PSYCHIATRIC NURSING By: Joshua James L. Diao, BSN-RN, BSMT, AMT, ASCPT, MAN(On-Going) Psych focuses in feelings or self-awareness. Beliefs determine feelings which affects behavior (manifestation of feelings) Sigmund Freud is the father of PSYCHOANALYSIS What happens to childhood will affect adulthood STRUCTURE OF PERSONALITY ID Impulsive, “want to”, wants pleasure. PLEASURE PRINCIPLE Guiding principle is PAIN AVOIDANCE SUPEREGO Should not Small voice of God To stop EGO Executive decision maker. In touch with REALITY principle. ID DOMINANT PERSONALITIES Manic Anti - Social experienced by serial killers Narcissistic SUPEREGO DOMINANT PERSONALITIES Obsessive Compulsive Anorexia Nervosa EGO – if destroyed result in impaired reality perception. Schizophrenia LIBIDO Sexual energy responsible for survival. PSYCHOSEXUAL STAGES OF DEVELOPMENT ACCDNG TO FREUD [O.A.P.L.G.] ORAL STAGE 0 – 18 months evident. ID is developed. *FIXATION – Person is stuck in certain developmental shape. *REGRESSION – Return to an earlier developmental stage. *EGO – Developed on the 6th month. ANAL STAGE 18 months – 3 years old. Able to control bladder, bowel. Best time for toilet training. SUPEREGO is developed. TOILET TRAINING Good Mother Bad Mother Successful Dirty Clean - Disorganized - organized - Disobedient - obedient - Anti-social - O.C - Anal expulsive - Anal retentive PHALLIC STAGE 3 – 6 years old. Experience pleasure by manipulating genitals. Love – hate relationship. Oedipus Complex boy loves parent of the opposite sex. Imitates daddy called IDENTIFICATION. Castration fears. Electra Complex girl loves parent of the opposite sex. Imitates mommy called identification. Penis envy. *Conscious – upper level of thinking. *Preconscious – tip of tongue. *Unconscious – protects us from traumatic experiences. LATENCY STAGE 6 – 12 years old. School age. Separation anxiety. Reading, Writing, Arithmetic. Lasts for 6 years. GENITAL STAGE 12 years old and above Sexual reawakening. Very important stage. PHARMACOLOGY NOTES ANTI ANXIETY DRUGS [S.A.T.L.V.M. – E.V.A.B.I.] Serax Equanil Ativan Vistaril Tanxene Atarax Librium Buspar Valium Inderal Miltown ERIC ERIKSON There is more to life than just sex. Psychosocial Theory of development. You can develop a positive side or a negative side. Developmental task begins at 0 – 18 months. POSITIVE NEGATIVE FACTOR 0 – 18 mos. Trust Mistrust Feeding 18 mos. – 3 yrs. Autonomy Shame & Doubt Toilet Training 3 yrs. – 6 yrs. Initiative Guilt Independence 6 yrs. – 12 yrs. Industry Inferiority School 12 yrs. – 20 yrs. Identity Role Confusion Peers 20 yrs. – 25 yrs. Intimacy Isolation Love 25 yrs. – 45 yrs. Generativity Stagnation Parenting 45 yrs. - above Ego Integrity Despair Reflection BEHAVIORAL MODELS Ivan Pavlov Classical Conditioning All behaviors are learned. BF Skinner Behavior can be learned and unlearned. Operant conditioning. If given reward there is repetition. If punished behavior becomes extinct. LOBES OF BRAIN 1. FRONTAL LOBE 3. PARIETAL LOBE Language Touch Learning Taste Personality Judgment 2. TEMPORAL LOBE Hearing Smell 3 STEPS TO INTERACT WITH ENVIRONMENT 1. Sensory – eyes, ears, tongue 2. Integration 3. Motor – voluntary or involuntary 4. OCCIPITAL LOBE Visual VOLUNTARY NERVOUS SYSTEM Also called as SOMATIC Motor nerve to muscle fiber you need ACETYLCHOLINE which is an “On switch”. Brain Spinal Cord Motor Nerve Synapse Muscle Fiber INVOLUNTARY NERVOUS SYSTEM Also called AUTONOMIC nervous system. AUTONOMIC NERVOUS SYSTEM Heart Rate SYMPATHETIC (Awake, ADRENERGIC) Increase PARASYMPATHETIC (Relax, CHOLINERGIC) Decrease Respiratory Rate Increase Decrease GI Decrease (Dry mouth, Constipation) Increase (Moist mouth, Diarrhea) GU Decrease (Urinary Retention) Increase (Urinary Frequency) Neurotransmitter Epinephrine, Norepinephrine Acetylcholine DRUGS WITH ANTICHOLINERGIC EFFECTS Anti – Anxiety Anti – Psychotic Anti – Cholinergic Anti – Depressants PHARMACOLOGY NOTES MONOAMINE OXIDASE INHIBITORS Marplan Nardil Parnate DEFENSE MECHANISMS 1. DISPLACEMENT – transfer of feelings to a less threatening object rather than the one who provoked it. 2. DENIAL – failure to acknowledge an unacceptable trait or situation. 3. DISSOCIATION – psychological flight from the self. 4. REGRESSION – return to an earlier development state. 5. REPRESSION – unconscious forgetting. 6. RATIONALIZATION – illogical reasoning for an unacceptable trait and situation. 7. REACTION FORMATION – doing the opposite of what you have done. 8. UNDOING – doing the opposite of what you have done. 9. IDENTIFICATION – assuming trait for personal, social, occupational role. 10. PROJECTION – attribute to others one’s unacceptable trait. 11. INTROJECTION – assume another person’s trait as your own. 12. SUPPRESSION – conscious forgetting. 13. SUBLIMATION – putting destructive energies or hostile feelings towards a more productive endeavors. 14. CONVERSION – unexpressed or repressed feelings are converted to physical symptoms. 15. COMPENSATION – over achievement in one area to cover a defective part. 16. SUBSTITUTION – replace difficult goal with more accessible one. PHARMACOLOGY NOTES ANTI – PARKINSON DRUG [C.A.P.A.B.L.E.S] Cogentin Artane Parlodel Akineton Benadryl Larodopa Eldepryl Symmetrel AUTONOMIC NERVOUS SYSTEM SYMPATHETIC PARASYMPATHETIC Pupils Dilate Constrict Blood Vessels Constrict Dilate Blood Pressure Increase Decrease THERAPEUTIC COMMUNICATION TECHNIQUES THERAPEUTIC NONTHERAPEUTIC 1. Offer Self 1. Don’t worry be happy 2. Silence – provide time to think 2. Changing the topic/subject 3. Making observation – what you see 3. Ignore the client you say 4. Value based judgment – never assume 4. Active Listening – nodding, eye contact 5. Flattery 5. Broad Opening – how are you today? 6. Advising 6. General Leads – Go on, I’m listening 7. 7. Restating – I’m sad “You’re sad?” Giving Opinion FEAR – protects us from something bad. ANXIETY Vague sense of impending doom. Triggers the sympathetic nervous system. Assess level of anxiety of client. TYPES OF ANXIETY MILD ANXIETY + 1 level of anxiety. Widened perceptual field. Restless (say you seem restless). Enhanced learning capacity. MODERATE ANXIETY + 2 level of anxiety. Client pace. Give PRN meds. SEVERE ANXIETY + 3 level of anxiety. Don’t know what to do/say. Directive orders (please sit down). PANIC + 4 level of anxiety. May commit suicide. Promote safety. Never touch patient. Hyperventilation (Respiratory Alkalosis) Breathe into paper bag. NURSING DIAGNOSIS PLANNING/IMPLEMENTATION Ineffective individual coping. Decrease level of anxiety. Powerlessness. Decrease environmental stimuli. Impaired skin integrity Relaxation techniques EVALUATION Effective individual coping. GENERALIZED ANXIETY DISORDER 6 month excessive worrying. Restless, difficulty concentration, sleep disorders, palpitations, edge of the seat, easy fatigability. PANIC ATTACKS/ DISORDER 15 – 30 minutes sympathetic nervous system escalation. Example is AGORAPHOBIA fear of open spaces. POST TRAUMATIC STRESS DISORDER Victims become survivors and experience flashbacks or nightmares. MALINGERING Pretending to be sick (conscious). Primary Gain anxiety decreases, able to escape source of anxiety. Secondary Gain able to get attention. SOMATOFORM DISORDER No protection Unconscious No organic basis of being sick DIFFERENT TYPES OF SOMATOFORM 1. Conversion Disorder Cannot speak, see, hear. Nervous system affected. 2. La Belle Indifference Do not care what happens to them. HYPOCHONDRIASIS has minor discomfort and interprets it as major illness. Focus on clients feelings. BODY DYSMORPHIC DISORDER Illusion of structural defect. Favorite past time is doctor hopping. Focus on clients feelings. PSYCHOSOMATIC Real pains/illness Real symptoms because of anxiety PSYCHOSOMATIC ↓ Increase Anxiety ↓ SNS ↓ Increase BP & HR ↓ Hypertension ↓ Fat Deposits ↓ Atherosclerosis ↓ Calcium ↓ Arteriosclerosis ↓ Decrease Oxygen ↓ Angina Pectoris ↓ MI ↓ Necrosis ↓ CHF ↓ Coma PHOBIA Irrational fear Etiology: Knowledge of certain object Bad experience Immediate nursing objective: Removal of stimulus will remove anxiety Systemic Desensitization gradually expose client to stimuli/feared object Employ relaxation techniques SYMPATHETIC NERVOUS SYSTEM GABA (Gamma Amino Butyric Acid) – stop Epinephrine and Norepinephrine – Go ANTI- ANXIETY MEDICATIONS Increase GABA and client becomes drowsy (no alcohol and coffee) May develop orthostatic hypotension Let patient sit then dangle feet and then stand Develop anti cholinergic effects If abruptly withdrawn to anti anxiety it may result to rebound phenomenon (1 week) may lead to seizures Do it in gradual and in tapered dose Anti anxiety leads to dependence AUTISM Unresponsive and does not want to be touched AUTISTIC SAVANT: high intelligence and has a ratio of 1:100 Assessment Appearance – flat affect and loves constancy and ritualistic Behavior – withdrawn Communication – echolalia NURSING DIANOSIS Impaired verbal communication Impaired social interaction Self mutilation Risk for injury PLANNING/IMPLEMENTATION Maslow’s hierarchy of needs Expressive Therapy – use of art as mode of communication EVALUATION Enhanced communication Improved social interaction Safety ATTENTION DEFICIT HYPERACTIVITY DISORDER 7 years and below onset Duration: 6 months and above Settings: house and school Assessment Appearance: dirty, clumsy, hyperactive, impatient, easily distracted and has no focus Behavior Communication: talkative NURSING DIAGNOSIS Risk for injury Impaired social interaction PLANNING/IMPLEMENTATION Structure: place to play, sleep, eat and study Schedule: there is always a time for everything that you do Set limits Safety EVALUATION Minimize risk for injury Improved social interaction FRONTAL LOBE OF ADHD Decreased glucose ↓ Decreased judgment ↓ Increase impulsiveness ADHD/ Hyperactivity Need a drug that brings glucose level up. Give RITALIN as stimulant May result in loss of appetite Given after meals Given 6 hours before bedtime EATING DISORDERS ANOREXIA NERVOSA BULIMIA NERVOSA Eat, eat, eat Eat, eat, vomit Less 85% expected body weight Normal weight 3 months Amenorrhea Irregular menstruation BULIMIA NERVOSA Metabolic alkalosis (vomiting results to decreased hydrochloric acid) Metabolic acidosis (diarrhea results to decreased bicarbonate) Dental caries Wound in knuckles MANAGEMENT Fluid and electrolyte imbalance Meal contract Weight gain for client After eating stay with client for 1 hour and accompany when going to the comfort room PHARMACOLOGY NOTES ANTI – PSYCHOTIC DRUG Stelazine Serentil Thorazine Trilafon Clozaril Mellaril Haldol Prolixin SCHIZOPHRENIA Ego disintegration Impaired reality perception Genetic vulnerability Stress – Diathesis Model Biological theory – increase dopamine level Exact cause unknown ASSESSMENT Affect: Appropriate, Inappropriate, Flat, Blunt (incomplete) Ambivalence: pulled into 2 opposing forces AUTISM: Looseness, no idea, not related to one another ASSESSMENT NEGATIVE POSITIVE Hypoactive Hyperactive Withdrawn Sociable Thought Blocking Flight of ideas Apathy I. ASSESS Content of thought NURSING DIAGNOSIS Disturbed thought process PLANNING/IMPLEMENTATION Present reality Provide safety EVALUATION Improved thought process II. ASSESS Hallucinations/ Illusions NURSING DIAGNOSIS Disturbed sensory perception PLANNING/IMPLEMENTATION Present reality Safety EVALUATION Improved sensory perception III. ASSESS Suspicious NURSING DIAGNOSIS Risk for other directed violence PLANNING/IMPLEMENTATION Present reality Safety EVALUATION Eliminate/minimize risk for other directed violence IV. ASSESS Suicidal NURSING DIAGNOSIS Risk for self directed violence PLANNING/IMPLEMENTATION Present reality Safety EVALUATION Eliminate/minimize risk for self directed violence LOOSENESS OF ASSOCIATION There is connection with statements FLIGHT OF IDEAS Jumping from on topic to another AMBIVALENCE Pulled between 2 strong opposing forces MAGICAL THINKING acting like magician ECHOLALIA Client repeats what you say ECHOPRAXIA Client repeats what you do WORD SALAD Just words no rhyme CLANG ASSOCIATION Words that rhyme NEOLOGISM Formation of new words (needs clarification) DELUSION: PERSECUTORY “The NBI is out to get me” DELUSION: RELIGIOUS “I am Jesus Christ the savior” DELUSION: GRANDEUR “ I am the queen of the world” DELUSION: IDEAS OF REFERENCE “The nurses are talking about me” CONCRETE ASSOCIATION Also known as “pilosopo” THOUGHT BLOCKING Unable to think HALLUCINATIONS ILLUSIONS STIMULUS ABSENT PRESENT VISUAL ABSENT PRESENT AUDITORY ABSENT PRESENT TACTILE ABSENT PRESENT Present reality to clients experiencing hallucinations Technique in handling clients with hallucinations Hallucinations Acknowledgement “I know the voices are real to you” Reality orientation “I know the voices are real but I don’t hear them” Diversion “Lets go to the garden” 10% of schizophrenic clients hear voices PARKINSON’S DISEASE If acethylcholine (on switch) is increased there is excessive movement resulting to decrease in dopamine (off switch) ANTI-PSYCHOTIC ↓ Decrease dopamine level ↓ Parkinson like effect ↓ Extra pyramidal side effect ↓ With akathesia ↓ Restless, inability to rest AKINESIA Muscle rigidity DYSTONIA Torticollis (wry-neck) OCULOGYRIC CRISIS Fixed stare OPISTHOTONUS Arched back Lips – smacking Tongue – protruding Cheeks – puffing The 3 are irreversible and called TARDIVE DYSKINESIA NEUROLEPTIC MALIGNANT SYNDROME Hyperthermia ANTI – PARKINSON DRUGS ANTICHOLINERGICS DOPAMINERGICS (Decrease ACh) (Increase Dopamine) ↓ ↓ Artane, Akineton Parlodel Benadryl Larodopa Cogentin Eldepryl Symmetrel OTHER SIDE EFFECTS OF DECREASE DOPAMINE Photosensitivity AGRANULOCYTOSIS – decrease WBC Clients prone to infection due to decrease WBC First sign for infection is sore throat TYPES OF SCHIZOPHRENIA DISORGANIZED CATATONIC PARANOID RESIDUAL UNDIFFIRENTIATED UNCLASSIFIED - Sad but smiles (Inappropriate affect) - No reaction (flat affect) - Flight of ideas (disorganized speech) - Giggling (hebephrenic giggle) - Combination of positive and negative signs and symptoms - Ambivalence - Waxy flexibility - Favorite word is “No” - Negativism (client do not follow what you tell them to do) Nursing management: Meet needs - Suspicious - Mistrust, scared, withdrawn Nursing management: - Gain TRUST by 1 to 1 short interaction but frequent - Foods should be in a sealed container - Medications should be in tamper resistant foil. Violent: - Keep door open - Position near door - Don’t touch client - Call for reinforcement - One arms length away from the client. - No more positive symptoms just withdrawn - Mixed classification, cant be classified PHARMACOLOGY NOTES BI-POLAR, MANIC Lithium: undergo first kidney test and check for blood levels Level: .6 – 1.2 meq/L Increase urination Tremors, fine hand Hydration of 3L/day Increase Uu (diarrhea) Mouth dry Signs of Lithium toxicity Nausea, vomiting, diarrhea Increase sodium **** WAIT FOR 2 – 4 WEEKS BEFORE LITHIUM THERAPY TAKES EFFECTS BIPOLAR DISORDER/ MANIC PROFILE 20 years old Female Stress Obese ASSESSMENT Decrease appetite (give finger foods) Decrease sleep (place in a private room) Hyperactive Increase sexual activity – only means of addressing anxiety so decrease level of anxiety Risk for injury/other directed violence Impaired social interaction (care giver role: strain and stay with client) Self esteem decrease (to cover up their sadness there is compensation to cover defective doing) Because there is decrease self esteem there will be increase compensation resulting to increase interference with ADL’s and harm to others Compensation is the culprit Management: increase self esteem to decrease compensation and decrease interference with ADL’s and harm to others HOW TO INCREASE SELF ESTEEM OF MANIC PATIENTS? T - no sports (basketball, volleyball), no fine motor skills only gross motor skills A -llot energies toward more productive endeavors (sublimation) S - escorted walk outdoors K - punching bag (displacement) PHARMACOLOGY NOTES ANTI – DEPRESSANTS Asendin Vivactil Norpralamin Elavil Tofranil Prozac Sinequan Paxil Anafranil Zoloft Aventyl ALCOHOL LEADS TO: Blackout: awake but unaware Confabulation: inventing stories to increase self esteem Denial: “I am not an alcoholic” Dependence: cant leave with out leading to enabling where in the significant other tolerates the abuser co dependence is another term Tolerance: gradual increase in amount of stimuli to experience the same euphoria MANAGEMENT Detoxification: withdrawal with medical doctor supervision Avoid alcohol therapy Aversion therapy a more technical term for avoid alcohol therapy Antabuse: Disulfiram makes the client never drink alcohol because it causes vomiting Alcoholics anonymous Interval of 12 hours after last dose of alcohol or experience nausea and vomiting and hypotension Alcoholism may result to Vitamin B1 (Thiamine) deficiency WERNICKE’S ENCEPHALOPATHY Problem with motor KORSAKOFF’S PSYCHOSIS Problem with memory 24 – 72 hours after last dose of alcohol expect: Delirium Tremens: sympathetic nervous system Prevent hallucinations/Illusions by placing client in a well lit room Formication: feeling of bugs crawling under the skin ALZHEIMERS DISEASE - Axon (away) and Dendrites (toward) nerve - Neurofibrillary tangles - Neurotic plaques ALCOHOL/ DELIRIUM ALZHEIMERS ONSET Abrupt Gradual LEVEL OF CONSCIOUSNESS Fluctuating Unaffected DURATION Hours to days Progressive MEMORY Short term memory loss Short term and long term (orient patient) 5 A’s OF ALZHEIMERS 1. Amnesia – memory loss 2. Anomia – don’t know the name 3. Agnosia – sensory problems smell, taste, sight 4. Aphasia EXPRESSIVE: cant say/express Frontal lobe is affected particularly broca’s area RECEPTIVE: cant hear Temporal lobe is affected particularly wernicke’s area 5. Apraxia – can’t do simple things Reminiscing Therapy – talk about past Patients with Alzheimer’s may experience hallucinations, illusions thus becomes restless and may wander As sun goes down client becomes restless, agitated, disoriented called “sundowning” Drug of choice is COGNEX and ARICEPT a cholinesterase inhibitor that increases Ach causing delay in disease progression SEROTONIN Responsible for happiness Decrease serotonin clients becomes sad give anti-depressants SELECTIVE SEROTONIN REUPTAKE INHIBITOR Safest drug Side effects low R I to 4 weeks Increases serotonin and affects only serotonin PROZAC, PAXIL, ZOLOFT TRICYCLIC ANTI DEPRESSANT Two – four weeks C A Has higher incidence of side effects Also increases norepinephrine ASENDIN, NORPRALAMIN, TOFRANIL, SINEQUAN, ANAFRANIL, AVENTYL, VIVACTIL, ELAVIL MONO AMINE OXIDASE INHIBITORS MAO kills serotonin Increased MAO results to decreased serotonin the more depressed the client becomes MAOI kills MAO and increases all neurotransmitters (serotonin, epinephrine, norepinephrine, dopamine but client becomes prone to hypertensive crisis Avoid tyramine rich foods Avocado, Alcohol Beer Chocolates, Cheese (aged) Fermented foods Pickles Preserved foods Soy sauce There is increase incidence of side effects after 2 – 6 weeks MARPLAN, NARDIL, PARNATE PERSONALITY DISORDERS 1. Schizophrenia They avoid people because there is no enjoyment 2. Avoidant They avoid people because they are afraid of criticisms They have talent but has no confidence 3. Anti-Social Constantly breaks law Project charm They are witty and articulate Manipulative 4. Borderline They perceive life as an empty glass They like splitting friends Sudden change in mood “labile affect” Prone to suicide 5. Dependent “Cant live if living is without you” 6. Histrionic Constantly wants to be the center of attention Excited, dramatic, manipulative 7. Narcissistic “I love myself” They get jealous even with achievement of family members 8. Obsessive – Compulsive “I am so organized” 9. Paranoid Suspicious May lead to domestic violence ANTI – DEPRESSANT SIDE EFFECTS MALE – Erectile dysfunction, prone to impotence GRIEF PROCESS [D.A.B.D.A] 1. 2. 3. 4. 5. Denial – shock/disbelief Anger – question “why me?” Bargaining – if, then Depression – 2 weeks or more sign and symptoms becomes major clinical depression Acceptance – client acts according to situation ASSESSMENT Decrease self actualization Decrease self esteem Withdrawn: stay with client Suicidal: risk for self directed violence Increase/decrease eat, increase/decrease sleep, hypoactive, decrease sexual urge Be sensitive to clients needs FOR SUICIDAL OBSERVE FOR Verbal communication “I wont be a problem” “This is my last day on earth” “I’ll soon be gone” Non-verbal communication Giving away of valuables Sudden change in mood WHEN THE CLIENT IS SUICIDAL WHAT WILL THE NURSE DO Direct: “Do you plan to commit suicide?” Irregular/interval visits Endorsement period, EARLY MORNING clients are most likely to commit suicide DOWNERS [A.B.O.N.-M.M.C.H.] Alcohol Marijuana Barbiturate Morphine Opiates Codeine Narcotics Heroine Resulting to: Bradycardia Bradypnea Moist mouth Pupils constrict Constipation Urinary retention Hypotension Coma Weight gain Narcotics overdose: give narcotic antagonist (NARCAN, NALOXONE HYDROCHLORIDE) UPPERS [C.H.A.R.] Cocaine Hallucinogens Amphetamines Resulting to: Tachycardia Awake Tachypnea Dry mouth Pupils dilate Hypertension Seizures Weight loss
