MENTAL HEALTH
⊗ "A state of well-being where a person can realize his or her own abilities to cope
with the normal stresses of life and work productively." (WHO)
⊗ A balance in person’s internal life and adaptation to reality.
⊗ A state of well-being in which a person is able to realize his potentials.
Criteria for Mental Health:
⊗ Self-awareness
♦ Ability to:
recognize one’s thoughts feelings, asset potentials and weakness.
experience genuine feelings as anger, happiness, resentment
♦ Leads to self-acceptance, self-understanding in order to understand others
⊗ Autonomy: ability to function independently and function with others
⊗ Perceptive ability
Awareness of stimuli, reality orientation.
Orientation to: Time, Place, Person
⊗ Integral capacity: Ability to harmonize psychic forces (id, ego, super ego).
⊗ Self-actuation
Ability to adopt to life changes, happy to work with others
Satisfaction in every endeavor
Genuine cooperation
⊗ Mastery of one’s environment: Awareness of the changes around him
MENTAL HYGIENE
⊗ A science that deals with: Promotive, Preventive, Curative, Rehabilitative
aspects of care.
MENTAL DISORDER
⊗ A medically diagnosable illness which results in significant impairment of one's
cognitive, affective or relational abilities and is equivalent to mental illness.
MENTAL ILLNESS
⊗ A state in which an individual shows deficit in functioning and is unable to
maintain personal relationship.
⊗ A state of imbalance characterized by a disturbance in a person’s thoughts,
feelings and behavior
⊗ Factors that increase the risk: Crises, Abuses, Poverty
Psychiatric Nursing: Lecture Aid
© Lester R. L. Lintao
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Criteria for Mental Disorder / Mental Illness:
⊗ Dissatisfaction with:
one’s characteristics, abilities and accomplishments
one’s place in the world
⊗ Ineffective:
interpersonal relationship
coping or adaptation to the events in one’s life
PSYCHIATRIC NURSING
⊗ An interpersonal process
⊗ Concerned with all the aspects of care
⊗ Both a Science and an Art
Science – uses different theories
Art - therapeutic use of self
⊗ Clientele:
Individual, family and the community
Both mentally healthy and mentally ill
Main tool of the nurse: Therapeutic use of self
Characteristics of a Good Psychiatric Nurse:
⊗ Empathy
⊗ Genuineness
⊗ Congruence
⊗ Unconditional positive regard
THE PSYCHIATRIC SETTING
Admitting a Client in the Psychiatric Setting
Areas to be assessed:
⊗ Health perception
⊗ Orientation
⊗ Metabolic pattern
⊗ Elimination pattern
⊗
⊗
⊗
⊗
Cognitive pattern: Judgment, Insight, Memory
Activity and exercise pattern
Thought process
Sleep-rest pattern
Psychiatric Nursing: Lecture Aid
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COMMON BEHAVIORAL SIGNS AND SYMPTOMS
Disturbance in Perception
⊗ Illusion - misperception of an actual external stimuli
⊗ Hallucination - false sensory perception in the absence of external stimuli
Management:
⊗ Acknowledge the feelings
⊗ Reorient to reality
⊗ Provide distractions
⊗
⊗
⊗
⊗
⊗
⊗
⊗
⊗
⊗
⊗
⊗
Neologism - pathological coining of new words
Circumstantiality - excessive inclusion of details
Word salad - incoherent mixture of words and phrases
Flight of ideas - shifting of one topic from one subject to another in a somewhat
related way
Looseness of Association - shifting of a topic from one subject to another in a
completely unrelated way
Verbigeration - meaningless repetition of word or phrases
Perseveration - persistence of a response to a previous question
Echolalia - pathological repetition of words of others
Stilted language – use of flowery words
Clang association - the sound of the word gives direction to the flow of thought
Delusion – fixed, false belief which cannot be corrected by appeal or logical
reasoning
Grandeur - an exaggerated belief of identity
Nihilistic - the client denies the existence of self or part of self
Persecution - belief that he or she is the object of environmental
attention and being singled out for harassment
Self-depreciation - worthlessness or hopelessness
Somatic - false belief to body function
Disturbances of Affect
⊗ Inappropriate affect - disharmony between the stimuli and the emotional
reaction
⊗ Blunted affect - severe reduction in emotional reaction
⊗ Flat affect - absence or near absence of emotional reaction
⊗ Apathy - dulled emotional tone
⊗ Lability of affect – rapid “mood swings”
Psychiatric Nursing: Lecture Aid
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Disturbances in Motor Activity
⊗ Echopraxia - the pathological imitation of posture/action of others
⊗ Waxy flexibility - maintaining the desired position for long periods of time
without discomfort
⊗ Akinesia - loss of movement
⊗ Bradykinesia - slowness of all voluntary movement including speech
⊗ Ataxia - loss of coordinated movement
⊗ Automatism - repeated purposeless behavior
Disturbances in Memory
⊗ Confabulation - filling in of memory gaps
⊗ Amnesia - inability to recall past events
• Anterograde - immediate past
• Retrograde - distant past
⊗ Déjà vu - a subjective feeling that an experience which is occurring for
the first time has been experienced before
⊗ Jamais vu – a feeling that the familiar does not seem familiar
⊗ Dementia
• gradual deterioration of intellectual functioning
• results in decreased capacity to perform ADL
Other behavioral signs & symptoms
⊗ Agitation – a state of anxiety associated with motor restlessness
⊗ Agnosia - inability to recognize and interpret sensory stimuli
⊗ Akathisia - a feeling of muscular quivering, an urge to move about constantly
and an inability to sit still
⊗ Ambivalence - presence of two opposing feelings at the same time
⊗ Delirium - refers to acute change or disturbance in a person's: LOC, cognition,
emotion , perception
⊗ Derealization - feeling of strangeness towards the environment
⊗ Dysthymia - persistent state of sadness
⊗ Elation (euphoria)- feeling of expression of excitement
⊗ Mutism – refusal to speak
⊗ Narcolepsy - sleep disorder characterized by frequent irresistible urge to sleep
with episodes of cataplexy (sudden loss of muscle power)
⊗ Insomnia – inability to attain enough sleep
⊗ Hypersomnia – excessive sleep
⊗ Parasomnia – abnormal sleep behavior
Psychiatric Nursing: Lecture Aid
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USE OF APPROPRIATE COMMUNICATION TECHNIQUES
Communication: reciprocal exchange of ideas between or among persons
Modes:
⊗ Verbal - written/spoken
⊗ Non-verbal - posture, tone of voice, facial expression
Types of Non-verbal communication:
⊗ Kinesis
• body movement
• eye contact
• gestures
⊗ Paralanguage
• voice quality
• non-language vocalization (crying, sobbing, moaning)
⊗ Proxemics – law of space relationship
⊗ Touch – physical act
⊗ Cultural artifacts
⊗ Meta communication
• based on role expectations
• hidden meaning of words
Elements:
FEEDBACK
g
Messa
e
(Channel)
(Context)
Therapeutic Communication: a way of interacting in a purposeful manner to
promote the client’s ability to express his / her thoughts and feelings openly.
Essentials for a Therapeutic Communication:
⊗ Genuineness
E
GR A T
⊗ Respect
⊗ Empathy
⊗ Attentive listening
⊗ Trust (rapport)
Psychiatric Nursing: Lecture Aid
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5
Barriers to Therapeutic Communication
⊗ Belittling
⊗ Interrupting / ignoring
⊗ Giving advice
⊗ Social response
⊗ Changing the subject
⊗ Approving / disapproving
⊗ Moralizing
NURSE – PATIENT RELATIONSHIP
Hildegard Peplau
Phase
Anxiety Tasks
Pre-Interaction Phase Nurse ⊗ Major task: develop self-awareness
⊗ begins when the
⊗ includes all of what the nurse thinks and does
nurse is
before interacting with the patient
assigned/chooses a
⊗ data gathering, planning for first interaction
patient
⊗ patient is excluded
as
an
active
participant
Orientation phase
Patient ⊗ Major task: establish trust and rapport
⊗ when the nurse⊗ conduct initial interview
patient
interacts
⊗ establish contract with the patient
for the first time
⊗ learn about the patient and his initial concerns
and needs
⊗ encourage the patient to feel comfortable
with the meeting
⊗ manage present emotions of the patient
⊗ provide support and empathy of the patient’s
feelings
⊗ assure confidentiality
Psychiatric Nursing: Lecture Aid
© Lester R. L. Lintao
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Phase
Anxiety Tasks
Working /
None ⊗ Major task: identification and resolution of the
Therapeutic Phase
patient's problems
⊗ it
is
highly
⊗ planning and implementation
individualized
Teach
⊗ more
structured
Learn
than
the
Change
orientation phase
⊗ the longest and
most
productive
Problems:
phase
⊗ Transference
⊗ limit setting must
the development of an emotional
be employed
attitude towards the nurse
positive or negative
⊗ Counter transference – experienced by the
nurse / therapist
Termination Phase
Patient ⊗ Reinforce and reward change and strength of
patient
⊗ Encourage expression of feelings about
termination of the relationship
⊗ Summarize the progress
⊗ Terminate the relationship without giving
promises
THEORIES OF HUMAN DYNAMICS
Psychosexual Development: Sigmund Freud
Levels of Consciousness and the Psychic Forces
Psychiatric Nursing: Lecture Aid
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Ego
(Reality)
Superego
(Moral)
Id
(Pleasure)
Neurosis
Psychosis
⊗ Libido - the instinctual drives
⊗ Regression and fixation are common terms in this theory.
⊗ Gave prominence to sexual feelings: defined "sex" as anything that gives
gratification
Stages:
Oral Stage (0-2 years)
⊗ The area of gratification is the mouth
⊗ Pleasures: sucking activities like fingers, toes or nipples
⊗ Dissatisfaction: resurface at a later age
overeating, smoking, nail-biting
Nursing Implication:
⊗ Provide oral stimulation by giving pacifiers
Breastfeeding may provide more stimulation
⊗ Do not discourage thumb sucking
Anal Stage (2-4 years)
⊗ Children's attention is focused on the anal region.
⊗ Pleasure: elimination
⊗ Covers the ideal age for "toilet training" (2 1/2 years)
⊗ 2 concepts:
Holding on
Letting go
Psychiatric Nursing: Lecture Aid
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Possible problems:
⊗ Compulsive need to be clean and orderly
⊗ Frugality and stinginess
⊗ Greed
⊗ Insistence on doing things at one's own rate at the expense of others
⊗ Rigid training
⊗ Excessive messiness and disorderly habits
Nursing Implication: Help children achieve bowel and bladder control without
undue emphasis on its importance.
Phallic Stage (4-6 years)
⊗ Pleasure: genital region
activities associated with stroking and manipulating their sex organs
⊗ Oedipus complex
⊗ Electra complex
⊗ Concept:
Onset of “normal homosexuality”
Nursing implications:
⊗ Accept child's sexual interest
⊗ Help the parents answer child's questions about birth or sexual differences
Latency Stage (6 to 12 years)
⊗ Period of calmness / stable period.
⊗ Many of the disturbing behaviors are buried in the subconscious mind
⊗ Their energies are absorbed by the concerns in school, peers, sports and other
recreational activities
Nursing Implication: Help the child have positive experiences
Genital Stage (12 years & up)
⊗ Oedipal feelings are reactivated toward opposite sex
⊗ The person is on his/her way in establishing a satisfying life of his/her own
Nursing Implication:
⊗ Provide appropriate opportunities for the child to relate with opposite sex
⊗ Allow child to verbalize feelings about new relationships
Psychiatric Nursing: Lecture Aid
© Lester R. L. Lintao
9
Psychosocial Development Theory: Erik Erikson
⊗ Childhood is very important in personality development.
⊗ Rejected Freud's attempt to describe personality solely on the basis of sexuality
believed that social factors greatly affect
felt that personality continued to develop beyond five years of age.
Period of Life
Infant
0-18 months
(Hope)
Trust
vs. Mistrust
Toddler
18 mos. to 3
years
(Willpower)
Primary
Person
Maternal
person
Paternal
person
Autonomy vs.
Shame/Doubt
Preschool
3 to 6 years
(Purpose)
Family
Positive Resolution
Negative Resolution
o Reliance on the
caregiver
o Development of trust
in the environment
o Fear, anxiety and
suspicion
o Lack of care, both
physical & psychological
by caretaker leads to
mistrust of environment
o Loss of self-esteem
o Sense of external
control may produce
self-doubt in others
o Sense of self-worth
o Assertion of choice
and will
o Environment
encourages
independence,
leading to sense of
pride
o The ability to learn to
initiate activities, to
enjoy achievement
and competence
Initiative vs.
Guilt
Schooler
Neighbors/ o Learning the value of
6 to 12 yrs.
School
work
(Competence)
o Acquiring skills and
tools of technology
Industry vs.
o Competence helps to
Inferiority
order life and make
things work
Adolescent Peer group o Experiments with
12 to 18 yrs,
various roles in
(Fidelity)
developing mature
individuality
Identity vs.
Role
confusion
Psychiatric Nursing: Lecture Aid
o The inability to control
newly developed power
o Realization of potential
failure leads to fear of
punishment and guilt
o Repeated frustrations
and failures lead to
feelings of inadequacy
and inferiority that may
affect their view of life
o Pressures and demands
may lead to confusion
about self
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Period of
Primary
Positive Resolution
Life
Person
Young Adult Partners o A commitment to
in
18 to 24 yrs.
others
(Love)
friendship o Close heterosexual
relationship and
Intimacy vs.
procreation
Isolation
Middle
Partner o The care and concern
Adult
for the next
24 to 54
generation
yrs.
o Widening interest in
(Care)
work and ideas
Generativity
vs. Selfabsorption
Late Adult,
54 yrs. to
death,
(Wisdom)
Integrity vs.
Despair
Mankind o Acceptance of one’s
life
o Realization of the
inevitability of death
o Feeling of dignity and
meaning of existence
Negative Resolution
o Withdrawal from such
intimacy, isolation, selfabsorption and alienation
from others
o Self-indulgence and
resulting psychological
impoverishment
o Disappointment of one’s
life and desperate fear of
death
Cognitive Development Theory: Jean Piaget
Stages:
Sensorimotor (0-2 years)
⊗ Reflex to complex
⊗ Begins to organize visual images and control motor responses
⊗ Coordinates sensory impressions
⊗ Pre-verbal stage
Preoperational Stage (2-7 years)
⊗ Transitional period
⊗ Egocentric and irreversible thinking
⊗ Words become symbols for objects – symbolic thinking
⊗ Formation of ideas of categorization
⊗ Lack of ability to go back and rethink a process or concept.
⊗ Mental image – the symbolic process which are evident in plays
⊗ Construction of verbal schemas – preconcepts
Psychiatric Nursing: Lecture Aid
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Concrete Operations (7 – 11 years)
⊗ Thinking appears to be stabilized
o ability to think of the possible consequences of actions
⊗ Logical implications
Formal Operations
(11 years to adulthood)
⊗ Full patterns of thinking
⊗ Ability to use logic and symbolic processes
o mathematical and scientific reasoning
⊗ Combinatorial thinking - multidimensional approach
o hypothetic or hypothetico-deductive reasoning
Moral Development Theory: Laurence Kohlberg
Level One
(Preconventional
Morality)
• Children’s judgments
are based on external
criteria.
• Standards of right and
wrong are absolute and
laid down by authority.
Level Two (Conventional
Morality)
• Children’s judgments
are based on the norms
and expectations of the
group.
Stage 1
• Behavior is based on the desire to avoid severe
physical punishment by a superior power.
• Right or wrong is based on consequences to him.
• Punishment = wrong act
Stage 2
• Actions are based largely on satisfying one’s own
personal needs.
Stage 3
• Good behavior is that which pleases others and
judgments are based on intentions.
• Children conform to rules to win the approval of
others and to maintain good relationships.
Stage 4
• What is right is what is accepted.
Psychiatric Nursing: Lecture Aid
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Level Three
(Post Conventional
Morality)
• The individual
recognizes the
arbitrariness of social
and legal conventions.
• The individual attempts
to define moral values
that are separate from
group norms.
Stage 5
• Behavior recognizes the laws as arbitrary and
changeable.
• For aspects of life not governed by laws, right and
wrong are personal decisions based on agreement
and contracts.
Stage 6
• Morality is based on respect for others rather than
on personal desires.
• The individual conforms to both social standards
and to internalized ideals to avoid selfcondemnation rather than to avoid social censure.
Other Theories
Behavioral Model (Ivan Pavlov, John Watson, B. F. Skinner)
⊗ Behavior is:
• a response to a stimulus from the environment
• learned and retained by positive reinforcement
Interpersonal Model (Harry Stack Sullivan)
⊗ Focused on the role of the environment and interpersonal relations as the most
significant influences on a individual’s development
⊗ Anxiety is communicated interpersonally
Human Motivational Need Model. (Abraham Maslow)
⊗ Hierarchy of needs in order of importance
⊗ Primary needs (physiologic) need to be met prior to dealing with higher level
needs
Psychobiologic Model
⊗ Focus is in mental illness as a biophysical impairment.
⊗ Human behavior is influenced by genetics, biochemical alterations and function
of brain and CNS.
⊗ The stress response is a neuroendocrine response
PSYCHOTHERAPY
⊗ A process in which a person enters into a contract to interact with a therapist to
relieve symptoms, resolve problems in living and seek personal growth
Psychiatric Nursing: Lecture Aid
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INDIVIDUAL THERAPY: Is a confidential relationship between client and therapist.
⊗ Hypnotherapy: Involves various methods and techniques to induce a trance
state where the patient becomes submissive to instructions
⊗ Humor therapy: Use of humor to facilitate expression of feelings and to
enhance interaction
⊗ Psychoanalysis: Focuses on the exploration of the unconscious, to facilitate
identification of the patient's defenses
GROUP THERAPY
• minimum number : 3
• Ideal number :8-10
Advantages:
• decreases
o isolation
o dependence
• develops
o coping skills
o interpersonal learning
o opportunities for helping others
o ability to listen to other members
⊗ Remotivation Therapy: Promotes expression of feeling through interaction
facilitated by discussion of neutral topics
⊗ Family therapy: A method in which family members gain:
o insight into the problems
o improve communication
o improve functioning of individual members as well as the family as a
whole.
o It focuses on the total family as an interactional system
⊗ Milieu Therapy
• A therapeutic environment is organized to:
o encourage and assist the client to control problematic behavior
o function within the range of social norms
⊗ Play therapy
• Effective for children suffering from maladjustment or behavior disorder.
• The child is usually placed in a play room
• Purpose - to discover the causes of the child's conflict through observation of
his play and to interpret it to the child.
Psychiatric Nursing: Lecture Aid
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⊗ Recreational therapy
• Uses activities which vitalize the patient's interest and help him / her to relax
and feel refreshed.
• Example: Playing baseball may be prescribed for as a means of expressing
hostility in a group.
⊗ Occupational therapy: Uses any mental or physical activity prescribed or guided
to aid an individual's recovery from a disease or injury.
⊗ Musical therapy
• Involves music which allows the child or adolescent to express herself or
himself.
• Also effective with those who have difficulty communicating.
⊗ Art therapy: Clients are encouraged to express their feelings or emotions by
painting, drawing or sculpture.
⊗ Psychodrama therapy: Patients dramatizes their emotional problems in a group
setting.
BEHAVIOR MODIFICATION THERAPY
• A mode of treatment that focuses on modifying observable (overt) and
quantifiable behavior
• Systematic manipulation of the environment and variables thought to be
functionally related to the behaviors.
• Limit Setting
o Therapist gives an advanced warning of the limit and the consequences
will follow if the client does not adhere to the limit.
o The consequences should occur immediately after the client has exceeded
the limit
o Consistency must occur with all personnel.
o Purposes:
o Minimizes manipulation and splitting of the staff.
o Provides a framework for the client to function in and enable a client
to learn to make requests.
• Systematic Desensitization
o Clients are exposed slowly to a feared object or a thing that inhibits
anxious responses and taught ways to relax.
o Effective in treating phobias.
Psychiatric Nursing: Lecture Aid
© Lester R. L. Lintao
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• Implosive therapy
o The clients are exposed abruptly to intense forms of anxiety producers,
either in imagination or in real life
• Cognitive Behavior therapy
o Uses confrontation as a means of helping the clients restructure or
rearrange irrational beliefs, maladaptive thinking, perception-, and
behaviors.
o Used for depression and adjustment difficulties.
• Biofeedback
o Teaches the clients to control or change aspects of their internal
environment.
• Aversion therapy
o Uses unpleasant or noxious stimuli to change inappropriate behavior.
o Examples
o Antabuse to treat alcoholics
• Assertiveness Training
o Clients are encouraged and taught how to appropriately relate to others
• Token-economy: Utilizes the principle of rewarding desired behavior to
facilitate change.
ELECTROCONVULSIVE THERAPY (ECT)
• Exact mechanism is unknown
• Requires a consent
Voltage :
Length
:
Frequency :
Interval :
Indicator :
70-150 volts
.5-2 seconds
6-12 treatments
48 hours
tonic-clonic seizure
Indications of use:
• Depression
• Mania
Contraindications:
• Fever
• Increased ICP
• Cardiac conditions
• TB with history of hemorrhage
Psychiatric Nursing: Lecture Aid
• Catatonic schizophrenia
•
•
•
•
Unhealed fracture
Retinal detachment
Pregnancy
Osteoporosis
© Lester R. L. Lintao
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Before the procedure:
• Take vital signs
• Diagnostic procedures
o X-ray
o ECG
o EEG
• Drugs given
o Atropine sulfate (decrease secretions)
o Anectine (Succinylcholine) (relax muscles)
o Methohexital Na (Brevital) (anesthetic)
During the procedure:
• Observe for tonic-clonic seizure
• Priority: Airway
After the procedure:
• Position
• Check vital signs
• Reorient the client
• Watch out for complications:
o Memory loss
o Headache
o Apnea
o Respiratory depression
o Fracture
BASIC CONCEPTS ON PSYCHOPHARMACOLOGY
MAJOR TRANQUILIZERS/ ANTIPSYCHOTICS
⊗ Indication: Schizophrenia and Other Psychosis
⊗ Desired effect: control of symptoms
⊗ Best taken after meals
⊗ MOA: Block selected dopamine receptors decrease dopamine reduce
symptoms
Types
Examples
Disadvantages
•
•
•
•
•
Typical
Haloperidol
Mellaril
Thorazine
EPS
Treats (+)
symptoms only
Psychiatric Nursing: Lecture Aid
Atypical
•
•
•
•
•
•
Risperdal
Seroquel
Clozaril
Expensive
Less available
More agranulocytosis
© Lester R. L. Lintao
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Advantages
• Cheaper
• Less or no EPS
• More available • For both (-) & (+) symptoms
Before 1990’s
After 1990’s
Side effects
Blurred vision
Dry mouth
Tachycardia, palpitation,
constipation, urinary retention
Side effects
Photosensitivity
Orthostatic hypotension
Extra Pyramidal Symptoms
o Pseudoparkinsonism
o pill-rolling tremors
mask-like face
o cog-wheel rigidity
o propulsive gait
o Akathisia - restless leg
syndrome
o Dystonia - defect in muscle
tone
Side effects
Neuroleptic Malignant
Syndrome (NMS)
• Muscle rigidity + high
grade fever
Nursing Action
Avoid driving
Give sugarless gum
Monitor & report
Nursing Action
Don’t expose skin to sunlight
Monitor BP
Advise gradual change in position
Discontinue the next dose
Report at once
Give antidote:
Anticholinergics
• Akineton
• Artane
• Benadryl
• Cogentin
Dopaminergics: L- Dopa
• Espequel
• Sporadel
Nursing Action
Withhold the next dose
Notify the physician
Cooling measures
Adverse effect: report promptly
• Tardive dyskinesia - lip smacking
• Agranulocytosis
o Assess for:
Fever
Sore throat
Lab data: WBC count
• Hepatotoxicity
o Assess for ALT & AST
Psychiatric Nursing: Lecture Aid
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MINOR TRANQUILIZERS/ ANXIOLYTICS
⊗ Common indication: Anxiety disorders
⊗ Desired Effect: Decreased anxiety, adequate sleep
⊗ Have sedative effects
Examples: (XL VASET)
Xanax (Alprazolam)
Librium (Chlordiazepoxide )
Valium (Diazepam)
Ativan (Lorazepam)
Serax (Oxazepam)
Esquanile
Tranxene (Chlorazepate Dipotassium)
Nursing Implications:
• Best taken before meals
• Advise to avoid driving
• Administer it separately with any drug
Anxiolytics +
• Alcohol = severe hypotension / hypersedation
• Another anxiolytic = respiratory depression death
• Other drugs = CNS depression
• Stimulants = less effective
ANTIDEPRESSANTS
Desired effects: increased appetite, adequate sleep
Tricyclic Antidepressants
Examples:
• Imipramine (Tofranil)
• Amitriptyline (Elavil)
Nursing Implications:
⊗ Best given after meals
⊗ Effectivity: after 2-3 weeks
⊗ Check the BP, it causes hypotension
⊗ Check the heart rate, it causes cardiac arrythmias
⊗ Monitor I & O
⊗ Monitor for signs of increased IOP
Psychiatric Nursing: Lecture Aid
© Lester R. L. Lintao
19
MAO INHIBITORS
Indication: refractory depression
Examples:
• Tranylcypromine (Parnate)
• Phenelzine (Nardil)
• Isocarboxazid (Marplan)
PaNaMa
Nursing Implications:
⊗ Best taken after meals
⊗ Report headache; it indicates hypertensive crisis
⊗ Avoid tyramine containing foods like:
• Avocado
• Banana
• Cheddar and aged cheese
• Soysauce
• Preserved foods
⊗ Effectivity: 2-3 weeks
⊗ Monitor the BP
⊗ There should be at least a two-week interval when shifting from one antidepressant to another
Selective Serotonin Reuptake Inhibitors
• Fluoxetine (Prozac)
• Paroxetine (Paxil)
• Fluvoxamine (Luvox)
• Celatopram (Celexa)
• Sertraline (Zoloft)
Nursing Implications:
⊗ Avoid the use of:
• Diazepam
• Tryptophan
• Alcohol
⊗ Monitor PTT, PT
⊗ Never give to pregnant / lactating mothers.
ANTI-MANIC AGENT
Examples:
• Lithium Citrate (Cibalith
– S)
• Lithium Carbonate (Eskalith, Lithane,
Lithobid)
Psychiatric Nursing: Lecture Aid
© Lester R. L. Lintao
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Nursing implications:
⊗ Never give to pregnant mothers
⊗ Best taken after meals
⊗ Increase intake of:
• fluids (3 L /day)
• sodium (3 gm/day)
⊗ Avoid activities that increase perspiration
⊗ Effectivity: 10-14 days
⊗ Antipsychotic is administered during the first 2 weeks
Level (mEq/L)
Status
.5 – 1.5
Therapeutic
1.6
S/Sx
Abnormal
Vomiting
Anorexia
Nausea
Diarrhea
Abdominal cramps
2.0 and above Fatally toxic Lethargy (Altered
LOC)
1.7 – 1.9
Toxic
Nursing Interventions
Monitor
Increase sodium & fluid
intake
D/C next dose
Report
*IV NSS
D/C next dose
Report
*MANNITOL (antidote)
D/C next dose
Report
*Dialysis
STRESS
• A nonspecific response of the body to any demand made upon it. (Hans Selye,
1936)
• A state produced by a change in the environment that is perceived as
challenging, threatening or damaging to the person’s dynamic equilibrium.
(Smeltzer, 1992)
Adaptation
• A constant ongoing process that occurs along time continuum, beginning with
birth and ending with death. (Smeltzer, 1992)
• A continuous process of seeking harmony in an environment.
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Types of Adaptation:
General Adaptation Syndrome (GAS)
• Involves the whole body in response to stress.
• Compared to life process as it focuses on the “wear and tear of the body
tissues.”
Phases:
• Alarm
o Acute phase of the syndrome
o Characterized as the “flight and fight” reaction
o Defensive by nature but self-limiting
o If stress is intense, it may lead to death
• Resistance
o Characterized as the state of adaptation
o Person moves back to homeostasis
• Exhaustion
o Result of a prolonged exposure to stress and adaptive mechanisms can no
longer persist.
Local Adaptation Syndrome
• Refers to inflammatory response and repair processes that occur at the local
site of tissue injury.
Eustress - positive stress
Distress - negative stress and damaging stress
CRISIS AND CRISIS INTERVENTION
• A situation that occurs when an individual's habitual coping ability becomes
ineffective to meet the demands of a situation.
• A serious interruption and disturbance of one's equilibrium or homeostasis
• Leads to potentially dangerous, self-destructive or socially unacceptable
behavior.
Characteristics
• Highly-individualized
• Self-limiting: 4-6 weeks
• Person affected becomes passive and submissive
• Affects a person’s support system
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Type
Maturational /
Developmental
Situational /
Accidental
Description
expected,
predictable and
internally
motivated
Unexpected,
unpredictable and
externally
motivated
Social / Adventitious Due to acts of
nature
Example
Puberty, adolescence, young
adulthood, marriage, or the aging
process.
Economic difficulty, illness, accident,
rape, divorce or death
Natural calamities
Phases
DENIAL
INCREASED
TENSION
DISORGANIZATION
REORGANIZATION
FULL
REORGANIZATION
CRISIS INTERVENTION
• Major Goal: Restore the maximum level of functioning (pre-crisis state)
• It is an active but temporary entry into the life situation of an individual or a
family during a period of stress.
• A way of entering into the situation to help them mobilize their resources and
to decrease the effect of stress.
Domestic Violence Requiring Crisis Intervention:
RAPE
• Nonconsensual sexual penetration of an individual, obtained by force or threat,
or in cases in which the victim is not capable of consent.
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Kinds of Rape
• Power – to prove masculinity
• Anger – means of retaliation
• Sadistic – to express erotic feelings
Silent Rape Syndrome
• A maladaptive reaction to rape
• The victim:
o fails to disclose information about the rape
o is unable to resolve feelings about the sexual assault
o Results to increase anxiety and may develop a sudden phobic reaction.
Rape Trauma Syndrome (RTS)
• Refers to a group of signs and symptoms experienced by a victim in reaction to
rape
Phases:
• Acute / Impact – shock, numbness, disbelief
• Repression / Denial – refusal to discuss the event
• Heightened Anxiety – fear, tension, nightmares
• Stage of Resolution
BATTERED WIFE SYNDROME (BWS)
• A form of cyclic domestic violence
• Men: low self-esteem
• Women: Dependent personality disorder
(taken from the book of Shiela Videbeck)
Characteristics of Abusive Husbands:
• They usually come from violent families
• They are immature, dependent and non-assertive
• They have strong feelings of inadequacy
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CHILD ABUSE
• An act of omission of responsibility or commission in which intentional harm is
inflicted on a child.
Components of Omission:
• Child abandonment – leaving the child physically
• Child neglect - lack of provision of those things which are necessary for the
child's growth and development
Types of Commission:
Physical Abuse - is an intentional physical harm inflicted on a child by a parent or
other person.
Emotional abuse - insult and undermining one's confidence
Sexual abuse - in the form of sexual contact
Characteristics of Abusive Parents:
• They come from violent families
• They were also abused by their parents
• They have inadequate parenting skills
• They are socially isolated because they don't trust anyone
• They are emotionally immature
• They have negative attitude towards the management of the abused
Warning signs of Child Abuse / Neglect:
• Child’s excessive knowledge on sex and abusive words
• Hair growth in various lengths
• Inconsistent stories from the child and parent/s
• Low self-esteem
• Depression
•
•
•
•
•
Apathy
Bruised or swollen genitalia; tears or bruising of rectum or vagina
Unusual injuries for the child’s age and development
Serious injuries (fractures, burns, lacerations)
Evidence of old injuries not reported
Assessment, Planning and Nursing Actions for Crisis
• Primary concerns:
o Physical injuries
o Alleviation of psychological trauma
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• Nurse should display:
o Sensitivity
o Attitude (Nonjudgmental)
o Confidentiality
o Respect
o Empathy
o Dignity
• Evidences are important:
o stained clothing
o fingernail scrapings
o mouth or anal smears containing semen
• Intervention focuses on family as a unit
• If the victim is a child: Play and art therapy
DEFENSE MECHANISM
• These are automatic and usually unconscious processes or act by the individuals
to:
o reduce or cope anxiety or fear
o resolve emotional or mental conflict
o protect one's self-esteem
o protect one's sense of security
• Becomes pathologic when overused
• Used by both mentally healthy and mentally-ill individuals
Common Defense Mechanisms Used:
• Compensation
o An attempt to overcome a real or imagined short coming, inferiority,
inabilities and weaknesses.
o A blind woman becomes proficient in playing piano.
• Conversion
o Emotional problems are converted to physical symptoms
o A student unprepared for a report suffered headache the day she is supposed
to deliver her report.
• Denial
o Failure to acknowledge an intolerable thought, feeling, experience or reality
o After being admitted to the CCU because of an AMI, a middle-aged man
insists that he is in the hospital for just a diagnostic work-up.
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• Displacement
o The redirection of feelings to a less threatening object
o After an argument with his father, a boy goes to the room and kicked his
door.
• Fantasy
o Conscious distortion of unconscious feelings or wishes
o A boy who is being bullied by his friends wished he had the power of
Wolverine.
• Fixation
o An unhealthy mechanism which is an arrest of maturation at certain stages of
development
• Introjection
o Symbolic assimilation or taking into oneself a love/hatred object. Derived
from the word "introject" which literally means to take into or ingest
o Common to depressed clients
o “Self-blaming”
• Identification
o An individual integrates certain aspects of someone else's personality into
one's own
o A young school teacher adopts his former mentor's teaching style when
conducting class sessions
• Intellectualization
o An overuse of intellectual concepts by an individual to avoid expression of
feelings
o A man who was asked to share a memorable experience about his
grandmother who died discussed the stages of death and dying by Elizabeth
Kubler Ross.
• Projection
o Attributing to others one's unconscious wishes/fears
o Literally, this means to "throw off” or to blame others
o A student who failed a subject blames his failure on poor teaching.
• Reaction – Formation (AKA overcompensation)
o Expression of feeling that is the direct opposite of one's real feeling.
o A student who dislikes one of her classmates may act or show concern
toward her.
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• Rationalization
o An individual finds a justifiable cause and acceptable reasons just to be saved
from an embarrassing and anxiety producing thoughts or situations.
• Regression
o The turning back to earlier patterns of behavior in solving personal conflicts
o Commonly seen to schizophrenic patients
o A person who becomes ill in the face of disappointment has regressed to a
form of childish behavior.
• Repression
o The involuntary or unconscious forgetting of unpleasant ideas or impulses.
• Suppression
o Permits the individual to store away or consciously forget the unpleasant,
painful and unacceptable thoughts, desires, experiences and impulses.
o "I'll think it about tomorrow", "I'd rather go now", "Can we change the
topic?"
o A boy walked out from the group and said "I have to go now", when he was
asked what happened to their relationship with his girlfriend.
• Substitution
o Replacing the desired unattainable goal with one that is attainable
o After failing the board exam 3 times, a woman worked as a nursing aide just
to be in the hospital.
• Sublimation
o The redirection of unacceptable instinctual drive with one that is socially
acceptable
o Instead of harming his mother, a man expressed his anger by composing a
song.
• Symbolization
o A less threatening object is used to represent another
o Missing her husband, a woman finds comfort in hugging her son who looks
like his father.
• Undoing
o An attempt to erase an act, thought, feeling, guilt or desire
o A man gives his wife a bunch of roses after their argument last night.
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ANXIETY
⊗ Subjective response to stress
⊗ Vague sense of impending doom
⊗ An
unpleasant
emotional
state
consisting
of
psychophysiological responses to anticipation of unreal or
imagined danger, resulting from unrecognized intrapsychic
conflict.
Signs and symptoms:
Physical
Mild
⊗ Increase in VS
⊗ Pupillary
dilatation
⊗ Diaphoresis
Physical
Moderate ⊗ Anorexia
⊗ Nausea
⊗ Vomiting
⊗ Agitation
⊗ Diarrhea /
constipation
Severe
⊗ Headache
⊗ Inability to
communicate
⊗ Physical
symptoms
becomes the
focus of attention
Panic
⊗ Fatigue
⊗ Muscular
weakness
Cognitive
Emotional
⊗ Increased
⊗ Minimal use of defense
attentiveness and
mechanism
alertness
Cognitive
Emotional
⊗ Decreased
⊗ Use of defense
perceptive ability
mechanism
⊗ Perceptive ability ⊗ Defense mechanisms
is greatly
operate
decreased
⊗ Inability to focus
on major events
⊗ Personality
disorganization
⊗ Defense mechanism
fail
Nursing Diagnoses:
⊗ Ineffective individual coping
⊗ Anxiety
Nursing Management:
⊗ Prioritize safety
⊗ Encourage the client to verbalize feelings
⊗ Administer medications, as ordered
⊗ Carefully listen to the client
⊗ Environmental stimuli must be controlled
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ANXIETY DISORDERS
Panic Disorder
⊗ A sudden surge of overwhelming anxiety and fear
⊗ May include terror, sense of unreality or fear of loosing control
⊗ Attack: 1 minute to 1 hour
Phobic Disorder
⊗ Phobia is an irrational, unrealistic or exaggerated fear of a specific object,
activity, or situation that in reality presents little or no danger.
Examples:
⊗ Acrophobia – heights
⊗ Agoraphobia - open places and of being alone in public places
⊗ Algophobia – pain
⊗ Arachnophobia - spiders (arachnoids)
⊗ Claustrophobia - enclosed place
⊗ Monophobia - being alone
⊗ Pathophobia – disease
⊗ Social phobia - criticism, humiliation or embarrassment.
⊗ Thanatophobia - crowds
Generalized Anxiety Disorder (GAD)
⊗ Involves anxiety and worry that is excessive and unrelenting.
⊗ May alter ADL
⊗ Clients may experience: fatigue, irritability, restlessness, muscle tension, sleep
disturbance
Obsessive Compulsive Disorder
⊗ An anxiety disorder characterized by uncontrollable, unwanted thoughts and
repetitive, ritualized behaviors.
Post-Traumatic Stress Disorder (PTSD)
⊗ A delayed reaction of the person who has been involved or exposed to
traumatic events.
⊗ Symptoms:
intense psychological distress
feeling of detachment or estrangement from others
insomnia
decreased concentration
avoidance of thoughts and feelings
recurrent distressing dreams
inability to recall an important aspect of the trauma
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Nursing Interventions
⊗ Modify environment – safe
⊗ Approach: kind-firmness
⊗ Nonjudgmental and calm attitude
⊗ Allow agreeable time for rituals
⊗ Give medications as ordered
⊗ Execute therapeutic modalities - biofeedback, change of the scenery,
therapeutic touch, hypnosis, massage or relaxation exercises
⊗ Desensitization
ANXIETY RELATED DISORDERS
Somatoform Disorders (Briquet’s Syndrome)
⊗ Characterized by physical symptoms that mimic disease or injury for which
there is no identifiable physical cause
⊗ Clients:
express emotional turmoil or conflict through physical symptoms
usually seek repeated medical attention
⊗ Associated with anxiety and depression
Somatization Disorder (Briquet’s Disease)
⊗ A disorder applied to patients who chronically and persistently complain of
varied physical symptoms that have no identifiable physical origin
Conversion Disorder
⊗ A condition in which an anxiety-provoking impulse is converted unconsciously
into functional symptoms.
⊗ Classic feature: Labelle indifference (lack of concern or distress)
⊗ Examples: Paralysis, blindness, loss of touch or pain sensation, dyspnea,
seizures or convulsions
Hypochondriasis
⊗ An individual presents an unrealistic or exaggerated physical complaints.
⊗ The person becomes, preoccupied with the fear of developing or having already
a disease or illness in spite of medical reassurance.
Body Dysmorphic Disorder
⊗ Preoccupation with an imagined defect in his or her appearance.
⊗ Slight physical abnormality = excessive concern / anxiety
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Dissociative Disorders
⊗ Conditions that involve disruptions or breakdowns of memory, awareness,
identity and/or perception
Dissociative Amnesia
⊗ Inability to recall extensive amount of important information
⊗ Caused by trauma
⊗ Characterized by:
Disorientation
Purposeless wandering
Impairment in ability to perform ADL
⊗ Rapid recovery generally occur
Depersonalization Disorder
⊗ Periods of detachment from self or surrounding which may be experienced as
"unreal" while retaining awareness that this is only a feeling and not a reality
Dissociative Identity Disorder
⊗ Occurrence of two or more personalities within the same individual, each of
which during sometime in the person's life is able to take control.
Nursing Interventions:
⊗ Professional attention
⊗ Education of family
⊗ Resolution of primary cause
⊗ Supportive therapies
⊗ Offer support and empathy
⊗ Nonjudgmental attitude
⊗ Administer medications, as ordered
⊗ Listen attentively
PERSONALITY DISORDERS
⊗ Pervasive and inflexible patterns of functioning that is stable overtime, and
leads to distress or impairment.
⊗ 10% to 13% of the general population
Types of Personality Disorders:
Eccentric Personality Disorder (Type A)
⊗ Paranoid (Suspicious and distrustful)
Persons who display pervasive and long stand suspiciousness
More common in men
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⊗ Schizoid (Socially distant and detached)
Pattern of detachment from social relationship
Chooses solitary activities
Topics are inanimate objects and ideas
⊗ Schizotypal (Odd and eccentric)
“mild schizophrenia”
Acute discomfort in close relationships
Cognitive or perceptual distortion
Dramatic-Erratic Personality Disorder (Type B)
⊗ Antisocial (aggressive and manipulative)
Pattern of disregard for the violation of the rights of others
Low self-esteem
⊗ Borderline (destructive and unstable)
Characterized by patterns of instability in relationships, self image and mood
Self-mutilating behavior
More common in women
⊗ Histrionic (emotional and dramatic)
Excessive emotionally and attention-seeking behaviors that are dramatic and
egocentric
Exaggerated expression of emotion
Overreaction to minor events
⊗ Narcissistic (boastful / superiority complex)
Grandiosity and need for constant admiration
Exploitation of others for fulfillment of own desire
Anxious or Fearful Personality Disorder (Type C)
⊗ Avoidant (inferiority complex)
Social inhibition
Feelings of inadequacy and sensitivity
Low self-esteem
Social withdrawal in spite of a desire for affection and acceptance
⊗ Dependent (submissive)
Submissive clinging behavior related to excessive need to be cared for by
others
Lack of self-confidence
Perceive self as helpless and stupid
⊗ Obsessive-Compulsive (perfectionist)
Preoccupied with orderliness, perfectionism, inflexibility, need to be in
control
Formal and serious interpersonal relationship
Judgmental of self and others
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⊗ Passive-Aggressive
Intentional inefficiency
Passive resistance to demands for adequate performance in both
occupational and social functioning
Nursing Diagnosis:
• Ineffective individual coping
• Self-esteem disturbance
Nursing Care:
• Avoid client attempts to manipulate
– Set limits and boundaries
– Consistency is essential
• Clear communication
• Deal with frustration
• Specific treatment of symptoms
DISORDERS COMMONLY DIAGNOSED TO CHILDREN
AUTISM
⊗ Characterized by:
impairment in communication skills
presence of stereotyped behavior, interests and activities.
⊗ Associated with impairment on social interactions
⊗ Treatable but not curable
⊗ More common among boys
⊗ Usually diagnosed at age 2
⊗ Main problem: Interpersonal functioning
⊗ Most acceptable cause: Biological factors - brain anoxia, intake of drugs
Signs and Symptoms
⊗ Odd play
⊗ Not cuddly
⊗ Echolalia
⊗ Crying tantrums
⊗ Head towards anything
⊗ Inanimate object
attachment
⊗ Loves to spin objects / self
⊗ Difficulty interacting with
others
⊗ Wants blocks
⊗ Acts as deaf
⊗ Resists normal teaching method / routine
changes
⊗ No fear of danger
⊗ Insensitive to pain
⊗ No eye contact
⊗ Giggling or silly laughing
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Nursing Interventions
⊗ Environment:
safe
consistent
⊗ Encourage the client to participate for self-care
⊗ Promote communication
Speak calmly when giving instructions
Use simple words or phrases
Repeat instructions as necessary.
⊗ Haloperidol - symptomatic relief for hyperactivity, stereotypical and selfdestructive behavior
MENTAL RETARDATION
⊗ Not a mental illness.
⊗ Onset: 18
⊗ IQ below 70
⊗ Manifested by sub-average intellectual functioning in:
Communication
Social skills
Self-care
Health and safety
Home living
Causes
⊗ HIV/ AIDS / rubella
⊗ Neurological / neurodevelopmental
impairment
infection
⊗ Exact gestational age is not reached
⊗ Alcoholic mother
(premature)
⊗ Thyroid deficiency
⊗ Excessive lead poisoning ⊗ Opiate intoxication
⊗ Nutritional deficiency (lack in Folic Acid)
⊗ Damage to the brain
⊗ Anoxia
⊗ Toxemia (pregnancy-induced hypertension)
⊗ Environmental factors
⊗ Severe RH incompatibility
Levels
Mild/moron
IQ
51-70 o
o
Moderate/Imbecile 36-50 o
o
Severe/Idiot
20-35 o
o
o
Profound
Below o
20
o
Implication
Difficulty adapting to school
Educable – needs assistance
Poor awareness of needs of others
Trainable – needs moderate supervision
Unable to learn academic skills
Poor motor development and minimal speech
Needs complete and close supervision
Has minimal capacity for sensorimotor function
Needs custodial care with a totally structured
environment
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Principles of Nursing Care
⊗ Protective care
⊗ Education of the family
Their involvement is an important factor in the plan of care to promote
progress and to minimize the stress.
⊗ Repetition
⊗ Role modeling
⊗ Restructuring
⊗ Focus of Education
Reading
Arithmetic
Writing
ATTENTION DEFICIT HYPERACTIVITY DISORDER
⊗ Common in boys
⊗ Usually diagnosed before age 7
⊗ Problems:
Inattention
Hyperactivity
Impulsivity
Causes:
⊗ Abuse of the child
⊗ Drug exposure
⊗ Hypoperfusion (brain)
⊗ Developmental problems
Neurologic impairment
Pre-natal trauma
Early malnutrition
Signs and Symptoms
⊗ Obstinacy
⊗ Negativism
⊗ Egocentrism
⊗ Fighting syndrome
⊗ Aggressiveness
⊗ Tolerance is low
⊗
⊗
⊗
⊗
⊗
⊗
⊗
Difficulty concentrating
Excessive talking
Fidgeting
Interrupt/intrudes on others
Child exhibits hyperactivity
Indulges in destructive behavior
Temper tantrums
Nursing Diagnosis - Potential for injury
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Nursing interventions:
⊗ Provide nutrition and safety
⊗ Provide an environment that:
is calm
is structured
enables appropriate reaction to the environmental stimuli
⊗ Plan a firm and consistent care in which limits and standards are set.
⊗ Parent education
⊗ Pharmacology:
• Methylphenidate (Ritalin)
• Dexedrine
• Cyclert
DISORDERS COMMONLY DIAGNOSED TO ADOLESCENTS AND ADULTS
EATING DISORDERS
⊗ More common among females.
Causes:
⊗ Psychological factors
Parental factors (domineering parents)
Individual factors (conflict about growing up)
Sociocultural factors
Anorexia Nervosa
⊗ Main sign: Morbid fear of gaining weight
⊗ Other signs:
Sensitivity to cold temperatures
Denial of hunger
Amenorrhea
Obvious thinness but feels fat
Deliberate self-starvation with
Lanugo all over the body
weight loss
Loss of scalp hair
Bulimia Nervosa
⊗ Extreme measures to lose weight
uses diet pills, diuretics or laxatives
purges after eating
extreme exercise
⊗ Signs of purging
swelling of the cheeks or jaw area
cuts and calluses on the back of the hands and knuckles (Russel’s sign)
teeth that look clear
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⊗ Peculiar signs
depression
loss of interest in activities
Findings: (for both)
⊗ Weight loss of 15% or more of original body weight
⊗ Amenorrhea
⊗ Social withdrawal and poor family and individual coping
⊗ History of high activity and achievement in academics, athletics
⊗ Electrolyte imbalance
⊗ Depression / distorted body image
Nursing Diagnosis:
⊗ Body image disturbance
⊗ Ineffective individual coping
Nursing Interventions:
⊗ Reinforce treatment plans and dietary prescriptions
⊗ Establish a trusting relationship
⊗ Monitor weight and vital signs
⊗ Encourage client to express feelings
⊗ Decrease emphasis on foods, eating, weight
⊗ Involve in decision-making
⊗ Employ limit setting
⊗ Stay with the client after meal and for 1st four hours
SUBSTANCE-RELATED DISORDERS
Alcoholism
⊗ A chronic disease or a disorder characterized by excessive alcohol
intake and interference in the individual’s health, interpersonal
relationship and economic functioning. (WHO)
⊗ Considered to be present when there is .1% or 10 ml for every
1000 ml of blood
Signs of use:
⊗ .1-.2% - low coordination
⊗ .2-.3% - presence of ataxia, tremors, irritability, stupor
⊗ .3 and above - unconsciousness
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Progression:
⊗ Pre-alcoholic
starts with social drinking
tolerance begins to develop
⊗ Prodromal
alcohol becomes a need
blackouts occur
denial starts
⊗ Crucial - cardinal symptoms of alcoholism develops
⊗ Chronic - the person becomes intoxicated all day
Outcome:
⊗ Brain damage
⊗ Alcoholic hallucinosis
⊗ Death
Behavioral problems:
⊗ Denial
⊗ Dependency
⊗ Demanding
⊗ Destructive
⊗ Domineering
Alcohol Withdrawal
⊗ Occurs when an individual abruptly stops drinking
⊗ Symptoms develop within few hours
⊗ Symptoms include:
Careless behavior
Autonomic hyperactivity
Unusual perceptions (illusions, hallucinations)
Tachycardia (impending delirium tremens)
Increased temperature
Obvious hand tremors
Nightmares and insomnia
Alcohol Withdrawal Delirium
⊗ AKA delirium tremens
⊗ Experienced within 48 to 72 hours after the last intake:
⊗ Symptoms include
Diaphoresis
Elevated VS
Agitation
Tremors (seizures)
Hyperexcitability to depression
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Chronic Problems:
Korsakoff's Psychosis
⊗ A form of amnesia
⊗ Characterized by
short-term memory loss
disorientation
inability to learn new skills
confabulation
⊗ Deficiency in B1 and B12.
Wernicke's Encephalopathy
⊗ An inflammatory hemorrhagic degenerative condition of the brain
⊗ caused by B1 deficiency
⊗ Symptoms include:
double vision
involuntary and rapid eye movements
lack of muscular coordination
decreased mental function
Nursing Diagnosis: Ineffective individual coping
Principles of Nursing Care:
⊗ Monitor vital signs
⊗ Well-lighted room
⊗ Diet as tolerated
Administration of glucose
Vitamins
Alcohol Detoxification:
⊗ Drug of Choice: Disulfiram (Antabuse) - delays the metabolism of alcohol
⊗ Avoid alcohol-containing products
⊗ 3 S’s of detoxification:
Safety
Sedation
Supplementation (Vitamin B complex, Vitamin C)
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DRUG-RELATED DISORDERS
Cocaine-Related Disorders (Stimulants)
⊗ Cocaine is a white powdered stimulant substance
⊗ Usually sniffed, snorted, smoked in a pipe or injected into a vein or
subcutaneous tissue.
⊗ Poor man’s cocaine:
Shabu (sha-boo)
⊗ Signs of use:
Cocaine psychosis
Obvious dilation of the pupils
Cardiac problems
Agitation
Insomnia
No appetite
Excessive sweating
Severe to panic anxiety
⊗ Classic sign: Perforated nasal septum
⊗ Can cause a sudden heart attack even in healthy young people.
Cannabis-Related Disorders (Cannabinoids)
Marijuana
⊗ Can act as stimulant or depressant and is often considered to be a mild
hallucinogen with some sedative properties
⊗ Is not physically addicting but may lead to psychological dependence
⊗ Plant : cannabis sativa
⊗ Active component is Tetrahydocannabinol
⊗ Routes of use:
Orally (capsules, tablets, on sugar cubes)
With food
Smoked in a pipe or rolled as cigarette.
⊗ Acts within 15 minutes
⊗ Effects lasts approximately 2 to 4 hours
⊗ Physiologic symptoms include
Increased appetite
Hypothermia
Nausea and vomiting
Excitement
Drowsiness
Movement problems (reduced coordination)
Inability to think clearly
Problems on judgment
Ataxia
Non-steady gait
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⊗ Classic sign: bloodshot eyes
⊗ In large doses, it may cause:
Hallucination
Suicidal ideations
Delusions of invulnerability
Long-term Goals:
⊗ Community resources
⊗ Other coping means aside from denial
⊗ Personal responsibility (behavioral contract)
⊗ Isolation
⊗ Nutrition
⊗ Group therapy
SEXUAL DISORDERS
⊗ Sexuality - is the result of biologic, psychological, social and experimental
factors that mold an individual's sexual development, self-concept, body image
and behavior.
Phases of the Sexual Response Cycle
⊗ Desire - the ability, interest and willingness to receive sexual stimulation
⊗ Excitement / Arousal
Result of psychological stimulation
Example is fantasizing during the desire phase and foreplay which involves
petting and fondling of erogenous zones or areas of the body that are
particularly sensitive to erotic stimulation.
⊗ Plateau – “intense moments”
⊗ Orgasm
formerly termed as climax
the shortest stage in the sexual response cycle
occurs when stimulation proceeds through the plateau stage to a point
where the body suddenly discharges accumulated sexual tension
⊗ Resolution
the final phase of sexual response
organs and body systems gradually return to the unaroused state
Sexual Dysfunction Disorders
⊗ Sexual Desire Disorders: Individuals who have little or no sexual desire or have
an aversion to sexual contact.
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⊗ Sexual Arousal Disorder: Individuals cannot complete the physiologic
requirements for sexual intercourse
Examples
Women cannot maintain lubrication
Men cannot maintain an erection
⊗ Orgasm Disorders: Inability to achieve orgasm phase
Example: Premature ejaculation
⊗ Sexual Pain Disorders: Individuals suffer genital pain (dyspareunias)
Example: Vaginismus
Paraphilia (Sexual Deviation)
⊗ A term which generally refers to abnormal sexual behavior
⊗ Lasts for 6 months leading to distress or impairment to functioning.
Examples:
Anilingus
Bestiality or
Zoophilia
Coprophilia
Cunnillingus
Exhibitionism
Fellatio
Fetishism
Frotteurism
Masochism
Necrophilia
Partialism
Pedophilia
Sadism
Telephone
Scatalogia
(AKA sex on phone)
Transvestism
Urophilia
Voyeurism
tongue brushing the anus
contact with animals
smearing feces on the partner
tongue brushing the vulva
Involves exposing one’s genitals to unsuspecting strangers
(usually women or children)
inserting the penis into the mouth
inanimate / non-living objects or articles
Touching or rubbing against the unsuspecting people.
Usually occurs in crowded places where escape is into the
crowd is possible.
Sexual gratification from experiencing pain
Involves the use of corpses
Inserting the penis into the other parts of the body
Use of prepubertal children (13 years of age or younger) in an
actual sexual act or a fantasy
Sexual gratification from inflicting pain
Involves telephoning someone and making lewd, obscene
remarks or conversation.
Sexual excitement through wearing the clothing of a woman
urinating on the partner
Act of observing unsuspecting person who is naked, in the
process of disrobing, or engaging in sexual activity
Includes cyber-voyeurism
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Gender Identity Disorder
⊗ AKA Transexualism
⊗ They believe that they were born as the wrong sex
⊗ Leads to persistent discomfort and feels inappropriate in the role of the
assigned sex.
Nursing Interventions:
⊗ Attitude:
Accepting
Empathic
⊗ Accept his feelings related to sexuality
⊗ Have a private area to discuss fears or concerns about sexuality
⊗ Intervene to discuss self-esteem issues, anxiety, guilt, and empathy for victims.
⊗ Employ limit setting.
⊗ Referral to the correct clinic.
SCHIZOPHRENIA AND OTHER PSYCHOSES
SCHIZOPHRENIA
⊗ A serious psychiatric disorder
⊗ One of the most profound disabling illnesses
⊗ Not a single disease entity but a combination of disorders
⊗ "split mind"
⊗ Characterized by:
• impaired communication
• loss of contact into reality
• deterioration from a previous level of
functioning
⊗ Nursing Diagnosis: Altered thought process
⊗ Theories
• Biological
• Neuroanatomic and neurochemical
• Immunovirological
Manifestations: Eugen Bleuler
⊗ Associative looseness
⊗ Autism
⊗ Affective disturbance
⊗ Ambivalence
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Positive symptoms:
⊗ Ambivalence
⊗ Associative Looseness
⊗ Delusions
⊗ Echopraxia
⊗ Flight of ideasHallucinations
⊗ Ideas of reference
⊗ Perseveration
Negative symptoms:
⊗ Alogia
⊗ Anhedonia
⊗ Apathy
⊗ Avolition
⊗ Blunted affect
⊗ Catatonia
⊗ Flat affect
Types
Disorganized
Prognosis: Poor
Defense
Mechanism:
Regression
Paranoid
Prognosis: Good
Defense
Mechanism:
Projection
Catatonic
Prognosis: Good
Defense
Mechanism:
Repression
Distinguishing features
Peculiar / bizarre
behavior
Incoherence
Stereotyping
Nursing Interventions
⊗ Assist with ADL
⊗ Encourage activity
⊗ Present reality
Hallucinations
Ideas of reference
Delusion of persecution
Suspiciousness
⊗ Priority: safety of others
⊗ Deal with the HID
⊗ Offer sealed foods /
unopened medicines
⊗ Never displace outbursts of
emotions
⊗ Explain procedures in simple
ways
⊗ Never argue with the patient
⊗ Priority: nutrition &
circulation
⊗ Provide distraction
⊗ Encourage activity
Wax flexibility
Stupor
Negativism – mutism,
rigidity, lack of response
Undifferentiated
• Patients whose manifestation cannot be easily fitted into one or the other
type
Residual
• Patients with minimal symptoms
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Nursing Intervention Principles:
⊗ Establish:
a trusting relationship and provide acceptance
a clear, consistent and open communication
⊗ Set limits
⊗ Decrease environmental stimuli
⊗ Observe for suicidal ideation
⊗ Administer medications, as ordered.
PSYCHOSES RELATED TO SCHIZOPHRENIA
Schizophreniform
Disorder
Schizoaffective
Disorder
Delusional Disorder
Brief Psychotic
Disorder
Shared Psychotic
Disorder (folie a deux)
⊗ Client presents symptoms of schizophrenia for less
than 6 moths
⊗ ADL may not be altered
⊗ Client presents symptoms of psychosis and all features
of a mood disorder (depression / mania)
⊗ Client has 1 or more bizarre delusions
⊗ ADL not impaired
⊗ Client experiences sudden onset of at least 1
psychotic symptom
⊗ Lasts from 1 day to 1 month
⊗ 2 people share a similar delusion
MOOD DISORDERS
Theories:
Biological
Neurochemical
Mania
⊗ Hereditary
⊗ High norepinephrine and
serotonin levels
Neuroendocrine
Psyhoanalytic
⊗ Defense mechanism against
depression
Psychiatric Nursing: Lecture Aid
Depression
⊗ Hereditary
⊗ Low norepinephrine and
serotonin levels
⊗ Elevated glucocorticoid
⊗ Elevated TSH
⊗ Rigid superego
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Common Types of Mood Disorders
Major Depressive Disorder
⊗ Lasts at least 2 weeks which impairs ADL
⊗ Characterized by depressed mood / loss of pleasure in most activities
Clinical Symptoms of Major Depressive Episode
⊗ Affect is flat
⊗ Loss of memory
⊗ Obvious sleep disturbances
⊗ Sad feelings / Social withdrawal
⊗ Emotional blunting
⊗ Reduced appetite
Mania – abnormally and persistently elevated mood lasting for 1 week
Clinical Symptoms of Manic Episode
⊗ Agitation
⊗ Flight of ideas
⊗ Increased activity
⊗ Grandiosity
⊗ High emotions
⊗ Talkative or pressured to keep talking
⊗ Easy distractibility
⊗ Reduced need for help
Bipolar Disorder
⊗ A person’s mood cycles between mania and depression for 1 week
⊗ Bipolar I Disorder
one or more of symptoms of manic episode
accompanied by major depressive episode
⊗ Bipolar II Disorder
one or more symptoms of major depressive episode with hypomania
Related disorders:
⊗ Dysthymic Disorder
Lesser severe than major depression
No symptoms such as impaired communication, delusions and hallucinations
⊗ Cyclothymic Disorder
⊗ DNOS (Depression Not Otherwise Specified) - lasts for 2 days-2 weeks
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Appearance
DM
Attitude
therapies
Activity
Priority NDx
Nursing
Management
Mania
Elated
Projection
Matter of fact
Depression
Sad
Introjection
Kind firmness
Non-stimulating
Never give anything that
requires attention
Risk for injury:
Directed at others
Individual therapies
Lithium
Diet
Monotonous
Risk for injury: self-directed
Group therapy
Antidepressants
ECT
SUICIDE
⊗ thought or act of taking one’s own life
⊗ ultimate form of self-destruction
⊗ "cry for help“
⊗ reunion wish or fantasy
⊗ progressive failure to adapt feelings of anger or hostility
⊗ a way to end feelings of hopelessness and helplessness
⊗ an attempt "to save face" or seek a release to a better life
Risk Factors
⊗ Sex (more female attempts suicide but more male commits suicide)
⊗ Use of drugs / alcohol
⊗ Identification with a dead family member
⊗ Chronic Illness (e.g. Cancer)
⊗ Irrational thinking
⊗ Depression/Dependent personality
⊗ Age (18-25 and 40)
⊗ Lethality of previous attempt/Losses
Nursing Diagnosis: Risk for injury-Self directed
Nursing care:
⊗ Safe environment
⊗ Always take overt or covert threats or attempts
seriously
⊗ Ventilation of feelings
⊗ Encourage activities
⊗ Monitor closely (one-on-one, 24/7)
⊗ Empathy (show acceptance & appreciation)
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CONDITION COMMONLY DIAGNOSED IN THE ELDERLY
Alzheimer’s Disease
⊗ A chronic, progressive degenerative cognitive disorder.
⊗ Marked by Dementia
⊗ Main Pathology: presence of senile plaques - destroys neurons (decreased
acethylcholline)
Signs and Symptoms:
⊗ Dementia
⊗ Cognitive disturbances
o Aphasia – deterioration of language function
o Apraxia – impaired motor function
o Agnosia – inability to recognize objects / people
⊗ Executive functioning - loss of abstract thinking
3 PHASES:
⊗ Forgetfulness - difficulty of remembering appointments
⊗ Advance - difficulty of remembering past events but not recent events
⊗ Terminal - death occurs in 1 year
Nursing Diagnosis: Altered thought processes
Nursing Care:
⊗ Priority: safety & security
⊗ Always reorient the client (clock & calendar)
⊗ Use color instead of numbers & letters
⊗ Consistency – 1 nurse to lessen confusion
DEATH AND DYING
DEATH/D YING: Elizabeth Kubler-Ross
Stages:
Denial - "NO NOT ME"
Anger - "WHY ME"
Bargaining - "IF ONLY"
Depression - Stage of silence
Acceptance - "YES, IT'S ME"
Nursing Diagnosis: Ineffective individual coping
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Nursing Care:
⊗ Listen to client’s verbalizations
⊗ Offer your presence always
⊗ Value the client’s beliefs and recognize your own beliefs
⊗ Emotional and family support
*** END ***
lerache.lintao@gmail.com
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