FUNDAMENTAL CONCEPTS

MENTAL HEALTH
– Is a state of emotional, psychological,
and social wellness evidenced by:
Satisfying interpersonal
relationships
Effective behavior and coping
Positive self-concept
Emotional stability
Self-awareness

1
Factors Affecting Mental Health:
• Mastering the Environment
• Reality orientation
• Stress Management
• Maximizing One’s Potential
• Autonomy and Independence
• Tolerating One’s Uncertainties
• Self-esteem

“MRS MATS”

2
STRESS
• is any biopsychosocial (external or
internal) experiences that one views as
demanding, challenging, and
threatening;

• Also char as:

– It is recurring.
– It is normal.
– It cannot be avoided.
– It is caused by a stressor.

3
STRESSOR
– is any condition, event, or agent
that increases the activity of the
Sympathetic NS;

• Stress Adaptation Syndrome (SAS)

“A R E”
1. Stage I – ALARM
– Activation of the SNS (or the Fight-
or-Flight Response)
– Increase epinephrine, NE, and
cortisol.
– Client is alert with increase anxiety.
4
1. Stage II – RESISTANCE
• Hormone readjustment;
• Decrease in size and activity of the
adrenal cortex;
• Increase use of defense mechanism;

2. Stage III – EXHAUSTION

• Loss of ability to stop stress;
• Exaggerated defense-oriented
behavior;
• Disorganized thinking and personality;
• May show signs of illusion,
hallucination and delusions;
• Client may be stuporous or violent
(PANIC)
5
GRIEF
– is a powerful emotional reaction to a
separation or loss from something that
is/are very valuable;

– is SELF-LIMITING;

– Stages of Death and Dying (Kubler-Ross)

“DABDA”
a. Denial
b. Anger
c. Bargaining
d. Depression
e. Acceptance

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• DENIAL
– “She’s not dead! She’s still alive!”

• ANGER
– “You’re the reason she’s dead!!!”

• BARGAINING
– “God, take me.. Spare her…”

• DEPRESSION
– “I’m not hungry, I just want to be alone.”

• ACCEPTANCE
– “At least she no longer have to suffer.”
– “He is in the presence of our Creator.”

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• CONCEPT OF DEATH:
1. TODDLER
– “No specific concept of death yet.”
– Reacts more to pain and discomfort;
– Separation anxiety may be felt;
– Focus is on the feelings of the
parents;

2. PRESCHOOL
– Death is like SLEEP;
– Or a form of PUNISHMENT;
– May use PLAY as a method of
therapy;

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1. SCHOOL AGE
– Death is personified or as a final stage
of life;

– May fear mutilation or punishment;

– Accept regressive or protest behavior

from the client;

– Encourage verbalization of feelings;

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1. ADOLESCENT
– Have MATURE understanding of death;

– May show strong emotions about death

(sadness, silence, anger, withdrawn)

– Encourage verbalization of feelings;

– Respect need for privacy and

expression of grief;

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1. ADULT
– Death is disruption of lifestyle;
– Effects of death to significant others;

2. OLDER ADULT (Elderly)

– Emphasis on religious beliefs for
comfort;
– Time for reflection, rest or peace;

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TRANSFERENCE
– is the unconscious transfer of special
feelings from a client to the nurse or
therapist.

COUNTERTRANSFERENCE
– Is the projection of the therapist’s
feelings about a significant other to
the patient during therapy;

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CRISIS
• Is an imbalance of the internal
equilibrium that results from a
stressor or threat to the patient;

Client is in bad situation

Problem-solving inadequate

Cannot immediately neutralize the stressor

CRISIS
13
• Types of Crisis:
• Maturational – growth and
development (identity
crisis, midlife crisis)

• Situational – unexpected
events (death, loss)

• Social – major disaster

(landslide, typhoon)

14
• Crisis is characterized by:
– Self-limiting, only last for 4-6
weeks

– Individualized - every person

have their own reaction.

– Person becomes passive and

submissive.

– Alteration in support system.

15
• Stages of a Crisis: (DIDA)
• Denial – first reaction;

• Increase tension – the person

recognizes the crisis but
continues to function;

• Disorganization – the person is

pre-occupied to solve the
conflict and alters his ADL;

• Attempts to reorganize – by
using his coping mechanism;

16
CRISIS INTERVENTION

• Aims to restore the person to a pre-

crisis state of functioning;

• Focuses on resolving the immediate

crisis;

17
 DEFENSE MECHANISMS
REPRESSION
Unconscious and involuntary forgetting of
painful ideas, events and conflicts.

– A nursing student who failed the recent

board exam, can’t remember any of the
questions asked.

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DEFENSE MECHANISMS

SUPPRESSION
Voluntary exclusion from
awareness, anxiety-producing
feelings, ideas and situations.

– A nursing student states, “I

cannot talk about my recent
board, please change the topic.”

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DEFENSE MECHANISMS

DENIAL
• Unconscious refusal to admit an
unacceptable idea or behavior.
• Sometimes mistaken for rationalization.

“I’m not drunk… I can still

drive…”

20
Alcoholics
Battered wives
DENIAL
Anorexia nervosa
Drug dependents

21
DEFENSE MECHANISMS
RATIONALIZATION
Attempts to make or prove that one’s
feelings or behaviors are justifiable.

– A student states, “I failed the recent

board exam because there was a
leakage and it doesn’t had any
credibility.”

22
DEFENSE MECHANISMS

INTELLECTUALIZATION
Using only logical explanations
without feelings or an affective
component.

An examinee explains how she

passed the NLE but hardly
showed any emotion regarding
the leakage.

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DEFENSE MECHANISMS

IDENTIFICATION
• A conscious or unconscious attempt
to model oneself after a respected
person.

– “I want to be just like you… a

very good reviewer …… nurse….
and ……… cheater.”

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DEFENSE MECHANISMS

INTROJECTION
Unconsciously incorporating
wishes, values, attitudes of others
as if they were your own.

While her mother is gone, a

young girl disciplines her brother
just like her mother would.

25
DEFENSE MECHANISMS

COMPENSATION
Covering up for a weakness by
overemphasizing or making up a
desirable trait.

An academically weak high

school student was sworn as
the new president of the
supreme SC.

26
DEFENSE MECHANISMS

REACTION FORMATION
A conscious behavior that is the
exact opposite of an unconscious
feeling.

An older brother who dislikes his

younger brother sends him gifts
for every holiday.

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DEFENSE MECHANISMS

SUBLIMATION
Channeling instinctual drives into
acceptable activities.

A former NPA hitman, talks about

the importance of life,
democracy, justice, and following
laws of the land.”

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DEFENSE MECHANISMS

DISPLACEMENT
Discharging pent-up feelings to a
less threatening object.

After the board exam, Andy went

directly to his room and smashed
his reading table.

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DEFENSE MECHANISMS

UNDOING
Doing something to counteract or
make up for a transgression or
wrongdoing.

After hitting his wife, Venicio

offered jewelries and money to
her.

30
DEFENSE MECHANISMS
PROJECTION
Blaming someone else for one’s
difficulties or placing one’s
unethical desires on someone else.
Involves in the development of
DELUSIONS;

A nursing graduate blamed a

dean of a nursing school in Recto
for not passing the nursing exam.
31
DEFENSE MECHANISMS

CONVERSION
• The unconscious expression of
intrapsychic conflict symbolically
through physical symptoms.

A nursing student suddenly went

blind after her recent nursing
board exam.

32
DEFENSE MECHANISMS

DISSOCIATION
• The unconscious separation of
painful feelings and emotions from
an unacceptable idea, situation, or
object.

A pretty nurse tells how

important to review months
before the board exam…. But
failed to remember her past
board failures. 33
DEFENSE MECHANISMS

REGRESSION
Return to earlier and more comfortable
developmental level.

An examinee went directly to her room

and sleeps in fetal position and thumb
sucks after knowing she failed the
board exam……..…… for physicians.

34
SELF - AWARENESS
• T he n ur se’s goal is t o a chieve
auth entic , o pen, a nd p er sonal
comm unic ation;

• T he n ur se must b e a ble to
examine per sonal feelin gs a nd
reactio ns ;

• A g ood under st anding and

acceptance of self allo w th e
nur se to a cknowle dge a
patie nt’s d if ferences and
uniqueness;
35
• QUADR ANT 1
– Is the o pe n quadr ant;

– “ kno wn to sel f and other s”

36
• QUADR ANT 2
– Is the b li nd quadr ant;

– “ Kno wn o nl y to OTH ERS,

unkno wn to sel f.”

37
• QUADR ANT 3
– Is the h id den qu adr ant;

– “ Kno wn O NLY to se lf ”

38
• QUADR ANT 4
– Is the u nk nown qu adr ant;

– “ Unk nown to the sel f and

to other s”

39
 1 2
Known to s elf Kn own o nly t o
and o th ers others

3 4
Kn own o nly t o Known neither
self to s elf nor to
others

JOHA RI WIN DOW

40
• T he f ollo wi ng th ree prin cip le s
help explain h ow t he self
fu nctio ns:
– A c hange in a ny o ne q uadrant
af fects a ll oth er q uadrants .

– T he s ma lle r q uadrant 1, the

poorer the c ommu nicatio n.

– W hen q uadrant 1 i s l ar ger

and o th er q uadrants a re
smalle r, “in ter per sonal
le ar ning is sig nifi cantl y
41
STE P 1
– T he g oal o f i ncreasing self-
awareness is “t o enlar ge t he
area of quadrant 1 whil e
reducin g th e size o f t he oth er
three q uadrants .”

– To i ncrease s elf-k nowledge, it

is necessar y to lis te n to th e
self;
– T he i ndivid ual allo ws g enuin e
emotio ns to b e e xperie nced,
and i dentifie s and accepts
per sonal n eeds; 42
STE P 2
– Reduce the siz e o f q uadrant 2
by LIS TE NIN G T O A ND
LEARNING F ROM O TH ER S ;

– As w e rela te to o ther s, we
broaden o ur SE LF-
PERCEPTIO NS ;

– Requir es activ e lis te ning and

openness to the f eedback
other s provid e;
43
STE P 3
– Reduce the siz e o f q uadrant 3
by self-dis clo sing or r evealin g
to o th er s imp or ta nt a spects of
the s elf ;

– SELF-DI SC LOSU RE i s b oth a

sig n o f p er so nali ty health a nd
a m eans o f a chie vin g h ealth y
per sonality ;

44
PSYCHOANALYTICAL MODEL
(or Psychodynamic Theory)

• By Sigmund Freud;

• Emphasizes unconscious processes or

psychodynamic factors as the basis for
motivation and behavior;

• Personality is developed by early childhood;

45
• Three Processes:
• Id – present at birth; wants to
experience only pleasure (pleasure
principle)

• Uses fantasies and images to seek

pleasure;
• Compulsive and acts without
morals;
• Ex. “I want to eat… sleep….. drink…

46
1. Ego – controls id impulses and mediates
between id and reality;

» Focuses on reality principle;

» Maintains contact with reality;

» Strives to meet the demands of the id

while maintaining the well-being of the
individual;

» Altered in client with anti-social PD;

47
 Superego – human conscience that directs
and controls thoughts and feelings;
 Concerned with right and wrong;

 “Small voice of GOD within us”

 Provides the ego with an inner control

to help cope with the id;

 Delays pleasure from id;

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 ID EGO SUPEREGO

Mania Schizophrenia Depression

Nascissistic Psychosis Anxiety
Anti-social PD OCD
(increase)
Anorexia n.
Anti-social PD
(decrease)

49
PSYCHOSEXUAL DEVELOPMENT

A. Oral Stage (birth – 18 months)

 Oral gratification;

 Child learns to handle anxiety by using the

oral cavity (biting and sucking activities)

 Infants explore the environment or assess an

object using their oral cavity.

50
A. Anal Stage (18 – 36 months)
 Child learns to control muscles, especially
those that control urination and defecation;

 Develops awareness of fullness of the

rectum;

 Takes pleasure in retaining or eliminating

feces;

 Acquisition of voluntary sphincter control

(TOILET TRAINING)
 Bowel Control – 18 months.
 Daytime Bladder Control – 30 months.
 Nocturnal Bladder Control – 36 months.
51
• Clues for Toilet Training:

stand alone.
walk steadily.
be dry of at least 2 hours.
demonstrate awareness of
defecating and voiding.
use words and gestures
regarding toilet need and
training.
please the PCG.

52
A. Phallic or Oedipal Stage (3 – 5 years old)

 Child takes pleasure in exploring and

manipulating the genitalia;

 Penis is the organ of interest for both sexes;

 Penis envy for girls;

 Fear of castration for boys due to oedipal

feeling to the mother;

 Attracted and wants to marry the opposite-

sex parent (Oedipal complex)

 Physiologic homosexuality may also be seen

in this stage.
53
A. Latency Stage (6 – 12 years old)

 Sexual development and energy are

quiescent;

 Resolution of the oedipal complex;

 Sexual drive is channeled into socially

appropriate activities such as school
work or sports;

54
A. Genital Stage (12 – 13 years old)

 Sexual interest emerges as the person

strives to develop satisfactory
relationships with potential sex
partners (intimacy)

 Corresponding with genital maturation

which result to sexual awakenings;

55
PSYCHOSOCIAL MODEL
• or Developmental Model;

• Established by Erik Erickson from Freud’s

psychoanalytical model;

• Spans the total life cycle from birth to death;

• Each stage of development is an emotional

crisis involving positive and negative
experiences;

56
 Life Stages
I. Trust vs Mistrust (0 – 18 months of age)
 Child develops sense of trust or mistrust of
others;

 Shares openly and relates to others;

 Interpersonal skills start to develop;

57
II. Autonomy vs Shame and Doubt
 18 months – 3 y/o;

 Child learns self-control or becomes very

conscious and full of doubt;

 Negativistic attitude;

 Exhibits motor self-control and independence

thru negativism;

 Parallel play is the social skill.

58
III. Initiative vs Guilt (3 – 5 y/o)

 Child initiates spontaneous activities or

develops fear of wrongdoing;

 Shows appropriate social behaviors;

 Curiosity and exploration;

 Social Skill: Cooperative Play

59
IV. Industry vs Inferiority (6 – 12 y/o)

 Child develops the social and physical skills

necessary to negotiate and compete in life;

 Acquisition of competence;

 Ability to cooperate and compromise;

 Identification with admired others

(teachers, parents)

60
V. Identity vs Role Diffusion ( 12 – 20 y/o )
 Teenager either integrates childhood
experiences into a personal identity;

 May develop self-doubts about sexual or

occupational roles;

 Establish relationship with the opposite sex;

 Fidelity with friends;

 Also value importance of beauty or self-image;

61
VI. Intimacy vs Isolation (18 – 25 or 30 y/o)

 The person develops commitment to work and

to other people;

 Ability to give and receive love;

 Responsible sexual behaviors;

62
VII. Generativity vs Stagnation (30 – 65 y/o)

 Productive, constructive, and creative activities;

 Personal and professional growth;

 Parental and societal responsibilities;

 Ability to care;

63
VIII. Integrity vs Despair (65 years old to death)
 The person reviews life for meaning, fulfillment,
and contributions made to the next generations;

 Sense of dignity and worth;

 Explores the philosophy of life;

 Have period of reminiscence;

 May result to regression and withdrawn;

64
 Psychosocial VIRTUE PATHOLOGY
Stage
T vs MT HOPE Psychosis
Addiction
Depression
A vs S and D WILL Impulsivity
Paranoia
Obs/Comp
Initiative vs G PURPOSE Conversion
Phobia
Inhibition
Ind vs Inf COMPETENCE Creative inhibition

Identity vs RD FIDELITY Gender-related

identity disorders
Inti vs Iso LOVE Schizoid

G vs S CARE Midlife crisis

Integrity vs D WISDOM Despair

65
Alienation
COGNITIVE - BEHAVIORAL MODEL

 By Piaget;

C. SENSORIMOTOR STAGE (birth – 18 months)

 The child learns by IMITATION;

 Also by object permanence;

66
B. PREOPERATIONAL STAGE ( 2 – 7 years old)

• Preconceptional Phase ( 2- 4 y/o)

• Learns using mental images and
develops symbolic language and play
(symbolism)

• Intuitive Phase ( 4 – 7 y/o)

• The child learns by separating
disparate objects and events and also
expands expressive language;
• Can give reason for belief and reactions
but still pre-logical;

67
C. CONCRETE OPERATIONS (8 – 12 years old)

• Child can systemically organize

thoughts and facts about the
environment;

• Can apply rules to things that are seen

and heard;

• Child begins abstract thinking;

68
D. FORMAL OPERATIONS (12 – adulthood)

• The person can think using

conceptual, abstract operations, and
CAN HYPOTHESIZE and evaluate
solutions to the problems;

69
Maslow’s Hierarchy of Needs

A. Physiologic Needs
 The most basic;
 Food, water, sleep, shelter, sexual
expression, and freedom from pain;

B. Safety and Security Needs

 Includes protection, security, and
freedom from harm or threatened
deprivation;

70
C. Love and Belongingness
 Includes enduring intimacy, friendship, and
acceptance;

D. Self-esteem Needs
 The need for self respect and esteem from
others;

E. Self-Actualization
 The need for beauty, truth, justice, and to
meet his highest potential;
 Few people ever become fully self-actualized;

71
Interpersonal Theory - by Sullivan;
– Behavior motivated by need to avoid anxiety and
satisfy needs;

Therapeutic Nurse-Client Relationship – by Peplau;

– The nurse and the client must work together to assist
client grow and to resolve problems;

Behavioral Model – by Pavlov and Skinner;

– Behavior is learned and retained by positive
reinforcements;
– Behaviors that are inadequate or inappropriate must
be replaced by more adaptive ones;
72
THERAPEUTIC COMMUNICATION
– Is an interactive process that occurs
between the patient and the health
professional;

– Focuses solely on the patient’s problem;

– Establishment of trust is the foundation of

a nurse-client relationship;

73
Techniques of Therapeutic
Communication
“C SOAP ME FEG and SURE STROL”
C – clarification

S – silence
O – offering self
A – accepting
P – presenting reality

M – making observation
E – empathy

74
F – focusing
E – exploring
G – giving recognition

and

S – suggesting collaboration
U – using broad openings
R – reflecting
E – encouraging description

75
S – sharing perceptions
T – translating into feelings
R – restating
O – offering general leads
L – listening

76
CLARIFICATION
– Encourage client to make idea more
understandable;

– Nurse: “I don’t understand what you

mean. Could you explain it to me?”

77
SILENCE
– Client able to think about self or his
problems;

– Does not feel any pressure to speak;

– Look into the eyes and listen to the

client while he is talking;

78
OFFERING SELF
– Offer to provide comfort to client by mere
presence;
– “I’ll sit with you.”
– “I’ll walk with you.”
– “I’m here for you.”

ACCEPTING
– by nodding and following what client says;

79
PRESENTING REALITY
– Reports events and situations as they really are;

– Client: “I don’t have a chance talking to my

doctor.”
– Nurse: “I saw you and your doctor talking this
morning”

– Client: “These voices are bothering. They want

me to jump from the window.”
– Nurse: “There are no other people here.” OR “I
don’t hear any voices except for ours.”

80
MAKING OBSERVATION
– Verbalize what you perceive;

– “I notice that you can’t sit still.”

– “I notice that something is bothering you.”

EMPATHY
– Showing or telling what you feel in relation to
the client’s suffering.

– “I know what you feel………”

– “I know this is hard for you……….”

81
FOCUSING
– Encouraging the client to stay or focus on the
topic;
– “You were talking about your mother.”
– “You were saying that your………..”

EXPLORING
– Encourage client to express feelings or ideas
deeply;
– “Tell me more about you and your mother.”
– “How did you respond to……..”

82
GIVING RECOGNITION
– Indicate to client your awareness of him and his
behaviors;

– “Good morning, I noticed that you combed your

hair today.”

– “I observed that you’re behaving

appropriately.”

83
SUGGESTING COLLABORATION
– Offer to work with client towards a specific
goal;
– Client: “I fail at everything I try.”
– Nurse: “May be we can figure out something
together so that you can accomplish something
you want to do.”

USING BROAD OPENINGS

– Encourage client to introduce the topic of
conversation; or to start a conversation;
– “Where shall we begin today?”
– “What are you thinking about?”
84
REFLECTING
– Direct client’s questions or statements back to
encourage expression of ideas and feelings;
– Client: “Do you think I should talk to my
doctor.”
– Nurse: “What do you want to talk about?”

ENCOURAGING DESCRIPTION
– Ask the client to verbalize his perception;
– “What is happening to you right now?”
– “What are you doing in front of the window?”

85
SHARING PERCEPTIONS
– nurse describes his or her understanding of
the patient’s feelings and ideas;
– Nurse: “I noticed that you have an unresolved
feelings towards your mother.”

TRANSLATING INTO FEELINGS

– Encourage client to verbalize feelings
expressed in another way;
– Client: “I will never get better.”
– Nurse: “You sound rather hopeless and
helpless.”

86
RESTATING
– Repeat what client has said;
– Client: “I don’t want to take my medicines.”
– Nurse: “You don’t want to take your
medicines?”

OFFERING GENERAL LEADS

– Encourage client to continue discussing the
topic;
– “And then?” or “Go on I’m listening.”
– “Tell me more about what you just said?”

LISTENING

87
Blocks to Constructive Communication

♦ These are methods of communication that

obstruct the process of therapeutic
conversations (“Non-therapeutic”)

♦ “BAD SCAR DROP”

88
B – belittling feelings
A – agreeing / disagreeing
D – denial
S – stereotypical response
C – changing topic
A – approval / disapproval
R – reassuring
D – defending
R – requesting explanation
O – offering advise
P – probing
.

89
NON-THERAPEUTIC COMMUNICATION

Belittling feelings “Everybody experiences

failures and downs.”
“I’ve felt the same sometimes.”
Agreeing / “That’s right….. I agree.”
Disagreeing
“It’s wrong… I don’t agree…”

Denial P – “I’m nothing.”

N – “Of course you’re
something.”

90
Stereotypical “Nice weather were having.”
response “I’m fine and how are you?”

Changing P – “I want to die!”

topic N – “Did your parents visited

Approval / “I’m you?”

glad that you…”
Disapproval
“I’d rather you wouldn’t…”

Reassuring “Everything will be alright.”

“Don’t worry it’s fine.”

91
Defending “That nurse is competent.”
“His thinking of you all the
time.”
Requesting “Why do you think that…”
explanation “Why do you feel this way…”
“Why did you do that?”
Offering advise “I think you should…”
“Why don’t you…”

Probing “Now tell me about you….”

“Tell me your history.”

92
 Phases of Therapeutic Relationship
A. ORIENTATION
– or Assessment or analysis;

– The nurse establishes trust with the client;

– The nurse assesses the client;

– Formulation of nursing diagnosis;

– Prioritization of the client’s problems;

– The nurse and the client establish mutually

agreed goals;

– Discussing the indications for termination;

93
B. WORKING PHASE
– Pertains to planning and intervention;

– the nurse plans outcomes and related

interventions to assist client to meet goals;

– The nurse facilitates the client’s expression of

problems, thoughts, and feelings;

– The nurse uses problem-solving approach;

94
C. TERMINATION PHASE

– Pertains to evaluation;

– The nurse evaluates outcomes, reassess

the problems, goals and interventions;

– Needs close attention to avoid destroying

the benefits gained from the
relationship;

95
– The nurse and client express feelings regarding
the termination of the interactions;

– The nurse observes the client for negative

behaviors:
• Regression
• Anger
• Inappropriate expressions (laughter)

– The nurse evaluates the entire nurse-client

relationship;

96
 PSYCHOPHARMACOLOGY
ANTI-PSYCHOTIC DRUGS
– Or neuroleptics or major tranquilizers;

– For acute and chronic psychosis;

– For bipolar I disorder, manic phase;

– Paranoid disorder;

– Severe nausea and vomiting*;

– Severe or pathologic hiccups*;

97
 Classification (Traditional or Typical
Classification)

1. Chlorpromazine (Thorazine) -
EARLIEST
2. Fluphenazine (Prolixin)
3. Thioridazine (Mellaril)
4. Trifluoperazine (Stelazine)
5. Haloperidol (Haldol)
6. Loxapine (Loxitane)

98
 Atypical Anti-psychotics:

1. Clozapine* (Clozaril)
2. Olanzapine* (Zyprexa)
3. Risperidone* (Risperdal)

99
Mechanisms of Action:
 Blocks dopamine receptors in
the nigrostriatal system causing
pseudoparkinsonism;

 Inhibits dopamine receptors in

the tubuloinfundibular system;

 Antagonizes serotonin receptors in

the cerebral cortex (Risperidone)
100
Typical Anti-psychotics

Decrease dopamine

Atypical Anti-psychotics

Decrease serotonin

101
Desired Effects of Antipsychotic
Drugs:
1. CNS Effects
a. sedation
b. emotional quieting
c. slowing of psychomotor functions

2. Modification of Psychiatric Symptoms

a. Resolution of “positive symptoms”
 Hallucinations
 Illusions
 Delusions
 Excitement
 Suspiciousness
102
b. Resolution of negative symptoms
 Accomplished by ATYPICAL

antipsychotic agents

1.Attention deficit
2.Asocial behavior
3.Blunted or flat affect
4.Communication difficulties
5.Difficulty with abstraction

103
SIDE EFFECTS

A. PNS Effects (anticholinergic effects)

C. PNS Effects (anti-adrenergic effects)

1. Orthostatic hypotension

3. Reflex tachycardia – due to lower

extremity vasodilatation;

104
“Anti-cholinergic effects are the
same irregardless of what
medication.”
 A – urinAry retention
 Blurring of vision – due to dilated pupils.
 Constipation
 Dry mouth and nasal passages
 Elevated heart rate (tachycardia)

105
C. CNS Effects (or EPSE)
1. Akathisia
 it is the most common EPSE;

 “inability to sit still”;

 px is restless, jittery or uneasy and

may report a lot of nervous energy;

 Tx: Anticholinergic antiparkinson

drugs (Artane, Biperiden, Cogentin)

106
2. Acute Dystonic Reactions (dystonia)
– rigidity of the muscles of the
tongue, face, neck or back;

– results to abnormality in posture, gait or

ocular movements;
 Torticollis

 Oculogyric crisis – rolling of eyes backward

in a fixed stare;
 Laryngeal-pharyngeal dystonia

– Tx: IM anticholinergic antiparkinson drug

(Benztropine or Cogentin)

107
3. Tardive Dyskinesia (TD) – potential
permanent complication;
– refers to abnormal voluntary skeletal
muscle movements usually jerky motion;

– appears after months or years of drug use

but may occur sooner;

– caused by dopamine hypersensitivity and

cholinergic deficit;

– “anticholinergics may aggravate TD”;

108
– usually affects the muscles of the mouth
and face:
1. Lip smacking
2. Grinding of the teeth
3. Rolling or protrusion of the tongue
4. Tics
5. Excessive facial movements
• Grimacing and blinking
• Chewing and lateral jaw movement
• Puffing of the cheeks;

– Tx:
 Bromocriptine (Parlodel);
 Reduction of dose;
 Discontinuation of the drug;

109
4. Drug-induced Parkinsonism
– or pseudoparkinsonism;

– motor retardation (bradykinesia) and

rigidity;
– difficulty in initiating or carrying out
motor activity;
– shuffling gait;
– resting tremors of the hands and feet;
– hypersalivation;

– Tx:
 Dosage reduction
 Antiparkinson drug (Akineton)

110
5. Neuroleptic Malignant Syndrome
– is a rare but life-threatening reaction to
neuroleptic drugs (1% of clients)

– 3-9 days after starting anti-psychotic (Haldol)

– manifestations:
a. hyperthermia – cardinal symptom.
b. rigidity
c. impaired consciousness
d. hypertension
e. cardiac arrhythmias

– Tx: Immediate discontinuation of the

drug;
Cooling blankets;
Dantrolene or Bromocriptine 111
1. Other Side Effects
• Hyperglycemia
• Jaundice
• Blood dyscrasias or agranulocytosis
(Clozapine)
• Orthostatic hypotension (Risperidone)
• Retinal pigmentation (Thioridazine)
• Galactorrhea and gynecomastia
(Increase secretion of prolactin)
• Amenorrhea and impaired ejaculation
• Sun burn

112
 ANTI-PARKINSON DRUGS

∞ Major cause of EPS malfunction is a

DEFICIENCY in the neurotransmitter
DOPAMINE (substantia nigra) and a
subsequent decrease in dopamine
transmission in the basal ganglia;

113
Mechanisms of Actions:
 Increases dopamine by increasing its precursor.
– Levodopa
– Carbidopa-levodopa (Sinemet)

 Stimulates the release of dopamine.

– Amantadine (Symmetrel)

 Increases the action of the dopamine receptors

(Dopamine agonists)
– Bromocriptine (Parlodel)
– Pergolide (Permax)

114
 Blocks the metabolism of dopamine by inhibiting
MAO type b.
– Selegiline (Eldepryl)

 Anti-parkinsons with anti-cholinergic properties.

– Benztropine (Cogentin)
– Biperiden (Akineton)
– Diphenhydramine (Benadryl)
– Ethopropazine (Parsidol)
– Procyclidine (Kemadrin)
– Trihexyphenidyl (Artane)

115
 ANTI-PARKINSON DRUGS
A – Artane , Amantadine
B – Biperiden, Bromocriptine
C – Cogentin
D – Diphenhydramine,
Dopamine precursors (Levodopa,
Sinemet)
E – Eldepryl
F – Pergolide

116
 ANTIDEPRESSANTS

 DEPRESSION is caused by an imbalance or

decreased availability of certain neurotransmitters
(deficiencies of norepinephrine, serotonin, and
possibly dopamine)

Norepinephrine
Serotonin DEPRESSION
Dopamine

117
 Goals in the tx of Depression:

 Reduce or remove all signs and

symptoms of depression – the most
important.

 Restore occupational and

psychosocial function;

 Reduce the incident of relapse and

recurrence;

118
 TRICYCLIC ANTIDEPRESSANTS

 Blocks reuptake of norepinephrine and

serotonin;

 Also increases receptor sensitivity to these

neurotransmitter;

119
 Desirable Effects:
– Sedation.
– Others increase psychomotor activity.
– Improved appetite.

 Side Effects:
– Anti-cholinergic side effects

– Orthostatic hypotension

120
 Nursing Implications:
– Take medications at night.

– Reassure that symptoms will decrease in

2 - 4 weeks

– Increase fiber and fluid diet.

– Assess for adverse drug reactions.

– Assess for suicide potential.

121
 Classifications:

– Tertiary Amines
– Imipramine (Tofranil)
– Amitriptyline (Elavil)
– Clomipramine (Anafranil) – used in OCD.

– Secondary Amines
- Amoxapine (Asendin)
- Nortriptyline (Aventyl)
- Desipramine (Norpramin)

122
 Classifications…

– Novel Cyclic Antidepressants

– Bupropion (Wellbutrin)
– Trazodone (Desyrel)
– Venlafaxine (Effexor)

123
B. SELECTIVE SEROTONIN REUPTAKE
INHIBITORS (SSRI)
– Fewer side effects that TCA;

– “First choice in treating depression.”

– MOA: inhibits reuptake of serotonin in neurons

which later increases the availability of serotonin
in several neurons;

– Therapeutic lag time is approximately 1 – 4

weeks;

124
 Side Effects:
– GIT Symptoms
– Nausea
– Diarrhea
– Weight loss

– CNS Symptoms
– Headache
– Dizziness
– Tremors
– Nervousness
– Decreased libido and orgasms

125
 Nursing Implications:
– Avoid incorporating with MAOI because of the
danger of ser otoni n syndr ome (coma,
hyperreflexia, hyperthermia, death)
• 14 days – stopping MAOI and starting SSRI:
• 5 weeks – stopping SSRI and starting MAOI;

– Avoided during the 1st trimester of pregnancy.

– WOF: Increase activities and mood of patients

because these are signs of suicidal ideations;

126
 Classification:

– Fluoxetine (Prozac)

– Fluvoxamine (Luvox)

– Paroxetine (Paxel)

– Sertraline (Zoloft)

127
C. MONOAMINE OXIDASE INHIBITORS
(MAOI)
– Monoamine Oxidase – involved in the
metabolic decomposition and inactivation of
amines (norepinephrine, dopamine and
serotonin);

– Administered to hospitalized patients or px

that can be closely monitored or supervised at
home;

– It takes 2 – 4 weeks for these drugs to take

effect;

128
 Side Effects:

– CNS Hyperstimulation
– Hypomania
– Agitation
– Insomnia
– Restlessness and euphoria
– Acute Anxiety Attack

– Hypertensive crisis (tachycardia, palpitations,

occipital headache, chest pain, elevated BP,
diaphoresis, and dilated pupils; sudden epistaxis)

129
 Nursing Implications:
– Take the medication EARLY IN THE DAY to
avoid insomnia;

– Caution client to avoid OTC drugs because

these contain AMINES and can cause
HYPERTENSIVE CRISIS.
 Cold remedies

 Decongestants

 Antihistamines

 Sleeping aids

 Stimulants

– Instruct the px TO AVOID FOODS HIGH IN

TYRAMINE (tyramine-restricted diet)
130
– Foods high in TYRAMINE:
A – aged cheese and avocado
 B – bananas, beer

 C – chocolate, coffee, chicken and pork

liver
 D – dried and preserved foods (pickles)

 E – etc (yogurt, sausage)

 F – fermented foods (beer, wine)

131
 Classifications:

– Phenelzine (Nardil)

– Tranylcypromine (Parnate)

– Moclobemide (Manerix) – atypical MAOI.

132
ANTI-MANIC DRUGS
(Mood Stabilizers)
LITHIUM
 Is used for manic phase of manic-depressive
illness and refractory depression;
 The exact action of lithium is UNKNOWN;
 Substitute for Na in neurons altering the
release and attachment of certain
neurotransmitters in most neurons;
 Increases the reuptake of NE and serotonin;

 Lithium has a lag time of 7 – 10 days;

133
 Lithium is well absorbed from the GIT
(via ORAL route)

 The typical dose for acute mania is 600 mg

TID which produces a therapeutic blood
dose of 0.6 – 1.2 mEq/L;

 Blood levels over 1.5 mEq/L can be toxic;

134
 Nursing Implications:

– WOF signs of early Li toxicity:

 Vomiting – earliest;
 Diarrhea and Drowsiness
 Muscular weakness
 Lack of coordination
 Polyuria

• Client may have mild exercise or activities.

• Advise px not to drive during Li therapy;

• Advise px to practice balanced diet and salt intake;

Increase Salt intake = decrease blood Li

Decrease salt intake = increase blood Li
135
• For Li determination, blood must be drawn
at least 8-12 hrs after the last dose and
performed in the morning (every 3 – 4
months of Li intake)

• Take Li with meals to avoid nausea and

vomiting;

• Increase fluid intake (2500-3000 ml) per

day to reduce thirst and maintain normal
fluid balance;

136
CARBAMAZEPINE (Tegretol)
• Used for px who do not respond to Li or for px Li is
contraindicated;

• Used in px with bipolar disorders and for px with

seizure disorders;

• Thought to inhibit the small abnormal activity in the

brain;

• Side Effects:
 Nausea and vomiting

 Anorexia

 Sedation and drowsiness

 Agranulocytosis
137
VALPROIC ACID (Depakene)
• Is an anticonvulsant with antimanic property;

• Effective in px with bipolar disorders;

• Rapid acting and with less effect on cognition;

• Side Effects:
 Transient hair loss

 Weight gain

 Tremors

 GI Upset

 Thrombocytopenia

138
 ANTIANXIETY DRUGS

• Are also known as anxiolytics;

• Classified into:
a. Benzodiazepines
b. Sedative-Hypnotics

139
Benzodiazepines
• are the major class of anxiolytics or minor
tranquilizers;
• Are used in px:
a. chronic anxiety
b. acute anxiety or persons in crises
c. presurgery
d. panic attacks
e. insomnia
f. alcohol withdrawal syndrome
g. bipolar disorders with Li therapy
h. seizures
140
• Types of Benzodiaze PAM… PAM…
1. Diazepam (Valium)
2. Lorazepam (Ativan)
3. Clonazepam (Klonopin)
4. Oxazepam (Serax) – for elderly.
5. Alprazolam (Xanax)
6. Chlordiazepoxide (Librium)
7. Clorazepate (Tranxene)
8. Buspirone (BuSpar)

141
• Adverse Drug Reactions:
1. CNS Depression

a. Drowsiness
b. Fatigue
c. Decreased coordination
d. Mental impairment
e. Slow reflexes
f. Confusion
g. Respiratory depression***

2. Anticholinergic side effects

142
 3. Problems of dependence, withdrawal, and
tolerance;

a. Dependence or addiction – the person

must take the drug to feel normal;

b. Withdrawal – physical signs and

symptoms that occur when the
addictive substance is
reduced or withheld;

c. Tolerance – the need to increase the

amount of a substance to achieve
the same effects;

143
• Nursing Interventions:

• Advise the px to avoid taking alcohol and other

CNS depressants with the drug.

• WOF of overdose ( somnolence, confusion, coma,

decreased reflexes, and hypotension)

• Advise the px to avoid driving;

• Monitor VS especially breathing;

144
Sedative-Hypnotics
• Are also used in the treatment of anxiety, insomnia,
and prevention of alcohol withdrawal syndrome;

• Barbiturates:
• Phenobarbital
• Secobarbital
• Pentobarbital

• Antihistamines:
• Diphenhydramine

145
 THERAPEUTIC LAG TIME

Anti-psychotics
TCA 2 – 4 weeks
MAOI

SSRI 1 – 4 weeks

Lithium 7 – 10 days

Clomipramine 2-3 months 146

ELECTROCONVULSIVE THERAPY
 An electrical current (70-150 v) passes thru electrodes
applied to the patient’s temple to induce a generalized
tonic-clonic seizure (or Grand Mal) and unconsciousness;

 Is use when other traditional therapies failed;

 Length of application: 0.5 - 2 secs;

 Length of seizure: 30 - 60 secs;

 The cumulative effect of ECT is approx 220 - 250 secs.

 Used to treat patients with depression, bipolar disorders,

manic, and psychotic symptoms;

 The exact action of ECT remains unknown;

147
∞ Nursing Interventions:
 Obtain an informed consent from the patient, family,
or legal representative of the patient;

 Teach the family and the patient about the treatment

and what to expect like:
– Short-term memory loss – resolve after 4-8
weeks;
– Disorientation
– Confusion
– Respiratory depression

 NPO post-midnight to prevent aspiration and

vomiting; at least 8 hrs.

 Remove all prostheses including hairpins and

dentures;

148
 Administer all preop meds as indicated like:
• AtSO4 – to decrease oral and nasal
secretions*;
• Succinylcholine – muscle relaxant;
• Short-acting barbiturates*
– Does not affect seizure threshold
– Ex. Methohexital

 Vital signs must be monitored before and after

the procedures;

 Tongue guard is inserted to prevent tongue

injury during seizure;

 Monitor heart rate and rhythm, blood pressure,

and EEG; 149
150
NEUROSIS
• is a maladaptive emotional state due to
unresolved emotional conflict;

NEUROSIS PSYCHOSIS
Does not need hospitalization Needs hospitalization

Minor reaction to stress Major reaction to stress

Normal reality Impaired reality

Can feel sufferings and wants to Does not know his ill
get well
Does not deny reality Denies reality

Exploits sex for secondary gain No secondary gain is derived

151
• OVERVIEW
• ANXIETY is a subjective feeling of
vague apprehension due to real or
perceived threat;

• is a NORMAL response to stress;

• Or may precede new experiences;

152
• ETIOLOGY
1. Biological Theory
a. **GABA – decrease;
b. Norepinephrine – increase;
c. Serotonin – increase;
d. Dopamine – increase;

1. Psychodynamic Theory
• Due to unresolved developmental conflicts;

153
1. Interpersonal Theory (by Sullivan)
– When expectations, approval, or
needs are not met.

2. Behavioral Theory
– Anxiety is a learned response to
combat stress;

154
∞ Kind of Anxiety (Freud)
• Reality Anxiety - from external real
threat;

• Neurotic Anxiety - fear that instinct

will cause one to do something that will
cause punishment;

• Moral Anxiety - guilt from a

wrongdoing against the conscience;

155
∞ Levels of Anxiety:
1. Mild Anxiety
 associated with the tension of everyday life;

 the individual is alert and attentive (SNS is stimulated)

 perceptual field is increased;

 “NO INTENSE FEELING BECAUSE SELF-CONCEPT

NOT THREATENED”

 With mild muscle tension;

 Interventions:
- Discuss source of anxiety.
- Problem solving to neutralize anxiety.
- Teach the client to accept anxiety as normal.
156
1. Moderate Anxiety
• the focus is on immediate concerns;
• narrows the perceptual field;
• selective inattentiveness occurs;
• learning and problem-solving still take place;
• “self-concept may be threatened” (may have
discomfort and irritability)
• may show moderate muscle tension with
increase vitals, mydriasis, and sweating;
• Interventions:
– Decrease anxiety by ventilation of feelings,
crying, or exercise.
157
1. Severe Anxiety
• a feeling that something bad is about to happen;
• With significant reduction in perceptual field;
• All behavior is directed at relieving the anxiety;
• learning and problem-solving are not possible;
• May show:
– Hyperventilation
– Severe muscle tension
– Rapid pacing or walking
– Shouting and trembling
• Interventions:
– Stay with the client.
– Decrease anxiety and pressure.
– Use kind, firm, and simple directions.
– IM anxiolytics as ordered.

158
1. Panic Level of Anxiety
• associated with dread and terror and a sense
of impending doom;

• the personality of the individual is

disorganized;

• the individual is unable to communicate or

function effectively;

• may experience loss of rational thoughts with

distorted perception;

159
• May have:
– Fight or flight
– Freeze
– Helplessness
– Out of control (jump from windows)
– Rage, anger, and terror

• Interventions:
– Guide firmly or physically take control.
– IM anxiolytics as ordered.
– Restraints if needed (FOR SAFETY)

160
III. COPING WITH ANXIETY

∞ Coping Mechanisms
 any effort that will decrease the stress
response;

 either a constructive or destructive mechanisms;

 they can be task-oriented to solve the problem;

 or defense-oriented to protect the px’s feelings;

161
 Type of Coping:
 Adaptive coping – for mild anxiety;

 Pallative coping – for moderate anxiety;

 Maladaptive coping – for severe anxiety;

 Dysfunctional coping – for panic level of

anxiety;

162
 Type of Coping:

 Adaptive – solve the problem.

 Ex. If you have an exam……… you study or
review…. You PASSED with flying colors….

 Pallative – temporarily decrease the anxiety but

does not solve the problem (allows the client to
return to problem solving)
 Ex. If you have an exam…. Go to the gym
first then review……. You’ll PASS….

163
 Maladaptive – unsuccessful to decrease
anxiety without attempting to solve the
problem.
 Ex. You have an exam…… Watch movies
with friends first……… then cramming for
review……. Result of exam…… FAILED!!!

 Dysfunctional – not successful in reducing the

anxiety or solving the problem; minimal
functioning becomes difficult;
 Ex. You have an exam ……… drinking spree
with buddies….. When you wake up……
UMAGA NA…. Result of exam ……. “Asa ka
pa…. Eh di bagsak!!!”
164
∞ Common Nursing Diagnosis:
∞ Ineffective individual coping***

∞ Anxiety

∞ Impaired adjustment

∞ Risk for injury

∞ Risk for violence, self-directed or

directed at others

∞ Fear

165
∞ Important Nursing Interventions:

C – calm environment
A – ask client to identify cause/s.
L – let client describe feelings.
M – monitor for suicide ideation.
E – expression of feelings.
R – release tension and energy
(art therapy)

166
 and
ANXIETY – RELATED
DISORDERS

167
GENERAL ANXIETY DISORDER (GAD)
– Characterized by diffused, persistent, or
unrealistic worry that rarely occurs by
itself;

– Increase amount of inner energy consumed

on controlling anxious feelings;

– Have used alcohol or other drugs to the

point of dependence to control anxiety;

168
– Person may experience physical symptoms:
• Dyspnea
• Palpitations
• Chest pain
• Gastric distress - diarrhea
• Tremors
• Insomnia
• Restlessness

– Tx:
• Anxiolytics
• Psychotherapy
169
PANIC DISORDER
– The cause is usually cannot be identified;

– sudden onset, with feelings of intense

apprehension, and dread;

– May be severe, recurrent, or intermittent lasting

5 – 30 minutes;

– Fear of losing control about themselves, “going

crazy,” heart attack, or dying;

– Client may also experience physical symptoms

similar to GAD; 170
– Treatment:
a. Relaxation techniques

c. Cognitive – Behavioral Therapy

e. Benzodiazepines – Alprazolam (Xanax)

g. *** Antidepressants – Sertraline;

Paroxetine;

171
OBSESSIVE-COMPULSIVE DISORDER
– Characterized by episodes of obsession
(unwanted, repetitive thought) and
compulsion ( unwanted, repetitive action)
that influence a person’s life;

– Char by irrational, repetitive, ritualistic

behaviors that the px uses in attempt to
control the anxiety resulting from
obsessions;

– Affects the ADL of the client;

172
– Anxiety occurs if O-C are resisted, and
from being powerless to stop obsession.

– Compulsive behaviors are related to

decrease or neutralize anxiety;

OBSESSION Increases anxiety

COMPULSION Decreases anxiety

173
– Treatment:
a. Behavioral techniques
• Desensitization
• Graded response
• Modeling of desired behaviors
• Cognitive therapy - to stop altered
thought.

c. Antidepressants – ***Clomipramine (Anafranil);

SSRI’s.

e. Anxiolytics

174
PHOBIA
– An irrational fear of an object or situation
that persists even though the px may
recognize it as unreasonable;

– Associated with panic-level of anxiety if

the object, situation, or activity cannot be
avoided;

– Client will do anything just to avoid the

phobic object regardless of the
consequences;
175
– Types of Phobia:

a. Agoraphobia
– fear of being alone in open or public
places where escape might be difficult
or impossible;

– Client may not leave home;

176
a. Social Phobia
– fear of situations in which one might
be embarrassed or criticized, and
the fear of making fool of oneself;

– includes the fear of eating in public

places, public speaking, or performing
in public places;

177
a. Specific Phobia
– a fear of a single object, activity, or
situation such as snakes, closed
spaces, and flying;
– Arachnophobia
– Aerophobia
– Acrophobia
– Aviophobia
– Claustrophobia

178
– Treatment:
a. Behavioral techniques
– ***desensitization – therapy of
choice.

b. Benzodiazepine Therapy

179
POSTTRAUMATIC STRESS DISORDER
(PTSD)
– Grieving-like behaviors that result from a
major and severe trauma like rape,
assault, accident, fire, war, or natural
disaster;

– Usually occurs AFTER a major traumatic

events (usually after ONE month)

– Acute Stress Disorder – anxiety during or

immediate after a traumatic event (within
4 weeks or 1 month)
180
– May show physical manifestations:
a. Flashbacks
b. Insomnia and nightmares
c. Eating problems
d. Depression and isolation
e. Hypervigilance and guilt about surviving
the event;

181
– Types of PTSD:
a. Acute – less than 3 months after the
event;

c. Chronic – 3 months or more after the

event;

e. Delayed – at least 6 months after the

event;

182
– Treatments:
a. Psychotherapy

b. Pharmacotherapy
1. Benzodiazepines
2. Antidepressants – SSRI.

183
– Nursing Interventions:

P – provide safe environment for

the client.

T – try to recall the traumatic

event.

S – suicide precaution.

D – don’t leave client alone.

184
 DISSOCIATIVE DISORDERS
– Is characterized by splitting off or
removal from conscious awareness of some
information, feeling, or mental function;

– Also associated with traumatic events and

severe anxiety;

185
Types of Dissociative Disorders:
c. Dissociative Identity Disorder
• or multiple personality;

• existence of two or more fully developed

distinct and unique personalities within the
person;

• the personalities may take full control of

the person one at a time;

186
• the personalities may or may not be aware
of each other;

• the person is unable to recall important

information;

• char by sudden transition from one

personality to the other RELATED TO
STRESS;

• “dissociation is used as a method of

distancing and defending self from anxiety
and traumatic events;”
187
• Clients with depersonalization disorder (like
DID) are not admitted unless they are
suicidal;

• GOAL: “Integrate the personalities or

memories so that they can coexist with the
original personality.”
Psychotherapy
Hypnosis
Amobarbital sodium.

188
a. Dissociative Amnesia
– inability to recall important personal
information because it is anxiety
provoking;

– memory impairment may be partial or

complete;

– amnesia may be anterograde (recent

information) or retrograde (past
information);

189
a. Dissociative (Psychogenic) Fugue
– Sudden travel away from home and
assumes a new personality with inability
to recall the past;
– This may occur suddenly for several hours
or days;

– Follows severe psychosocial stress

(marital quarrels, personal rejections, or
natural disaster)
– It allows escape or flight from an
intolerable situations.
190
– “When the fugue state stops or lost …..
the client returns home …… UNABLE to
recall the fugue state.”

– Tx:
• Psychotherapy
• Anxiolytics
• SSRI

191
a. Depersonalization Disorder
– An altered self-perception in which one’s
own reality is temporarily lost or
changed;

– Feeling of self- detachment;

– The client may experience feelings of

detachment but intact reality testing;
– To protect the client from an
overwhelming stress;

– Tx: SSRI (Fluoxetine)

192
 SOMATOFORM
DISORDERS
 Complains of physical symptoms or illness for
which no organic or physiologic cause can be
identified;

 Evidence is present or presumption exists that the

physical symptoms are connected to psychological
factors or conflicts;

 With prolonged periods of diagnostic work ups with

negative physical findings;

 “The nurse or health team must never assume that

patients are not sick.”

193
BODY DYSMORPHIC DISORDER
 Preoccupation with an imaginary defect in one’s
physical appearance even though the person
appears normal to others;

 Complaints of facial or body deformities;

 Client may have slight physical deformity but the

reaction or preoccupation is out of proportion to
the degree of deformity;

 Usually encountered during adolescence;

194
 Tendency to seek unnecessary surgery to
correct the imaginary defect or minor
flaws;

 May manifest with social impairment and

altered work performance resulting from
the client’s desire to hide the imaginary
defect;

195
CONVERSION DISORDER
 Alteration or loss of functioning of a
body part that is not related to any
physical abnormalities (eg. Paralysis,
blindness)

 Most symptoms are unconscious;

196
HYPOCHONDRIASIS
– Morbid preoccupation with fear or belief that one
has a serious disease based on personal
interpretation of physical health;
• Paralysis
• Anosmia
• Blindness
• Aphonia
• Seizures
• Anesthesia or paresthesia

– No physical evidence of serious disease;

– Char by unwavering conviction of his/her illness;

197
- May show “LA BELLE INDIFFERENCE.”

- Lack of concern regarding the

severity of the above symptoms;

- The client explains a severe disease

calmly…

198
PAIN DISORDER
– Preoccupation with pain with no diagnostic
findings as to the cause or intensity of pain;

– Pain that doesn’t follow anatomical nervous

system distribution;

– Have long history of several consultations with

numerous doctors, use of drugs, or alcohol
abuse;

– There is clear connection between a

psychological stressor and onset of symptoms;

– With marked impairment in lifestyle and ADL;

199
SOMATIZATION DISORDER
– These individuals verbalize recurrent, frequent,
and multiple somatic complaints for several years
without physiologic cause;

– Begins before age 30;

– Clients usually see several physicians thru the

years and even have exploratory and unnecessary
surgeries;

– May also have social and occupational

impairments;

200
– These px’s may have anxiety or depression;

– Or sleep disturbances, nervousness and

experience suicidal ideation because of
hopelessness about getting better;

– Common symptoms:
• Nausea and vomiting
• Dizziness
• Shortness of breath
• Dysmenorrhea
• Chest pain

201
Other Types of Somatoform Disorders:

1. MALINGERING
• Intentional production of false or
grossly exaggerated physical or
psychological symptoms to get
external compensation (leave, evading
prosecution, compensation)

• May have no real symptoms or over

exaggerated minor symptoms.

202
1. FACTITIOUS DISORDER
• aka Munchausen’s syndrome;

• When physical or psychological symptoms

are intentionally produced or feigned TO
GAIN ATTENTION;

• they may inflict injury to themselves to

receive attention;

• Munchausen’s by proxy – person inflicts

injury or illness on SOMEONE else to gain
attention or to be a hero;

203
 MOOD DISORDERS
♦ Associated with severe and painful
sadness or abnormal elation;

♦ Changes a person’s behavior,

cognition, motivation, and emotions;

♦ Most common psychiatric

diagnosis???

♦ Also known as AFFECTIVE

DISORDERS;

204
♦ Two Diagnostic Categories:

1. Major Depressive Disorder (MDD)

• A person experiences one or
more episodes of depression with
no manic or hypomanic
manifestations;

• Twice as many women than men;

• Onset is usually early - mid 20’s;

205
2. Bipolar Disorders
• A person experiences major
depression with one or more
manic or hypomanic episodes;

• Female and male ratio is the

same;

• Onset is usually late 20’s;

206
 MAJOR DEPRESSION
♦ Etiologies:
a. Biochemical Theory

• Altered or deficient levels of

norepinephrine and serotonin are
most often related to depression
(Dopamine, Acetylcholine and
GABA)

207
• Alterations in the functions of
the hypothalamic-pituitary-
adrenal system may cause
depression;

• Alterations in the circadian

rhythm (wake-sleep cycle) will
cause problem with sleep
patterns, arousal, activity, and
hormonal secretions;

208
a. Psychodynamic or Psychoanalytical
Theory
 Depression occurs as a result of a
person’s ego loss in relationship
to early life occurrences;

 Aggressive behavior
inappropriately directed at self;

209
a. Cognitive Theory
 Depression results when a person
perceives all stressful situations
as being negative;

210
a. Interpersonal Theory
 Stated that persons difficulties,
coping with individuals, life
events, and life changes can be
stressful and may lead to
depression;

211
a. Behavioral Theory
 Depression develops when one
feels helpless and unworthy.

d. Sociological Theory
 Stated that depression is caused
by abnormal medical, social
learning, stress, and response
mechanism by an individual;

212
Criteria for Major Depressive Disorder:
• **Depressed mood.

• **Anhedonia – inability to
experience or even imagine any
pleasant emotion;

• Sleep disturbances – insomnia or

hypersomnia;

• Possible weight loss or weight

gain.

• Fatigue or energy loss.

213
 • Reduced recognition and
concentration;

• Psychomotor agitation – increase or

decrease activities;

• Feelings of worthlessness or guilt;

• Recurrent death or suicidal thoughts;

∞ Symptoms must persists for a minimum

of 2 weeks.

∞ A person must have at least 5/9, one of

which is a depressed mood and/or
anhedonia.

214
♦ Other symptoms of depression:
– Apathy and sadness

– Hopelessness and helplessness

– Unworthiness and guilt

– Anger

– Decreased libido

– Private verbal berating of self

– Sudden crying without a cause

– Dependency and Passiveness

215
Nursing Diagnosis for MDD and
Bipolars:
• Ineffective individual coping

• Hopelessness
• Potential for injury
• Potential for violence
• Powerlessness
• Altered nutrition
• Sleep pattern disturbances
• Impaired verbal communication

216
Management:

C. Nurse Interventions
D – drugs
E – expression of feelings
P – patient involvement in physical
activities
R – reinforce decision making
E – nEvEr reinforce hallucination or
delusions
S – suicide precaution
S – safe environment

217
B. Pharmacotherapy
1. SSRI – Fluoxetine (Prozac)

2. TCA – Imipramine (Tofranil)

3. MAOI – Phenelzine (Nardil)

218
 BIPOLAR DISORDERS
♦ Approximately 2 million people
yearly suffer from bipolar disorders;

♦ Bipolar I disorders appear equally

common among men and women;

♦ In men, the first episode is usually of

manic manifestations;

219
♦ In women, it is depressive
symptoms that come first before
the manic signs;

♦ Characterized by episodes of
mania and depression with
periods of normal mood and
activity in between;

♦ Also known as manic-depressive

disorder;

220
 Clinical Manifestations of Mania:
Denial**, distractibility, and delusions
Resistance to treatment**
Hyperactivity**
Anorexia**
Pleasurable activity involvement
Irritability and insomnia
Elevated mood
Flight of ideas
Loud and rapid speech
Anger with labile mood
Grandiosity – or inflated self-esteem

“DR. HAPI E FLAG”

221
Types of Bipolar Disorders:
2. Bipolar I Disorder
• Has major depression and mania;

3. Bipolar II Disorder
• The person has major depression
and hypomanic rather than
mania;

222
Hypomanic Episode
♦ Is almost similar to mania but with
less severe level of impairment;

♦ Not severe enough to cause major

problems in school, work, or home;

♦ Manic episodes only last at least 4

days in duration and does not
warrant hospitalization;

223
B. Nursing Management

M - Maintain a safe environment.

Monitor sleeping pattern.
A - Always limit group activities.
N - Never reinforce altered
perceptions and delusions.
I - Institute motor programs
(running, walking)
A - Avoid stimulants. Provide finger
foods.

224
• Pharmacotherapy
– Lithium carbonate
• WOF signs of lithium toxicity.

• Carbamazepine
• Valproic acid

– Antianxiety drugs.

– **Antipsychotics – for psychotic

episodes during the manic phase of
Bipolar I.
225
 PERSONALITY DISORDERS
These are groups of psychiatric
disorders that affects behavioral
responses of an individual;

Persons with this type of disorders

are incapable of functioning
effectively in the society;

Patients are unaware of the adverse

impacts of their behaviors;

226
 DSM-IV CLASSIFICATION

Cluster A – Odd/ Eccentric

Aloof and emotionally distant
from others;

Behaviors are considered

strange;

– Paranoid Personality Disorder

– Schizoid Personality Disorder
– Schizotypal Personality Disorder
227
Cluster B – Dramatic / Erratic
The individual is egocentric or
self-centered;

Little ability to understand

another’s perspective;

 Borderline Personality Disorder

 Histrionic Personality Disorder
 Antisocial Personality Disorder
 Narcissistic Personality Disorder

228
Cluster C – Anxious / Fearful
Appears overly anxious about
various social and personal
issues;

Unusually concerned with the

rules, procedures, and
acceptance by others;

– Dependent Personality Disorder

– Avoidant Personality Disorder
– Obsessive-Compulsive Personality
Disorder
229
 CLUSTER A PERSONALITY DISORDERS

C. Paranoid Personality Disorder

Individual is very secretive,
suspicious, and don’t trust others;

Conviction that other people “are

out to do me in”

Also very aloof, cold, and overly

serious affect;

Uses projection;

230
A. Schizoid Personality Disorder
Steadfast determination to remain
distant and aloof;

Preferred solitary activities;

Lack of desire to develop social contacts

(answer using words or phrases)

Fearful of intimate relationships;

Tend to fantasize or daydream;

231
A. Schizotypal Personality
Disorder
Usually expressed unusual ideas and
magical thinking;

Inability to form and maintain age-

appropriate relationships;

May have transient psychotic symptoms

but not sufficient to be diagnosed as
schizophrenia;

Ex. People with ESP; can see and talk

with dead people (Sixth Sense)
232
 CLUSTER B PERSONALITY
DISORDERS
A. Antisocial Personality Disorder
More common in males;

Char by constant antisocial behaviors

(robbery, theft, alcoholism, vandalism,
etc.)

Sustained history of irresponsibility,

self-centeredness, and impulsiveness;

Lack of remorse for one’s destructive

actions;
233
Very manipulative and exploits others;

Manifests with anger that results in

hostile outburst;

Potential for violence;

Commonly uses rationalization;

Tx: Group Psychotherapy

234
A. Borderline Personality Disorder
The px may be impulsive with splitting
tendency and suicidal;

With outburst of intense anger and

rage;

Emotionally labile and with unstable

personality;

Tendency for self-mutilation;

Also are manipulative;

Most commonly treated;

235
A. Histrionic Personality Disorder
Melodramatic, colorful, highly energetic,
and seductive;

Tendency to have shallow relationships;

Self-centered character;

Wants to be the center of attention;

Tendency to make many demands on

others for reassurance;

236
A. Narcissistic Personality Disorder
More common in males;

Inflated sense of self-importance;

Feeling of entitlement for

recognition;

Feelings of worthlessness if not

praised and admired by others;

With labile affect;

Tx: Group Psychotherapy

237
 CLUSTER C PERSONALITY
DISORDERS
A. Dependent Personality Disorder
∞ Relies on others to assume large areas of
responsibilities for his life;

∞ Excessive need to be taken care of;

∞ Unassertive and passive;

∞ Fear of shame and criticism;

∞ Inability to take risks or to initiate anything;

∞ May show signs of depression and anxiety;

238
B. Avoidant Personality Disorder
Avoidance of any situation that could
result in criticisms and shame;

Px feels discomfort in social gatherings;

Px may be shy and fearful (of rejection or

disapproval)

Afraid to enter into a relationship unless

he/she feels secured and accepted;

239
C. Obsessive-Compulsive Personality
Disorder
Preoccupation with orders, rules and
regulations;

Usually perfectionist and meticulous;

Too busy working to have social life;

Has difficulty in making decisions;

Uses reaction formation, undoing, and

displacement;

240
by:
Manuel Sanchez Tu, Jr., RN, MD, USRN

241
 Morel described schizophrenia before as
dementia praecox (precocious senility);

 Bleuler later coined the term

schizophrenia which means “split mind”
(not split personality);

 95% of clients with schizophrenia have a

lifetime disease;

 It is the most common thought disorder;

242
 SUICIDE is the most common cause of
premature death of these clients;

 Usually appears in late adolescent or

early adulthood;

 Affects men and women almost equally;

243
II. Theoretical Perspective

A. Biological Theories

• Biochemical Theory
(Dopaminergic Hypotheses)

• Excessive dopaminergic activity in

cortical areas causes acute
positive symptoms of
schizophrenia (“HIDES”)

244
2. Neurostructural Theory
– Patients with schizophrenia have four
structural changes in the brain:
a. Cerebral ventricular enlargement.

c. Cerebral atrophy

e. Hypoplasia of the medial limbic

structures.

g. Decreased cerebral blood flow

specially in the prefrontal cortex.

245
3. Genetic Theory
– Higher incidence of schizophrenia in
patients with a diagnosed psychotic
relative;

– Monozygotic twins have a higher

incident rate compared to ordinary
individuals;

– Identical twins have 50% risk;

– Fraternal twins have 15% risk;

246
4. Perinatal Risk Factors
– Prenatal exposure to influenza

– Minor malformations developing during

early gestation

– Complications of pregnancy particularly

during labor and delivery;

247
B. Developmental Theory
• The “first stage (trust vs mistrust) is very
important in the development of
interpersonal relationship.”

• A child deprived of nurturing, loving

environment, neglected or rejected, is very
vulnerable to mental disturbances;

• Therapeutic intervention focuses on the

reestablishment of trust thru consistent,
anxiety-free relationship;

248
III. DSM-IV Criteria in the Diagnosis of
Schizophrenia
A. Characteristic symptoms:
• Two (or more) of the following, each
present for a significant portion of time
during a 1-month period (or less if
successfully treated):
 Delusions
 Hallucinations
 Disorganized speech (e.g., frequent
derailment or incoherence)
 Grossly disorganized or catatonic
behavior
 Negative symptoms (anergia, alogia)

249
B. Social / Occupational Dysfunction:
• Manifestations of psychosis will
significantly affect the level of
functioning of the client.

C. Duration
• Signs of the disturbance persist for
at least 6 months.

250
D. Schizoaffective and Mood Disorder
Exclusion:
• The manifestations of psychosis are
NOT secondary to other mental
illness.

E. Substance / General medical

condition exclusion:
• The manifestations of psychosis are
NOT secondary to substance abuse
(shabu use) or medical illness
(delirium, typhoid psychosis)

251
 BLEULER’S Four A’s
 Affective Disturbance

b. Inappropriate – affective response does

not match the circumstances;

d. Blunted – the response to certain

circumstances is weakly appropriate;

f. Flat – inability to generate any affective

response;

h. Labile – emotional tone changes quickly;

252
 Autism – preoccupation with the self
with little concern for external reality;

 Associative looseness – the stringing

together of unrelated topics with
VAGUE connections;

 Ambivalence – simultaneous opposite

feelings;

253
 Positive vs Negative Symptoms
of Schizophrenia
1. Positive Symptoms (type I)
 believed to be caused by an increase
in the amount of dopamine;

 Symptoms are additional of

abnormal cognition and perception;

 Targeted by typical anti-psychotics

(Haldol, Thorazine)

254
 Examples of Positive Symptoms:
– Hallucinations and hostility
– Illusions and ideas of reference
– Delusions
– Excitement
– Suspiciousness
– Bizarre behavior
– Agitation or tension
– Grandiosity

“HIDES BAG”

255
2. Negative Symptoms (type II)
• Symptoms are essentially an absence or
diminution of what should be ( lack of
affect, lack of energy)

• May be related to:

– decrease amount of dopamine
– cerebral atrophy
– decreased cerebral blood flow
– increase serotonin;

• Targeted by ATYPICAL anti-psychotics

(Clozapine, Olanzapine)

256
– Examples of Negative Symptoms:
1. Alogia – poverty of content; lack of
meaning or substance in what he
say;
2. Anhedonia
3. Asocial behavior
4. Attention deficit
5. Avolition – lack of motivation;
6. Blunted affect
7. Communication difficulties (echolalia,
neologism, word salad, etc)
8. Difficulty with abstraction;

257
 Objective vs Subjective Behavioral
Manifestations:

A. Objective Signs

1. Alterations in personal relationships.

 Poor attention span.
 Poor self care or grooming.
 Poor social communication.

258
2. Alterations of activity.
 Psychomotor agitation

 Echopraxia

 Catatonic rigidity

 Stereotype behaviors

259
Subjective Signs:

Autism and Ambivalence

Blocking
Clanging association and concrete
thinking
Delusions
rEtardation – slow mental activity.
Flight of ideas, mutism, and word salad.
neoloGism – invented words.
Hallucination
Illusions and ideas of reference

260
 Delusions – fixed, false beliefs;
 Somatic delusions

 Delusion of grandiosity

 Delusion of religion

 Delusion of nehilism (dead)

 Delusion of reference – other people is talking

about you.

 Delusion of influence or control

 Delusion of persecution

 Paranoid delusions

261
 Subtypes of Schizophrenia (DSM-IV)

2. Paranoid
 extreme suspiciousness
 persecutory delusions
 auditory hallucinations

 Uses PROJECTION.

 ND: Potential for violence,

directed to others or self.

262
1. Catatonic
 Increased purposeless motor activities
 Stuporous or waxy flexibility
 Rigid posturing behavior
 Mutism and negativism
 Peculiar movements
 Echolalia or echopraxia

 Uses REPRESSION.

 ND: Impaired motor activities.

263
3. Disorganized / Hebephrenic
 With child-like behaviors
 Incoherent speech
 Disorganized behavior
 Unsystematized delusions
 Inappropriate or flat affect
 Abnormal social behavior

 uses REGRESSION.

264
4. Undifferentiated
• Grossly disorganized and
incoherent behavior
• Severe hallucinations
• Prominent delusions
• Severely impaired level of
functioning.
• Or if the client’s manifestations will
not fall under the three categories.

265
5. Residual
• Absence of psychotic symptoms
although the px had previous
schizophrenia;

• Functional level moderately impaired

and the client can’t keep a permanent
job;

266
∞ Treatment:
1. Psychosocial Therapy
 Initially focuses on the patient’s physical
safety;

 “Helping px to become stronger than their

symptoms”

 Support the patient by abandoning

maladaptive behaviors for more acceptable
ones;

 Design a treatment plan to raise the patient’s

functional level and to educate the family on
how to respond appropriately to the patient’s
behavior;

267
2. Pharmacotherapy
• Use of phenothiazines (Thorazine) and
other neuroleptics;
• Adjunctive drugs such as antiparkinsons,
anticholinergics, propranolol, and
diphenhydramine may be used to control
adverse drug reactions;

3. Combination Therapy
• Psychotherapy and pharmacotherapy;
• To build a stable psychological foundation
and helping the patient accept
responsibility for self care, develop social
relationships, and vocational satisfaction;

268
 Nursing Diagnosis:
– Altered thought process***

– Sensory/perception alteration***

– Potential for violence, directed to self or

others;

– Ineffective individual coping

– Personal identity disturbance

– Impaired verbal communication

– Self-care deficit

– Impaired social interaction

269
∞ Nursing Interventions:

1. Safety
 Remove any unsafe objects from the
patient’s environment;

270
2. Environment
• Keep the px oriented to reality and 3
spheres;
• Minimize environmental stimuli;
• Communicate in clear, direct, and concise
manner;

3. Self-esteem
• Assist the px with grooming if needed;
• Allow the px to make decisions when
appropriate;
• Acknowledge the px’s abilities and skills,
and use them to reinforce teaching;
271
4. Social activities
• Give positive reinforcement when the px
voluntarily interacts with others;

• Encourage the px to participate in group

activities;

5. Ego development
• Validate the patient’s perceptions that are
accurate and correct all misperceptions;

272
6. Homeostasis
• Monitor the patient’s vital signs;
• Provide period for adequate sleep and diet;
• Control hyperactive psychomotor activity;
• WOF: adverse drug reactions (EPSE)

7. Correct delusions
• Establish and maintain reality for the
client.
• Teach the client to practice positive
thinking and IGNORING delusions.

273
8. Correct hallucinations and illusions
• Help maintain reality.

• Engage px in reality-based activities such as

card playing or occupational therapy.

274
 OTHER PSYCHOTIC DISORDERS
A. Schizoaffective Disorder
– Is a psychosis characterized by both
affective and schizophrenic
symptoms with substantial loss of
occupational and social
functioning;
– Schizophrenic symptoms are
dominant but are accompanied by
major depressive or manic
symptoms;

275
A. Delusional Disorder
– Manifest symptoms similar to
schizophrenia but with substantial
differences exists:
1. DELUSIONS have basis in reality.
2. Have not met the criteria of
schizophrenia.
3. Behavior is relatively normal other
than their delusions.
4. Duration of symptoms is brief.
5. Symptoms may be due to substance or
general medical conditions.

• Tx: Anti-psychotics
276
A. Brief Psychotic Disorder
– Psychotic disturbances that last less
than 1 month and are not related to
other mental disorders, general
medical conditions, or substance
abuse;
– Tx: Anti-psychotics

B. Schizophreniform Disorder
– Shows symptoms of typical
schizophrenia and last at least 1
month but no longer than 6 months;
– Tx: Anti-psychotics

277
COGNITIVE DISORDERS
– Cognitive abilities are processes that allow
the person to make sense of experience
and to interact productively with the
environment;
1. Judgment
2. Attention
3. Perception
4. Orientation
5. Reasoning
6. Memory

– Char by deficit in memory or cognition that

significantly changes a person’s level of
functioning;
– Also known as Organic Brain Disorders; 278
DELIRIUM (acute brain syndrome)
 Deficiency in the capacity to maintain
attention;

 With rapid onset and brief duration;

 Char by acute loss of conscious

awareness;

 May lasts for hours or weeks and

resolves in a few days (reversible);

279
 Causes:
1. Physical abuse
2. Infection - sepsis
3. Endocrine problems –
thyrotoxicosis
4. Trauma – massive blood loss;
5. Abuse of substance

280
– Signs and Symptoms:
1. Prodromal signs
• Restlessness
• Anxiety
• Sleep disturbance
• Irritability

• **Cloudy consciousness – cardinal

sign.
• Apathy
• Impaired cognition and memory
defects
• Disturbances in perception
• Disorganized thought process
281
– Nursing Diagnosis:

1. **Risk for injury related to

cognitive and psychomotor
deficit.

3. Self-care deficit related to

inability to carry out ADL.

282
– Nursing Interventions:

**Follow treatment plan to relieve cause of

delirium.

• Reality orientation
a. Call the px by name and keep a
clock and calendar in plain view.
b. Use very simple words and short
sentences.
c. Provide a safe and quiet
environment;

283
1. Monitor vital signs.

3. Set limitations on inappropriate and

harmful behaviors.

5. Provide adequate nutritional and fluid

intake if tolerated;

284
DEMENTIA (chronic brain syndrome)
– Char by memory impairment and insidious
loss of intellectual ability;

– May be due to destruction of neurons in

the brain;

– Etiology usually due to other

NEUROLOGIC diseases:
1. Parkinson’s Disease
2. Pick’s disease
3. Huntington’s chorea
4. Wernicke-Korsakoff’s Syndrome
5. Alzheimer’s Disease **** 285
∞ DSM-IV Criteria for Dementia

1. Memory impairment (amnesia)

3. At least one of the ff cognitive disturbances:

a. Aphasia – language disturbance
b. Apraxia – inability to carry out motor
activities despite intact motor function;
c. Agnosia – failure to recognize or
identify objects despite intact sensory
function;
d. Disturbance in executive functioning
(abstracting, planning, organizing)

4. Significant impairment in social or

occupational functioning after the onset of
illness.
286
 Feature Delirium Dementia

Onset Acute (night) Insidious

Course Fluctuating Stable

Duration Hours to days Months to years

Attention Fluctuates Unaffected

Orientation Impaired time Often impaired

Memory Immediate or recent Recent and remote

memory memory
Perception Illusions and visual Absent of perceptual
hallucination function
Speech Incoherent, rapid, Difficulty in finding
slow words
Course Reversible Irreversible
287
ALZHEIMER’S DISEASE
– Is the most common type of dementia;

– Exact cause is UNKNOWN;

– Is a degenerative brain disease causing

dementia that is progressive and most of the
time irreversible;

– Usually begins after age 60 but early signs can

be observed at age 40;

– Death may occur within five years after

diagnosis (pneumonia or from other infections)

– More common in males;

288
– Char by microscopic brain changes:

• Senile plaques**

• Degeneration of neurons or
“neurofibrillary tangles” **

• Cerebral atrophy **

• Reduced level of acetylcholine:**

• Loss of neurons in the basal
ganglia
• Increase action of
acetylcholinesterase enzyme;

289
– A’s of Alzheimer’s Disease:
ging
mnesia
gnosia
phasia
praxia
luminum deposition
myloid deposition
ntibodies abnormalities
cetylcholine abnormality
bnormality in chromosome 21
- ricept (donepezil) 290
– Clinical Manifestations of AD:
• Memory loss (amnesia) and mood swings
• Intolerance for activity
• Depression
• Anger
• Helplessness and hopelessness
• Incontinence and abnormal reflexes
• Lack of self-care and home care
• Altered sleep and arousal patterns
• Numerous behavioral symptoms
(hallucinations, delusions, dysphoria,
apathy, agnosia, apraxia, aphasia)

291
– Nursing Diagnosis:

1. **High risk for injury

3. Altered thought process

5. Anxiety

292
– Nursing Interventions:
 Ensure safety:
 removing toys and other dangerous
objects in the vicinity;
 rearranging furniture and use of pads;

 Support and meet the client’s basic needs

(food, shelter, clothing)
 Encourage activities of daily living.
 Provide sensory stimulation (reading,
music)
 Encourage life review or reminisce.
 Use clear, short and concise
communication.
293
– Pharmacotherapy:
1. Antipsychotics – for psychotic
symptoms;

3. Antidepressants – SSRI’s; Nortriptyline

and Desipramine;

5. Antianxiety – used for agitation, anxiety,

and sleep disturbances;
• Buspirone
• Lorazepam
• Oxazepam

294
1. Metabolic enhancers / Vasodilators - treat
cognitive impairment;
• Hydergine

2. Nootropic agents – used to enhance

neuronal metabolic activity;
• Nootrophil

3. Donepezil (Aricept) and Tacrine (Cognex)

• acetylcholinesterase inhibitors;

• TO INCREASE ACH LEVEL;

• Aricept given once daily with low

incidence of hepatotoxicity;
295
 SUBSTANCE ABUSE
 Causes maladaptive behaviors secondary to mood-
altering substances;

UPPERS Stimulation of SNS

DOWNERS Depression of SNS

 Substance abuse is a widespread concern with

broad social ramifications and personal
consequences;

 May lead to addiction;

296
 Most commonly abused substances:
1. Alcohol
2. Opiates
3. Narcotics
4. Hallucinogens
5. Stimulants
6. Inhalants

 ALCOHOL - is considered as the leading abused

substance;

 CIGARETTE – is the most commonly abused

substance by psychiatric patients;
297
 Intoxication Withdrawal

Stimulants (Uppers)
–Shabu
–Cocaine Stimulation of the Depression of the
–Ecstasy SNS SNS
–Cannabis*

Depressants
(Downers)
–Alcohol Depression of the Stimulation of the
–Narcotics SNS SNS
–Opiates
298
 ALCOHOL ABUSE
– Alcohol is a CNS depressant that is rapidly
absorbed into the bloodstream;

– Alcoholism is considered to be present when

there is 0.1% or 10mL for every 1000mL of blood;

– Levels:
.1 - .2% - slow coordination, slurred speech

.2 - .3% - tremors, irritability, violence

.3% and above - unconsciousness

299
 Effects of Alcohol Intake:
 Aggression
 Blackouts
 Coordination problem
 Difficulty walking (unsteady gait)
 Experience slurred speech
 F - polyuria
 Gone are inhibitions
 “Hanep makapag-relax”
 Impaired attention, concentration,
memory and judgment;

300
 An overdose or excessive alcohol intake
in short period of time can result to
(ABCD):

1. Altered level of consciousness

2. Breathing is depressed and
vomiting
3. Coma
4. Death

301
∞ Wernicke - Korsakoff’s Syndrome
 Char by amnesia, clouding of consciousness,
confabulation (falsification of memory) and
peripheral neuropathy;

 Results from inadequate amounts of

THIAMINE (B1) and NIACIN, and the
neurotoxic nature of alcohol;

 Tx: Vitamin B1 or B-complex replacement;

302
∞ Common Behavioral Problems:
1. Denial
2. Dependency
3. Demanding
4. Destructive
5. Domineering

303
Treatment:
 Symptoms of withdrawal usually begin 4 –
12 hours (6-8 hrs) after cessation or marked
reduction of alcohol intake;

 May lasts up to 5 days;

304
ALCOHOL WITHDRAWAL SYNDROME

Stage I Stage 2
– 6-8 hrs after last  8-12 hrs after lasts
intake. intake.
 Confusion
– Anxiety and
anorexia  Gross tremors
 Nervousness
– Insomnia and
tremors  Disorientation
 Auditory and
– N/V and
visual
hyperactivity hallucinations
– Increase pulse  Illusions
and BP  Nightmares
– Depression
305
Stage 3
– 12-48 hrs after last intake.
– Severe hallucinations
– Seizures (Dilantin)

Stage 4
– 3 – 5 days after last ingestion.
– Confusion and delirium.
– Clouding of consciousness.
– Disorientation.
– Visual and tactile hallucinations.
– Fever and increase BP.
– Tremors and tachycardia.
– Medical emergency.

306
 Alcohol withdrawal can be life-threatening,
so detoxification needs to be accomplish
under medical supervision;

 Safe withdrawal is usually accomplished by

benzodiazepines:
– Lorazepam (Ativan) – drug of choice;
– Diazepam (Valium)

307
 Disulfiram (Antabuse)
– Inhibits the breakdown of acetaldehydes
by an enzyme (aldehyde dehydrogenase)

Alcohol (Ethanol)
L
Alcohol dehydrogenase

I Acetaldehyde + H2
Aldehyde dehydrogenase

Acetic acid
V

E
CO2 + H2O (for excretion)
308
R
– “The person who drinks alcohol while taking
disulfiram will become ill”: (DISULFIRAM OR
ANTABUSE REACTION)
1. Sweating
2. Flushing of the neck and face
3. Tachycardia and palpitations
4. Hypotension
5. Throbbing headache
6. Nausea and vomiting
7. Dyspnea
8. Tremors
9. Weakness

309
– Disulfiram may also cause arrhythmias, MI,
cardiac failure, seizures, coma, and death;

– The unpleasant effects to alcohol is

intended to help stop alcohol drinking;

– Once disulfiram is started, the px must not

take alcohol because of the danger of
these adverse effects;
AVOID ALCOHOLIC BEVERAGES,
PERFUMES AND SHAVING CREAMS with ALCOHOL.

310
FETAL ALCOHOL SYNDROME (FAS)
– Is the result of alcohol’s inhibiting effects
on fetal development during the first
trimester of pregnancy;

– Pregnant women who drink alcohol run

the risk of seriously harming their unborn
child;

– Characteristics:
1. Microcephaly
2. Severe mental retardation
3. Stillborn
311
 SEDATIVES, HYPNOTICS, and ANXIOLYTICS
 These are CNS depressants;

 Intoxication symptoms: (“SIC LULI”)

1. Slurred speech and stupor
2. Impaired verbal communication
3. Coma
4. Lack of coordination
5. Unsteady gait
6. Labile mood
7. Impaired attention or memory

312
 Benzodiazepines when taken orally are
rarely fatal (ONLY causes lethargy and
confusion)

 Barbiturates (Parenteral or oral) can be

lethal when taken in overdose (2 – 10 g can
be fatal)
1. Coma
2. Respiratory arrest
3. Cardiac failure
4. Death
313
 Withdrawal Symptoms:
– Usually occurs 6 – 8 hrs after cessation of some
benzodiazepines;

– Manifested by:
1. Autonomic hyperactivity
a. Increase PR
b. Increase BP
c. Increase RR
d. Increase in temperature

2. Hand tremors
3. Anxiety
4. Nausea
5. Insomnia
314
6. Psychomotor agitation
 Detoxification from sedatives, hypnotics, and
anxiolytics often manage by TAPERING the amount
of drugs the client receives over a period of days or
weeks;

 Barbiturates can cause fetal abnormalities because

these can cross the placental barrier;

- Infants born to mothers who take barbiturates

during the last trimester of pregnancy can
experience withdrawal symptoms postpartum;

315
 OPIOIDS
 Are popular drugs because these desensitize the
person to both physiologic and psychological pain
and induce a sense of euphoria and well-being;

 Examples:
 Morphine*
 Opium*
 Meperidine (Demerol)*
 Codeine
 Hydrocodone
 Methadone – drug of choice during
detoxification.
 Heroin*

316
 OPIOID INTOXICATION happen after the
initial euphoric feeling:
1. Pinpoint pupils*
2. Apathy
3. Respiratory depression
4. Uncoordinated movements
5. Lethargy and listlessness
6. Attention and memory impairment
7. Slurred speech

317
 NALOXONE (opioid antagonist) - is the
treatment of choice for toxicity; NOT FOR
DETOXIFICATION;

- It reverses all the signs of opioid

toxicity by blocking the neuroreceptors
affected by opioids;

- Immediately improves px’s respiration

and consciousness;

318
 Withdrawal develops when (1) drug intake ceases
or is (2) markedly decreased, or it can also be (3)
precipitated by the administration of naloxone:
 Craving
 Restlessness and rhinorrhea
 Anxiety with aching backs and legs
 Nausea and vomiting
 Dysphoria and diarrhea
 Sweating
 Fever
 Insomnia
 Lacrimation

“CRANDS FIL” 319

 Heroin Withdrawal: “STRICY”
– Sneezing
– Tears
– Restlessness
– Irritability
– Coryza
– Yawning

 Methadone - is used to replace opioid

during detoxification to reduce signs
and symptoms of withdrawal;
320
STIMULANTS (Amphetamines, Cocaine,
Ecstasy )
– Also known as “uppers;”

– These drugs excite the CNS;

– The effects of these drugs, even though

they are different, are the virtually same;

– These drugs have limited clinical

indications and a high potential for abuse;

321
– Amphetamines are commonly used before
to lose weight (ex. IONAMINE)

– Cocaine and ecstasy have NO clinical use

and is highly addictive;
Commonly used as a recreational drug
because of intense and immediate
feeling of euphoria;

322
 Intoxication from stimulants develops
rapidly:
1. Super active
2. Talkative
3. Impaired judgment
4. “Mabilis pumayat” (weight loss)
5. Unhappiness or anger
6. Loss of appetite (anorexia)
7. Anxiety
8. The presence of hallucinations and illusions
9. Euphoria

323
10. Physiologic effects:
a. Tachycardia
b. Elevated BP
c. Dilated pupils
d. Diaphoresis with chills
e. Nausea
f. Chest pain and Confusion
g. Cardiac arrhythmias

∞ Cocaine users may also report “bugs” crawling

beneath the skin (FORMICATION) and foul
smells;

∞ Nasal septum perforation – is associated with

chronic snorting cocaine and is due to extreme
vasoconstriction which impedes blood supply
to the nasal septum causing necrosis;
324
∞ Cocaine or Stimulant Withdrawal:
 Occurs within a few hours to several days;

 Manifestations: (“ D MANIPIS”)
 Depressive symptoms
 Marked dysphoria – feeling of
unhappiness and anger;
 Agitation
 Nightmares
 Increase appetite
 Psychosis
 Increase suicidal ideations
 Sleeping disturbances
325
 CANNABIS (Marijuana)
– From Cannabis sativa, a hemp plant for making
ropes and cloth;

– contain DELTA-9 TETRAHYDROCANNABINOL

(THC) - the active substance;

– Marijuana – upper leaves, flowering tops, and

stems of the plant;

– Hashish – is the dried resinous exudates from the

leaves of the female plant;

– Cannabis most of the time is smoked like

cigarettes but it can be eaten (brownies)
326
– Therapeutic use of cannabis:
1. Lowers IOP
2. ** Relieves nausea and vomiting associated
with cancer chemotherapy (dronabinol,
nabilone)
3. Anorexia and weight loss of AIDS

– Cannabis Intoxications:
- Begins to act less than 1 minute after
inhalation;
- Peak levels occur in 20 – 30 minutes and
lasts at least 2 - 3 hours;

327
 Symptoms of Cannabis Intoxication:
 Tachycardia
 Hypotension
 Eye redness
 Psychotic symptoms (hallucinations)
 Abnormal motor coordination
 Short-term memory loss
 Inappropriate laughter (“laughing trip”)
 Social withdrawal
 Increase appetite (“food trip”)
 Disorientation, delirium, and
dysphoria

328
– Treatment is usually symptomatic and
overdose does not occur ( because easily
excreted )

– Withdrawal symptoms are usually not

present when sudden cessation is
performed;

329
 HALLUCINOGENS
 Also referred to as psychotomimetics or
psychedelics;

 Are substances that distort the user’s perception of

reality and produce symptoms similar to psychosis;

 Used to treat chronic alcoholism and reduction of

cancer pain and PLP;

330
 Two basic groups:
1. Natural
a. Mescaline – peyote from cactus;
b. Psilocybin – psilocin from mushrooms;
c. Cannabis

– Synthetic
a. LSD – lysergic acid diethylamide
b. STP – dimethoxy-4-methylamphetamine
c. Pencyclidine (PCP) – most potent;
d. DMT – dimethyltryptamine
e. MDA - methylenedioxyamphetamine

331
 Hallucinogen intoxication is marked by a
variety of maladaptive behavioral or
psychological changes:

1. Hallucinations
2. Anxiety
3. Paranoid ideation
4. Depression and dangerous behaviors
5. Ideas of reference

332
 Toxic reactions to hallucinogens (except PCP) are
primarily psychological and overdose usually will
not occur;

 Psychotic reactions are best managed by:

 Isolation from external stimuli.
 Using physical restraints if necessary for the
CLIENT’S SAFETY.

333
 INHALANTS
 Are diverse groups of drugs that are
inhaled for their effects:
1. Anesthetics
2. Nitrates
3. Organic solvents
 Gasoline
 Glue
 Paint thinner
 Spray paint

 Inhalants can cause significant brain

damage, PNS damage, and liver disease;
334
 Inhalants may cause acute toxicity:
1. Respiratory depression
2. Anoxia
3. Vagal stimulation
4. Arrhythmias
5. Death ( due to bronchospasm, cardiac
arrest, suffocation, or aspiration)

335
 Treatment consist of supporting respiratory
and cardiac functions until the substance is
removed from the body;

 There are no withdrawal or detoxification

procedures for inhalants;

336
 EFFECTS OF SUBSTANCE ABUSE
1. Decrease number of social friends.
2. Reduction of leisure activities.
3. Erosion of spiritual values and moral
standards.
4. Abnormal physical functions.
5. Mounting family tension and mental
deterioration.
6. Sexual and occupational problems.

337
 EATING DISORDERS
ANOREXIA NERVOSA
– is a disorder characterized by compulsive
resistance to eat and maintain body weight;

– Common in adolescent and young adult 12 –

18 years of age;

– With a mortality rate of 15 – 20%;

– Majority of cases are females;

– Clients usually die of severe malnutrition; 338

– Most of them are experiencing DENIAL
(unconscious refusal to admit their
disease)

– May be triggered by:

• adolescent crisis
• unconscious fear of growing up
• excessive concern and fear of obesity
• elevated feelings for self-control

339
– Manifestations of Anorexia Nervosa:
1. Hypothermia, and hypotension
2. Anemia with bradycardia/tachycardia.
3. Nutritional deficiency (malnutrition)
4. Obvious weight loss ( 15% or more of
original body weight ) ***
5. Resistance to eat (fear of eating)
6. Electrolyte imbalance (hypoK and hypoNa)
7. Keep high performance in school and
sports
8. Social withdrawal with poor individual
coping
9. Increase in size of salivary gland
(hypertrophy)
10. Amenorrhea (absence of at least 3 consecutive
menstrual cycle) 340
- Nursing Diagnosis:
1. Altered nutrition: less than body
requirements
2. Disturbed body image
3. Ineffective individual coping
4. Ineffective family coping
5. Fluid and Electrolyte imbalance

341
BULIMIA
– A syndrome char by recurrent binge eating
with lack of control and followed by purging
(vomiting, use of laxatives or diuretics, or
vigorous exercise)

– May also manifest with pica (or eating non-

nutritious foods such as plaster, paint, clay,
or sand)

– Common among adolescent and young

adults 17-23 years old;

– More common among women;

342
– Tend to be episodic with remissions and
relapse;

– Most clients know their illness;

– Is predispose to have depression;

– May have discord with family relationship;

– There is a profound history of obesity in the

family;

343
– Manifestations:
1. Body and weight conscious.
2. Unusual, extroverted, and impulsive
individuals.
3. Lability in weight (due to binge-eating
and long hours of fasting)
4. Induced purging after binge-eating.
5. Multiple dental staining
6. I - Electrolyte imbalance
(hyponatremia, hypokalemia, and
hypochlorinemia)
7. Engages in vigorous exercises.
8. Signs of depression. 344
 ANOREXIA NERVOSA
Diet… diet… diet….
Denial
> 15% weight loss
Amenorrhea
Hypertrophy of Salivary G.
Severe malnutrition
Lanugo formation
Course is continuous
“I’m fat….” (mirror)
SUPEREGO
Fear of obesity
BULIMIA
Eat..eat..vomit… exercise..
Know…. Hide …..
Fluctuating body weight
Irregular menstruation
Teeth erosion
Metabolic alkalosis (vomit)
Metabolic acidosis (diarrhea)
Course is episodic
Weight conscious
ID
345
- Nursing Diagnosis:
1. Altered nutrition: less than body
requirements
2. Ineffective family coping
3. Ineffective individual coping
4. Personal identity disturbance

346
Nursing Interventions for Eating Disorders:

- Weigh client daily.

- Encourage verbalization of feelings.
- Increase self-esteem.
- Go observe for signs of purging and
depression.
- Help clients reestablish proper eating
behavior.
- Monitor caloric intake.
- Electrolyte monitoring regularly.

347
 SEXUAL DISORDERS
– These are disorders that are related to
human sexuality due to psycho-
physiological causes;

– Types:
1. Alteration in gender identity
2. Alteration in sexual orientation
3. Alteration in sexual behavior
4. Alteration in sexual functioning
5. Painful sexual disorders
348
ALTERATION IN GENDER IDENTITY

1. Transsexualism
– Persistent discomfort about one’s sex
assignment;
– Caused by confused learning about
gender roles;
– Feeling of being trapped in the wrong
body;
– With intense feeling or preoccupation
about transsexual surgery;

349
2. Gender Identity Disorder of Childhood
– Persistent and intense distress at one’s
sexual identity;
– Client insists that he/she is an opposite
sex;
– Assertion that he/she will grow up to
have transsexual surgery;

3. Nontranssexual Cross Gender Disorder

– Persistent discomfort about one’s sex
but with no preoccupation with getting
rid of the genitalia;

350
ALTERATION IN SEXUAL ORIENTATION

1. Ego-Dystonic Homosexuality
• Weak heterosexual arousal with desire to
have heterosexual relationship;

• Client experience inappropriate

homosexual arousal pattern;

351
ALTERATION IN SEXUAL BEHAVIOR

1. Sexual Acting Out

– With disturbed conduct or poor impulse
control;
– Have extramarital affairs and
promiscuous individuals;
– With high sexual drive;
– Presence of inadequate coping and
interpersonal skills;

352
2. Paraphilia
– Sexual urges or fantasies that are
directed toward nonhuman objects, pain
to self, partner, or children, or other non-
consenting individuals;
– This may be asymptomatic;
– Behavior often followed by guilt, shame,
low self-esteem, or anxiety;
– Not due to other mental disorder;

353
Fetishism substitution of an inanimate
object for the genitals

Transvestism wearing clothes of the opposite

sex to achieve sexual pleasure
Exhibitionism Haha lam na =)

Pedophilia attraction to children less

than 13 y/o as sex objects
Voyeurism sexual gratification obtained by
watching the sexual plays of
others
Sadism sexual gratification obtained by
inflicting pain and punishment
to the partner
Masochism sexual pleasure from enduring
physical and psychological pain
354
Frotteurism sexual pleasure obtained
by touching or rubbing
against a non-consenting
person.
Necrophilia sexual gratification
obtained from corpse.
Telephone scatologia sexual gratification from or
during telephone
conversation.
Zoophilia intense sexual arousal or
desire for animals
Sodomy oral and anal intercourse
between males;

355
ALTERATION IN SEXUAL FUNCTIONING

1. Sexual Dysfunction – individual is

unsatisfied in his sexual function;

3. Hypoactive sexual desire – absence of

sexual fantasies and desires;

5. Sexual aversion – avoidance of genital

sexual contact with a partner;

356
4. Sexual arousal disorder
– Failure to attain and maintain erection
in males;
– Lack of lubrication in females;
– Persistent or recurrent lack of
subjective sense of sexual excitement
and pleasure;

357
PAINFUL SEXUAL DISORDERS

1. Vaginismus – an involuntary vaginal spasm

at penetration;
 Protection against anticipated pain
associated with sexual trauma, intense
guilt, or high religion offense;

2. Dyspareunia – painful sexual intercourse;

358
NURSING DIAGNOSIS
1. Altered sexuality patterns
2. Ineffective individual coping
3. Altered family process
4. Anxiety
5. Potential for violence: self-induced or to
others.

359
NURSING INTERVENTIONS:
1. Sexuality belief and values discussion.

3. Encourage to discuss feelings of guilt,

remorse, anger, and loneliness.

5. X – explain to the client the institution of

suicidal precaution.

360
 OVERVIEW OF SUICIDE
• is the 9th leading cause of death in the US;

• Among the three leading causes of death

for those aged 15-34 years old;

• Females are higher to COMMIT suicide;

• Men are 4x higher to COMPLETE

SUICIDE than females;

361
SUICIDE
 Or self-inflicted death;

 outcome of a person’s inability to deal

with catastrophic stress (depression)

• Suicide most often is the result of

depression, diagnosed or not;

 Suicide may occur in children,

adolescent, or adult populations;

362
 Suicidal ideation – includes a person’s
thoughts regarding suicide;

 Suicidal gestures – non-lethal self-injury

acts like:
1. Cutting of skin areas
2. Burning of skin
3. Ingestion of poisonous substances or
drugs

 Suicidal gestures may be considered as

“ATTENTION-SEEKING” measures and
MAY NOT LEAD to serious attempts or
completion;
363
• Suicidal threats – are person’s verbal statements
that may declare their intent to commit suicide;
Threats OFTEN PRECEDE an actual suicide
attempt;

• Suicide attempt – is the actual implementation

of a self-injurious act with the purpose of ending
a person’s life;

• The death by suicide of a psychiatric client is of

particular importance to the nurse because of
opportunities for assessment and interventions;

364
• (HIGH) Risk Factors for Completed
Suicide:
1. Caucasian and Native Americans
2. Living alone – single, divorced, widow/er
3. Age 40-60 and older
4. Male sex
5. Prior suicide attempts – 50-85%
6. Substance use (alcoholism, drugs)
7. Hopelessness and helplessness
8. Unemployed or financial problems
9. General medical illness – terminal cancer
10. Severe anhedonia

365
• Assessment of Suicidal Patients:
 It is important for the nurse to be able to
assess the suicidal potential of mentally ill
clients because of higher risk in
committing suicide;

• Plan
• The more developed the plan, the
greater risk of suicide;
• Impulsive suicide attempts can also
result in death but generally are less
often lethal because of lack of planning;

366
2. Method
• Some methods of suicide are more lethal
than others;

• One important factor in determining the

lethality of a method is the time between
initiation and the delivery of the lethal
impact of the method;

• Ex. GSW is more lethal than drowning or

suffocation;

367
• Types of Methods:
1. Gunshot
2. Jumping from high places
3. Hanging
4. Drowning
5. Carbon monoxide poisoning
6. Overdose with certain drugs
(alcohol, barbiturates, and other
CNS depressants, ASA, valium)
7. Wrist cutting
8. Ingestion of poisonous substances

368
3. Rescue
• A person who deliberately attempts to
deceive would-be rescuers has a high lethal
potential;

• The more detailed the plan, the more lethal

and accessible the method;

• The more effort to block rescuers, the

greater the chance for a successful suicide;

369
– Nursing Diagnosis:
• Ineffective individual coping
• Potential for violence: self-directed
• Fear
• Anxiety

370
• Nursing Interventions:
1. Assess and evaluate client for suicidal risk to
develop a reasonable plan of care.

3. Suspect suicidal ideation in most depressed

clients.

5. Inquire directly about the frequency and

content of suicidal ideations.
– The nurse will not provoke suicide.
– The nurse will convey concern, worth of
the client, and a sense of
understanding.
– To plan nursing care.
371
1. Evaluate client’s access to a means of
suicide to block the access.

3. Develop a formal “no suicide” contract

with the client.

5. Advise the client to discontinue drugs

and/or alcohol intake.

372
 DEVELOPMENTAL DISORDERS
• MENTAL RETARDATION
• Or Cognitive Developmental Delay;

• Is defined by IQ BELOW 70 before 18 y/o

that is accompanied by impairments in
performing age-expected activities in daily
living;

• 3% of the US population are considered MR;

• Most mentally retarded are in the MILD

range;
373
• The causes of MR:
• Specific
• Down’s syndrome – most common.
• Fragile X syndrome
• Phenylketonuria

• Multifactorial causes
• Congenital anomalies
• Perinatal trauma
• Postnatal trauma
• Postnatal infections

374
DSM-IV Classification of Mental
Retardation
Severity IQ Range
Mild / Moron 55 - 69
Moderate/ Imbecile 40 - 54
Severe/ Idiot 25 - 39
Profound Below 25

Normal IQ 90 – 110
Borderline 70 – 89

375
• MILD MR – capable of EDUCATION;
- Mental age of 8 – 12 years old;
- Can learn to read, write, achieve
vocational skills, and function in the
society;

• MODERATE MR – the client is TRAINABLE;

- Mental age of 3 – 7 years old;
- Can learn the activities of daily
living;
- Can be trained to work;

376
• SEVERE MR – the client is barely trainable;
- Mental age 0 -2 years old;
- Totally dependent and in need of
custodial care;
- May say few words;
- With uncoordinated motor
movements;

• PROFOUND MR – mental age of young

infant;
- Requires full-time care;
- No academic skills;
- No fine or gross motor skills;
377
B. DOWN SYNDROME (TRISOMY 21)
 Is the most common identifiable cause
of MR;

 Down syndrome is one of the most

widely known syndromes associated
with MR;

378
 Clinical Manifestations:
1. Characteristic facial anomalies and others.
a. Brachycephaly
b. Epicanthal folds
c. Flat nasal bridge
d. Low-set ears
e. Oblique palpebral fissures
f. Protruding tongue
g. Simean crease of palms

2. Congenital heart defects – VSD, TOF, PDA

3. Mental retardation
4. Hypotonia
5. Growth retardation
379
C. Fragile X Syndrome
 2nd most common identifiable cause of MR;

 Most common inherited cause;

 Dx made during mid-childhood;

 Clinical Manifestations:
1. Mild to moderate MR
2. Elongated face, prominent ears,
macrocephaly, high-arched palate;
3. Macroorchidism at puberty
4. Autism
5. Attention deficit, hyperactive
6. Self-mutilating or self-injurious behaviors;
380
D. Turner’s Syndrome
 rare genetic disorder found among females;

 There is an absence of a normal 2nd sex

chromosomes;

 Genetic analysis reveals a 45,X chromosome

constitution;

 Clinical Manifestations:
1. The most prevalent:
a. Short stature, webbed neck, low
posterior hairline, edema of the hand
and feet;
b. Broad chest with inverted or
underdeveloped nipples;
c. Immature reproductive organs, primary
amenorrhea 381
AUTISTIC DISORDER
• Char by detachment from reality when self-
preoccupation and self-involvement are
predominant;

• Strong genetic contributions but the exact

cause remains UNKNOWN;

• Others suggest:
o increase level of serotonin
o abnormal serotonin receptors;

• Most are mentally retardate;

• Onset is usually at 30 months of age;

382
• Clinical Manifestations:
1. Profoundly disturbed social
relatedness;
2. Constant delay in the developmental
profile;
3. Aloof and indifferent to others;
4. Prefers inanimate objects than human
contacts;
5. Temper tantrums
6. Language is delayed and deviant:
• Abnormal intonation
• Pronoun reversals
• Echolalia

383
1. Stereotypical behaviors
• Rocking
• Hand flapping
• Extraordinary insistence on
sameness
• Preoccupation with peculiar
interests (fans, aircons)

384
• Nursing Interventions:
1. Maintain a consistent and familiar
environment.

3. Set consistent and firm limits for

behaviors.

5. Encourage verbalization of feelings and

concerns.

7. Prevents destructive behaviors.

9. Provide routine for ADL’s.

385
• Pharmacologic Tx:
1. Haloperidol (Haldol) - to decrease or
relieve:
• Temper tantrums
• Aggressiveness
• Self-injury
• Hyperactivity
• Stereotypical behaviors

2. Naltrexone
3. Clomipramine
4. Clonidine
5. Stimulants
386
 DISRUPTIVE BEHAVIOR DISORDERS

ATTENTION-DEFICIT HYPERACTIVITY
DISORDER
• Is char by inattention, impulsiveness, and
overactivity;
• Is a relatively common among SCHOOL-
AGED CHILDREN (2-11%);
• The exact etiology is STILL UNKNOWN;
• Experts suggest that dysfunction of the
frontal lobe;
• May occur together with learning
disabilities;

387
• Possible Etiologies:
1. Environmental exposures
a. Perinatal insults
b. Head injury
c. Psychosocial adversity
d. Lead poisoning

• Food additives and history of allergies.

• Genetic predisposition especially

among identical and fraternal twins.

388
MAIN PROBLEMS OF ADHD:***
I – Inattention
H – Hyperactivity
I – Impulsivity

NURSING DIAGNOSIS:
Risk for injury.***

389
• Management:
1. Multidisciplinary approach (environmental and
behavioral) is the treatment of choice.

3. Pharmacotherapy
• CNS STIMULANTS work for 70-75% of ADHD
(only for children older than 7 years old)
 Effective in decreasing motor activities and
increasing attention span and
concentration;

 *** Methylphenidate (Ritalin) – most

common;
 Dextroamphetamine (Dexadrin)
 Pemoline (Cylert)
 Clonidine (Catapres)

• TCA’s (Imipramine, desipramine, nortriptyline )

390
TIC DISORDERS
• Term used to describe several disorders that
are characterized by motor and/or vocal tics;

• TIC – is a sudden, rapid, recurrent, non-

rhythmic, stereotyped motor movement or
vocalization;

 Tics can be suppressed for a period of

time but not indefinitely;

 Tics are exacerbated by stress and

diminished during sleep and when the
person is engaged in an absorbing
activity;
391
• Motor Tics – typically rapid, jerky
movements of the eyes, face, neck, and
shoulders;

• Vocal Tics – most common are throat

clearing, grunting, or other repetitive
noises;

 Echolalia
 Palilalia
 Coprolalia

392
• TOURETTE’S SYNDROME – is a chronic
idiopathic movement disorder that is char by the
presence of multiple motor and vocal tics for more
than 1 year;

 May experience all types of tics in his lifetime;

 Will lead to significant impairment on social,

academic, or occupational functioning;

 May feel ashamed and self-conscious;

 Rare and more common among BOYS than

girls;

 Onset usually by age 7 years;

 Dx: Haloperidol (Haldol)

393
ABUSE
– Wrongful use and maltreatment of
another person (spouse, partner,
child, or elderly)

– May lead to:

» Physical injuries
» Psychological injuries

394
– Victims of abuse may also show:
 Upset
 Numb
 Agitation
 Withdrawn – low self-esteem
 Aloof

– Domestic violence goes undisclosed

for months or years (due to FEAR OF
THE ABUSER)

395
– Char of a Violent Family:

• Social Isolation
• Do not invite others into their home or
tells others what is going on;
• Threat from the abuser;

3. Abuse of Power and Control

• Abuser is almost always in a position of
power and control over the victim;
• Physical, economic, or social power;

396
1. Alcohol and Drug Abuse
• Abuser commonly uses alcohol or
drugs;
• Alcoholism is also present in 50% of
abused women;
• Alcohol and drugs are also associated
with date rape;

2. Intergenerational transmission process

• Family violence is a learned response;
• 1/3 of abusive men grew from a violent
family or with history of abuse;

397
SPOUSE OR PARTNER ABUSE

– Is the maltreatment or misuse of one person

by another in the context of an intimate
relationship;

– 90 – 95% of domestic violence victims are

WOMEN;

– Pregnancy increases violence in a

relationship;

398
– This can be:

1. Psychological or emotional abuse

– Name-calling
– Belittling
– Shouting
– Destroying properties
– Threats
– Refusing to speak to the victim

399
1. Physical Abuse 1. Sexual Abuse
• Shoving • During sex;
• Pushing • Biting
• Battering nipples
• Choking • Pulling hair
• Fractures • Slapping
• Homicide • Hitting
• Rape

400
– Char of an Abuser:

inAdequacy
“Isip Bata” (immature)

pUr problem-solving skills

low Self-esteem
jEalous and possessive
act is Rewarding

401
– Why women stay with their abusive
husbands?

2. DEPENDENCY - is the most

common reason.

4. Cycle of Violence

402
 CYCLE OF VIOLENCE

Violent behavior

Tension Building Period of

Remorse
403
1. Violent Behavior
• Explodes in violent / abusive attack;

2. Period of Remorse
• Or “Honeymoon Period”
• Regret and apology
• “I’m sorry…. It will never happen again….
Promise…”
• Buys gifts, flowers, jewelries, etc.
• Wife believes her husband.
• May start from weeks to months…. Then
becomes frequent.

404
 1. Tension Building Stage
– Arguments again ensue;
– Silence
– No complaints

– “Assess for signs of abuse…”

405
CHILD ABUSE
– or child maltreatment;

– Intentional injury to a child;

– May include:
• Physical abuse and injuries
• Neglect or failure to prevent harm
• Failure to provide care
• Abandonment
• Sexual assault
• Torture
406
– Types of Child Abuse:
• Physical
• Emotional
• Neglect
• Sexual

407
– Physical Abuse
• Usually due to corporal punishment;
• Hitting and Burning
• Biting and Cutting
• Poking
• Twisting limbs
• Scalding with hot water

• “Evidence of old injuries (healed fx) and

multiple bruises of various stages.”

• “Stop crying…………”
• “Diumebs ka na naman..……….”
408
– Emotional Abuse
• Verbal assaults
• Constant family violence
• Withholding affection and love

409
– Neglect
• Is the most common type of
maltreatment;

• Refused or delay to seek medical

help.
• Abandonment
• Inadequate supervision
• Disregard for safety
• Spousal abuse in child’s presence
• Failure to enroll to school
410
– Sexual Abuse
• 75% of cases involve father-daughter
incest;

• Rape
• Sodomy
• Molestation
• Exploitation of minors

411
– Char of Parents (in Child Abuse)
• Lack of parenting skills
• Lack of understanding in children’s
needs
• Lack of money
• Lack of education
• With history of child abuse

412
– Warning Signs of Abused Children:
• A – Absence of trauma but with
serious injuries (fracture, burns,
lacerations)
• B – Bruised, red, swollen, teared genitalia
(vagina and anal)
• U – Unusual injuries for age and
development (Femoral fx in a 2 month
old)
• S – Switching and inconsistencies in
child’s history.
• E – Evidence of old injuries.***
• D – Delay in seeking treatment for severe
injury.
413
– Nursing Interventions:
1. Ensure the child’s safety and well-
being.
2. Thorough psychiatric evaluation.
3. Establish trust to help child deal
with trauma of abuse.
4. Use play therapy to express his
feelings.
5. Refer to social works.

414