitoring or restraints in extreme cases), but these are justified by beneficence – to prevent harm and treat an acute condition. The use of restraints or sedation should follow hospital policy and ethical review if prolonged. Always treat the delirious person with dignity and explain actions to them, even if they seem not to understand (the human presence and tone can be comforting). If decision-making capacity is lost due to delirium, involve the healthcare proxy or next of kin for decisions; this underscores the importance of advance directives (which nurses should advocate for before patients become delirious or otherwise incapacitated).

Summary: Delirium in older adults is a common, serious condition that requires rapid assessment and intervention. Nurses are on the frontline to detect Acute Confusion and institute measures like reorientation, safety precautions, and multi-component prevention strategies that can literally prevent delirium or shorten its course​aafp.org​ncbi.nlm.nih.gov. The guiding principle is to find and fix the cause while keeping the patient safe and supported. Unlike dementia, delirium is usually reversible – many patients return to baseline cognition when precipitating factors are resolved. The outcome is improved by nursing actions such as vigilant monitoring, environment management, coordination of care, and family education. In essence, nursing care for delirium is holistic: it addresses the biological aspect (managing medical causes), the psychological aspect (reducing fear and confusion), and the environmental aspect (optimizing surroundings for orientation and safety). By doing so, nurses significantly reduce morbidity associated with delirium, including preventing complications like falls or aspiration, and helping the patient recover their clarity of mind.

Dementia (Alzheimer’s Disease)

Definition and Progression: Dementia – now formally termed Major Neurocognitive Disorder in DSM-5 – is a chronic, progressive decline in cognitive function that interferes with independence in daily activities​ncbi.nlm.nih.gov. Unlike delirium, dementia has an insidious onset and a steady (often gradual) course over months to years. The most common form of dementia is Alzheimer’s disease (AD), accounting for roughly 60–80% of cases​ncbi.nlm.nih.gov. Alzheimer’s disease is characterized pathologically by neurodegeneration associated with amyloid plaques and tau tangles in the brain; clinically, it typically presents with prominent short-term memory loss (difficulty recalling recent conversations or events) progressing to impairment in other domains such as language (aphasia), visuospatial skills (getting lost in familiar places), and executive function (poor judgment, difficulty with complex tasks). DSM-5 criteria for Major Neurocognitive Disorder due to Alzheimer’s require evidence of significant cognitive decline in one or more cognitive domains, impairment in independent functioning (for example, needing help with finances, medications, transportation), a gradual onset with continuing decline, and no other medical or psychiatric explanation​ncbi.nlm.nih.gov​ncbi.nlm.nih.gov. Early in the disease, a person might manage basic self-care but struggle with IADLs like managing money or remembering appointments. As it progresses to moderate stage, the individual cannot live independently safely – they forget names of close family, may wander, and need help with ADLs (bathing, dressing). In severe dementia, continuous care is needed as the person may become nonverbal, bed-bound, and lose control of basic bodily functions.

Epidemiology and Impact: Dementia is predominantly a disease of older adulthood. Age is the strongest risk factor – for instance, Alzheimer’s affects an estimated 1 in 10 people over age 65, and as many as 1 in 3 over age 85. With an aging global population, dementia cases are soaring. Currently about 47 million people worldwide live with dementia, and this number is projected to triple to 131 million by 2050​ncbi.nlm.nih.gov. In the U.S., Alzheimer’s disease is now the 5th leading cause of death for those over 65​ncbi.nlm.nih.gov. It imposes a huge burden on families and healthcare systems; costs of care (both direct medical costs and indirect costs like lost income of caregivers) are enormous​ncbi.nlm.nih.gov. There is also an emotional toll – families watch their loved one’s personality and abilities fade, which can be profoundly distressing. Nurses should be mindful of the potential for caregiver burnout and depression; caring for someone with dementia full-time is often exhausting. Awareness of health disparities is important too: some research suggests certain ethnic minority elders (like African Americans and Hispanics in the U.S.) have higher prevalence of dementia and may have later diagnosis due to access issues. Community education about brain health and early warning signs can help promote earlier diagnosis and intervention (such as starting medications or planning care while the patient still has decision-making capacity).

Common Nursing Diagnoses: The ongoing cognitive decline in dementia leads to several nursing diagnoses. Chronic Confusion is a key diagnosis, reflecting the long-term, irreversible nature of the cognitive impairment (distinguished from the acute confusion of delirium)​ncbi.nlm.nih.gov. Impaired Memory – especially for recent events – is nearly universal; nursing care plans often highlight memory aids to address this. Disturbed Thought Processes and Impaired Verbal Communication are relevant diagnoses as the dementia progresses and patients may have trouble finding words or following conversations​ncbi.nlm.nih.gov​ncbi.nlm.nih.gov. Safety-related diagnoses are paramount: Risk for Injury or Risk for Falls due to disorientation, poor judgment, and gait instability. Many dementia patients wander (ambulatory but purposeless walking, potentially leaving home and getting lost) – Risk for Wandering or Impaired Environmental Interpretation Syndrome can be used to capture that tendency and need for a controlled environment. As self-care deteriorates, Self-Care Deficit (bathing, dressing, toileting, feeding) diagnoses come into play​ncbi.nlm.nih.gov. Basic needs like nutrition can suffer if patients forget to eat or can’t prepare food, leading to Imbalanced Nutrition: Less than Body Requirements. Disturbed Sleep Pattern is also common; many individuals with Alzheimer’s have fragmented sleep at night and may catnap or be restless​ncbi.nlm.nih.gov. Psychosocially, Social Isolation might occur as communication difficulties and behavior changes widen the gap between the patient and their social circle​ncbi.nlm.nih.gov. For family or primary caregivers, Caregiver Role Strain is a critical nursing diagnosis to monitor – many caregivers of dementia patients experience stress, health problems, or depression themselves.

Therapeutic Interventions – Cognitive Support: While dementia is not curable (except rare types with specific causes), various interventions can slow decline or maximize remaining abilities. A core nursing intervention is to promote orientation and a familiar routine without causing distress. In early stages, orientation cues like calendars, labels on drawers, and placing family photos with names can help jog memory. However, as dementia advances, rigid reorientation (constantly correcting them) may frustrate the patient. The nurse can employ validation therapy, which means acknowledging the person’s feelings and reality even if it’s not factual. For example, if a patient with moderate AD is looking for her long-deceased mother, instead of insisting “Your mother died 30 years ago” (which could traumatize them as if hearing it anew), the nurse might say, “You miss your mother – tell me about her,” and then gently redirect to a soothing activity. This approach avoids confrontation and reduces anxiety. Reminiscence therapy can be very beneficial: encouraging the person to talk about their past (which is often better preserved than recent memory) can stimulate cognition and improve mood. The nurse might use a photo album or music from the patient’s young adulthood to spark pleasant memories. Cognitive stimulation activities, such as simple puzzles, singing familiar songs, or a “memory box” of personal mementos, help maintain cognitive function. Nurses in long-term care often facilitate such activities in group settings (like trivia or current event discussions tailored to their ability).

Ensuring Safety and Meeting Basic Needs: Safety is a continuous concern with dementia patients. The nursing care plan should include modifications to the environment: keep pathways clear to prevent falls, install night lights to reduce confusion in the dark, and use devices like door alarms or a WanderGuard system for those prone to exit-seeking. If the patient wanders at night, provide a safe space to wander (a circular hallway) or a quiet supervised activity to channel restlessness. In the home setting, caregivers might need to secure the home (locks, fencing, notifying neighbors of the situation). Nurses can educate families on “elder-proofing” the house (similar to child-proofing: locking up cleaning chemicals, removing stove knobs if the person might forget to turn off the stove, etc.). Fall prevention strategies such as grab bars, removing loose rugs, and non-skid footwear are important as many dementia patients also have gait impairment. As for ADLs, early on, cueing and simplifying tasks helps maintain independence: for instance, layout clothes in the order they should be put on, use verbal step-by-step prompts (“Now put on your shirt. Good, now the pants.”). In later stages, the nurse or caregiver may have to physically assist or perform the ADLs while preserving the person’s dignity (e.g. using a towel to cover them during bathing, explaining each step while bathing or toileting). Maintaining nutrition and hydration may require offering finger foods if the person can’t use utensils, or frequent small meals of favorite familiar foods. Watch for dysphagia (swallowing difficulty) in advanced dementia, which might necessitate a modified texture diet or ultimately feeding tube decisions (which involve ethical discussions and advance directives).

Communication Techniques: Communication with a person with dementia should be calm, clear, and kind. The nurse should approach from the front, establish eye contact, and address the person by name. Use short, simple sentences and give one instruction at a time, allowing extra time for processing. Avoid quizzing or saying “Don’t you remember?” which can embarrass or agitate them. If the patient is having word-finding difficulty, encourage non-verbal communication (pointing, gestures) or gently offer the word if you can guess it. Nonverbal cues from the nurse are also important – a warm smile, reassuring touch (if appropriate and not startling to them), and a soothing tone can convey safety and care even if the exact content isn’t fully understood. When the patient becomes frustrated or upset, the nurse should remain unruffled, validate their emotion (“I see you are upset”), and then redirect to a calming activity or change the environment (for example, take them for a walk, or turn off a television if it’s causing distress).

Pharmacologic Management: While no cure exists for Alzheimer’s disease, some medications can modestly improve symptoms or slow progression for a time. Cholinesterase inhibitors (donepezil, galantamine, rivastigmine) are commonly prescribed in mild to moderate AD​ncbi.nlm.nih.gov. They work by preventing breakdown of acetylcholine, a neurotransmitter important for memory and learning, thereby slowing the worsening of symptoms in some patients​ncbi.nlm.nih.gov​ncbi.nlm.nih.gov. Donepezil is used in all stages of AD, while rivastigmine and galantamine are generally for mild-moderate stages​ncbi.nlm.nih.gov. These medications are not a cure and not every patient responds, but a significant number see stabilization or slight improvement in cognitive testing and daily function for a period (often 6-12 months or more)​ncbi.nlm.nih.gov. Nurses should monitor for side effects like GI upset (nausea, diarrhea are common due to cholinergic effects), bradycardia, or syncope. Memantine is another medication, an NMDA receptor antagonist indicated for moderate to severe AD​ncbi.nlm.nih.gov. It helps regulate glutamate, which in excess can cause neuronal damage, and may provide a modest benefit in cognition and daily activities in later stages​ncbi.nlm.nih.gov​ncbi.nlm.nih.gov. Often memantine is used in combination with a cholinesterase inhibitor for additive effect. The nurse must educate families that these drugs do not stop the disease but can slow decline; expectations should be managed. Regular cognitive evaluation will continue, and at some point, if the medications no longer seem beneficial or cause adverse effects, discontinuation might be considered by the healthcare provider.

In recent developments, disease-modifying therapies targeting amyloid plaques have emerged (e.g. aducanumab, and more recently lecanemab). Aducanumab received FDA approval for early Alzheimer’s, aiming to reduce amyloid burden in the brain​ncbi.nlm.nih.gov. However, its approval is controversial due to unclear clinical benefit and high cost​ncbi.nlm.nih.gov. If a patient is on or considering such therapies, nurses should ensure they and their family understand the risks (edema or microhemorrhages in brain seen on MRI) and the intensive monitoring involved. These treatments are still being studied; thus, most current nursing management focuses on supportive care and symptom management.

Besides cognitive enhancers, many patients with dementia experience behavioral and psychological symptoms of dementia (BPSD) – such as depression, anxiety, aggression, agitation, hallucinations, or sleep disturbances. Non-pharmacologic strategies are first-line (as described earlier: routine, reassurance, exercise, meaningful activities to reduce boredom). But sometimes medications are needed for these symptoms: Antidepressants (particularly SSRIs like sertraline or citalopram) can help with depressive symptoms or anxiety and have a fairly good safety profile in the elderly​ncbi.nlm.nih.gov. Antipsychotics (like risperidone, quetiapine, olanzapine) may be used with caution for severe agitation or psychosis that is causing potential harm – but they carry increased risk of stroke and mortality in dementia patients (Black Box warning for use in elderly dementia-related psychosis). If used, they should be at the lowest dose for the shortest time and with informed consent about risks. Sleep aids should be used sparingly; instead, encourage non-drug sleep hygiene (maybe melatonin supplement, or just daytime exercise and limiting caffeine). Acetaminophen is sometimes given trially if a patient is frequently agitated, on the theory that unexpressed pain might be the cause (some dementia patients cannot articulate pain well, so they act out).

Psychosocial Support and Education: An essential component of dementia care is supporting the caregivers. Nurses should educate family members about the disease trajectory and realistic expectations. Early on, help the patient and family plan for the future – this includes legal planning (power of attorney for health and finances, advance directives about end-of-life care and possibly feeding tubes or resuscitation wishes while the patient can still decide)​ncbi.nlm.nih.gov. Connect families to resources like the Alzheimer’s Association, local support groups, and respite care services. Caregiver stress is a major issue; encourage caregivers to take breaks and care for their own health. Culturally, caregiving norms differ – some cultures expect family (often female relatives) to shoulder all care at home; others might turn to formal care systems sooner. Be culturally sensitive and provide options that align with the family’s values, whether that’s arranging home health aides or discussing when nursing home placement might be appropriate for safety. The concept of elder protection is important as dementia patients are vulnerable to neglect or exploitation. Nurses should teach families signs of caregiver burnout that could lead to neglect, and the importance of asking for help before reaching that point. Financial exploitation is another risk; a cognitively impaired elder might be scammed or even taken advantage of by unscrupulous family. Ensuring a trustworthy person is overseeing the elder’s finances (via power of attorney) and involving social workers or case managers if any suspicion arises is part of the nurse’s advocacy role. Remember that by law, healthcare workers must report suspected elder abuse or neglect – this applies to dementia patients in any setting​onlinenursing.duq.edu​justice.gov.

Maintaining Quality of Life: Although dementia inevitably progresses, there is much that can be done to maintain a good quality of life for as long as possible. Nurses should tailor activities to the person’s remaining strengths and interests. If someone loved gardening, perhaps supervised time in a garden or with potted plants can bring joy even when they forget recent events. If music from their era lights them up, incorporate music therapy. Pet therapy is another wonderful modality – many dementia units have resident pets or therapy animal visits which often bring out smiles and engagement in even withdrawn patients. Small successes should be celebrated, and the person should be treated as the adult they are – respect is vital; never infantilize or talk over the person as if they aren’t there. Use their preferred name, include them in conversations, and seek their input on simple choices (“Would you like to wear the blue shirt or red shirt today?”) to give a sense of autonomy.

Summary: Caring for patients with dementia, especially Alzheimer’s disease, is a marathon, not a sprint. Nurses provide continuity of care across settings – from clinic education at diagnosis, to acute care if hospitalized for other illnesses, to home health or long-term care support. The focus is on maximizing independence and dignity while ensuring safety. Interventions range from cognitive stimulation and memory aids in early stages to total care and comfort measures in late stages​ncbi.nlm.nih.gov​ncbi.nlm.nih.gov. Family and caregiver support is intertwined with patient care because the well-being of the patient often depends on the wellness of their caregivers. By educating caregivers, coordinating community resources (like day programs, respite, support groups), and planning for future needs, nurses help families navigate the long journey of dementia. While the cognitive decline cannot be reversed, its impact can be softened – through compassionate nursing care that preserves the personhood of the individual. Every smile elicited, every instance of anxiety soothed, and every safe day at home is a meaningful outcome. As research continues (with advances such as new medications and early detection biomarkers on the horizon), nurses will adapt and continue to be at the heart of dementia care: advocating, educating, and caring for those who can no longer fully care for themselves, and doing so with empathy and respect.

Summary: Across the lifespan – from developmental disorders like ASD and ADHD in childhood, through acute crises such as adolescent suicidality and eating disorders, to neurocognitive disorders in old age – mental health conditions pose unique challenges that require tailored nursing approaches. The common thread is a holistic, patient-centered care that addresses not just the clinical symptoms but also the emotional, cultural, and ethical dimensions of each condition. Using DSM-5 criteria informs accurate assessment and diagnosis, while NANDA-I nursing diagnoses provide a framework to identify patient-specific problems and guide interventions. Evidence-based practices – whether it’s ABA therapy for autism, stimulant medication for ADHD, CBT for bulimia, the CAM tool for delirium, or cholinesterase inhibitors for Alzheimer’s – are integrated into nursing care to improve outcomes​pmc.ncbi.nlm.nih.gov​ncbi.nlm.nih.gov. Psychosocial support, including therapeutic communication and education, empowers patients and families to participate in the care process and cope with the stressors that accompany these disorders. Culturally competent care ensures sensitivity to each patient’s background and beliefs. Moreover, legal and ethical considerations (like patient rights, confidentiality, and mandatory reporting duties) are observed to protect vulnerable individuals, such as safeguarding suicidal teens or protecting elders with dementia from abuse​pmc.ncbi.nlm.nih.gov​nursinghomesabuse.org. Nurses coordinate with interprofessional teams – psychiatrists, therapists, dietitians, social workers, and others – embracing a collaborative approach that is the hallmark of mental health nursing. By staying informed on current trends and research (such as rising youth suicide rates or new dementia treatments), nurses continuously adapt care strategies to the evolving landscape. In essence, the nurse’s role in all these scenarios is that of an advocate, caregiver, educator, and counselor, ensuring that patients across the lifespan receive compassionate, competent care that addresses both their physiological and psychosocial needs. Through skilled assessment, planning, intervention, and evaluation, nurses help mitigate the impact of these stressor-induced alterations and enhance quality of life for patients and their families​ncbi.nlm.nih.gov​ncbi.nlm.nih.gov.