Professional Documents
Culture Documents
PSYCHIATRIC NURSING
MENTAL HEALTH
Is a state of emotional, psychological,
and social wellness evidenced by
satisfying personal relationships,
effective behavior and coping, a
positive self concept, and emotional
stability.
COMPONENTS OF MENTAL
HEALTH (Johnson, 1997)
Autonomy and Independence
Maximizing One’s Potential
Tolerating Life’s Uncertainties
Self-esteem
Mastering the Environment
Reality Orientation
Stress Management
COMPONENTS OF MENTAL
HEALTH – AUTONOMY AND
INDEPENDENCE
The individual can look within for guiding
values and rules to live by.
A) Autonomy
B) Absence of anxiety
C) Ability to control others
D) Happiness
ANSWER
Letter A
A) Urbanization
B) Poverty
C) Political turmoil
D) Genetics
ANSWER
Letter B
A) Psychiatric Nursing
B) Psychology
C) Psychiatry
D) Mental Hygiene
ANSWER
Letter D
Most of the time, the nurse’s values and beliefs will conflict with
those of the client, the nurse must learn to accept these
differences among people and view each client as a worthwhile
person regardless of the client’s opinions and lifestyle.
QUADRANT II
Blind / Unaware Self
Qualities known only to others
QUADRANT III
Hidden / Private Self
Qualities known only to oneself
QUADRANT IV
Unknown
An empty quadrant to symbolize
qualities as yet undiscovered by
oneself or others
CREATING
First Step A JOHARI WINDOW
– Appraise one’s own qualities by creating a list of
those qualities:
One’s values
Attitudes
Feelings
Strengths
Behaviors
Accomplishments
Needs
Desires
Sad thoughts
CREATING A JOHARI WINDOW
Second Step
– Find out how others perceive you by
interviewing others and asking them
to identify qualities they see in you,
both positive and negative.
CREATING A JOHARI WINDOW
Third Step
– Compare lists and assign qualities to
the appropriate quadrants.
FOUR QUADRANTS OF THE
JOHARI WINDOW
If Quadrant I is the
longest list, this
indicates the person is
open to others; a small
Quadrant I means the
person shares little
about himself or
herself with others
FOUR QUADRANTS OF THE
JOHARI WINDOW
If Quadrants I and III
are both small, the
person demonstrates
little insight.
FOUR QUADRANTS OF THE
JOHARI WINDOW
The goal is to work
toward moving
qualities from
Quadrants II, III and IV
into Quadrant I
(qualities known to
oneself and others),
which indicates the
person is gaining self-
knowledge and self-
awareness.
METHODS USED TO INCREASE
SELF-AWARENESS
ROLE PLAY
– Putting yourself in the client’s situation allows you to think about his
or her thoughts, feelings and actions.
INTROSPECTION
DISCUSSION
– Talk with others about your own experiences and feelings and how
they feel about similar experiences.
– Try to seek alternative points of view.
Example
– An electrical cord on the floor may
appear to be a snake!
DISTURBANCES IN PERCEPTION:
HALLUCINATION
False sensory perception in the absence of an
external stimuli
Perceptual experiences that do not exist in
reality
Example
– A person may see “angels” hovering above
when nothing is there
– A person may hear voices in a room
wherein he is alone
DISTURBANCES IN
THINKING
DISTURBANCES IN THINKING:
NEOLOGISM
Pathological coining of new words
Example:
– Nurse: “How have you been sleeping lately?”
– Client: “Oh, I go to bed early, so I can get plenty of rest.
I like to listen to music or read before bed. Right now I
am reading a good mystery. Maybe I will write a mystery
someday. But is it isn’t helping, reading I mean. I have
been getting only 2 or 3 hours of sleep at night.”
DISTURBANCES IN THINKING:
WORD SALAD
Incoherent mixture of words and phrases.
Example:
– “Corn, potatoes, jump up, play games, grass,
cupboard.”
DISTURBANCES IN THINKING:
VERBIGERATION
Meaningless repetition of words and
phrases.
Example:
– “I want to go home, go home, go
home, go home.”
DISTURBANCES IN THINKING:
PERSEVERATION
Persistence of a response to a previous question.
Example:
– Nurse: “How have you been sleeping lately?”
– Client: “I think people have been following me.”
– Nurse: “Where do you live?”
– Client: “At my place people have been following me.”
– Nurse: “What do you like to do in your free time?”
– Client: “Nothing because people are following me.”
DISTURBANCES IN THINKING:
ECHOLALIA
Pathological repetition of words of others.
Example:
– Nurse: “Can you tell me how you are
feeling?”
– Client: “Can you tell me how you are
feeling? how you are feeling?”
DISTURBANCES IN THINKING:
FLIGHT OF IDEAS
Shifting of one topic from one subject
to another in a somewhat related way.
Excessive amount and rate of speech
composed of fragmented or unrelated
ideas.
DISTURBANCES IN THINKING:
LOOSENESS OF ASSOCIATION
Shifting of a topic from one subject to another in a
completely unrelated way.
Example:
– Nurse: ”Do you have enough money to buy that candy bar?”
– Patient: “I have a real yen for chocolate. The Japanese have all
the yen and have taken all of our money and marked it. You
know, you have to be careful of the Marxists because they are
friends with the Swiss and they have all the cheese and all the
watches and that means they have taken all the time. The worst
thing about Swiss cheese is all the holes. People have to be
careful about falling into holes.”
DISTURBANCES IN THINKING:
CLANG ASSOCIATION
The sound of the word gives direction to the
flow of thought.
Examples:
Examples:
– The client may claim to be engaged to a famous
movie star or related to some public figure such
as claiming to be the daughter of the President of
the Philippines
Severe reduction in
emotional reaction.
Restricted range of
emotional feeling,
tone, or mood
DISTURBANCES IN AFFECT:
FLAT AFFECT
The pathological
imitation of posture or
action of others.
Imitation of the
movements and
gestures of another
person whom the client
is observing.
DISTURBANCES IN MOTOR
ACTIVITY:
WAXY FLEXIBILITY
Maintaining the
desired position for
long periods of time
without discomfort
even when it is
awkward or
uncomfortable.
DISTURBANCES IN
MEMORY
DISTURBANCES IN MEMORY:
CONFABULATION
Filling in of memory gaps to save face in an embarasing situation.
Example:
– Nurse: “Do you know Gemma? (referring to one of the residents at the
patient’s home)
– Patient: “Yes, I know her. I used to play cards with her husband.”
– Actually, Gemma’s husband had been dead for many years and the
patient had never met him
DISTURBANCES IN MEMORY:
AMNESIA
Inability to recall past events.
DISTURBANCES IN MEMORY:
ANTEROGRADE AMNESIA
Loss of memory of the immediate past.
DISTURBANCES IN MEMORY:
RETROGRADE AMNESIA
Loss of memory of the distant past.
DISTURBANCES IN MEMORY:
DEJA VU
Feeling of having been to a place
which one has not yet visited.
DISTURBANCES IN MEMORY:
JAMAIS VU
Feeling of NOT having been to a place
which one HAS VISITED.
SAMPLE BOARD QUESTION
A patient changes topics quickly while relating
his past psychiatric history. However, the
nurse is able to follow his thoughts. The
patient’s pattern of thinking is called?
A) Looseness of association
B) Flight of ideas
C) Clang association
D) Confabulation
ANSWER
Letter B
A) Clang association
B) Flight of ideas
C) Derealization
D) Neologism
ANSWER
Letter B
A) Lessen isolation
B) Protect their self-esteem
C) Control others
D) Enhance memory recall
ANSWER
Letter B
A) Illusion
B) Hallucination
C) Delusion
D) Confabulation
ANSWER
Letter A
A) Looseness of association
B) Hallucination
C) Delusion
D) Clang association
ANSWER
Letter B
Rationale: Hallucination is a
disturbance in perception.
CORE CONCEPTS ON
THERAPEUTIC
COMMUNICATION
COMMUNICATION
COMMUNICATION
It is the interchange of information
between two or more people
Values
– Principles, standards of quality considered worthwhile or
desirable
Culture
– The totality of socially transacted behavior patterns,
arts, beliefs, institutions, products of human work
characteristic of a community or population
LEVELS OF COMMUNICATION
Intrapersonal
– Occurs when a person communicates within himself
Interpersonal
– Takes place within dyads (groups of two persons) and in
small groups.
– The level of person-to-person communication is the heart of
of psychiatric nursing
Public
– Communication between a person and several other people
MODELS OF COMMUNICATION
Communication is an Act
Communication is an Interaction
Communication is a Transaction
COMMUNICATION IS AN ACT
It is something that a person is doing to another person
(example: person A talks to person B)
There is an attempt to transfer the thoughts or ideas of
one person into someone else’s head.
It suggests that the receiver plays a passive role and
does not affect the communicator
When misunderstandings occur, either the
communicator is faulted for failing to send the correct
message or the receiver is faulted for having allowed
something to interfere with the transmission of a
correct message.
The model is, therefore, inadequate
COMMUNICATION IS AN
INTERACTION
It takes into account the process of
mutual influence.
Non-verbal Communication
VERBAL COMMUNICATION:
THE SPOKEN WORD
Denotation
Connotation
2) Appropriateness
– The reply is fitting and relevant to the
communication; it is neither too much nor
too little
CHARACTERISTICS OF
SUCCESSFUL COMMUNICATION
3) Efficiency
– The language used is understood
4) Flexibility
– The absence of over-control or
under-control
ESSENTIAL INGREDIENTS TO
FACILITATE COMMUNICATION
Respond with empathy
Examples
– “Yes”
– “I follow what you said”
– Nodding
Rationale
– An accepting response indicates the nurse has heard and followed
the train of thought.
– It does not indicate agreement but is nonjudgmental.
– Facial expression, tone of voice, and so forth also must convey
acceptance or the words will lose their meaning
THERAPEUTIC COMMUNICATION
TECHNIQUES: BROAD
OPENINGS
Definition
– Allowing the client to take the initiative in introducing the topic
Examples
– “Is there something you’d like to talk about?”
– “Where would you like me to begin?”
Rationale
– Broad openings make explicit that the client has the lead in the
interaction.
– For the client who is hesitant about talking, broad openings
may stimulate him or her to take the initiative
THERAPEUTIC COMMUNICATION
TECHNIQUES: CONSENSUAL
VALIDATION
Definition
– Searching for mutual understanding, for accord in the meaning of
the words.
Examples
– “Tell me whether my understanding of it agrees with yours.”
– “Are you using this word to convey that . .”
Rationale
– For verbal communication to be meaningful, it is essential that the
words being used should have the same meaning for all
participants.
– Sometimes words, phrases, or slang terms have different
meanings and can be easily misunderstood.
THERAPEUTIC COMMUNICATION
TECHNIQUES: ENCOURAGING
COMPARISON
Definition
– Helping the client to understand by looking at similarities and
differences.
Examples
– “Was it something like. . . ?”
– “Have you had similar experiences?”
Rationale
– Comparing ideas, experiences, or relationships brings out many
recurring themes.
– The client benefits from making these comparisons because he or
she might recall past coping strategies that were effective or
remember the he or she has survived a similar situation
TECHNIQUES:
ENCOURAGING DESCRIPTION OF
PERCEPTIONS
Definition
– Asking client to verbalize what he or she perceives.
Examples
– “Tell me when you feel anxious”
– “What is happening?”
– “What does the voice seem to be saying?”
Rationale
– To understand the client, the nurse must see things from his or her
perspective.
– Encouraging the client to describe ideas fully may relieve the
tension the client is feeling, and he or she might be less likely to
take action on ideas that are harmful or frightening.
THERAPEUTIC COMMUNICATION
TECHNIQUES: ENCOURAGING
EXPRESSION
Definition
– Asking client to appraise the quality of his or her experience.
Examples
– “What are your feelings in regard to. . ?”
– “Does this contribute to your distress?”
Rationale
– The nurse asks the client to consider people and events in
light of his or her own values.
– Doing so encourages the client to make his or her own
appraisal rather than accepting the opinion of others.
THERAPEUTIC COMMUNICATION
TECHNIQUES: EXPLORING
Definition
– Delving further into a subject or idea.
Examples
– “Tell me more about that.”
– “Would you describe it more fully?”
– “What kind of work?”
Rationale
– When clients deal with topics superficially, exploring can help them
examine the issue more fully.
– Any problem or concern can be better understood if explored in depth.
– If the client expresses an unwillingness to explore a subject, however,
the nurse must respect his or her wishes.
THERAPEUTIC COMMUNICATION
TECHNIQUES: FOCUSING
Definition
– Concentrating on a single point.
Examples
– “This point seems looking at more closely.”
– “Of all the concerns you have mentioned, which is most
troublesome?”
Rationale
– The nurse encourages the client to concentrate his or her energies
on a single point, which may prevent a multitude of factors or
problems from overwhelming the client.
– It is also a useful technique when a client jumps from one topic to
another.
TECHNIQUES:
FORMULATING A PLAN OF
ACTION
Definition
– Asking the client to consider kinds of behavior likely to be
appropriate in future situations.
Examples
– “What could you do to let your anger out harmlessly?”
– “Next time this comes up, what might you do to handle it?”
Rationale
– It may be helpful for the client to plan in advance what he or
she might do in future similar situations.
– Making definite plans increases the likelihood that the client
will cope more effectively in a similar situation
THERAPEUTIC COMMUNICATION
TECHNIQUES: GENERAL LEADS
Definition
– Giving encouragement to continue.
Examples
– “Go on.”
– “And then?”
– “Tell me about it.”
Rationale
– General leads indicate that the nurse is listening and following what
the client is saying without taking away the initiative for the
interaction.
– They also encourage the client to continue if he or she is hesitant
or uncomfortable about the topic.
THERAPEUTIC COMMUNICATION
TECHNIQUES: GIVING
INFORMATION
Definition
– Making available the facts that the client needs.
Examples
– “My name is. . .”
– “Visiting hours are. . .”
– “My purpose in being here is. . .”
Rationale
– Informing the client of facts increases his or her knowledge
about a topic or lets the client know what to expect.
– The nurse is functioning as a resource person
– Giving information also builds trust with the client.
THERAPEUTIC COMMUNICATION
TECHNIQUES: GIVING
RECOGNITION
Definition
– Acknowledging, indicating awareness.
Examples
– “Good Morning Ms. A. . .”
– “You’ve finished your list of things to do.”
– “I notice that you’ve combed your hair.”
Rationale
– Greeting the client by name, indicating awareness of change, or
noting efforts the client has made all show that the nurse
recognizes the client as a person, as an individual.
– Such recognition does not carry the notion of value, that is, of being
“good” or “bad”.
THERAPEUTIC COMMUNICATION
TECHNIQUES:
MAKING OBSERVATIONS
Definition
– Verbalizing what the nurse perceives.
Examples
– “You appear tense.”
– “Are you uncomfortable when . . ?”
– “I notice that you are biting your lip.”
Rationale
– Sometimes clients cannot verbalize or make themselves
understood.
– Or the client may not be ready to talk.
THERAPEUTIC COMMUNICATION
TECHNIQUES: OFFERING SELF
Definition
– Making oneself available.
Examples
– “I will sit with you awhile.”
– “I will stay here with you.”
– “I am interested in what you think.”
Rationale
– The nurse can offer his or her presence, interest, and desire to
understand.
– It is important that this offer is unconditional, that is, the client
does not have to respond verbally to get the nurse’s attention.
THERAPEUTIC COMMUNICATION
TECHNIQUES: PLACING EVENT IN TIIME
SEQUENCE
Definition
– Clarifying the relationship of events in time.
Examples
– “What seemed to lead up to. . ?”
– “Was this before or after?”
– “When did this happen?”
Rationale
– Putting events in proper sequence helps both the nurse and client to see
them in perspective.
– The client may gain insight into cause-and-effect behavior and
consequences, or perhaps some things are not related.
– The nurse may gain information about recurrent patterns or themes in
the client’s behavior relationship.
THERAPEUTIC COMMUNICATION
TECHNIQUES: PRESENTING
REALITY
Definition
– Offering for consideration that which is real.
Examples
Examples
– Client: “Do you think I should tell the doctor?”
– Nurse: “Do you think you should?”
– Client: “My brother spends all my money and then has the nerve to ask for
more.”
– Nurse: “This causes you to feel angry?”
Rationale
– Reflection encourages the client to recognize and accept his or her own
feelings.
– The nurse indicates that the client’s point of view has value, and that the
client has the right to have opinions, make decisions, and think
independently
THERAPEUTIC COMMUNICATION
TECHNIQUES: RESTATING
Definition
– Repeating the main idea expressed.
Examples
– The nurse repeats what the client has said in approximately or nearly the
same words the client has used.
– This restatement lets the client know that he or she communicated the
idea effectively.
– This encourages the client to continue
– Or if the client has been misunderstood, he or she can clarify his or her
thoughts.
THERAPEUTIC COMMUNICATION
TECHNIQUES:
SEEKING INFORMATION
Definition
– Seeking to make clear that which is not meaningful or that
which is vague.
Examples
– “I am not sure that I follow.”
– “Have I heard you correctly?”
Rationale
– The nurse should seek clarification throughout interactions
with clients.
– Doing so can help the nurse to avoid making assumptions
that understanding has occurred when it has not.
– It helps the client to articulate thoughts, feelings, and ideas
more clearly.
THERAPEUTIC COMMUNICATION
TECHNIQUES: SILENCE
Definition
– Absence of verbal communication, which provides time for the client
to put thoughts or feelings into words, regain composure, or continue
talking.
Examples
– “Perhaps you and I can discuss and discover the triggers for
your anxiety.”
– “Let’s go to your room and I will help you find what you are
looking for.”
Rationale
– Putting into words what the client has implied or said indirectly
tends to make the discussion less obscure.
– The nurse should be as direct as possible without being
unfeelingly blunt or obtuse.
– The client may have difficulty communicating directly
– The nurse should take care to express only what is fairly obvious;
otherwise the nurse may be jumping to conclusions or interpreting
the client’s communication
THERAPEUTIC COMMUNICATION
TECHNIQUES: VOICING DOUBT
Definition
– Expressing uncertainty about the reality of
the client’s perceptions.
Examples
– “Isn’t that unusual?”
– “Really?”
– “That is hard to believe.”
THERAPEUTIC COMMUNICATION
TECHNIQUES: VOICING DOUBT
Rationale
– Another means of responding to distortions of reality is
to express doubt.
– Such expression permits the client to become aware
that others do not necessarily perceive events in the
same way or draw the same conclusions.
– This does not mean the client will alter his or her point
of view, but at least the nurse will encourage the client
to reconsider or reevaluate what has happened.
– The nurse neither agreed nor disagreed; however, he or
she has not let the misperceptions and distortions pass
without comment.
NON-THERAPEUTIC
COMMUNICATION
TECHNIQUES
NON-THERAPEUTIC
COMMUNICATION TECHNIQUES
These responses cut off
communication and make it more
difficult for the interaction to continue
Definition
– Telling the client what to do.
Examples
– “I think you should.”
– “Why don’t you?”
Rationale
– Giving advice implies that only the nurse knows
what is best for the client.
NON-THERAPEUTIC
COMMUNICATION TECHNIQUES:
AGREEING
Definition
– Indicating accord with the client.
Examples
– “That is right.”
– “I agree.”
Rationale
– Approval indicates the client is “right” rather than “wrong.”
– This gives the client the impression that he or she is “right” because
of agreement with the nurse.
– Opinions and conclusions should be exclusively the client’s
– When the nurse agrees with the client, there is no opportunity for
the client to change his or her mind without being “wrong”
COMMUNICATION TECHNIQUES:
BELITTLING FEELINGS
EXPRESSED
Definition
– Misjudging the degree of the client’s discomfort.
Examples
Examples
– “But how can you be the President of the United States?”
– “If you are dead, why is your heart beating?”
Rationale
– Often the nurse believes that if he or she can challenge the
client to prove unrealistic ideas, the client will realize there is
no “proof” and then will recognize reality.
– Actually challenging causes the client to defend the delusions
or misperceptions more strongly than before.
NON-THERAPEUTIC
COMMUNICATION TECHNIQUES:
DEFENDING
Definition
– Attempting to protect someone or something from verbal attack.
Examples
– “This hospital has a fine reputation.”
– “I am sure your doctor has your best interests in mind.”
Rationale
– Defending what the client has criticized implies that he or she has
no right to express impressions, opinions, or feelings.
– Testing the client that his or her criticism is unjust or unfounded
does not change the client’s feelings but only serves to block
further communication
NON-THERAPEUTIC
COMMUNICATION TECHNIQUES:
DISAGREEING
Definition
– Opposing the client’s ideas.
Examples
– “That is wrong.”
– “I definitely disagree with. . .”
– “I do not believe that. . .”
Rationale
– Disagreeing implies the client is “wrong”
– Consequently the client feels defensive about his or her
point of view or ideas.
NON-THERAPEUTIC COMMUNICATION
TECHNIQUES: GIVING APPROVAL
Definition
– Sanctioning the client’s behavior or ideas.
Examples
– “That is good.”
– “I am glad that. . ”
Rationale
– Saying what the client thinks or feels if “good” implies that the
opposite is “bad”.
– Approval then, tends to limit the client’s freedom to think, speak, or
act in a certain way.
– This can lead to the client’s acting in a particular way just to please
the nurse.
NON-THERAPEUTIC
COMMUNICATION TECHNIQUES:
GIVING LITERAL RESPONSES
Definition
– Responding to a figurative comment as though it were a
statement of fact.
Examples
– Client: “They are looking in my head with a television camera.”
– Nurse: “Try not to watch television.” OR “What channel?”
Rationale
– Often the client is at a loss to describe his or her feelings, so such
comments are the best he or she can do.
– Usually it is helpful for the nurse to focus on the client’s feelings in
response to such statements.
NON-THERAPEUTIC
COMMUNICATION TECHNIQUES:
INDICATING THE EXISTENCE OF
AN EXTERNAL SOURCE
Definition
– Attributing the source of thoughts, feelings,
and behavior to others or to outside
influences.
Examples
– “What makes you say that?”
– “What made you do that?”
– “Who told you that you were a prophet?”
COMMUNICATION TECHNIQUES:
INDICATING THE EXISTENCE OF AN
EXTERNAL SOURCE
Rationale
– The nurse can ask, “What happened?” or
“What events led you to draw such a
conclusion?”
– But to question “What made you think that?”
implies that the client was made or compelled
to think in a certain way.
– Usually the nurse does not intend to suggest
that the source is external but that is often
NON-THERAPEUTIC
COMMUNICATION TECHNIQUES:
INTERPRETING
Definition
– Asking to make conscious that which is unconscious; telling the
client the meaning of his or her experience.
Examples
– “What you really mean is. . .”
– “Unconsciously you are saying. . .”
Rationale
– The client’s thoughts and feelings are his or her own, not to be
interpreted by the nurse or for hidden meaning.
– Only the client can identify or confirm the presence of feelings.
COMMUNICATION TECHNIQUES:
INTRODUCING AN UNRELATED
TOPIC
Definition
– Changing the subject.
Examples
– Client: “I would like to die.”
– Nurse “Did you have visitors last night?”
Rationale
– The nurse takes the initiative for the interaction away from
the client.
– This usually happens because the nurse is uncomfortable,
does not know how to respond, or has a topic he or she would
rather discuss.
MAKING STEREOTYPED
COMMENTS
Definition
– Offering meaningless cliches or trite comments.
Examples
Examples
– “Now tell me about this problem. You know I have to find out.”
– “Tell me your psychiatric history.”
Rationale
– Probing tends to make the client feel used or invaded.
– Clients have the right not to talk about issues or concerns if
they choose.
– Pushing and probing by the nurse will not encourage the client
to talk.
NON-THERAPEUTIC
COMMUNICATION TECHNIQUES:
REASSURING
Definition
– Indicating there is no reason for anxiety or other feelings of discomfort.
Examples:
– “I would not worry about that.”
– “Everything would be alright.”
– “You are coming along just fine.”
Rationale
– Attempts to dispel the client’s anxiety by implying that there is not
sufficient reason for concern completely devalues the client’s feelings.
– Vague reassurances without accompanying facts are meaningless to the
client.
NON-THERAPEUTIC
COMMUNICATION TECHNIQUES:
REJECTING
Definition
– Refusing to consider or showing contempt for the client’s
ideas or behaviors.
Examples
– “Let us not discuss. . .”
– “I do not want to hear about. . .”
Rationale
– When the nurse rejects any topic, he or she closes it off from
exploration.
– In turn, the client will feel personally rejected along with his
or her ideas.
NON-THERAPEUTIC
COMMUNICATION TECHNIQUES:
REQUESTING AN EXPLANATION
Definition
– Asking the client to provide reasons for thoughts, feelings,
behaviors, events.
Examples
– “Why do you think that?”
– “Why do you feel that way?”
Rationale
– There is a difference between asking the client to describe what is
occurring or has taken place and asking him to explain why.
Usually a “why” question is intimidating.
– In addition, the client is unlikely to know “why” and may become
defensive trying to explain himself or herself.
NON-THERAPEUTIC
COMMUNICATION TECHNIQUES:
TESTING
Definition
– Appraising the client’s degree of insight.
Examples
– “Do you know what kind of hospital this is?”
– “Do you still have the idea that. . ?”
Rationale
– These types of questions force the client to try to recognize
his or her problems.
– The client’s acknowledgement that he or she does not know
these things may meet the nurse’s needs but is not helpful
for the client
NON-THERAPEUTIC
COMMUNICATION TECHNIQUES:
USING DENIAL
Definition
– Refusing to admit that a problem exists.
Examples
– Client: “I am nothing.”
– Nurse: “Of course you are something. Everybody is something.”
– Client: “I am dead.”
– Nurse: “Do not be silly.”
Rationale
– The nurse denies the client’s feelings or the seriousness of the
situation by dismissing his or her comments without attempting to
discover the feelings or meaning behind them.
NON-VERBAL COMMUNICATION
This is transmitted with or without verbal
communication.
It is essential that the nurse become aware of
her own non-verbal communication in addition
to becoming skillful in identifying the client’s
non-verbal communication.
Non-verbal communication provides clues about
the validity of the spoken words and congruency
with the client’s behavior.
The phrase “Actions speak louder than words” is
generally accurate.
NON-VERBAL COMMUNICATION
A list of ways in which non-verbal
communication is conveyed to others follows:
– Tone of voice
– Voice inflection
– Facial Expression
– Silence
– Gestures
– Mannerism
– Posture
NON-VERBAL COMMUNICATION
List of ways in which non-verbal
communication is conveyed to others:
– Eye contact
– Rate of speech
– A “hurry up” attitude
– An “I couldn’t care less” attitude
– Physical appearance
– Touch
– Space
GUIDELINES FOR
IDENTIFYING THERAPEUTIC
RESPONSES IN THE BOARD
EXAM
GUIDELINES FOR IDENTIFYING
THERAPEUTIC RESPONSES IN
THE BOARD EXAM
Identify therapeutic and non-therapeutic phrases
Avoid focus on the nurse (use of the word “I”); or focus on the doctor.
Focus on the patient instead.
– “It seems…”
– “It sounds…”
– “I will sit with you…”
– “I will stay with you…”
– “I will check…”
– “Tell me…”
THERAPEUTIC RESPONSES IN THE
BOARD EXAM: LOOK FOR NON-
THERAPEUTIC PHRASES
– “That’s good!”
– “That’s bad!”
– “You’re the best!”
– “You’re the worst!”
THERAPEUTIC RESPONSES IN THE
BOARD EXAM: LOOK FOR NON-
THERAPEUTIC PHRASES
– “Always…”
– “Never…”
– “None…”
– “All….”
THERAPEUTIC RESPONSES IN THE
BOARD EXAM: LOOK FOR NON-
THERAPEUTIC PHRASES
– Manic patients
This would discourage them from over-control of
the conversation
Rationale
– Responses to why questions are considered
prying, violate the client’s privacy and places the
client in a defensive position
THERAPEUTIC RESPONSES IN THE
BOARD EXAM: USE OF ‘WHAT’
QUESTIONS
– “What is happening?”
– “What does the voice seem to be saying?”
– “What transpired after that?”
THERAPEUTIC RESPONSES IN THE
BOARD EXAM: AVOID FALSE
REASSURANCES
Examples:
– “I would not worry about that.”
– “Everything would be alright.”
– “You are coming along just fine.”
Rationale
– This response blocks the fears, feelings and other thoughts
of the client. Furthermore, vague reassurances without
accompanying facts are meaningless to the client
GUIDELINES FOR IDENTIFYING
THERAPEUTIC RESPONSES IN THE
BOARD EXAM: USE OF THE WORD ‘I’
Example:
– Client: “Should I move from my home to
a nursing home?”
– Nurse: “If I were you, I’d go to a nursing
home, where you’ll get your meals
cooked for you”
Rationale:
– Therapeutic Communication is always client-centered, it is
never nurse-centered.
THERAPEUTIC RESPONSES IN THE
BOARD EXAM: USE OF THE WORD
‘YOU’
Examples
– Client: “I am dead.”
– Nurse: “Are you suggesting that you feel lifeless?”
– Client: “I am way out in the ocean.”
– Nurse: “You seem to feel lonely or deserted.”
Rationale:
– Therapeutic Communication is always client-
centered, it is never nurse-centered.
THERAPEUTIC RESPONSES IN THE
BOARD EXAM: USE OF DIRECT
QUESTIONS FOR SUICIDAL PATIENTS
Authoritarian Answer
– Avoid statements like “I think you
should. . I should know, I am the nurse”
Rationale
– Giving authoritarian answers implies
that only the nurse knows what is best
for the client
WHAT TO REMEMBER IN
THERAPEUTIC COMMUNICATION
Be empathetic and not just
sympathetic!
EMPATHY
Is the ability of the nurse to perceive the meanings
and feelings of the client and to communicate that
understanding to the client.
It is considered one of the essential skills a nurse
must develop
Being able to put himself on the client’s shoes does
not mean that the nurse has had the same exact
experiences as the client
Nevertheless, by listening and sensing the
importance of the situation to the client, the nurse
can imagine the client’s feelings about the
experience
EMPATHY
Both the client and the nurse give a “gift of self”
when empathy occurs – the client by feeling safe
enough to share feelings, and the nurse by
listening closely enough to understand.
A) Sender
B) Context
C) Receiver
D) Message
ANSWER
Letter B
A) Focusing
B) Use of silence
C) Giving broad opening
D) Reflecting
ANSWER
Letter C
Planned
Time-limited
Professional
BASIC ELEMENTS OF THE
NURSE-PATIENT RELATIONSHIP
Trust
Rapport
Setting limits
Therapeutic communication
PHASES OF THE
NURSE-PATIENT RELATIONSHIP
Pre-orientation phase
Orientation phase
Working phase
Termination phase
PRE-ORIENTATION PHASE
Begins when the nurse is assigned to a
patient
Limit-setting is employed
It is a mutual agreement
Example:
– A female nurse who has teenage children and
who is experiencing extreme frustration with an
adolescent client may respond by adopting a
parental or chastising tone.
Examples:
– Health education
– Information dissemination
– Counseling
SECONDARY LEVEL OF
PREVENTION
Interventions that limit the severity of a disorder.
Examples:
– Crisis intervention
– Administration of medications
TERTIARY LEVEL OF
PREVENTION
Interventions aimed at reducing the disability
after a disorder.
Examples:
– Alcoholics Anonymous
– Occupational therapy
SAMPLE BOARD QUESTION
NO.1
Promotion of mental illness is best achieved by?
Rationale: Strengthening an
individual’s coping mechanism is one
of the best ways to prevent mental
illness.
SAMPLE BOARD QUESTION
NO.2
A psychiatric nurse would be more likely
to work with people with mental disorders
in which of the following settings?
A) Shelters
B) Neighborhood centers
C) Prisons
D) All of these
ANSWER
Letter D
A) Monitoring of medication
administration
B) Monitoring of blood pressure
C) Assessing of skin problems
D) All of these
ANSWER
Letter D
A) Primary
B) Secondary
C) Tertiary
D) Any of these
ANSWER
Letter C
A) Health promotion
B) Rehabilitation
C) Case finding
D) Prompt treatment
ANSWER
Letter A
Genuineness / Congruence
– Ability to use therapeutic tools appropriately
Socializing Agent
– Assists the patient to feel comfortable
with others
Counselor
– Listens to the patient’s verbalizations
ROLES OF THE NURSE IN
PSYCHIATRIC SETTINGS
Parent Surrogate
– Assists the patient in the performance of
activities of daily living.
Patient Advocate
– Enables the patient and his relatives to know
their rights and responsibilities
Teacher
– Assists the patient to learn more adaptive
ways of coping
ROLES OF THE NURSE IN
PSYCHIATRIC SETTINGS
Technician
– Facilitates the performance of nursing procedures
Therapist
– Explores the patient’s needs, problems and
concerns through varied therapeutic means
Reality Base
– Enables the patient to distinguish objective reality
and subjective reality
ROLES OF THE NURSE IN
PSYCHIATRIC SETTINGS
Healthy Role Model
– Acts as a symbol of health by
serving as an example of healthful
living.
THE NERVOUS SYSTEM
AND HOW IT WORKS
BRAIN
The brain is divided
into:
Cerebrum
Cerebellum
Brain Stem
Limbic System
CEREBRUM
The LEFT HEMISPHERE is the
center for logical reasoning and
analytic functions such as reading,
writing and mathematical tasks.
The RIGHT HEMISPHERE is the
center for creative thinking,
intuition, and artistic abilities
CEREBRUM
CEREBRUM
Each cerebral
hemisphere is divided
into four lobes:
Frontal
Parietal
Temporal
Occipital
FRONTAL LOBES OF CEREBRUM
These control the:
Organization of
thought
Body movement
Memories
Emotions
Moral behavior
FRONTAL LOBES OF CEREBRUM
The frontal lobes:
Helps regulate
arousal
Focus attention
Allow problem
solving and decision
making to occur
FRONTAL LOBES OF CEREBRUM
Abnormalities in the
frontal lobes are
associated with:
Schizophrenia
Attention Deficit
Hyperactivity
Disorder
Dementia
PARIETAL LOBES OF CEREBRUM
The parietal lobes are
involved with:
Interpreting
sensations of taste
and touch
Assisting in spatial
orientation
TEMPORAL LOBES OF CEREBRUM
These function as
centers for:
Hearing
Memory
Expressions of
emotions
OCCIPITAL LOBES OF CEREBRUM
They assist in:
Coordinating
language generation
Visual interpretation
Depth perception
CEREBELLUM
It is the center for
coordination of
movements and
postural adjustments
CEREBELLUM
Inhibited transmission
of a neurotransmitter,
DOPAMINE, in this area
is associated with a
lack of smooth,
coordinated
movements in
diseases such as
PARKINSON’S DISEASE
and DEMENTIA
BRAIN STEM
This includes the
following:
Midbrain
Pons
Medulla Oblongata
MEDULLA OBLONGATA OF THE
BRAIN STEM
This contains the vital
centers for respiration
and cardiovascular
function
PONS OF THE BRAIN STEM
This bridges the gap
both structurally and
functionally, serving as
a primary motor
pathway
MIDBRAIN OF THE BRAIN STEM
This includes most of the
RETICULAR ACTIVATING
SYSTEM (RAS) and the
EXTRAPYRAMIDAL
SYSTEM (EPS).
The RAS influences
motor activity, sleep,
consciousness and
awareness.
The EPS relays
information about
movement and
coordination from the
brain to the spinal nerves
LIMBIC SYSTEM
This includes the
following:
Thalamus
Hypothalamus
Hippocampus
Amygdala
THALAMUS OF THE LIMBIC SYSTEM
This regulates:
Activity
Sensation
Emotion
HYPOTHALAMUS OF THE LIMBIC
SYSTEM
This is involved with:
Temperature
regulation
Appetite control
Endocrine function
Sexual drive
Impulse behavior
associated with
feelings of anger,
rage and excitement
HIPPOCAMPUS AND AMYGDALA OF
THE LIMBIC SYSTEM
These structures are
involved in emotional
arousal and memory.
LIMBIC SYSTEM
Disturbances in the
limbic system have
been implicated in a
variety of mental
illnesses, such as:
The memory loss seen
in DEMENTIA
The poorly controlled
emotions and impulses
seen in PSYCHOTIC or
MANIC BEHAVIOR
NEUROTRANSMISSION
– Efficacy
– Potency
– Half-life
EFFICACY
This refers to the maximal therapeutic
effect that can be achieved by a drug.
POTENCY
This describes the amount of drug
needed to achieve that maximum effect
Contraindications
Interactions
Antidepressants
Mood Stabilizers
Anti-anxiety Drugs
Stimulants
1) ANTIPSYCHOTIC DRUGS
ANTIPSYCHOTIC DRUGS
These are also known as NEUROLEPTICS
Thiothixene C, L, INJ 6 – 30 6 - 60
(Navane)
Haloperidol T, L, INJ 2 – 20 1 - 100
(Haldol)
Loxapine C, L, INJ 60 – 100 30 - 250
ATYPICAL ANTIPSYCHOTIC
DRUGS
GENERIC FORMS DAILY EXTREME
(TRADE) DOSAGE DOSAGE
NAME (mg) RANGE
(mg/day)
Clozapine T 150 – 500 75 - 700
(Clozaril)
Risperdone T 2–8 1 – 16
(Risperdol)
Olanzapine T 5 – 15 5 - 20
(Zyprexa)
MECHANISM OF ACTION OF
ANTIPSYCHOTIC DRUGS
The major action of all antipsychotics in the
nervous system is to block receptors for the
neurotransmitter dopamine.
Spasms or stiffness in
muscle groups can
produce torticollis
(twisted head and
neck)
SIDE EFFECTS OF ANTIPSYCHOTIC
DRUGS – (EPS) – ACUTE DYSTONIA
Spasms or stiffness in
muscle groups can
produce opisthotonus
(tightness in the entire
body with the head
back and an arched
neck)
SIDE EFFECTS OF ANTIPSYCHOTIC
DRUGS – (EPS) – ACUTE DYSTONIA
Spasms or stiffness in
muscle groups can
produce an oculogyric
crisis (eyes rolled back
in a locked position)
TREATMENT FOR (EPS)
ACUTE DYSTONIA
Rapid relief is brought about by
immediate treatment with
anticholinergic drugs such as:
– Intramuscular or intravenous
diphenhydramine (Benadryl)
TREATMENT FOR (EPS)
ACUTE DYSTONIA
Recurrent dystonic reactions would
necessitate a lower dosage or a
change in the antipsychotic drug.
DRUGS – (EPS) –
PSEUDOPARKINSONISM
Drug-induced Parkinsonism or pseudoparkinsonism
have the following symptoms:
– A stiff, stooped posture
– Masklike facies
– Decreased arm swing
– A shuffling, festinating gait (with small steps)
– Cogwheel rigidity (ratchet-like movements of joints)
– Drooling
– Tremor
– Bradycardia
– Coarse pill-rolling movements of the thumb and
fingers while at rest
TREATMENT FOR (EPS)
PSEUDOPARKINSONISM
Pseudoparkinsonism is treated by
changing to an antipsychotic
medication that has a lower incidence
of EPS or by adding an oral
anticholinergic agent or amantadine .
SIDE EFFECTS OF ANTIPSYCHOTIC
DRUGS – (EPS) – AKATHISIA
Akathisia is reported by the client as an intense
need to move about
Symptoms of TD include:
– Involuntary movements of the tongue, facial and neck
muscles, upper and lower extremities, and truncal
musculature
– Tongue-thrusting and protrusion, lip-smacking, blinking,
grimacing and other excessive, unnecessary facial
movements
TREATMENT FOR (EPS)
TARDIVE DYSKINESIA
Although TD is irreversible, its progression can be arrested by
decreasing or discontinuing the antipsychotic medication.
Preventing the occurrence of TD is done by keeping maintenance
dosages as low as possible, changing medications, and
monitoring the client periodically for the initial signs of TD.
Persons who have already developed signs of TD but who still
need to take antipshychotic medication are often given
clozapine, which has not yet been found to cause, or therefore
worsen, TD.
OTHER SIDE EFFECTS OF
ANTIPSYCHOTIC DRUGS
Neuroleptic Malignant Syndrome
Anticholinergic Side Effects
SIDE EFFECTS OF ANTIPSYCHOTIC
DRUGS –NEUROLEPTIC MALIGNANT
SYNDROME (NMS)
NMS is a potentially fatal, idiosyncratic reaction to
an antipsychotic drug with the following symptoms:
– Rigidity
– High fever
– Autonomic instability such as unstable blood
pressure, diaphoresis, pallor, delirium and
elevated levels of enzymes (particularly CPK).
– Confusion
– Being mute
– Fluctuation from agitation to stupor
SIDE EFFECTS OF ANTIPSYCHOTIC
DRUGS –NEUROLEPTIC MALIGNANT
SYNDROME (NMS)
Dehydration, poor nutrition, and
concurrent medical illness all increase the
risk for NMS.
TREATMENT FOR
NEUROLEPTIC MALIGNANT SYNDROME
(NMS)
This includes the following:
Protriptyline T 15 - 40 10 - 60
(Vivactil)
Maprotiline T 100 - 150 50 - 200
(Ludiomil)
SIDE EFFECTS OF CYCLIC
ANTIDEPRESSANT DRUGS
The cyclic antidepressant drugs block cholinergic
receptors, resulting in anticholinergic effects such
as:
– Dry mouth
– Constipation
– Urinary hesitancy or retention
– Dry nasal passages
– Blurred near vision
– Agitation, delirium and ileus are more severe
anticholinergic side effects that may occur in the
elderly.
SIDE EFFECTS OF CYCLIC
ANTIDEPRESSANT DRUGS
Other common side effects include:
– Orthostatic hypotension
– Sedation
– Weight gain
– Tachycardia
– methylphenidate (Ritalin)
– pemoline (Cylert)
– dextroamphetamine (Dexedrine)
MECHANISM OF ACTION OF
STIMULANT DRUGS
– the physician
– Atropine sulfate
To decrease secretions
– Anectine (Succinylcholine)
To promote muscle relaxation
A) Anectine
B) Brevital
C) Ritalin
D) Atropine sulfate
ANSWER
Letter D
A) “I cannot sleep”
B) “I have a headache”
C) “I know you”
D) “I feel that my muscles are stiff”
ANSWER
Letter B
A) “I have a headache”
B) “I cannot breathe”
C) “I cannot remember anything”
D) “I am hungry”
ANSWER
Letter B
– Therapeutic Group
To gain insight into their problems (i.e. –
Alcoholics Anonymous)
– Socialization group
To enhance interaction among patients
Goals include:
– Enhancement of communication among family members
– Mobilizing the family’s inherent strengths
– Strengthening family problem-solving behaviors
PSYCHOANALYSIS
A method of psychotherapy which focuses on the exploration of
the unconscious, to facilitate identification of the patient’s
defenses
Positive reinforcement
– Example:
Examples:
– A patient snaps a rubber band on the wrist when
bothered by an intrusive thought
– Covert sensitization
Patient imagines scenes that pair undesired behavior
with unpleasant consequences of overeating.
TOKEN ECONOMY
An example of behavior modification
technique which utilizes the principle
of rewarding desired behavior to
facilitate change
DESENSITIZATION
Periodic exposure of the individual to a
feared object, until the undesirable
behavior disappears or is lessened
COGNITIVE THERAPY
Short term structured therapy between the
patient and the therapist oriented towards
present problems and solutions.
Cognitive Restructuring
– Thought Stopping
A) 5
B) 10
C) 20
D) Unlimited
ANSWER
Letter B
A) Serve as a leader
B) Focus on the sick member
C) Neutralize blaming by setting
contract
D) Use paradoxical communication
ANSWER
Letter C
A) Basketball
B) Painting
C) Writing
D) Listening to music
ANSWER
Letter A
Cultural
– Customs and traditions
Biological
– Personality is not inherited
Familial
– Parenting style
DIVISIONS OF THE MIND OR
LEVELS OF AWARENESS
Freud believed that the human personality
functions at three levels of awareness:
– Conscious
– Preconscious
– Unconscious
DIVISIONS OF THE MIND /
LEVELS OF AWARENESS –
CONSCIOUS
This refers to the perceptions, thoughts,
and emotions that exist in the person’s
awareness such as being aware of
happy feelings or thinking about a loved
one
– Id
– Superego
– Ego
ID
Is the part of one’s nature that reflects
basic or innate desires such as:
– Pleasure-seeking behavior
– Aggression
– Sexual impulses
Focus
– Anus and surrounding area are major source of
interest
– Acquisition of voluntary sphincter control (toilet
training)
Indicators of Fixation: Parsimonious, punctual,
precise, obsessive-compulsive (overemphasized
cleanliness), passive-aggressive
PHALLIC OR OEDIPAL STAGE
Age
– 3 – 5 years
Focus
– Penis is organ of interest for both sexes.
– Masturbation is common
– Penis envy (wish to possess penis) seen in girls;
oedipal complex (wish to marry opposite-sex parent
and be rid of same-sex parent) seen in boys and girls.
Indicators of Fixation: Exhibitionism due to fear of
castration
LATENCY STAGE
Age
– 5 – 11 or 13 years
Focus
Focus
– Final stage of psychosexual development
– Begins with puberty and the biologic capacity for
orgasm; involves the capacity for true intimacy
– Area of gratification includes secondary sex
characteristics, reawakening of sexual drives.
Indicators of Fixation: Identity crisis
ERIKSON’S THEORY OF
PSYCHOSOCIAL
DEVELOPMENT
ERIKSON’S THEORY OF
PSYCHOSOCIAL DEVELOPMENT
In each stage, the person must
complete a life task that is essential to
his or her well-being and mental health.
– Hope
Task
Concepts
– The child is able to think abstractly and is
able to apply the scientific method
– The child learns to think and reason in
abstract terms, further develops logical
thinking and reasoning, and achieves
cognitive maturity.
SAMPLE BOARD QUESTION
NO.1
Erikson described the psychosocial tasks of
the developing person in his theoretical
model. The primary developmental task of
the young adult (age 18 – 25) is?
A) Latency
B) Oral
C) Anal
D) Phallic
ANSWER
Letter D
A) Anal
B) Latency
C) Genital
D) Phallic
ANSWER
Letter C
1) Anal
2) Phallic
3) Sensorimotor
4) Pre-operational
A) Trust
B) Autonomy
C) Initiative
D) Industry
ANSWER
Letter C
A) Disorganization
B) Reorganization
C) Attempt to escape the problem
D) Increased tension
ANSWER
Letter A
Power Rape
Sadistic Rape
ANGER RAPE
Distinguished by physical violence and cruelty
to the victim
Tell you with whom you may be friends or how you should
dress, or ties to control other elements of your life
Denial Phase
– Characterized by the victim’s refusal to talk about the
event
Heightened Anxiety
– Characterized by fear, tension, and nightmares
Stage of Reorganization
– The victim’s life normalizes
NURSING CARE FOR RAPE
VICTIMS
In the emergency setting, provide immediate
emotional support
A) Aggression
B) Bestiality
C) Exposure
D) Sexual passion
ANSWER
Letter A
– Name-calling
– Belittling
– Screaming
– Yelling
– Destroying property
– Making threats
– Refusing to speak to or ignoring the victim
SPOUSE OR PARTNER ABUSE
Physical abuse includes the following:
– Shoving
– Pushing
– Biting nipples
– Pulling hair
– Rape
BATTERED WIFE SYNDROME
Cycle of domestic violence characterized by
wife-beating by the husband, humiliation and
other forms of aggression
A) Assertiveness
B) Alcohol abuse
C) Self-blame
D) Suicidal thoughts
ANSWER
Letter A
A) Maturity
B) Low self-esteem
C) Assertiveness
D) Patience
ANSWER
Letter B
A) Acute phase
B) Honeymoon stage
C) Tension building phase
D) Time between the acute phase and the
tension building phase
ANSWER
Letter D
Sexual Abuse
Neglect
Psychological Abuse
TYPES OF CHILD ABUSE –
PHYSICAL ABUSE
Physical abuse of children often results from
unreasonably severe corporal punishment or unjustifiable
punishment such as hitting an infant for crying or soiling
his diapers
Examples include:
– Incest
– Rape
– Sodomy performed directly by the person or with an
object
– Oral-genital contact
– Acts of molestations such as rubbing, fondling, or
exposing the adult’s genitals
TYPES OF CHILD ABUSE –
SEXUAL ABUSE
Sexual abuse includes:
Moderate Anxiety
Severe Anxiety
Panic Anxiety
MILD ANXIETY
It is a positive state of heightened
awareness and sharpened senses,
allowing the person to learn new
behaviors and solve problems.
Anxiety
PRINCIPLES OF NURSING CARE
IN ANXIETY
Calm
Administer medications
A) Remove anxiety
B) Develop the person’s awareness of anxiety
C) Protect the person from anxiety
D) Develop the person’s capacity to tolerate
mild anxiety
ANSWER
Letter D
A) Self-esteem disturbance
B) Ineffective individual coping
C) Unilateral neglect
D) Altered thought process
ANSWER
Letter B
Examples:
– Napoleon complex: diminutive man
becoming an emperor
– Nurse with low self-esteem works double
shifts so her supervisor will like her
CONVERSION
Expression of an emotional conflict through the
development of a physical symptom, usually
sensorimotor in nature.
Example:
– A teenager forbidden to see x-rated movies is
tempted to do so by friends and develops
blindness, and the teenager is unconcerned
about the loss of sight.
DENIAL
Failure to acknowledge an unbearable
condition; failure to admit the reality of a
situation, or how one enables the problem to
continue
Examples:
– Diabetic eating chocolate candy
– Spending money freely when broke
– Waiting 3 days to seek help for severe
abdominal pain
DISPLACEMENT
Ventilation of intense feelings toward
persons less threatening than the one
who aroused those feelings.
Examples:
– A person who is mad at the boss yells
at his or her spouse
– A child who is harassed by a bully at
school mistreats a younger sibling.
DISSOCIATION
Dealing with emotional conflict by a
temporary alteration in consciousness or
identity
Examples:
– Amnesia that prevents recall of
yesterday’s auto accident
– An adult remembers nothing of
childhood sexual abuse
FIXATION
Immobilization of a portion of the
personality resulting from unsuccessful
completion of tasks in a developmental
stage
Examples:
– Never learning to delay gratification
– Lack of a clear sense of identity as an
adult
IDENTIFICATION
Modeling actions and opinions of influential
others while searching for identity, or
aspiring to reach a personal, social, or
occupational goal.
Example:
– Nursing student becoming a critical care
nurse because this is the specialty of an
instructor she admires.
INTELLECTUALIZATION
Separation of the emotions of a painful
event or situation from the facts
involved; acknowledging the facts but
not the emotions.
Example
– Person shows no emotional
expression when discussing serious
car accident.
INTROJECTION
Accepting another person’s attitudes,
beliefs, and values as one’s own.
Example:
– A person who dislikes guns becomes
an avid hunter, just like a best
friend.
PROJECTION
Unconscious blaming of unacceptable
inclinations or thoughts on an external
object.
Examples:
– Man who has thought about same-gender
sexual relationship but never had one,
beats a man who is gay.
– A person with many prejudices loudly
identifies others as bigots.
RATIONALIZATION
Excusing own behavior to avoid guilt,
responsibility, conflict, anxiety, or loss of
self-respect
Examples:
– Student blames failure on teacher
being mean
– Man says he beats his wife because
she does not listen to him.
REACTION FORMATION
Acting the opposite of what one thinks
or feels.
Examples:
– Woman who never wanted to have
children becomes a super-mom.
– Person who despises the boss tells
everyone what a great boss she is.
REGRESSION
Moving back to a previous developmental
stage in order to feel safe or have needs met
Examples:
– Five-year-old asks for a bottle when new
baby brother is being fed.
– Man pouts like a four-year-old if he is not
the center of his girlfriend’s attention.
REPRESSION
Excluding emotionally painful or anxiety-
provoking thoughts and feelings from
conscious awareness
Examples:
– Woman has no memory of the mugging
she suffered yesterday
– Woman has no memory before age 7 when
she was removed from abusive parents.
RESISTANCE
Overt or covert antagonism toward
remembering or processing anxiety-
producing information.
Examples:
– Nurse is too busy with tasks to spend time
talking to a dying patient
– Person attends court-ordered treatment for
alcoholism but refuses to participate.
SUBLIMATION
Substituting a socially acceptable activity for
an impulse that is unacceptable
Examples:
– Person who has quit smoking sucks on
hard candy when the urge to smoke arises.
– Person goes for 15-minute walk when
tempted to eat junk foods.
SUBSTITUTION
Replacing the desired gratification with
one that is more readily available.
Example:
– Woman who would like to have her
own children opens a day care
center.
SUPPRESSION
Conscious exclusion of unacceptable thoughts
and feelings from conscious awareness.
Examples:
– A student decides not to think about a parent’s
illness in order to study for a test
– A woman tells a friend she cannot think about
her son’s death right now
UNDOING
Exhibiting acceptable behavior to make up for or
negate unacceptable behavior.
Examples:
– A person who cheats on a spouse brings the
spouse a bouquet of roses.
– A man who is ruthless in business donates large
amounts of money to charity
SAMPLE BOARD QUESTION
NO.1
When upset, the patient curls into a
fetal position in bed. The nurse judges
the patient to be exhibiting?
A) Fixation
B) Regression
C) Substitution
D) Symbolization
ANSWER
Letter B
A) Displacement
B) Rationalization
C) Projection
D) Sublimation
ANSWER
Letter C
A) Denial
B) Regression
C) Displacement
D) Sublimation
ANSWER
Letter A
Relaxation exercises
Deep breathing
Decatastrophizing
Assertiveness Training
POSITIVE REFRAMING
Turning negative messages into positive messages
The therapist teaches the person to create positive
messages for use during panic episodes
Instead of thinking, “My heart is pounding. I think I am
going to die” the client thinks, “I can stand this. This is
just anxiety. It will go away.”
The client can write down these messages and keep
them readily accessible such as in an address book,
wallet or calendar
DECATASTROPHIZING
Involves the therapist’s use of questions to more realistically
appraise the situation; the therapist may ask, “What is the worst
thing that could happen? Is that likely? Could you survive that?
Is that as bad as you imagine?”
The client uses thought-stopping and distraction techniques to
jolt himself from focusing on negative thoughts
Splashing the face with water, snapping a rubber band worn on
the wrist, or shouting are all techniques that can break the cycle
of negative thoughts
ASSERTIVENESS TRAINING
Helps the person take more control over life situations
Techniques help the person negotiate interpersonal
situations and foster self-assurance
They involve using “I” statements to identify feelings and
to communicate concerns or needs to others.
Examples include “I feel angry when you turn your back
while I’m talking,” “I want to have 5 minutes of your time
for an uninterrupted conversation about something
important”
SPECIFIC PHOBIA
Is characterized by significant anxiety
provoked by a specific feared object or
situation which often leads to
avoidance behavior
SYMPTOMS OF SPECIFIC
PHOBIA
Marked anxiety response to the object
or situation
Avoidance or suffered endurance of
object or situation
Significant distress or impairment of
daily routine, occupation, or social
functioning
Adolescents and adults recognize their
fear as excessive or unreasonable.
MANAGEMENT OF SPECIFIC
PHOBIA
Anti-anxiety medications
Systematic Desensitization
SYSTEMATIC OR SERIAL
DESENSITIZATION
The therapist progressively exposes the client
to the threatening object in a safe setting until
the client’s anxiety decreases
During each exposure, the complexity and
intensity of exposure gradually increase but
each time the client’s anxiety decreases.
The reduced anxiety serves as a positive
reinforcement until the anxiety is ultimately
eliminated
EXAMPLE OF SERIAL
DESENSITIZATION
For a client who fears flying, the therapist would encourage
the client to hold a small model airplane while talking about
his or her experiences
Later the client would talk about flying while holding a larger
model of an airplane
Later exposures might include walking past an airport, sitting
in a parked airplane, and finally taking a ride in the plane
Each session’s challenge is based on the success achieved in
the previous sessions
SOCIAL PHOBIA
Is characterized by anxiety provoked
by certain types of social or
performance situations, which often
leads to avoidance behavior
SYMPTOMS OF SOCIAL PHOBIA
Fear of embarrassment or inability to perform
Avoidance or dreaded endurance of behavior or
situation
Recognition that response is irrational or excessive
Belief that others are judging him or her
negatively
Significant distress or impairment in relationships,
work, or social life
Anxiety can be severe or panic level
MANAGEMENT OF SOCIAL
PHOBIA
Anti-anxiety medications
Thought Stopping
GENERALIZED ANXIETY
DISORDER
Is characterized by at least six months
of persistent and excessive worry and
anxiety that interferes with a person’s
life
It is also characterized by motor
tension, autonomic hyperactivity and
cognitive vigilance
SYMPTOMS OF GENERALIZED
ANXIETY DISORDER
Apprehensive expectations more days than not for 6
months or more about several events or activities
Uncontrollable worrying
Significant distress or impaired social or occupational
functioning
Three of the following symptoms:
– Restlessness
– Easily fatigued
– Difficulty concentrating or mood going blank
– Irritability
– Muscle tension
– Sleep disturbance
MANAGEMENT OF
GENERALIZED ANXIETY
DISORDER
Anti-anxiety medications
Anti-depressants
Psychotherapy
ACUTE STRESS DISORDER
Is the development of anxiety,
dissociative, and other symptoms
within 1 month of exposure to an
extremely traumatic stressor
Anti-depressant medications
Group therapy
POST-TRAUMATIC STRESS
DISORDER
Is characterized by the re-experiencing
of an extremely traumatic event,
avoidance of stimuli associated with
the event, numbing of responsiveness,
and persistent increased arousal
Anti-depressant medications
Group therapy
PRIORITY NURSING DIAGNOSIS
FOR ANXIETY DISORDERS
Ineffective individual coping
PSYCHOPHARMACOLOGIC
MANAGEMENT OF POST-
TRAUMATIC STRESS DISORDER
Anti-anxiety or anxiolytic drugs or
minor tranquilizers
– Diazepam (Valium)
– Oxazepam (Serax)
– Chlordiazepoxide (Librium)
– Chlorazepate Dipotassium
(Tranxene)
– Alprazolam (Xanax)
EFFECTS OF ANXIOLYTIC DRUGS
Decreased anxiety
Adequate sleep
WHEN TO ADMINISTER
ANXIOLYTIC DRUGS
Best taken before meals, food in the
stomach delays absorption
SIDE EFFECTS OF ANXIOLYTIC
DRUGS
Drowsiness
Sedation
Poor coordination
Temperamental Factors
– Due to emotional climate at home
Biological Factors
– Due to imbalance in hormones and neurotransmitters
Psychoanalytic Factors
– Due to fixation at certain psychosexual stage of development
DSM-IV-TR PERSONALITY
DISORDER CATEGORIES
The Diagnostic and Statistical Manual of Mental Disorders – Text Revision
of the American Psychiatric Association, in 2000, has made the following
classification of personality disorders:
– Cluster A: Individuals whose behavior appears odd or eccentric
(paranoid, schizoid, and schizotypal personality disorders)
– Cluster B: Individuals who appear dramatic, emotional, or erratic
(antisocial, borderline, histrionic, narcissistic)
– Cluster C: Individuals who appear anxious or fearful (avoidant,
dependent, obsessive-compulsive)
CLUSTER A
Paranoid
Schizoid
Schizotypal
PARANOID PERSONALITY
DISORDER
Symptoms / Characteristics
– Mistrust and suspicion of others
– Guarded or hypervigilant and generally appear alert to
any impending danger
– Restricted affect
– Mood is labile, quickly changing from quietly suspicious
to angry or hostile
– Responses become sarcastic for no apparent reason
– Uses the defense mechanism of projection, which is
blaming other people, institutions or events for their
own difficulties
PARANOID PERSONALITY
DISORDER
Nursing Interventions
Nursing Interventions
– The nurse must approach these clients in a formal,
business-like manner and refrain from chit-chat and
jokes (serious and straightforward approach)
Involve the client in treatment planning
Because these clients need to feel in control, it is important to
involve them in formulating plans of care.
The nurse asks what the client would like to accomplish in
concrete terms.
Clients are more likely to engage in the therapeutic process if
they believe they have something to gain
SCHIZOID PERSONALITY
DISORDER
Symptoms / Characteristics
– Detached from social relationships
– They display a constricted affect and little, if any
emotion; aloof and indifferent, appearing emotionally
cold, uncaring,or unfeeling
– Report no leisure or pleasurable activities because they
rarely experience enjoyment
– Have a pervasive lack of desire for involvement with
others in all aspects of life
– They do not have or desire friends, rarely date or
marry and have little or no sexual contact
– Involve themselves more with things than people
SCHIZOID PERSONALITY
DISORDER
Nursing Interventions
– Focus on improved functioning of
the client in the community
– Assist the client to find a case
manager – one who can help the
client obtain services and health
care, manage finances, etc.
SCHIZOTYPAL PERSONALITY
DISORDER
Symptoms / Characteristics
– Has social and interpersonal deficits
marked by acute discomfort with
and reduced capacity for close
relationships
– Has cognitive or perceptual
distortions
– Possesses eccentric behavior
SCHIZOTYPAL PERSONALITY
DISORDER
Symptoms / Characteristics
– Clothes are ill fitting, do not match, and may be
stained or dirty
– Cognitive distortions include ideas of reference
(events have special meaning for him), magical
thinking that he has special powers, unfounded
beliefs
– Interpersonal relationships are troublesome and
may have only one significant relationship with
a first degree relative
SCHIZOTYPAL PERSONALITY
DISORDER
Nursing Interventions
– Development of self-care skills
– Nurse encourages client to establish
a daily routine for hygiene and
grooming
– Improve community functioning and
provide social skills training
CLUSTER B
Antisocial
Borderline
Histrionic
Narcissistic
ANTISOCIAL PERSONALITY
DISORDER
Symptoms / Characteristics
– Violation of the rights of others
– Lack of remorse for behavior
– Shallow emotions
– Lying
– Rationalization of own behavior
– Poor judgment
– Impulsivity
– Irritability and aggressiveness
– Lack of insight
ANTISOCIAL PERSONALITY
DISORDER
Symptoms / Characteristics
– Thrill-seeking behaviors
– Exploitation of people in
relationships
– Poor work history
– Consistent irresponsibility
ANTISOCIAL PERSONALITY
DISORDER
Nursing Interventions
– Promote responsible behavior
Limit setting
– State the limit in a matter-of-fact, non-
judgmental manner
– Identify consequences of exceeding the limit
– Identify expected or acceptable behavior
– Consistent adherence to rules and treatment
plan
ANTISOCIAL PERSONALITY
DISORDER
Consistent limit setting in a matter-of-fact, non-
judgmental manner is crucial to success
A client may approach the nurse flirtatiously and
attempt to gain personal information.
– The nurse would use limit-setting by saying, “It is not
acceptable for you to ask personal questions. If you
continue, I will terminate our interaction. We need to use
this time to work on solving your job-related problems.”
The nurse should not become angry or respond to the
client harshly or punitively
ANTISOCIAL PERSONALITY
DISORDER
Nursing Interventions
– Confrontation
Point out problem behavior
Keep client focused on self, behavior
rather than justifying it.
ANTISOCIAL PERSONALITY
DISORDER
Dependent
Obsessive-Compulsive
AVOIDANT PERSONALITY
DISORDER
Symptoms / Characteristics
– Has a pervasive pattern of social
discomfort and reticence, low self-esteem
and hypersensitivity to negative
evaluation
– They fear rejection, criticism, shame or
disapproval
– They remain aloof in their relationships
and feel inferior to others
AVOIDANT PERSONALITY
DISORDER
Nursing Interventions:
– These clients require much support and
reassurance from the nurse
– The nurse can help them to explore
positive self-aspects, positive responses
from others, and possible reasons for self-
criticism
– Helping clients to practice self-
affirmations and positive self-talk may be
useful in promoting self esteem
AVOIDANT PERSONALITY
DISORDER
Nursing Interventions:
– Other cognitive restructuring techniques such as
reframing and decatastrophizing can enhance self worth
– Positive reframing means turning negative messages
into positive messages
Instead of thinking “I will fail”, the client thinks “I may fail but I
will keep trying until I succeed.”
– Decatastrophizing involves the nurse’s use of questions
to realistically appraise the situation
“What is the worst thing that could happen? Is that likely?
Could you survive that? Is that as bad as you imagine?”
The client uses thought-stopping and distraction techniques to
jolt himself out of negative thoughts
DEPENDENT PERSONALITY
DISORDER
Symptoms / Characteristics
– Has a pervasive and excessive need to be taken care of which leads
to submissive and clinging behavior and fears of separation
– Has incessant demands for attention from others, lacks self-
confidence, needs excessive reassurance and advice
– They are pre-occupied with excessive fears of being left alone to
care for themselves
– They perceive themselves as unable to function outside a
relationship with someone who can tell them what to do
DEPENDENT PERSONALITY
DISORDER
Nursing Interventions:
– The nurse must help the clients to express feelings of grief and
loss over the end of a relationship while fostering autonomy
and self reliance
– Helping clients to identify their strengths and needs is more
helpful than encouraging the overwhelming belief that the
client can’t do anything alone
– Clients may need assistance in daily functioning like planning
menus, shopping, budgeting money, etc.
– The nurse teaches problem-solving and decision-making skills
OBSESSIVE-COMPULSIVE
PERSONALITY DISORDER
Symptoms / Characteristics
– Has a pervasive pattern of preoccupation with
perfectionism, mental and interpersonal control and
orderliness at the expense of flexibility, openness
and efficiency
– They are formal, serious and answer questions with
precision and much detail
– Clients check and recheck the details of any project
or activity
– They have problems with judgment and decision-
making – specifically actually reaching a decision
OBSESSIVE-COMPULSIVE
PERSONALITY DISORDER
Symptoms / Characteristics
– They have low self-esteem and are always harsh,
critical, and judgmental of themselves; they believe
they “could have done better” regardless of how
well the job has been done
– They have difficulty in relationships, few friends,
and little social life
– They cannot tolerate lack of control
– They have difficulty working collaboratively,
preferring to “do it myself” so it is done correctly
OBSESSIVE-COMPULSIVE
PERSONALITY DISORDER
Nursing Interventions:
– Nurses may be able to help clients to view
decision-making and completion of projects from a
different perspective
Rather than striving for the goal of perfection, clients
can set a goal of completing the project or making the
decision by a specified deadline
Helping clients to accept or to tolerate less-than-perfect
work or decisions made on time may alleviate some
difficulties at work or at home
OBSESSIVE-COMPULSIVE
PERSONALITY DISORDER
Nursing Interventions:
– Use of cognitive restructuring techniques
like decatastrophizing may challenge
some rigid and inflexible thinking
– Encouraging clients to take risks, such as
letting someone else plan a family
activity, may improve relationships
– Practicing negotiation with family or
friends may help them to relinquish some
of their need for control
OTHER RELATED DISORDERS
Depressive Personality Disorder
A) Passive
B) Aggressive
C) Passive - Aggressive
D) Assertive
ANSWER
Letter C
A) Id
B) Ego
C) Superego
D) “Not me”
ANSWER
Letter B
– Brain anoxia
– Intake of drugs
MOST COMMON SIGNS AND
SYMPTOMS OF AUTISM
Resist normal teaching method
Silly laughing or giggling
Echolalia
Acts as deaf
No fear of danger
Insensitive to pain
Crying tantrums
Loves to spin objects
MOST COMMON SIGNS AND
SYMPTOMS OF AUTISM
Resists change in the routine
Not cuddly
Sustained odd play
Difficulty interacting with others
No eye contact
Wants blocks and not balls
Points to anything
Attachment to inanimate objects
COMMON PROBLEMS AND
APPROPRIATE MANAGEMENT
Tantrums
– Involves head-banging
– Place a helmet on the head
Communication
– All vowels
– Use of short sentences when talking to the child
Routines
– Provide consistency
PRIORITY NURSING DIAGNOSIS
Risk for injury
SAMPLE BOARD QUESTION
NO.1
Autism can usually be diagnosed when
the child is about?
A) 2 years of age
B) 6 years of age
C) 6 months of age
D) 1 to 3 months of age
ANSWER
Letter A
A) Psychoanalysis
B) Behavior modification
C) Group therapy
D) Play therapy
ANSWER
Letter B
A) Retardation of activity
B) Short attention span
C) Difficulty in responding to a nurturing relationship
D) Poor academic performance
ANSWER
Letter C
A) Developing self-confidence
B) Accepting healthy nurturance
C) Maintaining contact with reality
D) Encouraging the child to play with a
ball
ANSWER
Letter D
MODERATE / 35 / 40 TO 50 / 55 TRAINABLE
IMBECILE
SEVERE / IDIOT 20 / 25 TO 35 / 40 NEEDS CLOSE
SUPERVISION
Role Modeling
Writing
Basic Arithmetic
SAMPLE BOARD QUESTION
NO.1
A child scores between 55 and 68 on a
standardized intelligent quotient (IQ)
assessment test. The nurse is aware that this
degree of intellectual impairment would be
considered?
A) Mild
B) Severe
C) Profound
D) Moderate
ANSWER
Letter A
A) Finding a cure
B) Optimal development
C) Identifying the problem
D) Curing major symptoms
ANSWER
Letter B
– Inattentiveness
– Over-activity
– Impulsiveness
Hyperactivity
Impulsivity
COMMON ETIOLOGICAL
FACTORS
Neurologic impairment
Pre-natal trauma
Early malnutrition
– Inattentive behaviors
– Dextroamphetamine (Dexedrine)
– Amphetamine (Adderall)
STIMULANT DRUGS USED TO
TREAT ADHD
GENERIC (TRADE) DOSAGE (mg/day) NURSING
NAME CONSIDERATIONS
– Allow breaks
NURSING CARE FOR ADHD
Structured daily routine
– Minimize changes
NURSING CARE FOR ADHD
Client / Family education and support
A) Lethargy
B) Preoccupation with body parts
C) Very poor skills
D) Short attention span
ANSWER
Letter D
A) Dizziness
B) Headache
C) Increased appetite
D) Delayed physical growth
ANSWER
Letter D
Amenorrhea
Feelings of ineffectiveness
Inflexible thinking
Cold intolerance
Lethargy
SIGNS AND SYMPTOMS OF
ANOREXIA NERVOSA
Emaciation
Electrolyte imbalances
Menstrual irregularities
Dependence on laxatives
Esophageal tears
SIGNS AND SYMPTOMS OF
BULIMIA NERVOSA
Fluid and electrolyte abnormalities
Self-esteem disturbance
A) Antidepressant
B) Cognitive behavior therapy
C) Anti-depressants and cognitive-behavior
therapy
D) Total parenteral nutrition and
antidepressants
ANSWER
Letter C
A) Acceptable
B) Abnormal
C) Easy to control
D) Physically dangerous
ANSWER
Letter B
Autoerotic Asphyxia
Sexual Masochism
Transvestitism
NON-COERCIVE PARAPHILIAS -
FETISHISM
Sexual arousal elicited by inanimate
objects (shoes, leather, rubber) or
specific body parts (feet, hair)
NON-COERCIVE PARAPHILIAS -
AUTOEROTIC ASPHYXIA
Constriction of the neck to enhance a
masturbation experience; often leads
to accidental death
NON-COERCIVE PARAPHILIAS -
SEXUAL MASOCHISM
Erotic interest in receiving
psychological or physical pain, real or
fantasized
NON-COERCIVE PARAPHILIAS -
TRANSVESTITISM
Using the apparel of the opposite sex
COERCIVE PARAPHILIAS
Exhibitionism
Voyeurism
Frotteurism
Obscene Phone Callers / Telephone
Scatologia
Pedophilia
Urophilia
Coprophilia
Sadism
COERCIVE PARAPHILIAS -
EXHIBITIONISM
Intentional exposure of the genitals to
a stranger or unsuspecting person
Cunnillingus
Fellatio
Partialism
OTHER FORMS OF PARAPHILIA
ANNILINGUS
Tongue brushing of the anus
OTHER FORMS OF PARAPHILIA
CUNNILLINGUS
Tongue brushing of the vulva
OTHER FORMS OF PARAPHILIA
FELLATIO
Inserting the penis into the mouth
OTHER FORMS OF PARAPHILIA
PARTIALISM
Inserting the penis into the other parts
of the body
TYPE OF THERAPY PERFORMED
ON PATIENTS WITH PARAPHILIAS
Behavior Modification
– A therapeutic intervention involving the
application of learning principles in order to
change maladaptive behavior
– A method of attempting to strengthen a desired
behavior or response by reinforcement , either
positive or negative
Positive reinforcement is given to the client who
exhibits the desired behavior
Negative reinforcement involves removing a stimulus
immediately after a (positive) behavior occurs so that
the behavior is more likely to occur again
TYPE OF THERAPY PERFORMED
ON PATIENTS WITH
PARAPHILIAS
Aversion Therapy
– An example of behavior modification in which
a painful stimulus is introduced to bring about
avoidance of another stimulus with the end
view of facilitating behavioral change
Token Economy
– An example of behavior modification
technique which utilizes the principle of
rewarding desired behavior to facilitate
change.
SEXUAL ADDICTION
The frequency of sexual activity can be viewed on a
continuum, with most people falling in the middle
range
People with these addictions spend 50% or more of all waking hours
dealing with sex, from fantasy to acting out behavior.
Arousal Disorders
Orgasm Disorders
DISORDERS OF SEXUAL DESIRE
Inhibited Sexual Desire
– Persistently low interest or a total lack of interest in
sexual activity
Sexual Aversion Disorder
– They have had orgasm in the past but are not currently
experiencing them
Situationally Non-orgasmic
– Insight
Therapist attempts to learn and understand what is causing
and perpetuating the sexual problem
SEX THERAPY
Common components
– Cognitive Restructuring
Clients identify and re-evaluate their non-
sexual fears about sexual interaction
– Behavioral Interventions
Focus is on changing the non-sexual behavior
that contributes to sexual problems
Assertiveness training, communication training,
stress-reduction exercises and problem-solving
techniques
SCHIZOPHRENIA
SCHIZOPHRENIA
The term “schizophrenia” (split mind) was coined by
Bleuler to describe a lack of integration of the
patient’s functions
There is disharmony between the patient’s thinking,
feeling and acting.
Schizophrenia causes distorted and bizarre thoughts,
perceptions, emotions, movements and behavior.
It cannot be defined as a single illness; rather it is
thought of as a syndrome or disease process with
many different varieties and symptoms
SCHIZOPHRENIA
The main problem in schizophrenia is
Altered Thought Process
Catatonic Type
Disorganized Type
Undifferentiated Type
Residual Type
SCHIZOPHRENIA
PARANOID TYPE
Characterized by persecutory (feeling
victimized or spied on) grandiose
delusions, hallucinations, and
occasionally, excessive religiosity
(delusional religious focus) or hostile
and aggressive behavior.
SCHIZOPHRENIA
CATATONIC TYPE
Characterized by marked psychomotor disturbance, either
motionless or excessive motor activity.
Catatonic Negativism
– Apparently motive-less resistance to all instruction or
attempts to be moved
Catatonic Rigidity
– Maintenance of a rigid posture against efforts to be
moved
SCHIZOPHRENIA
CATATONIC TYPE
Catatonic Excitement
– Excited motor activity, apparently
purposeless and not influenced by
external stimuli
Catatonic Posturing
– Voluntary assumption of
inappropriate posture.
SCHIZOPHRENIA
DISORGANIZED TYPE
Incoherence, marked loosening of
associations, or grossly disorganized
behavior
Autism
Apathy
Ambivalence
SYMPTOMS OF SCHIZOPHRENIA
The symptoms of schizophrenia are divided into
two major categories:
Echopraxia Perseveration
POSITIVE OR HARD SYMPTOMS
OF SCHIZOPHRENIA –
AMBIVALENCE
Holding seemingly contradictory
beliefs or feelings about the same
person, event or situation
POSITIVE OR HARD SYMPTOMS
OF SCHIZOPHRENIA –
ASSOCIATIVE LOOSENESS
Fragmented or poorly related thoughts
and ideas
POSITIVE OR HARD SYMPTOMS
OF SCHIZOPHRENIA -
DELUSIONS
Fixed false beliefs that have no basis in
reality
POSITIVE OR HARD SYMPTOMS
OF SCHIZOPHRENIA -
ECHOPRAXIA
Imitation of the movements and
gestures of another person whom the
client is observing.
POSITIVE OR HARD SYMPTOMS
OF SCHIZOPHRENIA - FLIGHT
OF IDEAS
Continuous flow of verbalization in
which the person jumps rapidly from
one topic to another
POSITIVE OR HARD SYMPTOMS
OF SCHIZOPHRENIA –
IDEAS OF REFERENCE
False impressions that external events
have special meaning to the person
POSITIVE OR HARD SYMPTOMS
OF SCHIZOPHRENIA -
PERSEVERATION
Persistent adherence to a single idea or topic; verbal repetition of a
sentence, word, or phrase; resisting attempts to change the topic
Example:
Blunted Affect
NEGATIVE OR SOFT SYMPTOMS
OF SCHIZOPHRENIA - ALOGIA
Tendency to speak very little or to
convey little substance of meaning
(poverty of content)
NEGATIVE OR SOFT SYMPTOMS
OF SCHIZOPHRENIA -
ANHEDONIA
Feeling no joy or pleasure from life or
any activities or relationships
NEGATIVE OR SOFT SYMPTOMS
OF SCHIZOPHRENIA - APATHY
Feelings of indifference toward people,
activities, and events
NEGATIVE OR SOFT SYMPTOMS
OF SCHIZOPHRENIA - BLUNTED
AFFECT
Restricted range of emotional feeling,
tone, or mood
NEGATIVE OR SOFT SYMPTOMS
OF SCHIZOPHRENIA -
CATATONIA
Psychologically induced immobility
occasionally marked by periods of
agitation or excitement; the client
seems motionless, as if in a trance
NEGATIVE OR SOFT SYMPTOMS
OF SCHIZOPHRENIA - FLAT
AFFECT
Absence of any facial expression that
would indicate emotions or mood
NEGATIVE OR SOFT SYMPTOMS
OF SCHIZOPHRENIA - LACK OF
VOLITION
Absence of will, ambition, or drive to
take action or accomplish tasks
GENERAL SIGNS AND
SYMPTOMS OF SCHIZOPHRENIA
1) Perceptual changes
– Perceptions may either be heightened or blunted
– May occur in all the senses, or in just one or two
1a) Illusions
Client’s misperceives or exaggerates stimuli in the external
environment
1b) Hallucinations (hallmark of schizophrenia)
Subjective perception of something that does not exist in the
external environment
May be visual, olfactory, gustatory, tactile, or auditory
GENERAL SIGNS AND
SYMPTOMS OF SCHIZOPHRENIA
2) Disturbances in thought
– The thinking is nudged or unclear
– Thoughts are disconnected or
disjointed
– Connections between one thought and
another are vague
– Examples:
2a) Clang Associations
2b) Delusions
CLANG ASSOCIATIONS
Are ideas that are related to one
another based on sound or rhyming
rather than meaning.
Examples
– A male client may say that he is pregnant
– A client may report decaying intestines or
worms in the brain
REFERENTIAL DELUSIONS /
IDEAS OF REFERENCE
Involve the client’s belief that television
broadcasts, music, or newspaper articles have
special meaning for him or her
Examples:
– The client may report that the president was
speaking directly to him on a news broadcast
or that special messages are sent through
newspaper articles
GENERAL SIGNS AND SYMPTOMS
OF SCHIZOPHRENIA
3) Changes in communication
– Clients have difficulty responding appropriately to
events and people they encounter because of their
distorted perceptions, impaired ability to sort and
assimilate these perceptions, and difficulty
communicating responses clearly
– Examples:
3a) Thought Disorganization
3b) Thought Blocking
3c) Tangential Communication
3d) Circumstantial Communication
3e) Alogia
THOUGHT DISORGANIZATION
Example:
– Nurse: “How have you been sleeping
lately?”
– Client: “Well, I guess, I do not know,
hard to tell.”
GENERAL SIGNS AND
SYMPTOMS OF SCHIZOPHRENIA
4) Disruptions in emotional responses
– Restricted or inappropriate
expression or emotion
GENERAL SIGNS AND SYMPTOMS
OF SCHIZOPHRENIA
5) Motor Behavior Changes
– Disorganized behavior and catatonia (manifested
by unusual body movement or lack of movement)
– Examples:
5a) Catatonic Excitement
– The client moves excitedly but not in response to
environmental influences
5b) Catatonic Posturing
– Clients hold bizarre postures for a period of time
5c) Stupor
– Client holds the body still and is unresponsive to the
environment
GENERAL SIGNS AND
SYMPTOMS OF SCHIZOPHRENIA
6) Self care deficits
– Examples:
8a) Magical Thinking
8b) Thought Insertion
8c) Thought Withdrawal
8d) Thought Broadcasting
MAGICAL THINKING
Belief that events can happen simply
because one wishes them to happen.
THOUGHT INSERTION
They may state that others are placing
thoughts in their mind or in their head
against their will
THOUGHT WITHDRAWAL
They may state that others are taking
their thoughts out of their head
THOUGHT BROADCASTING
They may state that they believe
others can hear their thoughts
– Example:
“I want to go home, go home, go home,
go home.”
ECHOLALIA
This is the client’s imitation or
repetition of what the nurse says.
– Example:
Nurse: “Can you tell me how you are
feeling?”
Client: “Can you tell me how you are
feeling? how you are feeling?”
STILTED LANGUAGE
This is the use of words or phrases that
are flowery, excessive, and pompous
– Example:
“Would you be so kind, as a
representative of Florence Nightingale,
as to do me the honor of providing just
a wee bit of refreshment, perhaps in the
form of some clear spring water?”
PERSEVERATION
Persistent adherence to a single idea or topic; verbal repetition of a
sentence, word, or phrase; resisting attempts to change the topic
Example:
– Example:
“Corn, potatoes, jump up, play games,
grass, cupboard.”
OTHER DISORDERS RELATED
TO SCHIZOPHRENIA
1) Delusional
– Similar to schizophrenia because they hold
unusual bizarre beliefs and cannot be
reasoned with regarding these beliefs.
– Unlike schizophrenic clients, delusional clients
do not have persistent hallucinations
Delusions have a basis reality
Hallucinations are not a dominant feature
Behavior is within normal range except in relation
to delusion
Behavior does not meet criteria for schizophrenia
OTHER DISORDERS RELATED TO
SCHIZOPHRENIA
2) Psychotic disorders not elsewhere classified
2a) Schizophreniform Disorder
The duration of all symptoms (acute and residual) is less than six
months and a return to normal functioning is possible. (Note that 6
months is the amount of time necessary to meet the diagnostic
criteria for schizophrenia)
2b) Schizoactive Disorder
Dominant schizophrenic symptoms are accompanied at some, but
not all times by a major depressive or manic syndrome
There is a mood disorder in the form of either depression or mania
OTHER DISORDERS RELATED TO
SCHIZOPHRENIA
2) Psychotic disorders not elsewhere classified
– Antipsychotics or neuroleptics
Conventional antipsychotics
– These are dopamine antagonists
Atypical antipsychotics
– Newer schizophrenic drugs which are both
dopamine and serotonine antagonists
CONVENTIONAL
ANTIPSYCHOTICS
Chlorpromazine (Thorazine)
Trifluoperazine (Trilafon)
Fluphenazin (Prolixin)
Thioridazine (Mellaril)
Mesoridazine (Serentil)
Thiothixene (Navane)
Haloperidol (Haldol)
Loxapine (Loxitane)
Molindone (Moban)
Perphenazine (Etrafon)
Trifluoperazine (Stelazine)
ATYPICAL ANTIPSYCHOTICS
Clozapine (Clozaril)
Risperidone (Risperdol)
Olanzapine (Zyprexa)
Quetiapine (Seroquel)
Ziprasidone (Geodon)
EFFECTS OF ANTIPSYCHOTICS
Prescribed primarily for efficacy in
decreasing psychotic symptoms like
delusions, hallucinations and looseness
of association
Akathisia
Tardive Dyskinesia
DYSTONIC REACTIONS
They appear early in the course of treatment and are
characterized by spasms in discrete muscle groups such as the
neck muscles (torticollis) or eye muscles (oculogyric crisis)
A) Delusions
B) Hallucinations
C) Decreased sensitivity
D) Ideas of reference
ANSWER
Letter C
A) Undoing
B) Projection
C) Rationalization
D) Suppression
ANSWER
Letter B
A) Agitation
B) Hallucinations
C) Delusions
D) Ambivalence
ANSWER
Letter A
8) Biologic Factor
– Mania is related to increased norepinephrine
while depression is related to low
norepinephrine
COMMON PRECIPITATING
FACTORS OF MOOD DISORDERS
Loss of a loved one
Major life events
Roles strain
Decreased coping resources
Physiological changes
DIFFERENT TYPES OF MOOD
DISORDERS
The two main types of mood disorders are:
– Depression
Characterized by anergia (lack of energy),
exhaustion, agitation, noise intolerance, and
slowed thinking process
– Bipolar Disorders
Diagnosed when a person’s mood cycles
between extremes of mania and depression
SUBTYPES OF DEPRESSIONS
Major Depression
Dysthymic Depression
Hypomanic
Bipolar I
Bipolar II
Cyclothymia
MANIA
The diagnosis of manic episode or mania requires at
least 1 week of unusual and incessantly heightened,
grandiose or agitated mood in addition to three or
more of the following symptoms:
– Exaggerated self-esteem
– Sleeplessness
– Pressured speech
– Flight of ideas
– Reduced ability to filter extraneous stimuli
MANIA
The diagnosis of manic episode or mania requires at least 1
week of unusual and incessantly heightened, grandiose or
agitated mood in addition to three or more of the following
symptoms:
– Distractability
– Increased activities with increased energy
– Multiple, grandiose high-risk activities involving poor
judgment and severe consequences such as spending
sprees, sex with strangers, and impulsive investments
HYPOMANIC
Less severe than mania
– Antimanic Medications
Lithium Carbonate
– Anticonvulsant Medications
Used as mood stabilizers
LITHIUM CARBONATE
It is a salt contained in the human body
Tiredness
Psychopharmacology
– Cyclic antidepressants
– Monoamine oxidase inhibitors
– Selective serotonin reuptake
inhibitors
ELECTROCONVULSIVE THERAPY
(ECT)
Involves application of electrodes to the
head of the client to deliver an electrical
impulse to the brain; this causes a seizure
Contraindications to ECT
– Fever
– Increased intracranial tumor
– TB with history of hemorrhage
– Cardiac condition
– Recent fracture
– Retinal detachment
– Pregnancy
FACTS ABOUT ELECTROCONVULSIVE
THERAPY (ECT)
Need for consent prior to ECT
– Yes, consent is needed
FACTS ABOUT
ELECTROCONVULSIVE THERAPY
(ECT)
Medications given to clients prior to ECT
– Atropine sulfate
To decrease secretions
– Anectine (Succinylcholine)
To promote muscle relaxation
A) Suicidal tendency
B) Underlying hostility
C) Delusions
D) Flight of ideas
ANSWER
Letter B
A) Cheeseburger
B) Rice toppings
C) Chicken soup
D) Potato chips
ANSWER
Letter A
– Depression
– Bipolar disorder
– Schizophrenia
– Substance abuse
– Post-traumatic stress disorder
– Borderline personality disorder
RISK FACTORS FOR SUICIDE
Environmental factors that increase suicide
risk include:
– Isolation
– Recent Loss
– Lack of social support
– Unemployment
– Critical life events
– Family history of depression or suicide
RISK FACTORS FOR SUICIDE
A history of suicide attempts increases
risk for suicide.
Egoistic Suicide
– The individual’s ties to the community are too
loose or tenuous, and the individual is not
interested in maintaining his or her relationship
with the community
THEORETIC FOUNDATIONS OF
SUICIDE
Sociologic Theories
Anomic Suicide
– An individual experiences the aloneness
or estrangement that occurs when there
is a precipitous deterioration in one’s
relationship with the society
THEORETIC FOUNDATIONS OF
SUICIDE
Sociologic Theories
– Fatalistic Suicide
An individual is excessively regulated,
or there are no personal freedoms or no
hope (e.g., suicide of slaves)
THEORETIC FOUNDATIONS OF
SUICIDE
Sociologic Theories
– Altruistic Suicide
Rules of customs demand suicide under
certain conditions, or self–inflicted
suicide is honorable
LEVELS OF SELF-DESTRUCTIVE
BEHAVIOR
Chronic self-destructive behavior
– Smoking, gambling, self-mutilation
Suicidal threat
– A threat more than a casual statement
of suicidal intent and accompanied by
behavioral changes, e.g., mood
swings, temper outbursts, decline in
school or work performance
LEVELS OF SELF-DESTRUCTIVE
BEHAVIOR
Suicidal gesture
– More serious warning signal than a threat
that may be followed by an act that is
carefully planned to attract attention
without seriously injuring the subject
Suicidal attempt
– A strong and desperate call for help
involving a definite risk
FAMILY CHARACTERISTIC OF
SUICIDAL PATIENTS
Poor family history or tendencies
Early trauma
Rigid, disorganized or dysfunctional
family system
Disturbed parent-child relationship
Unresolved loss
History of abuse
COGNITIVE STYLES OF
SUICIDAL PATIENTS
Ambivalence
Listen
SAMPLE BOARD QUESTION
NO.1
A 19 year-old patient is brought to the
emergency room because she slashed her
wrists. What is the nurse’s first concern?
A) Omnipotence
B) Grandiosity
C) Low self-esteem
D) Self-satisfaction
ANSWER
Letter C
A) Cheerfulness
B) Psychomotor retardation
C) Agitation
D) Hostility
ANSWER
Letter A
A) Enter the room quietly and move beside her to assess her injuries
B) Call for back-up before entering the room and restraining her.
C) Move as much glass away and then quietly sit next to her
D) Approach her slowly and in a calm voice call her name and tell her
that the nurse is here to help her
ANSWER
Letter D
Memory for past events may still exist, but the person has no recall
of recent ones.
– Music therapy
– Drug therapy
NURSING CARE FOR
ALZHEIMER’S PATIENTS
Promote optimal orientation
A) Be highly structured
B) Be changed each day to meet the patient’s need for
variety
C) Be simplified as much as possible to avoid problems
with decision-making
D) Provide many opportunities for making choices to
simulate the patient’s involvement and interest
ANSWER
Letter A
A) Minimizing regression
B) Correcting memory loss
C) Rehabilitating toward independent
functioning
D) Preventing further deterioration
ANSWER
Letter A
A) Meningitis
B) Delirium tremors
C) Neurosyphilis
D) Alzheimer’s disease
ANSWER
Letter D
A) Functional disorder
B) An irreversible condition
C) Generally reversible condition
D) Delirious state
ANSWER
Letter B
A) Apraxia
B) Mnemonic disturbance
C) Agnosia
D) Aphasia
ANSWER
Letter C
2) Learning Theories
– Due to a learned behavior
3) Biological Theories
– Due to inherited traits
4) Socio-cultural Theories
– Due to effects of mass media
MANIFESTATIONS OF
DIFFERENT BLOOD LEVELS OF
ALCOHOL
Alcoholic hallucinosis
– Auditory hallucinations reported approximately 48
hours after heavy drinking.
POSSIBLE OUTCOMES OF
ALCOHOLISM
Brain damage
Alcoholic hallucinosis
Death
COMMON BEHAVIORAL
PROBLEMS OF ALCOHOLIC
PATIENTS
Denial
Dependency
Demanding
Destructive
Domineering
COMMON DEFENSE
MECHANISMS UTILIZED BY
ALCOHOLICS
Denial
Rationalization
Isolation
Projection
STAGES OF ALCOHOL
WITHDRAWAL SYNDROME
1) Tremulousness
– Occurs during the drinking period up
to 2 hours afterward.
– There is anxiety, agitation and
irritability
– As it progresses, tremors,
tachycardia and diaphoresis are
exhibited
STAGES OF ALCOHOL
WITHDRAWAL SYNDROME
2) Hallucinations
– Begins 12 – 48 hours after the
person stops drinking
– Gastrointestinal symptoms of
nausea, vomiting, diarrhea and
anorexia are present
STAGES OF ALCOHOL
WITHDRAWAL SYNDROME
Delirium tremens
– A condition of severe memory disturbance,
agitation, anorexia and hallucinations
– Begins a few days after drinking stops and
ends within 1 – 5 days
– There is elevated temperature, severe
diaphoresis, hypertension and tachycardia
– Behavioral symptoms include confusion
with disorientation, agitation, tremors, and
alterations in sensory perception.
COMMON WITHDRAWAL SIGNS
AND SYMPTOMS
Hallucinations (visual and tactile)
Tremors
The client must avoid a wide variety of products that contain alcohol such as cough syrup,
lotions, mouthwash, perfume, aftershave, vinegar and vanilla and other extracts.
The client must read product labels carefully because any product containing alcohol can
–
produce the symptoms.
DRUGS
DRUG USED FOR ALCOHOLIC
USE DOSAGE PATIENTS
NURSING
CONSIDERATIONS
Disulfiram Maintain 500 mg/day for 1-2 Teach client to read labels
(Antabuse) abstinence weeks, then 250 to avoid products with
from alcohol mg/day alcohol
Reorganization / Restitution
– Life normalizes
STAGES OF DEATH / DYING
Denial
– “No, not me!”
Anger
– “Why me?”
Bargaining
– “If only….”
STAGES OF GRIEF / GRIEVING
Depression
– Stage of silence
Acceptance
– “Yes, it is me”
PRIORITY NURSING DIAGNOSIS
FOR THE GRIEVING / DYING
Ineffective individual coping
PRIORITY NURSING DIAGNOSIS
FOR THE GRIEVING / DYING
Be physically present
Be non-judgmental