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PSYCHIATRIC NURSING

Presented by:
Dave Jay Sibi. Manriquez, RN
Introduction
• MENTAL HEALTH – balance in a
persons internal life and
adaptation to reality

• Mental ILL Health – state of


imbalance characterized by a
disturbance in a persons
thoughts, feelings and behavior
Psychiatric nursing
• interpersonal process whereby the
professional nurse practitioner
,through the therapeutic use of self
(art) and nursing theories (science),
assist clients to achieve psychosocial
well being.
• Core : interpersonal process
Related Terms
• Mental hygiene
– measures to promote mental health ,
prevent mental illness and suffering and
facilitate rehabilitation
– Main tool: therapeutic use of self
– It requires self-awareness
• Methods to increase self-awareness:
– Introspection
– Discussion
– Experience
– Role play
• Assessment (psychosocial
processes )
– Appearance , behavior or mood
– Speech , thought content and thought
process
– Sensorium
– Insight and judgment
– Family relationships and work habits
– Level of growth and development
Common Behavioral Signs and
Symptoms
Disturbances in perception
• Illusion
– misinterpretation of an actual external
stimuli

• Hallucinations
– false sensory perception in the absence
of external stimuli

PERCEPTION
PERCEPTION
PERCEPTION
PERCEPTION
PERCEPTION
Disturbances in thinking and speech
• neologism – coining of words that
people do not understand

• Circumstantiality – over inclusion of


inappropriate thoughts and details

• Word salad – incoherent mixture of


words and phrases with no logical
sequence
THINKING & SPEECH
• Verbigeration – meaningless
repetition of words and phrases
• Perseveration – persistence of a
response to a previous question
• Echolalia – pathological repetition of
words of others
• Aphasia – speech difficulty and
disturbance
– Expressive , receptive or global

THINKING & SPEECH


• Flight of ideas- shifting of one topic
from one subject to another in a
somewhat related way
• Looseness of association-incoherent
illogical flow of thoughts (unrelated
way)
• Clang association – sound of word
gives direction to the flow of thought

THINKING & SPEECH


• Delusion – persistent false belief,
rigidly held
– Delusions of grandeur: special
/important in a way
– Persecutory: threatened
– Ideas of reference: situation/events
involve them
– Somatic: body reacting in a particular
way

THINKING & SPEECH


– Jealous: thinking that their partner is
unfaithful
– Erotomanic: person, usually of high
status, is in love with the client
– Religious: illogical ideas about God and
religion exhibited by extreme or
extraneous behavior
– Mixed: combination of above without a
predominant theme

THINKING & SPEECH


• Magical thinking – primitive thought
process thoughts alone can change
events
• Autistic thinking – regressive thought
process; subjective interpretations
not validated with objective reality
• Dereism – unorganized thinking

THINKING & SPEECH


Disturbances of affect
• Inappropriate – 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

AFFECT
• Depersonalization – feeling of
strangeness from one’s self
• Derealization – feeling of strangeness
towards environment
• Agnosia – lack of sensory stimuli
integration

AFFECT
Disturbances in motor activity
• Echopraxia – imitation of posture of
others
• Waxy flexibility – maintaining position
for a long period of time
• Ataxia – loss of balance
• Akathesia – extreme restlessness

MOTOR ACTIVITY
• Dystonia- uncoordinated spastic
movements of the body
• Tardive dyskinesia – involuntary
twitching or muscle movements
• Apraxia – involuntary unpurposeful
movements

MOTOR ACTIVITY
Disturbances in memory
• Confabulation – filling of memory
gaps
• Déjà vu – something unfamiliar
seems familiar
• Jamais vu- something familiar seems
unfamiliar
• Amnesia – memory loss (inability to
recall past events)
– Retrograde-distant past
– Anterograde – immediate past
– MEMORY
Dynamics of Human Behavior
• Behavior – the way an individual
reacts to a certain stimulus

• Conflict – situation arising from


the presence of two opposing
drives

• Need - organismic condition that


requires a certain activity
Dynamics of Human Behavior
• Personality
– totality of emotional and behavioral
traits that characterize the person in day
to day living under ordinary conditions; it
is relatively stable and predictable.
FORMATION OF PERSONALITY
• TEMPERAMENT
– biological-genetic template that interacts with
our environment.
– a set of in-built dispositions we are born with
– mostly unalterable
– our nature.
• CHARACTER
– the outcome of the process of socialization, the
acts and imprints of our environment and
nurture on our psyche during the formative
years (0-6 years and in adolescence).
– the set of all acquired characteristics we
posses, often judged in a cultural-social
context.
• Sometimes the interplay of all these
factors results in an abnormal personality
THEORIES OF PERSONALITY
DEVELOPMENT
Freud’s
PSYCHOSEXUAL THEORY
• Libido – inner drive
• Parts of body –focus of gratification
• Unsuccessful resolution - fixation
• Structures of personality
– Id: pleasure principle-instinct
– Ego: controls action and perception –
reality principle
– Superego: moral behavior - conscience
• 0-18 m0s ;oral – mouth – trust and
discriminating
• 18 mos. – 3 years ; anal – bowels –
holding on or letting go
– Negativism and toilet training age
• 3 -6 years phallic ; genitals –
exploration and discovery ( inc.
sexual tension)
– Gender identification and genital
awareness
– Oedipus and Electra complex
– Castration anxiety and penis envy
• 6-12 years – latency (quiet stage)
sexual energy diverted to play.
Institution of superego: control of
instinctual impulses
• 12 – young adult – genital ;
reawakening of sexual drives –
relationships
– Sexual maturation
– Sexual identity ,ability to love and work
Eric Erickson’s
PSYCHOSOCIAL THEORY
• 0-12mos • TRUST vs. MISTRUST
• 1-3y • AUTONOMY vs. SHAME &
DOUBT
• 3-6 • INDUSTRY vs. INFERIORITY
• 6-12 • INITIATIVE vs. GUILT
• 12-18 • IDENTITY vs. IDENTITY
CONFUSION
• INTIMACY vs. ISOLATION
• 18-25
• 25-60 • EGO INTEGRITY vs.
STAGNATION
• GENERATIVITY vs. DESPAIR
• 60 and above
INFANCY
• CONSISTENT MATERNAL –CHILD
INTERACTION – TRUST
• INNER FEELING OF SELF WORTH
• HOPE
TODDLER
• ALLOW EXPLORATION
• PROVIDE FOR SAFETY
• “NO, NO” – NEGATIVISM
• OFFER CHOICES / REVERSE PSYCHOLOGY
• TOILET TRAINING – 18 MOS.-BOWEL
– DAYTIME BLADDER: 2 yo
– NIGHTIME BLADDER: 3 yo
• REWARD W/ PRAISE AND AFFECTION
• INDEPENDENCE
PRE-SCHOOL
• PROVIDE PLAY MATERIALS
• SATISFY CURIOSITY
• TEACH AND
REINFORCE(HYGIENE,SOCIAL
BEHAVIOR)
• SIBLING RIVALRY
• WILLPOWER
SCHOOL AGE
• HOW TO DO THINGS WELL-SUPPORT
EFFORTS
• CHUMS AND HOBBIES
• NEEDS TO EXCEL/ACCOMPLISH
• NEED FOR PRIVACY AND PEER
INTERACTION
• COMPETENCE
ADOLESCENCE
• MAKE DECISION,EMANCIPATION
FROM PARENTS
• BODY IMAGE CHANGES
• NEED TO CONFORM BUT KEEP
INDIVIDUALITY
• SELF - AWARENESS
YOUNG ADULT

• COMMITMENT AND FIDELITY

• RESPONSIBILITY

• ACHIEVEMENT OF INDEPENDENCE
MIDDLE ADULTHOOD
• SUPPORT-PERIOD OF ROLE TRANSITIONS

• MIDLIFE CRISIS

• ADJUSTMENT AND COMPROMISE

• MOST PRODUCTIVE AND CREATIVE

• ALTRUISM
LATE ADULTHOOD
• SELF ACCEPTANCE

• SELF WORTH

• WISDOM
Jean Piaget’s
COGNITIVE THEORY
0-2 SENSORIMOTOR
• REFLEXES
• IMITATIVE REPETITIVE BEHAVIOR
• SENSE OF OBJECT PERMANENCE AND
SELF SEPARATE FROM ENVT.
• TRIAL AND ERROR RESULTS IN
PROBLEM SOLVING
2-7Y PRE-OPERATIONAL
• SELF-CENTERED,EGOCENTRIC
• CANNOT CONCEPTUALIZE OTHER’S VIEW
• ANIMISTIC THINKING
• IMAGINARY PLAYMATE – SYMBOLIC MENTAL
REPRESENTATION – CREATIVITY
• 2-4 PRE-CONCEPTUAL (PRE-LOGICAL)
• 4-7 INTUITIVE (UNDERSTANDING OF
ROLES)
7-12Y CONCRETE OPERATIONAL

• LOGICAL CONCRETE THOUGHT


• INDUCTIVE REASONING (SPECIFIC TO
GENERAL)
• CAN RELATE, PROBLEM SOLVING
ABILITY
• REASONING AND SELF-REGULATION
12-ABOVE: FORMAL OPERATIONAL
THOUGHT
• Abstract thinking
• Separation of fantasy and fact
• Reality oriented
• Deductive reasoning
• Apply scientific method
Havighurst’s
DEVELOPMENTAL TASKS
• Baby to early childhood
– Right from wrong and Conscience
• Late childhood
– Physical skills, wholesome attitude,
social roles
– Conscience morality and values
– Fundamental skills in academics
– Personal independence
• Adolescence
– Sexual social roles
– Relationships
– Independence and ideology
• Early adulthood
– Career
– Selecting a mate
– Finding Civic or social responsibility
• Middle age
– Achieving Civic or social responsibility
– Adjusting to changes
– Satisfactory career performance
– Adjusting to aging parents
– Adjusting to parental roles
• Old age
– Adjusting to changes
– Establishing satisfactory living
arrangements and affiliations
Kohlberg’s
MORAL DEVELOPMENT/ THINKING/
JUDGEMENT
• PRE-CONVENTIONAL (0-6)
– PUNISHMENT AND OBEDIENCE
– OBEDIENCE TO RULES TO AVOID
PUNISHMENT
• CONVENTIONAL ( 6-12 )
– MUTUAL INTERPERSONAL
EXPECTATIONS,RELATIONSHIPS AND
CONFORMITY
– SOCIAL SYSTEM AND CONSCIENCE
MAINTENANCE
– BEING GOOD IS IMPORTANT SELF
RESPECT OR CONSCIENCE
• POST –CONVENTIONAL (12 – 18 Y)
– PRIOR RIGHT OR SOCIAL CONTRACT
– UNIVERSAL ETHICAL PRINCIPLE
– ABIDE FOR COMMON GOOD
– RATIONAL PERSON-VALIDITY OF
PRINCIPLES-AND BECOME COMMITTED
TO THEM
– INNER CONTROL OF BEHAVIOR
UNDERSTANDING THE EQUALITY OF
HUMAN RIGHTS AND DIGNITY OF HUMAN
BEINGS AS INDIVIDUALS
Harry Stack Sullivan’s
INTERPERSONAL THEORY
INFANCY

• NEED FOR SECURITY-INFANT LEARNS


TO RELY ON OTHERS TO GRATIFY
NEEDS AND SATISFY WISHES,
DEVELOPS A SENSE OF BASIC TRUST,
SECURITY AND SELF WORTH WHEN
THIS OCCURS
TODDLERHOOD / EARLY CHILDHOOD
• CHILD LEARNS TO COMMUNICATE
NEEDS THROUGH USE OF WORDS
AND ACCEPTANCE OF DELAYED
GRATIFICATION AND INTERFERENCE
OF WISH FULFILLMENT
PRE-SCHOOL
• DEVELOPMENT OF BODY IMAGE AND SELF-
PERCEPTION
• ORGANIZES AND USES EXPERIENCES IN
TERMS OF APPROVAL AND DISAPPROVAL
RECEIVED
• BEGINS USING SELCTIVE INATTENTION
AND DISASSOCIATES THOSE EXPERIENCES
THAT CAUSE PHYSICAL OR EMOTIONAL
DISCOMFORT AND PAIN
SCHOOL AGE
• THE PERIOD OF LEARNING TO FORM
SATISFYING RELATIONSHIPS WITH
PEERS-USES
COMPETITION,COMPROMISE AND
COOPERATION
• THE PRE-ADOLESCENT LEARNS TO
RELATE TO PEERS OF THE SAME SEX
ADOLESCENCE
• LEARNS INDEPENDENCE AND HOW
TO ESTABLISH SATISFACTORY
RELATIONSHIPS WITH MEMBERS OF
THE OPPOSITE SEX
YOUNG ADULTHOOD
• BECOMES ECONOMICALLY,
INTELLECTUALLY AND EMOTIONALLY
SELF SUFICIENT
LATER ADULTHOOD
• LEARNS TO BE INTERDEPENDENT
AND ASSUMES RESPONSIBILITY FOR
OTHERS
SENESCENCE
• DEVELOPS AN ACCEPTANCE OF
RESPONSIBILITY FOR WHAT LIFE IS
AND WAS AND OF ITS PLACE IN THE
FLOW OF HISTORY
TREATMENT MODALITIES
REMOTIVATION THERAPY
• TREATMENT MODALITY THAT
PROMOTES EXPRESSION OF
FEELINGS THROUGH INTERACTION
FACILITATED BY DISCUSSION OF
NEUTRAL TOPICS
• STEPS :
climate of acceptance
creating bridge to reality
sharing the world we live in
appreciation of works of the world
climate of appreciation
MUSIC THERAPY
• Involves use of music to facilitate
expression of feelings, relaxation and
outlet of tension
PLAY THERAPY
• enables patient to experience intense
emotion in a safe environment with the
use of play
• children express themselves more easily
in play. revealing as reflection of child’s
situation in the family
• provide toys and materials – facilitate
interaction – observe and help child
resolve problems through play
Group therapy
• Treatment modality involving three or
more patients with a therapist to relieve
emotional difficulties, increase self –
esteem, develop insight , LEARN NEW
ADAPTIVE WAYS TO COPE WITH STRESS
and improve behavior with others
• IDEAL 8 – 10 MEMBERS
MILIEU THERAPY
• Consists of treatment by means of
controlled modification of the patient’s
environment to facilitate positive
behavioral change
• Increase patient’s
– Awareness of feelings
– Sense of responsibility and
– Help return to community
• clients plan social and group interaction
• token programs , open wards and self
medication are done
FAMILY THERAPY
• A METHOD OF PSYCHOTHERAPY WHICH
FOCUSES ON THE TOTAL FAMILY AS AN
INTERACTIONAL SYSTEM
• PROBLEM IS A FAMILY PROBLEM
• focus on sick members behavior as source
of trouble / symptom serve a function for
the family
• members develop sense of identity
• points out function of the sick member for
the rest of the family
PSYCHOANALYTIC
• focuses on the exploration of the
unconscious, to facilitate identification of
the patients defenses
• ANXIETY RESULTS BETWEEN CONFLICTS OF
ID AND EGO
• Becomes aware of unconscious thoughts
and feelings to understand anxiety and
defenses
HYPNOTHERAPY
• Various methods and techniques to
induce a trance state where patient
becomes submissive to instructions
BEHAVIOR MODIFICATION
• Application of learning principles in
order to change maladaptive
behavior
• Believes that psychological problems
are a result of learning
• Everything learned can be unlearned
BEHAVIOR MODIFICATION
• OPERANT CONDITIONING
– Use of rewards to reinforce positive
behavior
– Perceived and self-reinforcement
becomes more important than external
reinforcement

• DESENSITIZATION
– Slow adjustment or exposure to feared
objects (phobias)
– Periodic exposure until undesirable
behavior disappears or lessens
AVERSION THERAPY
• An example of behavior modification
• Painful stimulus is introduced to bring
about an avoidance of another
stimulus
• End view: behavioral change
OTHER THERAPIES
• HUMOR THERAPY
– To facilitate expression and enhance
interaction

• ACTIVITY THERAPY
– Group interaction while working on a
task together
BIOLOGICAL/ MEDICAL THEORY
• EMOTIONAL PROBLEM IS AN ILLNESS
• cause may be inherited or chemical
in origin
• FOCUS OF TREATMENT IS
MEDICATIONS AND ECT
BIOLOGICAL THERAPY
• ELECTROCONVULSIVE THERAPY
– Artificial induction of a grand mal seizure by
passing a controlled electrical current through
electrodes applied to one or both temples
– mechanism of action – unclear
– voltage: 70 – 150 volts
– Duration: 0.5 – 2.0 seconds
– 6 to 12 treatments
– intervals of 48 hours
• indicators of effectiveness – occurrence of
generalized tonic – clonic seizures
• indications – depression , mania and
catatonic schizophrenia
• s/e: confusion, disorientation, short
-term memory loss, seizure (30-60 sec)
• NPO prior
• Contraindications
– Fever, pregnancy
– Inc ICP, fracture
– retinal detachment
– TB with hemoptysis
– cardiac d/o
• consent needed
• Reorient after, supportive care
• medications given :
– Atropine sulfate: decrease secretions
– Succinylcholine (Anectine): promote
muscle relaxation
– Methohexital Sodium ( Brevital ):
serves as an anesthetic agent
• common complications:
– loss of memory
– headache
– apnea
– fracture
– respiratory depression
Psychopharmacologic Therapy
Benzodiazepine
Benzodiazepines
• Indications
– Anxiety
– Sedation/sleep
– Muscle spasm
– Seizure disorder
– Alcohol withdrawal syndromes
Benzodiazepine
Anti-anxiety drugs
Generic Trade name
Alprazolam Xanax
Chlordiazepoxide Librium
Clorazepate Tranxene
Diazepam Valium
Lorazepam Ativan
Oxazepam Serax
Busipirone BuSpar
Benzodiazepine
Side effects
• Drowsiness/ sedation
• Ataxia
• Feelings of detachment
• Increase irritability and hostility
• Anterograde amnesia
• Increased appetite & weight gain
• Nausea
• Headache, confusion
Anti-depressant
Anti-depressants
• Indications
– Depression
– Bipolar depression
– Panic disorder
– Bulimia
– Obsessive-compulsive d/o
• Possibly
– Attention deficit/Hyperactivity d/o
– Post Traumatic Stress D/o
– Conduct d/o
Anti-depressant
Tricyclic (TCA)
Generic Trade name
Amitriptyline Elavil
Imipramine Tofranil
Trimipramine Surmontil
Nortriptyline Pamelor
Trazodone Desyrel
Bupropion Wellbutrin
Anti-depressant
Side effects
• Orthostatic hypertension
• Anticholinergic effect
– Dry mouth, blurred vision, constipation,
excessive sweating, urinary hesitancy/
retention, tachycardia, agitation,
delirium, exacerbation of glaucoma
• Neurologic effects
– sedation, psychomotor slowing, poor
concentration, fatigue, ataxia, tremors
• Decrease libido and sexual
performance
Anti-depressant
Monoamine Oxidase inhibitors
Generic Trade name
Isocarboxazid Marplan
Phenelzine Nardil
Tranylcypromine Parnate
Anti-depressant
Side effects
• Postural lightheadedness
• Constipation
• Delay ejaculation or orgasm
• Muscle twitching
• Drowsiness
• Dry mouth
Anti-depressant
Dietary restrictions
• Cheese, esp. aged and matured
• Fermented or aged protein
• Pickled or smoked fish
• Beer, red wine, sherry; liquor &
cognac
• Yeast
Hypertensive
• Fava or broad beans
Tyramine Crisis
• Beef or chicken liver
• Spoiled/ overripe fruits; banana peel
• yogurt
Anti-depressant
Hypertensive Crisis
• Signs
– Sudden elevation of BP
– Explosive headache, occipital may
radiate frontally
– Head & face flushed
– Palpitations, chest pain
– Sweating, fever
– Nausea, vomiting
– Dilated pupils, photophobia
– Intracranial bleeding
Anti-depressant
• Treatment
– Hold next MAO dose
– Don’t let pt. lie down
– IM chlorpromazine 100 mg
– Fever: manage by external cooling
techniques
Anti-depressant
Serotonin Reuptake Inhibitors
Generic Trade name
Fluoxetine Prozac
Sertraline Zoloft
Paroxetine Paxil
Venlafaxine Effexor
Anti-depressant
Side effects
• Nausea • Headache
• Diarrhea • Male sexual
• Insomnia dysfunction
• Dry mouth • Drowsiness
• Nervousness • Dizziness
• Sweating
Mood stabilizin
Mood stabilizing drugs
• Indications
– Acute mania
– Bipolar prophylaxis
• Possibly
– Bulimia
– Alcohol abuse
– Aggressive behavior
– schizoaffective
Mood stabilizin
• Mode of action
– Normalizes the reuptake of certain
neurotransmitters such as serotonin,
norepinephrine, acetylcholine and
dopamine
– Reduces the release of norepinephrine
thru competition with calcium
– Effects intracellularly
• Lag period: 7-10 to 14 days
Mood stabilizin
Lithium carbonate
• Trade names
– Eskalith Preparation: tab, cap, liq &
SR form
– Lithotabs
Dose: 900 to 3600 mg/day
– Lithane
– Lithonate
• MOA: unclear; interfere with metabolism of
neurotransmitters; alter Na transport in
nerves and muscle cells
• Prelithium workup
– Urinalysis (BUN and creatinine)
– ECG, FBC, CBC
Mood stabilizin
Side effects
• Early
– Nausea and diarrhea
– Anorexia
– Fine hand tremor (propranolol)
– Thirst, Polydipsia (dec. crea, inc.
albumin)
– Metallic taste
– Fatigue
– Lethargy
• Late
– Weight gain
– acne
Mood stabilizin
Contraindications
• Brain damage/ CV disease
• Epilepsy
• Elderly/ debilitated
• Thyroid and renal disease
• Severe dehydration
• Pregnancy (1st trimester)

• Can augment the effects of anti-


depressants
Mood stabilizin
Nursing considerations
• Therapeutic serum level: 0.5 – 1.2 meq/L
• Maintenance level: 0.6 -1.2 meq/L
• Toxic
– Mild to moderate: 1.5 to 2 meq/L
– Moderate to severe: 2 – 2.5 meq/L
– Needs dialysis: 3 meq and above
• Early signs of toxicity
– Lethargy, mild nausea, vomiting, fine hand
tremors, anorexia, polyuria, polydipsia, metallic
taste, fatigue
• Late signs of toxicity
– Ataxia, giddiness, tinnitus, blurred vision,
polyuria
Mood stabilizin
Nursing considerations
• Lithium levels should be checked q 2-3
mos
• Serum drawn in the AM, 12H after last
dose
• Common causes of inc. levels
– Dec. Na intake
– Diuretic therapy
– Dec. renal functioning
– F&E loss
– Medical illness
– Overdose
– NSAIDS
Mood stabilizin
Nursing considerations
• Diet: adequate Na+ and fluid
– 3g NaCl/ day
– 6-8 glasses of H2O
• No caffeine
• No driving: wait for clinical effect
Mood stabilizin
Management
• Moderately severe toxicity
– Osmotic diuresis: urea/ mannitol
– Aminophylline & PLR IV
– Adequate NaCl
– Peritoneal/ hemodialysis
• Severe toxicity
– Assess hx quickly
– Hold next lithium dose
– Check BP, rectal T°, RR, LOC, support O2
– Obtain labs
– ECG
– Emetic, NGT lavage
– Hydrate: 5-6L/day c PLR; FBC-CDU
Mood stabilizin
Other drugs
• Carbamazepine (Tegretol)
– Side effects
• Dizziness 800 to 1200
• Ataxia mg/day
• Clumsiness
• Sedation
• Dysarthria
• Diplopia
• Nausea & GI upset
– Preparation: liq, tab, chewable tab
Mood stabilizin
Nursing considerations
• Assess drug levels q 3-4 days
• Monitor salt and fluid intake
• Avoid alcohol and non-prescription
drugs
• Refer dec. in UO
• Don’t stop abruptly
• C/I: pregnancy
• Take with meals
Mood stabilizin
Other drugs
• Valproic acid (Depakote, Depakene)
– Side effects
• Nausea
• Hepatoxicity
• Neurotoxicity
• Hematological toxicity
• Pancreatitis
– Prep: tab, cap, sprinkles
• MOA: inc. levels of GABA; inhibits the
kindling process or “snoball”-like
effect seen in mania & seizures
Mood stabilizin
Nursing considerations
• Therapeutic level: 50 – 100 ug/mL
• Dose: 1, 000 – 1,500 mg/day
• Monitor serum levels 12H after last
dose
• Toxic effects
– Severe diarrhea, vomiting, drowsiness,
mm. weakness, lack of coordination
– Renal failure, coma, death
Anti-psychotic
Anti-psychotic drugs
• Indications
– Psychotic symptoms of schizophrenia,
acute mania and depression
– Gilles de Tourette disorder
– Treatment-resistant bipolar disorder
– Huntington’s disease and other
movement disorder
• Possibly
– Paranoid
– Childhood psychoses
Anti-psychotic
• MOA: block receptors of dopamine
(D2, D3, D4)
• If unresponsive after 6 weeks of
therapy, another class is tried
• General considerations
– Calms without producing impairment of
sleep
– High therapeutic index
– Non addicting, no tolerance
– Avoided in pregnancy
Anti-psychotic
TYPICAL: High Potency

Fluphenazine (Prolixin)
Haloperidol (Haldol)
Thiothexene (Navane)
Trifluoperazine
(Stelazine)
Anti-psychotic
Moderate Potency

Loxapine (Loxitane)
Molindone (Moban)
Perphenazine (Trilafon)
Anti-psychotic
Low Potency

Chlopromazine (Thorazine)
Chlorprothixene (Taractan)
Mesoridazine (Serentil)
Thioridazine (Mellaril)
Anti-psychotic
ATYPICAL
Clozapine (Clozaril)
Resperidone (Risperdal)
Olanzapine (Zyprexa)
Quetiapine (Seroquel)
Sertindole (Serlec’t)
Ziprasidone (Zeldox)
Anti-psychotic
Contraindications
• CNS depression: brain damage,
excess alcohol/ narcotics
• Parkinson’s disease
• Allergy
• Blood dyscrasias
• Acute narrow angle glaucoma
• BPH
Anti-psychotic
Side effects
• Hypotension
• Sedation
• Dermal and ocular syndrome
• Neuroleptic malignant syndrome
• Anticholinergic syndrome
• Movement syndrome (Extrapyramidal
Syndrome)
N
• Atropine psychosis
ew!

• Agranulocytosis
• Seizures
Anti-psychotic
Neuroleptic Malignant Syndrome
• A potentially fatal, idiosyncratic reaction to
an antipsychotic drug
• 10-20% mortality rate
• Sx: TTT: dantrolene (Dantrium),
– rigidity, Bromocriptine (Parlodel)
– high fever,
– autonomic instability (BP, diaphoresis, pallor,
delirium, elev. CPK), confused or mute, fluctuate
from agitation to stupor
• Occurs in the first 2 weeks of therapy
• Risk: high dose of high-potency drugs;
dehydration, poor nx, concurrent med
illness
Anti-psychotic
Movement Syndromes
• Akathisia
• Dystonia
• Tardive dyskinesia
• Bradykinesia
• Parkinsonism
Anti-psychotic
N
ew!
Other s/e
• Atropine psychosis (geriatrics)
– Hyperactivity, agitation, confusion,
flushed skin, sluggish reactive pupils
– TTT: IM physostigmine
• Agranulocytosis (Clozapine)
– Occurs 3-8 wks after
– Medical emergency
– s/s: fever, malaise, sore throat,
leukopenia
– TTT: d/c, reverse iso, antibiotics
• Seizures (Clozapine)
– Occurs in 5% of patients; TTT: D/c drug
Anti-psychotic
Anticholinergics

Benztropine (Cogentin)
Trihexyphenidyl (Artane)
Biperiden (Akineton)
Procyclidine (Kemadrin)

• Not withdrawn abruptly


• Provide cool environment
ANTIPARKINSONIAN MEDICATIONS
• Adjunct to anti-psychotic agents to balance
dopamine/ acetylcholine in the brain
• s/e: glaucoma, tachycardia, HPN, cardiac
dx, asthma, duodenal ulcer
• A/e: blurred vision, photosensitivity,
drowsiness, orthostatic hypotension, CHF,
hallucinations
• COMMON DRUGS:
– Trihexyphenidyl (Artane)
– benztropine (Cogentin)
– Biperiden (Cogentin)
– Selegiline (Eldepryl)
– Pergolide (Permax)
• ANTIHISTAMINE
– Diphenhydramine HCl (BENADRYL)
• DOPAMINE RELEASING AGENT
– Amantadine (SYMMETREL)
• Nursing considerations
– Best taken after meals
– Avoid driving
– Check BP
– Alcohol increases sedative effects
– Avoid sudden position change
– Drug is not withdrawn abruptly
PSYCHIATRIC DISORDERS
ANXIETY DISORDERS
• PANIC DISORDERS
• SPECIFIC PHOBIA
• SOCIAL PHOBIA
• OCD
• PTSD
• ACUTE STRESS DISORDER
• GENERALIZED ANXIETY
DISORDER
ANXIETY DISORDERS
PANIC ATTACKS
• Discrete period of intense fear or
discomfort in which at least 4 if the ff
sx develop abruptly and peak within
10 mins:
– Palpitations, pounding heart, or
accelerated HR
– Sweating
– Trembling or shaking
– Sensations of SOB and smothering
– Feeling of choking
ANXIETY DISORDERS
– Chest pain or discomfort
– Nausea or abd. Pain
– Feeling dizzy, unsteady, lightheaded or
faint
– Derealization or depersonalization
– Fear of losing control or going crazy
– Fear of dying
– Paresthesias
– Chills or hot flashes

ANXIETY DISORDERS
SPECIFIC→ PHOBIA ← SOCIAL
• Excessive and • Fear of social
unreasonable cued performance
by the presence or situations in which
anticipation of a the person is
specific object or exposed to
situation unfamiliar people
• Defense mech or to possible
commonly used scrutiny by others
include repression
and displacement

ANXIETY DISORDERS
OBSESSION COMPULSION
• Recurrent and • Px feels driven to
persistent perform repetitive
thoughts, impulses, behaviors or
or images are mental acts in
experienced during response to
the disturbance as obsession or
intrusive and according to the
inappropriate rules that one
• Cause anxiety or deems must be
distress applied rigidly.
• Px knows that • Aimed at reducing
these are just anxiety
product of one’s
own mind. ANXIETY DISORDERS
OBSESSION COMPULSION
• Fear of dirt & germs • Excessive hand
• Fear of burglary or washing
robbery • Repeated checking of
• Worries about door and window locks
discarding something • Counting and
important recounting of objects
• Concerns about in everyday life
contracting a serious • Hoarding of objects
illness • Excessive
• Worries that things straightening,
must be symmetrical ordering, or of
or matching arranging things
• Repeating words or
prayers silently
ANXIETY DISORDERS
POST TRAUMATIC STRESS SYNDROME
• Person has experienced, witnessed or
been confronted with an event that
involved actual or threatened death
or serious injury, or a threat to
physical integrity
• Person reexperiences these in the
mind
• Involves intense fear, helplessness, or
horror and numbing of general
responsiveness (PSYCHIC NUMBING)

ANXIETY DISORDERS
ACUTE GENERALIZED
STRESS ANXIETY
• Meets the criteria • Excessive anxiety
for exposure to a or worry, occurring
traumatic event in more days than
and person not for at least 6
experiences 3 of mos, about a
the ff sx:
number of events
– sense of
detachment, or activities
– reduced awareness • Finds it difficult to
of one’s control the worry
surroundings,
– derealization,
– depersonalization,
– dissociated amnesia
ANXIETY DISORDERS
MOOD/ AFFECTIVE DISORDERS
• BIPOLAR D/O
– BIPOLAR I: current or past experience of
manic episode, lasting at least a week,
that is severe enough to cause extreme
impairment in social or occupational
functioning.
• MANIA: hyperactivity
• DEPRESSED: extreme sadness or withdrawal
• MIXED
– BIPOLAR II: hx of 1 or more mj depressive
episodes & at least 1 hypomanic episode;
no mania

MOOD DISORDERS
• MAJOR DEPRESSIVE D/O
– @ least 5 sx of same 2- wk period with
one being either depressed mood or loss
of interest or pleasure.
– Single episode or recurrent
– Other sx: wt loss, insomnia, fatigue,
recurrent thoughts of death, diminished
ability to think, psychomotor agitation or
retardation, feelings of worthlessness.

MOOD DISORDERS
• CYCLOTHYMIC D/O
– Hx of 2 yrs of hypomania with numerous
periods of abnormally elevated,
expansive or irritable moods.
– Does not meet the criteria of mania or
depression.
• DYSTHYMIC D/O
– @ least 2 yrs of usually depressed mood
and at least 1 of the sx of mj depression
without meeting the criteria for it
• SEASONAL AFFECTIVE D/O
– Depression that comes with shortened
daylight in fall and winter that disappears
during spring and summer.

MOOD DISORDERS
Dealing with Inappropriate Behaviors
AGGRESSIVE BEHAVIOR
• Assist the client in identifying feelings of
frustration and aggression
• Encourage the client to talk out instead of
acting out feelings of frustration
• Assist the client in identifying precipitating
events or situations that lead to
aggressive behavior
• Describe the consequences of the
behavior on self and others
• Assist in identifying previous coping
mechanisms
• Assist the client in the problem-solving
techniques to cope with frustration or
aggression
MOOD DISORDERS
DEESCALATION TECHNIQUES
• Maintain safety
• Maintain large personal space and use
nonaggressive posture
• Use calm approach and communicate with
a calm, clear tone of voice (be assertive
not aggressive
• Determine what the client considers to be
his or her need
• Avoid verbal struggles
• Provide clear options that deal with
behavior
• Assist with problem-solving and decision
making regarding the options MOOD DISORDERS
MANIPULATIVE BEHAVIORS
• Set clear, consistent, realistic, and
enforceable limits and communicate
expected behaviors
• Be clear about consequences
associated with exceeding set limits
• Discuss behavior in nonjudgmental
and nonthreatening manner
• Avoid power struggles
• Assist in developing means of setting
limits on own behavior
MOOD DISORDERS
SCHIZOPHRENIA
• characterized by impairments in the
perception or expression of reality and by
significant social or occupational
dysfunction.
• Once considered as a deadly disease
• There is lack of insight in behavior
• Dx: late adolescence and early adulthood
– 15-25 y.o. (men); 25-35 y.o. (women)
• Obsolete term: dementia praecox =
“cognitive deterioration early in life”
• Eugene Bleuler: schiz “split”; phren “mind”

SCHIZOPHRENIA
Risk factors
• Genetics: identical twins 50%, 15% for fraternal
twins
• Biochemical factors
– Dopamine hypothesis: overactive
– Serotonin imbalance
– Decreased brain volume, enlarged ventricles, deeper
fissures, and loss or underdeveloped brain tissue
• Psychoanalytic
– lack of trust during the early stages
– Weak ego
– Defenses: REPRESSION, REGRESSION, PROJECTION
• Environment influences: poverty, lack of social
support, hostile home environment, isolation,
unsatisfactory housing, disruption in
interpersonal relationships (divorce or death),
job pressure or unemployment

SCHIZOPHRENIA
Subtypes
• Catatonic type
– prominent psychomotor disturbances
are evident. Symptoms can include
catatonic stupor and waxy flexibility
• Disorganized type
– where thought disorder and flat affect
are present together
• Paranoid type
– where delusions and hallucinations are
present but thought disorder,
disorganized behavior, and affective
flattening are absent
SCHIZOPHRENIA
• Residual type
– where positive symptoms are
present at a low intensity only
• Undifferentiated type
– psychotic symptoms are present
but the criteria for paranoid,
disorganized, or catatonic types
has not been met

SCHIZOPHRENIA
Symptoms
According to Bleuler: 4 A’s
– Affect is inappropriate
– Associative looseness
– Autistic thinking
– Ambivalence

SCHIZOPHRENIA
Symptoms
• Positive symptoms
– delusions, auditory hallucinations and
thought disorder and are typically
regarded as manifestations of psychosis.
• Negative symptoms
– considered to be the loss or absence of
normal traits or abilities
– E.G. flat, blunted or constricted affect
and emotion, poverty of speech and lack
of motivation.

SCHIZOPHRENIA
Symptoms
• Social isolation
• Catatonic behavior
• Hallucinations
• Incoherence (marked looseness of association)
• Zero/ lack of interest, energy and initiative
• Obvious failure to attain expected level of dev’t
• Peculiar behavior
• Hygiene and grooming impaired
• Recurrent illusions and unusual perception
experiences
• Exacerbations and remissions are common
• No organic factors accounts for the symptoms
• Inability to return to baseline functioning after
relapse
• Affect is inappropriate
SCHIZOPHRENIA
Nsg Dx: Abnormal thought process
• BLOCKING: sudden cessation of a thought
in the middle of a sentence, unable to
continue the train of thought
• CIRCUMSTANTIALITY: before getting to the
point of answering a question, the
individual gets caught up in countless
details and explanations
• CONFABULATION
• LOOSENESS OF ASSOCIATION
• NEOLOGISM
• WORD SALAD

SCHIZOPHRENIA
Interventions
• Assess physical needs
• Set limits
• Maintain safety
• Initiate one-on-one interaction & progress
to small groups
• Spend time with clients
• Monitor for altered thought process
• Maintain ego boundaries, avoid touching
• Limit time of interaction
• Be neutral
• Do not make promises that can’t be kept
SCHIZOPHRENIA
• Establish daily routines
• Do not “go along” with the client’s
delusions or hallucinations
• Provide simple complete activities
• Reorient
• Speak to the client in simple direct
and concise manner
• Set realistic goals
• Explain everything that is being done
• Decrease stimuli
• Monitor for suicide risk
SCHIZOPHRENIA
• Environment
– Provide safe environment
– Limit stimuli
• Psychological Ttt
– Behavior therapy
– Social skills training
– Self-monitoring
• Social ttt
– Milieu therapy
– Family therapy
– Group therapy (long-term ttt)

SCHIZOPHRENIA
Related psychotic disorders
• SCHIZOAFFECTIVE DISORDER schiz +
mood disorder (mania/ depression)
• BRIEF PSYCHOTIC DISORDER sudden
onset of psychotic symptoms, lasts
less than 2 mos and client returns to
premorbid level of functioning
• SCHIZOPHRENIFORM DISORDER schiz
sx lasting between 1 month and
<6mos
• DELUSIONAL DISORDER
characterized by prominent,SCHIZOPHRENIA
PERSONALITY DISORDERS
• CLUSTER A (odd & eccentric)
– paranoid, schizoid, schizotypal
• CLUSTER B (bad, dramatic &
erratic)
– antisocial, borderline,
histrionic, narcissistic
• CLUSTER C (anxious & fearful)
– avoidant, dependent, OCD
PERSONALITY D/O
CLUSTER A: ODD & ECCENTRIC
• PARANOID
– chronic hostility projected to others; suspicious
and mistrusts people
– Seen mostly in men
• SCHIZOID
– social detachment = “loner” & “introvert”
– Restriction of emotions
– Attention fixed on objects rather than people
– Functions well in vocations
• SCHIZOTYPAL: interpersonal deficits
– Magical thinking, telepathy
– Apparent in childhood or adolescence

PERSONALITY D/O
Interventions for PARANOID D/O
• Asses for suicide risk
• Avoid direct eye contact
• Establish trusting relationship
• Promote increased self-esteem
• Remain calm, nonthreatening
and nonjudgmental
• Provide continuity of care
• Respond honestly to the client

PERSONALITY D/O
• Follow thru on commitments
• Provide a daily schedule of
activities
• Gradually introduce client to
groups
• Do not argue with delusions
• Use concrete, specific words

PERSONALITY D/O
• Do not be secretive with client
• Do not whisper in presence of client
• Assure that the client will be safe
• Provide opportunity to complete
small tasks
• Monitor eating, drinking, sleeping
and elimination patterns
• Limit physical contact
• Monitor for agitation and decrease
stimuli as needed

PERSONALITY D/O
CLUSTER B: ERRATIC, DRAMATIC, OR
EMOTIONAL
• ANTISOCIAL
– Syn: sociopath, psychopathic & semantic
d/o
– Etiology:
• Genetics interfere in the dev’t of positive
interpersonal relationships
• Brain damage or trauma
• Low socioeconomic status
• Faulty family relationships: neglect
• Secondary gains
– 15-40 y.o.
PERSONALITY D/O
• Signs
– Lack of remorse or indifference to
persons hurt
– Immediate gratification
– Failure to accept social norms
– Impulsivity
– Consistent irresponsibility
– Aggressive behavior
– Reckless behavior that disregards the
safety of others
• 80-90% of all crime is committed by
antisocials (NIHM, 2000)
ANTISOCIAL PERSONALITY D/O
• BORDERLINE
– Latent, ambulatory and abortive
schizophrenics
– Between moderate neurosis and
frank psychosis but quite stable
– Theories
• faulty separation from mother; parent
and child are bound by guilt
• Trauma at 18 mos (weakening of ego)
• Unfulfilled need for intimacy

BORDERLINE PERSONALITY D/O


• Signs
– instability
– Impulsivity: unpredictable gambling,
shoplifting, sex & substance abuse
– hypersensitivity, self-destructive,
profound mood shifts
– unstable & intense relations
– Disturbance in self concept
• Common in women
• Defenses: denial, projection, splitting,
projective identification
BORDERLINE PERSONALITY D/O
• HISTRIONIC
– Pattern of theatrical or overtly dramatic
behavior
– Signs
• Discomfort when the client isn’t the center of
attention
• Self-dramatization and exaggerated
emotions
• uses physical appearance, sexually seductive
and provocative behavior
• Excessively impressionistic speech lacking in
detail (labile emotions)
– Problems in dependence & helplessness
– More frequent in women
HISTRIONIC PERSONALITY D/O
• NARCISSISTIC
– Exaggerated or grandiose sense of self-
importance
– Develop early in childhood
– Preoccupied with fantasies of unlimited
success, power and beauty
– Signs
• arrogance, need for admiration,
• lack of empathy,
• seductive, socially exploitative, manipulative
– Occurs more in men

NARCISSISTIC PERSONALITY D/O


CLUSTER C: ANXIOUS OR FEARFUL
• AVOIDANT
– Sensitive to rejection, criticism,
humiliation, disapproval, or shame
– Interferes with participation in
occupational activities, dev’t of
relationships, and take personal risks
– social inhibition, longs for relationships
– Anxiety, anger and depression are
common
– Social phobia may occur
– Seen in 10% of clients in mental clinics

AVOIDANT PERSONALITY D/O


• DEPENDENT
– Lacks confidence and unable to function
in an independent role
– Allows other persons to be responsible
of their lives
– Most frequent personality disorder in the
mental health clinic
– submissive behavior, low self-esteem,
inadequate, helpless

DEPENDENT PERSONALITY D/O


• OBSESSIVE-COMPULSIVE
– Preoccupied with rules & regulations,
overly concerned about trivial detail,
excessively devoted to their work
– Depression is common
– Men are more affected than women

O-C PERSONALITY D/O


UNDER STUDY PERSONALITY D/O
• PASSIVE-AGGRESSIVE: sullen and
argumentative, resents others, resists
fulfilling responsibilities, complains of
being unappreciated
• DEPRESSIVE: gloomy, brooding
pessimistic, guilt-prone, highly critical
of self and others, cheerless.

PERSONALITY D/O
Interventions
• Maintain safety against self-destructive
behaviors
• Allow the client to make choices and be as
independent as possible
• Encourage the client to discuss feelings
rather than act them out
• Provide consistency in response to the
client’s acting out
• Discuss expectations and responsibilities
with the client
• Inform the client that harm to self, others,
and property is unacceptable
PERSONALITY D/O
• Identify splitting behavior
• Assist the client to deal directly with
anger
• Develop a written contract with the
client
• Encourage the client to participate in
group activities, and praise
nonmanipulative behavior
• Set and maintain limits
• Remove the client from group
situations in which attention-seeking
behaviors occur
• Provide realistic praise for positive
behaviors in social situations
PERSONALITY D/O
PSYCHOLOGICAL SEXUAL D/O
• Hypoactive sexual disorder
(asexuality)
• Sexual aversion disorder (avoidance
of or lack of desire for sexual
intercourse)
• Female sexual arousal d/o (failure of
normal lubricating arousal response)
• Male erectile d/o
• Female orgasmic disorder
• Male orgasmic disorder
SEXUAL DISORDERS
• Vaginismus
• Secondary sexual dysfxn
• Paraphilias
• Gender identity d/o
• PTSD due to genital mutilation or
childhood sexual abuse

Other sexual problems


• Sexual dissatisfaction (non-specific)
• Lack of sexual desire
• anorgasmia
• Impotence
• STD

SEXUAL DISORDERS
• Infidelity
• Delay or absence of ejaculation,
despite adequate stimulation
• Inability to control timing of
ejaculation
• Inability to relax vaginal muscles
enough to allow intercourse
• Inadequate vaginal lubrication
preceding and during intercourse
• Burning pain on the vulva or in the
vagina with contact to those areas
SEXUAL DISORDERS
• Unhappiness or confusion related to
sexual orientation
• Persistent sexual arousal syndrome
• Sexual addict
• hypersexuality
• Post Ejaculatory Guilt Syndrome, the
feeling of guilt after the male orgasm

SEXUAL DISORDERS
SEXUAL EXPRESSION
• HETEROSEXUALITY
• HOMOSEXUALITY
• BISEXUALITY
• TRANSVESTISM

SEXUAL DISORDERS
PARAPHILIAS
• EXHIBITIONISM: the recurrent urge or
behavior to expose one's genitals to
an unsuspecting person.
• FETISHISM: the use of non-sexual or
nonliving objects or part of a person's
body to gain sexual excitement.
Partialism refers to fetishes
specifically involving nonsexual parts
of the body.
• FROTTEURISM: the recurrent urges or
behavior of touching or rubbing
against a nonconsenting person.
SEXUAL DISORDERS
• SEXUAL MASOCHISM: the recurrent
urge or behavior of wanting to be
humiliated, beaten, bound, or
otherwise made to suffer.
• SEXUAL SADISM: the recurrent urge
or behavior involving acts in which
the pain or humiliation of the victim is
sexually exciting.
• TRANSVESTIC FETISHISM: a sexual
attraction towards the clothing of the
opposite gender.
SEXUAL DISORDERS
• PEDOPHILIA: the sexual attraction to
prepubescent or peripubescent
children.
• VOYEURISM: the recurrent urge or
behavior to observe an unsuspecting
person who is naked, disrobing or
engaging in sexual activities, or may
not be sexual in nature at all.

SEXUAL DISORDERS
• Other paraphilias not otherwise
specified ("Sexual Disorder NOS")
– telephone scatalogia (obscene phone
calls)
– necrophilia (corpses)
– partialism (exclusive focus on one part of
the body)
– zoophilia(animals)
– coprophilia (feces)
– klismaphilia (enemas)
– urophilia (urine)

SEXUAL DISORDERS
SOMATOFORM D/O
• SOMATIZATION D/O: hx of many physical
complaints beginning before the age of 30
occurring over a pd of several yrs resulting
in ttt being sought or significant
occupational or social fxning.
• CONVERSION D/O: 1 or more sx of deficits
affecting voluntary motor or sensory
function suggesting a neurological or
general medical condition; preceded by
conflicts or stressors; can’t be explained
and sanctioned by cultural behavior.
– Most common: blindness, deafness, paralysis,
inability to talk
– “La belle indifference”
• HYPOCHONDRIASIS: preoccupation
with fears of having, or ideas that one
has, a serious dse based on the
person’s misinterpretation of bodily sx
and persist despite appropriate
medical eval and reassurance and has
existed for @ least 6 mos.
(e.g.:extensive use of home remedies)
• PAIN D/O: pain in 1 or more
anatomical sites severe enough to
warrant clinical attention and causes
clinically significant distress or
impairment in fxning.
Interventions
• Do not reinforce the sick role
• Discourage verbalization about
physical symptoms by not responding
with positive reinforcement
• Explore with the client the needs
being met by the physical symptoms
• Convey understanding that the
physical symptoms are real to the
client
• Report and assess any new physical
complaint
EATING DISORDER BEHAVIORS
• BINGE: rapid consumption of large
quantities of food in a discrete period of
time. (A: hundrends of Cal; B: thousands of
Cal at a sitting)
• PURGE: Maladaptive eating regulation
response that includes excessive exercise,
forced vomiting, OCD Rx diuretics, diet
pills, laxatives and steroids.
• FAST/ RESTRICT: Includes vegetarian diet
eliminating all meat without substituting
nonanimal sources of protein, OC about
food choices, and eating habits.
EATING DISORDERS
ANOREXIA BULIMIA
• Rare vomiting or • Frequent
diuretic/laxative abuse • Less wt loss
• More severe wt loss • Slightly older
• Slightly younger • More extroverted
• More introverted • Hunger experienced
• Hunger denied • Eating behavior
• Eating behavior may considered foreign and
be considered normal source of distress
and a source of • More sexually active
esteem • Avoidant, dependent,
• Sexually inactive or borderline features
• Obsessional and as well as obsessional
perfectionist features features
dominate EATING DISORDERS
ANOREXIA BULIMIA
complications
• Death from • Death from
starvation (or hypokalemia or
suicide, in suicide
chronically ill) • Menses irregular or
• Amenorrhea absent
• Drug and alcohol
• Fewer behavioral abuse, self-
problems (these mutilation, and
increase with level other behavioral
of severity) problems

EATING DISORDERS
DELIRIUM
• The medical dx term that describes an organic
mental disorder characterized by a cluster of
cognitive impairments with an acute onset with a
specific precipitating factor.
• Sx: diminished awareness of the environment,
disturbances in psychomotor activity and sleep-
wake cycle.
• COGNITIVE: the mental process characterized by
knowing, thinking, and judging.
– COGNITIVE DISSONANCE: arises when 2 opposing beliefs
exists at the same time.
– COGNITIVE DISTORTIONS: (+) or (-) distortions of reality
that might include errors of logic, mistakes in reasoning,
or individualized view of the world that do not reflect
reality.
– Term: confusion = cognitive impairment
» See dementia

COGNITIVE DISORDERS
DEMENTIA
• The medical dx term that describes an
organic mental d/o characterized by a
cluster of cognitive impairments of
generally gradual onset and irreversible
without identifiable precipitating
stressors.
• Types:
– VASCULAR or MULTI-INFARCT
– VASCULAR WITH ALZHEIMER’S DSE
– AD: most common
– DEMENTIA WITH LEWY BODIES: 2nd most
common; neurofilament material
– PARKINSONIAN DEMENTIA
– AIDS DEMENTIA COMPLEX

COGNITIVE DISORDERS
– FRONTAL LOBE DEMENTIA or PICK’S
DSE: cytoplasmic collections; 3rd most
common; loss of expressive language &
comprehension
– CREUTZFELDT-JAKOB DSE: prion
(proteinaceous infectious particles) = spongy
brain; related to TSE & BSE in mad cow
dse
– CORTICOBASAL DEGENERATION or
HUNTINGTON’S DSE/CHOREA: jerky
mov’ts
– SUPRANUCLEAR PALSY: clumping of
protein tau = slow mov’t, weak eye
mov’t (esp. downward), impairedCOGNITIVE DISORDERS
• Reversible Causes:
– Subdural hematoma
– Tumor (meningioma)
– Cerebral vasculitis
– Hydrocephalus
• Terms: disorientation, memory loss
(sensory, primary, secondary, tertiary,
working memory), confabulation, confusion
• Disturbing behaviors
– Aggressive psychomotor
– Nonaggressive psychomotor
– Verbally aggressive
– Passive
– Functionally impaired: loss of ability to do self-
care
COGNITIVE DISORDERS
DELIRIUM vs. DEMENTIA
• Rapid onset w/ wide • Gradual, chronic
fluctuations with continuous
• Hyperalert to decline
difficult to arouse • Normal LOC
LOC • Labile affect
• Fluctuating affect • Disoriented,
• Disoriented, confused Attention
confused intact, sleep
• Attention & sleep usually normal
disturbed • Memory impaired
• Memory impaired • Disordered
• Disordered reasoning &
reasoning calculation
COGNITIVE DISORDERS
DELIRIUM vs. DEMENTIA
• Incoherent, • Disorganized, rich
confused, in content,
delusional, delusional,
stereotyped paranoid
• Illusions, • No change in
hallucinations perception
• Poor judgment • Poor judgment
• Insight may be • No insight
present in lucid • Consistently poor &
moment progressively
• Poor but variable in worsens in MSE
MSE COGNITIVE DISORDERS
ALZHEIMER’S DEMENTIA
• Most common type of dementia
• Stages:
– MILD: impaired memory, insidious loses
in ADL, subtle personality changes,
socially normal
– MODERATE: obvious memory loss,
overt ADL impairment, prominent
behavioral difficulties, variable social
skills, supervision needed
– SEVERE: fragmented memory, no
recognition of familiar people,
assistance needed with basic ADL,
fewer troublesome behaviors, reduced
mobility (4 A’s)
COGNITIVE DISORDERS
Symptoms
• AGNOSIA: Difficulty recognizing well-
known objects
• APHASIA: Difficulty in finding the
right word
• APRAXIA: Inability or difficulty in
performing a purposeful organized
task or similar skilled activities
• AMNESIA: Significant memory
impairment in the absence of
clouded consciousness or other
cognitive symptoms
COGNITIVE DISORDERS
PSYCHIATRIC D/O IN CHILDREN
• MENTAL RETARDATION
• PERVASIVE DEV’TAL D/O
– AUTISM
– RETT’S D/O
– CHILDHOOD DISINTEGRATIVE D/O
– ASPERGER’S D/O
– PDD NOS
• LEARNING D/O
– READING
– MATHEMATICS
– WRITTEN EXPRESSION
– ACADEMIC PROBLEM
– LEARNING D/O NOS
CHILDHOOD DISORDERS
• MOTOR SKILLS D/O
• COMMUNICATION D/O
– EXPRESSIVE LANGUAGE
– MIXED RECEPTIVE/EXPRESSIVE
– PHONOLOGICAL
– STUTTERING
– SELECTIVE MUTISM
– COMMUNICATION D/O NOS
• MOV’T & TIC D/O
– DEV’TAL COORDINATION
– TRANSIENT TIC

CHILDHOOD DISORDERS
– CHRONIC MOTOR&VOCAL TIC
– TOURETTE’S D/O
– STEREOTYPIC MOV’T D/O
– TIC D/O NOS
• DISORDERS OF INTAKE &
ELIMINATION
– PICA
– RUMINATION
– FEEDING D/O
– ENURESIS
– ENCOPRESIS
– OTHER: BULIMIA, ANOREXIA
CHILDHOOD DISORDERS
• ADHD & DISRUPTIVE BEHAVIOR D/O
– ADHD
– ADHD NOS
– CONDUCT D/O
– OPPOSITIONAL DEFIANT
– CHILD ANTISOCIAL
– DISRUPTIVE BEHAVIOR NOS
• MOOD D/O
– MJ DEPRESSIVE D/O
– BIPOLAR I OR II
– DYSTHYMIC
– MIXED EPISODE
– HYPOMANIC EPISODE
– MOOD D/O DUE TO MEDICAL CONDITION
– SUBSTANCE-INDUCED MOOD D/O

CHILDHOOD DISORDERS
• ANXIETY D/O
• D/O OF RELATIONSHIP
– SEPARATION ANXIETY
– REACTIVE ATTACHMENT OF INFANCY OR
EARLY CHILDHOOD
– PARENT-CHILD RELATIONAL PROBLEM
– SIBLING RELATIONAL PROBLEM
– PROBLEMS RELATED TO ABUSE OR
NEGLECT

CHILDHOOD DISORDERS
MENTAL RETARDATION
• an IQ below 70, significant limitations in two or
more areas of adaptive behavior (i.e., ability to
function at age level in an ordinary environment),
and evidence that the limitations became
apparent in before 18 y.o.
• The following ranges, based on the
Wechsler Adult Intelligence Scale (WAIS), are in
standard use today:
• Class IQ Terms
Profound Below 20 Idiot
Severe 20–34 Imbecile
Moderate 35–49 Moron
Mild 50–69
Borderline 70–79
CHILDHOOD DISORDERS
RETT’S D/O
• Development is normal until 6-18 months,
when language and motor milestones
regress,
• purposeful hand use is lost
• Acquired deceleration in the rate of head
growth (resulting in microcephaly in some)
• Hand stereotypes are typical and breathing
irregularities such as hyperventilation,
breath holding, or sighing are seen in
many.
• Early on, autistic-like behavior may be
seen CHILDHOOD DISORDERS
CHILDHOOD DISINTEGRATIVE D/O or
HELLER’S SYNDROME
• CDD has some similarity to autism,
but an apparent period of fairly
normal development is often noted
before a regression in skills or a
series of regressions in skills.
• characterized by late onset (>3 years
of age) of dev’tal delays in language,
social function and motor skills; skills
apparently attained are lost
CHILDHOOD DISORDERS
ASPERGER’S D/O
• characterized by difference in language and
communication skills, as well as repetitive or
restrictive patterns of thought and behavior.
• Signs: unable to interpret or understand the
desires or intentions of others and thereby are
unable to predict what to expect of others or what
others may expect of them
– Narrow interests or preoccupation with a subject to the
exclusion of other activities
– Repetitive behaviors or rituals
– Peculiarities in speech and language
– Extensive logical/technical patterns of thought
– Socially and emotionally inappropriate behavior and
interpersonal interaction
– Problems with nonverbal communication
– Clumsy and uncoordinated motor mov’ts

CHILDHOOD DISORDERS
CHRONIC MOTOR/ VOCAL TIC
• TIC is a sudden, repetitive,
stereotyped, nonrhythmic,
involuntary movement (motor tic) or
sound (phonic tic) that involves
discrete groups of muscles.
• can be invisible to the observer (e.g.
abdominal tensing or toe crunching)

CHILDHOOD DISORDERS
TOURETTE’S D/O
• characterized by the presence of
multiple physical (motor) tics and at
least one vocal (phonic) tic; these tics
characteristically wax and wane
• TTT: Neuroleptic medications
– haloperidol (Haldol)
– pimozide (Orap)

CHILDHOOD DISORDERS
ADHD
Inattention: Hyperactivity-impulsive
• Failure to pay close attention to behaviour
details or making careless mistakes • Fidgeting with hands or feet or
when doing schoolwork or other
activities squirming in seat
• Trouble keeping attention focused • Leaving seat often, even when
during play or tasks inappropriate
• Appearing not to listen when spoken • Running or climbing at
to inappropriate times
• Failure to follow instructions or finish • Difficulty in quiet play
tasks
• Avoiding tasks that require a high
• Frequently feeling restless
amount of mental effort and • Excessive speech
organization, such as school projects • Answering a question before
• Frequently losing items required to the speaker has finished
facilitate tasks or activities, such as • Failure to await one's turn
school supplies
• Excessive distractibility • Interrupting the activities of
• Forgetfulness others at inappropriate times
• Procrastination, inability to begin an • Impulsive spending, leading to
activity financial difficulties
• Difficulties with household activities
(cleaning, paying bills, etc.)
• Difficulty falling asleep, may be due
to too many thoughts at night
• Frequent emotional outbursts CHILDHOOD DISORDERS
• Frequently prescribed stimulants are
methylphenidate (Ritalin and
Concerta), amphetamines (Adderall)
and dextroamphetamines
(Dexedrine)
• Feingold diet which involves
removing salicylates, artificial colors
and flavors, and certain synthetic
preservatives from children's diets.

CHILDHOOD DISORDERS
CONDUCT D/O
• repetitive and persistent pattern of
behavior in which the basic rights of
others or major age-appropriate
societal norms or rules are violated,
– AGGRESSION TO PEOPLE & ANIMALS
– DESTRUCTION OF PROPERTY
– DECEITFULNESS OR THEFT
– SERIOUS VIOLATIONS OF RULES
• Beginning before age 13

CHILDHOOD DISORDERS
OPPOSITIONAL DEFIANT
• characterized by an ongoing pattern of
disobedient, hostile, and defiant behavior toward
authority figures that goes beyond the bounds of
normal childhood behavior
• Signs
– Losing temper
– Arguing with adults
– Refusing to follow the rules
– Deliberately annoying people
– Blaming others
– Easily annoyed
– Angry and resentful
– Spiteful or even revengeful
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CHILDHOOD DISORDERS
SUBSTANCE ABUSE
• Excessive or unhealthy use of substances,
such as alcohol, tobacco or drugs, or use of
products such as food
• Terms:
– TOLERANCE: the declining effect of the same
drug dose when it is taken repeatedly over time
– HABITUATION: a psychological dependence of
the use of a drug
– ADDICTION: the biological and/ or psychological
behaviors related to substance dependence
– WITHDRAWAL SYMPTOMS: result from a
biological need that develops when the body
becomes adapted to having an addictive drug
in the system; occurs when serum levels
decrease SUBSTANCE ABUSE
ADDICTION
• ALCOHOL: blood alcohol levels of 0.1%
(100mg alcohol/dl of blood) or higher
– WITHDRAWAL
• Anorexia
• Anxiety
• Easily startled
• Hyperalertness
• HPN
• Insomnia
• Irritability
• Jerky mov’t
• Possibly: hallucinations, illusions or vivid nightmares
• Seizures (7-48 hrs after cessation)
• Tachycardia
• tremors
SUBSTANCE ABUSE
– WITHDRAWAL DELIRIUM
• Agitation
• Anorexia
• Anxiety
• Delirium
• Diaphoresis
• Disorientation with fluctuating levels of
consciousness
• Fever (100 to 103 F)
• Hallucinations and delusions
• Insomnia
• Tachycardia and HPN
– Disulfiram (Antabuse) therapy

SUBSTANCE ABUSE
Nursing care
• Obtain info about drug type and amount
consumed
• Assess v/s
• Remove unnecssary obj from environment
• Provide one-on-one supervision if necessary
• Provide a quiet, calm environment with
minimal stimuli
• Maintain orientation
• Ensure safety
• Use restraints
• Provide physical needs
• Provide food and fluids as tolerated
• Administer medications
• Collect blood and urine samples for drug
SUBSTANCE ABUSE
SPOUSE ABUSE
• Battering precipitates 1:4 suicide attempts
of all women
• Wives explain the injuries as being self-
inflicted or accidental
• Phases
– Tension-building: series of small incidents that
leads to beating
– Acute beating phase: wife becomes object of
assault behavior
– Loving phase: batterer is remorseful and
assures spouse that he will not harm her again.
This leads to reconciliation.
ABUSE
• Myths
– They believe that if they try not to antagonize
with their husband, he will change.
– Efforts to coerce the wife out of the victim role
can be fruitful.
• Facts
– Women stay in relationships with men who
batter because they feel guilty or responsible of
the husband’s behavior
– Wife develops little sense of self-worth,
immobilized and unable to remove self from the
relationship.
• Assessment: injuries, other evidence
• Interventions: with consent
ABUSE
CHILD ABUSE
•PHYSICAL BATTERING
•EMOTIONAL
•SEXUAL
•NEGLECT

ABUSE
ELDERLY ABUSE
• A variety of behaviors that threaten
the health, comfort, and possibly the
lives of the elderly, including physical
and emotional neglect, emotional
abuse, violation of personal rights,
financial abuse, and direct physical
abuse.
• Commonly committed by care givers.

ABUSE
SEXUAL ABUSE
• Components
– Sexual Misuse: inappropriate sexual
activity
– Rape: there is actual penetration
– Incest: refers to the relationship
between the victim and abuser blood
relative or step parent role
• Interventions
– Children: thru play or role playing with
puppets
– Prevention of further sexual abuse
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ABUSE
COMPLETED SUICIDE
• Self-inflicted death

• LEVELS OF SUICIDE
– Ideation: thought
– Attempt: acted upon but failed
– Completed

SUICIDE
CHEMICAL RESTRAINT
• CHEMICAL RESTRAINTS: Medications used
to restrict the patient’s freedom of
movement or for emergency control of
behavior but are not a standard treatment
for the px’s medical or psychiatric
condition.
• PHYSICAL RESTRAINTS: Are any manual
method or physical or mechanical device
attached to or adjacent to the px’s body
that he or she cannot easily remove and
that restricts freedom of movement or
normal access to one’s body, material or
equipment.
SECLUTION AND RESTRAINTS
• SECLUTION: the involuntary
confinement of a person alone in a
room from which the person is
physically prevented from leaving.
– No therapeutic evidence other than a
last resort to ensure safety.
– Evidence suggest that it adds to further
trauma and physical harm
• GUIDELINES
– All hospital staff who have direct contact with
the px should have ongoing education and
training in the proper use of seclusion and
restraints and other alternatives
– Physician or licensed practitioner should
evaluate need within 1 hour after the initiation
of this intervention.
– Max of 4 hours for adults, 2 hours for ages 9-
17, and 1 hour for children under 9 yrs
– Orders may be renewed for 24 hrs before
another face to face evaluation
– Continuous assessment, monitoring and
evaluation; recorded
– Good nursing care
– For both restrained and secluded: constant
monitoring face to face or by both audio and
video equipment.
– Px should be released ASAP
OTHER GUIDELINES
• SECLUSION • RESTRAINTS
– Room should allow – Give support &
observation and reassurance
communication with – Position in
px anatomical position
– Remove all items – Privacy is important
that px might use to – v/s & Circulation
harm self check
– Should be released
– Document: rationale,
q 2hrs
response to
– Avoid tying to the
intervention, side rails of bed
physical condition,
– Assist in periodic
nsg care, & rationale change in body
for termination positions
TERMINATING THE INTERVENTION
• As soon as met the criteria for
release
• Review with px the behavior that
precipitated the intervention & px’s
capacity to exercise control over
behavior
• DEBRIEFING: reviewing the facts
related to an event & processing the
response to them; can be used after
any stressful event
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THERAPEUTIC IMPASSES
• Are blocks in the progress of the
nurse-pt relationship
• Provokes intense feelings in both the
nurse and patient
– RESISTANCE
– TRANSFERENCE
– COUNTERTRANSFERENCE
– BOUNDARY VIOLATIONS
RESISTANCE
• Reluctance or avoidance of
verbalizing or experiencing troubling
aspects of oneself
• Eg: suppression or repression,
intensification of sx, self-devaluation
or hopelessness, intellectual
inhibitions, acting out or irrational
behavior, superficial talk, intellectual
insight/ intellectualization,
transference reactions.
TRANSFERENCE
• Unconscious response in which the px
experiences feelings and attitudes
toward the nurse that were originally
associatated with other significant
figures in his or her life.
– HOSTILE TRANSFERENCE: anger and
hostility, resistance
– DEPENDENT TRANSFERENCE:
submissive, subordinate and regards the
nurse as a god-like figure; views
relationship as magical
What do you do?
•LISTEN
•CLARIFY
•REFLECT
•EXPLORE/ ANALYZE
COUNTERTRANSFERENCE
• Created by the nurse’s specific emotional
response to the qualities of the patient;
inappropriate in the context, content and
intensity of emotion; nurses identify the px
with individuals from their past, and
personal needs
• Types: Reactions of INTENSE
– love or caring
– Disgust or hostility
– Anxiety, often in response to resistance
by the px
• Eg.
– Difficulty empathizing
– Feelings of depression before or after the
session
– Carelessness about implementing the contract
– Drowsiness during the sessions
– Encouragement of the px’s dependency
– Arguments with the px
– Personal or social involvement with the px
– Sexual or aggressive fantasies toward the px
– Tendency to focus on only one aspect or way of
looking at information presented by the px
– Attempts to help the px with matters not related
to the identified nursing problems
– Feelings of anger or impatience because of the
px’s unwillingness to change
– Dreams about or preoccupation with the px

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