4. Demanding behavior
1. Definition: a strong and persistent struggle to obtain satisfaction of self-oriented needs (such as control, self-esteem) or relief from anxiety.
2. Assessment:
1. Attention-seeking behavior.
2. Multiple requests.
3. Frequency of questions.
4. Lack of reasonableness; irrationality of request.
3. Analysis/nursing diagnosis: defensive coping and impaired social interaction related to:
1. Feelings of helplessness and hopelessness.
2. Feelings of powerlessness and fear.
3. A way of coping with anxiety.
4. Nursing care plan/implementation:
1. Control own irritation; assess reasons for own annoyance.
2. Anticipate and meet client’s needs; set time to discuss requests.
3. Confront with behavior; discuss reasons for behavior.
4. Ignore negative attention seeking and reinforce appropriate requests for attention.
5. Make plans with entire staff to set limits.
6. Set up contractual arrangement for brief, frequent, regular, uninterrupted attention.
7. Health teaching: teach appropriate methods for gaining attention.
5. Evaluation/outcome criteria: fewer requests for attention; assumes more responsibility for selfcare.

5. Denial of illness
1. Definition: an attempt or refusal to acknowledge some anxiety-provoking aspect of oneself or external reality. Denial may be an acceptable first phase of coping as an attempt to allow time for adaptation.
2. Assessment:
1. Observe for coping mechanisms such as dissociation, repression, selective inattention, suppression, displacement of concern to another person.
2. Note behaviors that may indicate denial of diagnosis:
1. Failure to follow treatment plan.
2. Missed appointment.
3. Refusal of medication.
4. Inappropriate cheerfulness.
5. Ignoring symptoms.
6. Use of flippant humor.
7. Use of second or third person in reference to illness.
8. Flight into wellness, overactivity.
3. Use of earliest and most primitive defense by closing eyes, turning head away to separate from what is unpleasant and anxiety provoking.
4. Note range of denial: explicit verbal denial of obvious facts, disowning or ignoring aspects or minimizing by understatement.
5. Be aware of situations such as long-term physical disability that make people more prone to denial of anger. Denial of illness protects the ego from overwhelming anxiety.
3. Analysis/nursing diagnosis: ineffective denial related to:
1. Untenable wishes, needs, ideas, deeds, or reality factors.
2. Inability to adapt to full realization of painful experience or to accept changes in body image or role perception.
3. Intense stress and anxiety.
4. Nursing care plan/implementation:
1. Long-term goal: understand needs met by denial.
2. Short-term goal: avoid reinforcing denial patterns.
1. Recognize behavioral cues of denial of some reality aspect; be aware of level of awareness and degree to which reality is excluded.
2. Determine if denial interferes with treatment.
3. Support moves toward greater reality orientation.
4. Determine person’s stress tolerance.
5. Supportively help person discuss events leading to, and feelings about, hospitalization.
3. Health teaching:
1. Explain that emotional response is appropriate and common.
2. Explain to family and staff that emotional adjustment to painful reality is done at own pace.
5. Evaluation/outcome criteria: indicates desire to discuss painfill experience.


6. Dependence
1. Definition: reliance on other people to meet basic needs, usually for love and affection, security and protection, and support and guidance; acceptable in early phases of coping.
2. Assessment:
1. Excessive need for advice and answers to problems.
2. Lack of confidence in own decision-making ability and lack of confidence in self-sufficiency.
3. Clinging, too-trusting behavior.
4. Gestures, facial expressions, body posture, recurrent themes conveying “I’m helpless.”
3. Analysis/nursing diagnosis:
1. Chronic low self-esteem related to inability to meet basic needs or role expectations.
2. Helplessness and hopelessness related to inadvertent reinforcement by staff’s expectations.
3. Powerlessness related to holding a belief that one’s own actions cannot affect life situations.
4. Nursing care plan/implementation:
1. Long-term goal: increase self-esteem, confidence in own abilities.
2. Short-term goals: provide activities that promote independence.
1. Limit setting - clear, firm, consistent; acknowledge when demands are made; accept client but refuse to respond to demands.
2. Break cycle of nurse avoids client when he or she is clinging and demanding client’s anxiety increases —> demands for attention increase —> frustration and avoidance on nurse’s part increase.
3. Give attention before demand exists.
4. Use behavior-modification approaches:
1. Reward appropriate behavior (such as making decisions, helping others, caring for own needs) with attention and praise.
2. Give no response to attention-seeking, dependent, infantile behavior; goal is to increase incidence of mature behavior as client realizes little gratification from dependent behavior.
5. Avoid secondary gains of being cared for, which impede progress toward aforementioned goals.
6. Assist in developing ability to control panic by responding less to clients high anxiety level.
7. Help client develop ways to seek gratification other than excessive turning to others.
8. Resist urge to act like a parent when client becomes helpless, demanding, and attention seeking.
9. Promote decision making by not giving advice.
10. Encourage accountability for own feelings, thoughts, and behaviors.
1. Help identify feelings through nonverbal cues, thoughts, recurrent themes.
2. Convey expectations that client does have opinions and feelings to share.
3. Role model how to express feelings.
11. Reinforce self-esteem and ability to work out problems independently. (Consistently ask: “How do you feel about.. “What do you think?”)
3. Health teaching:
1. Teach family ways of interacting to enforce less dependency.
2. Teach problem-solving skills, assertiveness.
5. Evaluation/outcome criteria:
1. Performs self-care.
2. Asks less for approval and praise.
3. Seeks less attention, proximity, physical contact.