Reactions to Illness in the Hospitalized Adult

How Psychiatric Diagnosis are Made

Assessment Skills in a Crisis Situation

Suicidal in the Hospitalized Patient


Principles of Psychopharmacological Intervention

Major Classifications of Psychiatric Drugs and Their Side Effects

Anti psychotic Agents

Psychopharmacologic Management of the Patient in Acute Alcohol Withdrawal

Special Problems of the Elderly


Suggested Reading


Post Examination


            Our own responses to physical illness provide us with some basic insight into the typical responses of our patients to an episode of ill health.  Generally, we react negatively to the signs of even a minor illness.  We may feel resentful, angry, disappointed, or frustrated.  An illness never occurs when we can afford the time off to care for and nurture ourselves as would be optimal.  Often an illness develops concurrent with pre-existing instances when we respond initially with acceptance, after a day or so in bed we resort to impatience with our bodies’ betrayal.  An illness provides a reminder that we are not in complete and ultimate control of our lives.  Ill health may generate thoughts or feelings about our vulnerability, the unpredictability of life our on-going aging process or other related psychological or philosophical issued we generally avoid.  If all this can be provoked by a run in with this seasons’ flu, what is the experience of a hospitalized adult patient?

            The coping tasks of the ill adult are varied and significant.  Although each patient will, hopefully, not confront all of them, there are 8 major tasks facing the ill adult.  All of these relate to 4 areas of basic human need as identified by Maslow:  basic physiological needs; safety; love and belonging; and the need for self-esteem.


  1. Change in body image
  2. Reality of their own mortality
  3. Coping with altered relationships with others
  4. Dealing with an altered level of dependency
  5. Adjusting to physiological changes
  6. Grieving for their losses (self or life style)
  7. Fear of recurrent problems
  8. Illness occurs with other stressors

The term “coping” deserves some discussion before moving on to the description of the tasks.  Although a common term, it implies many meanings.  In the broadest of interpretations, one may define coping as meeting the challenges and demands of life in a physiologically successful manner,  More specifically coping may mean problem solving on an emotional, cognitive or motor level, separately or concurrently.  Psychologically, coping usually means an individual’s response to perceived threats to their internal emotional well being.  Coping is usually a learned
response pattern to stressful events which the individual has developed though a trial and error process over their life span,  As such, coping is a process rather than an event.

            As most illness challenge an individual both physically and emotionally, coping with illness involves multi-levels of physical emotional activity.  Think for a moment of your own bout with the flu – you are called upon to manage your physical symptoms, deal with your absence from work, problem-solve the difficulties your illness may present to your family members, cope with your emotional response to being ill and so forth.  How much more complex is the challenge of coping with hospitalization?

            In today’s health care climate, hospitalization implies a seriousness that recalls the fears of previous generations when hospitals were viewed as a place people go to die.  Today, people are hospitalized for acute illnesses.  During their usual brief stay, ill adults are often confronted with a change in body image.  This is obvious in surgical patients who suffer an incision and often removal of a body part.  Even in non-surgical situations, however, most patients experience a change in their self-image as it relates to body image.  In many cases, people cannot perform basic bodily functions unassisted.  IV’s, for example, replace drinking liquids or a catheter may replace the customary trip to the bathroom.  Cardiac patients may experience their illness as having “something wrong” with the core of their physical being,.  These are concrete illustrations of alterations in perception of body image.  On a more abstract level, changes in body image may cause an individual to feel “less than” their previous self or to wonder if others perceive them as less adequate than adequate than prior to their illness.

            Illnesses which warrant hospitalization frequently serve to confront an individual with the reality of their own mortality.  Symbolically illnesses are frequently characterized by a sense of vulnerability.  The defenses, bravado, or facade that may effectively protect an individual from awareness of their own mortality is often stripped away when one relinquishes their “identity” and dons a hospital gown.  Furthermore, a hospitalized patient today is surrounded by seriously ill individuals.  The atmosphere may be tense, the staff very busy and professional, and the array of technology impressive if not frightening.  In many instances such as critical care or step down units, an individual’s typical defenses which usually protect them from serious thought about their own mortality and provoke the ill adult to think about spiritual, psychological or philosophical issues on a personal level.  Often such concerns are on the minds of close family members or friends as well.  A family communication system which supports verbalization of these feelings and concerns may provide the most helpful coping mechanism for dealing with this issue.

            Another of the major tasks for the ill adult is coping with altered relationships with others in their social/support system.  The illness of an adult often impacts their relationships with their significant others.  The patient typically experiences greater needs for support and nurturance from others in reaction to their health impairment; they may feel more dependent, less in control, more anxious, or less decisive as they enter and attempt to negotiate the health care system.  Their self-esteem and self-image may suffer in adjusting to the routine of assessment, diagnosis and on-going treatment.

Concurrent with these emotional events in the ill individual, significant others are experiencing their own emotional responses to their loved one’s illness.  Friends and family members may feel confused, over-whelmed, uncertain, uncomfortable, sad, upset, angry, disbelieving or other strong reactions,.  Their responses may vary and fluctuate.  Significant others may feel unable to comfort the ill individual or may over-react to the illness.  Whatever their response, the initial situation is one of emotional instability just when the ill adult needs more stability and support than usual.

            Illness in an adult can initiate significant alterations in family relationships.  For example, the CVA of a parent can elevate an adult child to a parental role and cause the patient to be relegated to a more childlike position in the family constellation.  Or the serious illness of a middle-aged adult can propel a comfortably retired grandparent into role of housekeeper/parent to young grandchildren.  These are two possible upheavals that cause significant stress and pose major coping challenges in adult illness.  Each scenario would require significant family adaptation on emotional, physical and financial levels at a time when all are severely stressed by the presenting problem of the illness.

            Another significant issue involved is that of dealing with an alteration in dependence.  Few of us are comfortable thinking of ourselves as dependent and needing the care of others yet a serious physical illness forces this reality upon an individual.  Suddenly ones’ usual predictable routine is completely altered.  The illness interrupts and disrupts an individuals’ lifestyle.  In the hospital, the client’s day is externally directed and he/she must relinquish all but minimal control of their time to MD, nurses, and other hospital personnel.  In many situations, care and assistance may be required for the most basic daily functions – hygiene, eating, ambulation and elimination.
This drastic change may have literally occurred overnight or evolved after a brief period of crisis.  In serious illness this focus may be sustained for a long period as life at home becomes oriented around MD visits, lab tests, physical therapy, etc.  These changes are a serious challenge to an individual’s self-image and self-esteem.

            Concurrent with this, is the task of adjusting to physiological changes.  While the emotional tasks seem to predominate, adjustment to our bodies changed physiology is also a significant demand.  This area includes the lifestyle and self care changes many adults must make to accommodate to illness.  Typical changes include dietary, exercise, stress reduction, medication usage, alterations in libido, alteration in physical abilities such as after an amputation, alterations in sensory abilities or sensitivity.  Often, because these needs are concrete, quantifiable and visible, these physiological changes become a focal point, even a battle ground.  Non-compliance can be an enormous issue for the newly diagnosed diabetic or recovering cardiac patient, for example.  The individual can use non-compliance as a way to express their anger and frustration, even their rejection of their altered life situation.

            For many ill adults the emotional issues and challenges of altered health status combined with physiologic adjustments create a grieving for their former lifestyle.  This grief may be expressed in an overt, direct manner or more indirectly through a sad or introspective mood.  The individual may verbalize wishes for the wholeness, vigor, strength or well-being they enjoyed prior to the onset of their condition.  Also, they may experience guilt or regret that they did not adequately value their well being and took their health “for granted”.  These comments often dismay significant others who feel at a loss for a meaningful response.  A sensitive care giver who can provide acceptance, empathy and understanding of the patients’ perceived loss can offer needed support and role model an appropriate response for family members as well.  The patient may experience themselves as a “new person” who is unfamiliar and practice with uncertainty their “new self” with nursing staff.  In some individuals, staff may witness all the well-known stages of grieving as described by Kubler-Ross as the individual relinquishes their former self and self image.

            This sense of loss coupled with uncertainty regarding their “new self” may contribute to another of the major coping tasks, fear of recurrent problems.  The betrayal by the body which permeates so much of the emotional turmoil ill adults experience often takes on a life of its own as the individual begins to fear future possible health problems.  These fears may be supported by ignorance, misunderstandings or deficits in the patients’ knowledge regarding their illness.  Additionally patient teaching proceeds slowly when an individual (and possibly significant others, as well) is impaired due to anxiety or depression.  Many individuals will verbalize fears and a general pessimism regarding their health status and their future.

            The final coping task in this list relates to a fact of contemporary life that we are all familiar with.  Each of us has a life replete with stresses.  Yet illnesses strike individuals concurrent with an array of other stressors.  For example, financial stressors are prevalent in today’s economic climate; these may be severely complicated by reduced income and increased health care costs.  Marital and familial stressors exist in many families; these too, are complicated by the role changes and the physiologic/emotional changes that arise from serious illness.  And then there are the everyday stressors, the car still breaks down, or the children are ill or the work schedule is inflexible,.  The patient’s illness typically takes precedence, at least for a time, over other concurrent stressors,  This very shift can cause increased stress to other family members who must take on added coping and problem solving responsibilities,  Additionally, the ill adult is often painfully aware of the stress caused by their absence from home, family, work and so on,  The individual may experience guilt, depression or other emotional reactions both to their illness and to the inconvenience and disruption caused by their illness,.  Obviously this can become very complex.

            Stressors are not limited to an individual’s personal situation.  Just the act of hospitalization causes significant stress related to many issues previously discussed.  Depression and anxiety are the two most common responses to serious illness and both diminish further the patient’s self-esteem, and feelings of helplessness as well as impair cognitive ability to process and integrate new information,.  In our very busy practice settings, it is sometimes difficult to remember very basic strategies which promote self-esteem.  For example, ill adults often appreciate not being touched unannounced by caregivers.  Verbalizing what you need to do prior to beginning your work on an IV or taking vital signs is quite basic yet our preoccupation with our goals can lead to such oversights.  When procedures or treatments are required, don’t forget to give a simple step-by-step explanation and keep the individual posted as you proceed.  When asked to assess their hospital experiences, ill adults sometimes complain about the absence or privacy in the setting.  Caregivers can become insensitive to patient’s needs for privacy particularly around checking body parts, wounds or apparatus,  Pulling the curtains before throwing back the covers is a small act of respect that is much appreciated.

            How, then, do adults cope with illness and all the challenges illness presents?  Luckily, coping is not a skill one must develop after the onset of illness.  Coping for each individual is a lifelong process.  Learning or developing coping skills began in early childhood and progressed as the stresses and challenges of daily living became more complex and persistent.  As individuals proceed through life, life experience, their belief system, their family and personal values and the various priorities and commitments they establish all impact on coping skills.  In very broad terms, the ranges of coping styles cover a continuum from approach style at one end through avoidant style at the other.  Approaching coping behaviors are ones which directly engage the problem and the concurrent emotions,  Individuals with an approach coping style plunge into the recommended therapy and actively fight to regain their health,  Such patients want very detailed information and education; they wish to be totally engaged in all information and education; they wish to be totally engaged in all aspects of evaluation and treatment; they set goals and follow through,  Other approach strategies include an ability to regain a sense of control both through understanding, involvement and through self management (relaxation, seeks support and help, verbalizes feelings, etc).  Additionally, diversion, involvement in social events, and maintenance of independence are approach style coping strategies.

            At the other end of the spectrum are adults whose basic coping style is avoidance.  These individuals utilize denial, repression, projection and other strategies to minimize their perception of threat from their illness.  Non-compliance with or misunderstanding of treatment can be ways an individual denies or minimizes the seriousness of their illness.  Passive behavior is an avoidance strategy as are delaying decisions, withdrawing from supports and significant others, manipulation, maintenance of unrealistic hope or abuse of substances including alcohol, drugs and nicotine.  Between the two extremes are individuals who mix coping skills from both ends of the spectrum.  The majority of people fall in the mid range on this continuum.  It may be difficult initially to accurately assess which coping style predominates in an individual.  However, it is important for the nurse to identify an individual’s coping style, and when possible, specific individual strategies.  Typically, ill adults cope as best they can given the circumstances.  Caregivers must accept ad support a patients coping abilities even when they believe other strategies might before effective.  It is more helpful to focus on the patient’s best restructure coping skills during an acute illness.  The stress of a major illness and hospitalization will generally not facilitate learning new coping skills although the nurse may refer the individual to resources which can assist them to expand their coping repertoire during their recovery.

            The initial goals of coping strategies include minimizing uncomfortable emotional responses such as anxiety, fear, guilt, etc; enhancement of self-esteem; maintenance of positive/supportive relationships; and generation of hope.

            There are many reactions that ill adults may have to illness.  Three major categories of reaction are frequently seen in hospitalized individuals.

  1. The angry individual – Anger is often a reaction to perceived powerlessness.  When a patient feels powerless, they may relate in an angry manner with staff in an unconscious attempt to externalize their uncomfortable inner experience.  Their angry style may also be an indirect expression that others are responsible for their internal discomfort.  Such patients may be loud, demanding, rude, time consuming and very frustrating to staff.  Successful interventions may include acknowledging the patient’s individuality and unique situation; keeping them informed; responding to their realistic needs while setting firm limits re:  amount of time the nurse has available.  For example, a caregiver might review with the individual their care for the shift and negotiate with the individual when they want their bath or dressing changed.  The caregiver might then say to the patient “I will be back in one hour to change your dressing.  Is there anything you need before I leave?  I’ll be caring for other patients until I return at 10 o’clock,” in a neutral, informational tone of voice.  Be sure to return on time for the procedure or inform the patient that you will be delayed.

  2. The agitated, hyper vigilant individual – This response presents its own set of challenges to the caregiver.  The anxiety underlying the agitation is often a response to the individuals feeling of helpless or decreased control due to their illness.  These uncomfortable perceptions cause anxiety and the anxiety, in turn, increases the uncomfortable feelings.  The hyper vigilance represents an attempt to regain a sense of control by asking questions to obtain information but the anxiety may prevent the ill adult from adequately processing and integrating the information received.  Some successful interventions might include consistency in staff assignment; suggesting relaxation interventions, such as deep breathing, hot shower, diversion (reading, sewing, etc.); providing patient teaching while a family member is present and encouraging the individual to make notes to review later; and providing the patient with adequate pain control.

  3. The withdrawn individual – This type of reaction is serious for a number of reasons.  A withdrawn patient can become “lost in the cracks.”  He/she may not receive the assessment and intervention this behavior requires and can be ignored emotionally and even physically in a busy practice setting.  Some patients are naturally isolative and have only a minimal support system because of their personality style.  In others, however, this reaction may be related to a clinical depression which needs further assessment.  Some helpful interventions include identifying the behavior as a problem and interviewing the patient as well  as significant others to establish a baseline – is this typical coping or an abnormal, unusual response to stress; monitor the behavior from day to day for increase or decrease in intensity; relay your concerns to other caregivers including the patients’ physician,  Finally, nurses need to have a basic knowledge of the process of assessing suicidality, and the ability to ask the appropriate questions when circumstances indicate this intervention is appropriate.