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Psych Notes 2009

Psych Notes 2009

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Overview of Mental Health and Psychiatric Nursing Mental Health and Mental Illness ◦ Components and is influenced by a wide

variety of factors: Autonomy and independence Maximizing one’s potential Tolerating life’s uncertainties Self-esteem Mastering the environment Reality orientation Stress Management  Mental Health and Mental Illness  Mental health :(WHO) ◦ “ state of complete physical, mental, and social wellness, not merely the absence of disease or infirmity.” It emphasizes the positive – a state of well being and does not focus on the lack of disease or disorder.  Mental Health and Mental Illness ◦ Someone is mentally healthy when  The person with a balance between the integrated body, mind, and spirit and the environment.  Mental Disorder ◦ Clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress. ◦ Criteria to diagnosed mental disorder Dissatisfaction with one’s characteristic, ability and accomplishment. Ineffective or unsatisfying relationship Ineffective coping with life events Lack of personal growth  Mental Health and Mental Illness Mental health Mental Illness ability to effectively adapt to stress in - responses to stress that create problems in intrapersonal the here and now. and interpersonal functioning in the here and now. Factors Mentally healthy Mental Disorder Personality characteristics Un-accepting to self  Accepts / requires balance Dislikes self love self Dependent on others  to love, work, play,  Goal Lacks direction in life  relationships, oriented Unrealistic perception of strengths and  spiritual  Thinks/acts independentl weaknesses  emotional Lacks productivity in lifestyle y Difficulty in meeting needs  Aware Dissatisfaction with one’s characteristics, strengthsabilities and accomplishments. weakness   Adaptation to stress mechanisms for coping with stress – crisis è respond appropriately. Work productively In control of self and environment a majority of time Effective coping Mechanisms  Problems d/t stress maladaptive behaviors Feels out of control of self; r/t feelings and actions. Feels lack of control over environmental factors Ineffective coping mechanisms

Interpersonal relationships Develop meaning or purpose in life.

Able to accept others Love others Care for others To be loved by other.

 Disruption in ability to relate
successfully with others. feelings of others Unable to love, Care To feel loved by others.

 Unable to accept thoughts and    Ineffective or unsatisfying
socially acceptable way.

interpersonal relationships.

 Inability to meet basic needs in
Perception of environment and reality Display grasp of reality    Positive perception Reality oriented Able to find meaning in life.

   

Negative perception of environment Thoughts and perceptions may not be reality based. Unable to find meaning or purpose in life.Dissatisfaction with one’s place in the world. Ineffective coping or adaptation to the events in one’s life as well as a lack of personal growth.

Diagnostic and statistical Manual of Mental Disorder ◦ Three purposes To provide a standardized nomenclature and language for all mental health professions. To provide defining characteristics or symptoms that differentiate specific diagnosis. To assist in identifying the underlying causes of disorders. Psychiatric Nursing ◦ is a specialized area of nursing that uses both science and art to provide nursing care to individuals and groups in a wide variety of settings. ◦ The nurse-client relationship is the vehicle through which the nurse fulfills independent, interdependent and dependent roles. ◦ A specialized area of nursing emphasizing theories of human behavior as its scientific aspects and purposeful use of self as its art. The Roles in Psychiatric Nurse as a Team ◦ Manages the inpatient or outpatient nursing care of clients. ◦ Administers medications ◦ Completes assessment on clients ◦ Established outcomes ◦ Writes nursing diagnosis ◦ Implements plans of care including client / family teaching. Neurobiologic Theories and Psychopharmacology  Great strides are being made in understanding the brain and mental illness, but much is still unknown; nurses need to keep abreast of developments to provide effective teaching Central Nervous System  Brain  Cerebrum  Cerebellum  Brain stem  Limbic system  Spinal cord  Nerves that control voluntary acts  Cerebrum

    

Divided into two hemispheres with four lobes each: a) Frontal- Thought process • Formulate & select goals • Plan • Initiate plan, terminate actions • Decision making, insights • Motivation • Social judgment • Voluntary motor ability starts • Control the organization of thought, body movement, memories, emotions, and moral behavior Frontal- Thought process • helps regulate arousal, focuses attention and allows problem solving and decision making. • Abnormalities : schizophrenia, attention deficit/hyperactivity disorder, dementia • b) Parietal Interpret sensations of taste, touch and spatial orientation. Receives & identify sensory information Concept formation and abstraction Proprioception and body awareness Reading, mathematics Right – left orientation c) Temporal( Auditory)  Language comprehension  Stores sounds – memory – language, speech  Connects the limbic system “emotional brain” to allow esxpression of emotions ( sexual, aggressive, fear, etc.)  Parietal- Sensory & Motor  Receives & identify sensory information  Concept formation and abstraction  Proprioception and body awareness  Reading, mathematics  Right – left orientation  Centers for the sense of smell, hearing, memory, and expression of emotions. ( Auditory)  Language comprehension  Stores sounds – memory – language, speech  Connects the limbic system “emotional brain” to allow esxpression of emotions ( sexual, aggressive, fear, etc.) Occipital Lobe – Vision  Interprets visual images  Visual association  Visual memories  Involved with language formation  Assist in the coordinating language generation and visual interpretation, i.e. depth perception.  Vision  Interprets visual images  Visual association  Visual memories  Involved with language formation Cerebellum  Center for coordination of movements and postural adjustments.  Receives and integrates information from all body areas to coordinate movement and posture

Brain Stem  Regulates the internal organs ( regulation of blood gases , maintenance of blood pressure.)  Initial processing center for sensory information that is then sent on to cerebral cortex.  Midbrains, pons, medulla oblongata and the nuclei of cranial nerves 3 to 12.  RAS –motor activity, sleep, consciousness, & awareness  Extrapyramidal system - relays information about movement and coordination from the brain and spinal nerves.  Locus seruleus – is the area of brain stem associated with stress, anxiety and impulsive behavior. Limbic System  Above the brain stem and includes:  Thalamus  Hypothalamus  Amygdala 1. Thalamus- regulates activity, sensation, and emotion 2. Hypothalamus - temperature regulation, appetite control, endocrine function, sexual drive and impulsive behavior associated with feelings of anger, rage or excitement. 3. Hippocampus and amygdale – are involved in emotional arousal and memory. 4. Disturbances: dementia or memory loss; poorly controlled emotions and impulses seen in psychotic and manic behavior.  spinal cord  nerves NEUROTRANSMITTERS Neurotransmitters include: 1) Bioamines  Dopamine (control of complex movements, motivation, cognition, regulation of emotional responses)- integration of thoughts & emotions • Involved with decision making• Stimulates hypothalamus to release hormones

 1.

 Norepinephrine (attention, learning, memory, sleep, wakefulness, mood regulation) sympathetic

sexual behaviors, regulation of emotions) 2) NEUROPEPTIDES - Neuromodulator  Histamine (Neuropeptides)(alertness, control of gastric secretions, cardiac stimulation, peripheral allergic responses) 3) CHOLINERGICS a. Acetylcholine (sleep and wakefulness cycle, signals muscles to become alert)learning, mood regulator ( brain, spinal cord, PNS, neuromuscular junction of skeletal muscle) from dietary choline in red meat, vegetables.  Excitatory or inhibitory Sleep and wakefulness cycle, signals muscles to become aler

 Epinephrine (flight-or-fight response)  Serotonin (food intake, sleep, wakefulness, temperature regulation, pain control,

4) AMINOACIDS
· Glutamate (an excitatory amino acid) · GABA (modulates other neurotransmitters)  - inhibition; dec.aggression, excitation, & anxiety  Anticonvulsant, muscle relaxing

 Psychopharmacology Psychopharmacology and medication management are important in the treatment of many mental illnesses.

Principles of Pharmacological treatment in psychiatric patients: a. Psychotropic medications DO NOT CURE mental illness. b. Clients require physical and psychiatric assessments c. Various view about the use of psychotropic medications; may bring about nonadherence to medication treatment. d. Clients must give informed consent -- explanation of the risks vs. benefits. e. Psychotropic medications have different onset of actions. ---Most medications require daily administrations for one - weeks before their intended effects are evident some medications act more immediately. ( benzodiazepines, antipsychotic) a. Its selection is based on its target symptoms ( i.e. delusional thinking; panic attacks; hallucinations) b. The dosage of medications is often adjusted

PHASES OF DRUG TREATMENT 1. Inititation Phase: Assessment a) Psychiatric evaluation - diagnosis and target symptoms b) A nursing assessment c) Physical examination d) N. assesses, observes and monitor’s C’s responses, teaches ( action, dosage, frequency, side effects) 2. Stabilization Phase: a) Medication is adjusted or titrated – achieve max. amount of improvement; minimum side effects. b) Monitor body temp., BP, pulse, mental status, side effects and unusual adverse reactions. c) May have Augmentation strategy d) Polypharmacy – using more than one group from a class of medications. 3. Maintenance Phase a) Target symptoms have improved; continuity of medications – prevents relapse. 4. Discontinuation Phase a) Discontinuance, tapering Purpose Of Psychotherapeutic medications:  Relieve or reduce symptoms of dysfunctional thoughts, moods, or actions, mental illness or disorder.  Improve client’s functioning.  Increase client’s adherence ( or compliance) and amenability to other therapies. 1. ANTIPSYCHOTIC DRUGS ( 1950)  Other names: neuroleptics; major tranquilizer, ataractic, psychic energize.  Effective in the treatment of psychoses. Use to modify behavior and relieve the symptoms.  Used to lessen : hallucinations, dementia, delusions, illusions, aggressive behaviors, disorganized speech, inappropriate affect and behavior. Types: A. ATYPICAL ANTIPSYCHOTICS CONVENTIONAL; ATYPICAL; NEW GENERATION ( Neuroleptics) Clozaril, Risperdal, Zyprexa, Seroquel, Geodon  Action: Block postsynaptic dopamine – serotonin receptors. The newer also affect serotonin levels.  Effects: ◦ Treatment of hallucination, and delusion ( also called positive symptoms) ◦ Reduction of aggressive behaviors. ◦ Non- addicting; clients do not develop tolerance.

Side Effects:     

Sedation Weight gain Insomnia Agitation Minimal anticholinergic effects

 TYPICAL/TRADITIONAL/ ( NEUROLEPTICS) CONVENTIONAL ANTIPSYCHOTIC DRUGS phenothiazines (Thorazine, Prolixin, Mellaril, Stelazine); Navane, Haldol, Loxitane, Moban  Action: Mechanism of Actions:  block receptors to dopamine  Calms an excites patients without producing impairment of motor function sleep.  High therapeutic effects --- can be given in high dose with minimal risk.  Non addicting—patients do not develop tolerance.  Side Effects:  EPS Sedation  Anticholinergic effects  Skin rash  Weight gain  Photosensitivity  Reduction of seizure thresholad  Orthostatic hypotension  Galactorrhea/ amenorrhea  Sexual dysfunction  ANTIPSYCHOTIC( TYPICAL) Teaching:  Failure to take antipsychotic medication -- lead to relapses and repeated hospitalization.  It should be lowered to elderly Side Effects: a) Extrapyramidal effects (EPS) Management: Mgt: Lowering the dosages  Changing to another antipsychotic drugs  Administering anticholinergic drugs a. Acute dystonia – a. Torticollis b. Opisthotonus c. Oculogyric Management:  Anticholinergic drugs i.e. muscular benztropine (Cogentin), or dipenhydramine.  Recurrent à lowering or change of drugs. b) Pseudoparkinsonism – drug induced parkinsonism; triad- rigidity, slowed movement(akinesia) tremor.  Akinesia – absent or slowed movement

 Management: c)
 Change of drugs  Adding anticholinergic drugs e.g. Amantadine ( Symmetrel) Akathisia – an intense need to move about.inability to sit still or restlessness

 Restlessness(muscles)  anxious and agitated,(mind)
 rigid posture/gait lack of spontaneous gestures.

 Internal restlessness, inability to sit still ( leads to discontinue drugs).  Management:

 Change of antipsychotic drugs  Beta blocker  Anticholinergic or benzodiazepines  Anti histamines d) Neuroleptic Malignant Syndrome (NMS)  Potentially fatal, idiosyncratic reaction of antipsychotic or neuroleptic drugs  Signs and symptoms:  Rigidity  High fever  Autonomic instability  Confused or mute  Dehydration, poor nutrition, concurrent medical illness ( high risk) Management:  Discontinuance of all antipsychotic medications  Supportive medical care – rehydration and hypothermia e) Tardive Dyskinesia (TD)  A syndrome of permanent, involuntary movements  Tongue thrusting and protrusion, lip smacking, blinking, grimacing , unnecessary facial movements.  Caused by – medication After 6 mos., reduced or withdrawn Management:  Maintenance dosages as low as possible  Changing medications  Monitoring periodically Management: Client teaching for antipsychotic drugs:  Drink sugar free fluids and hard candies to ease dry mouth.  avoid calorie-laden beverages and candies –to avoid dental caries, weight gain  increase fluid and bulk forming food, exercise – prevent constipation.  Stool softeners but no laxative.  Use of sunscreen – prevent burning.  rising slowly – prevent hypotension or dizziness.  Monitor drowsiness or sleepiness. Avoid driving.  Medication can be taken 3-4 hrs. late. If more than 4 hrs.late omit the dose. NEW-GENERATION ANTIPSYCHOTIC DRUGS aripiprazole (Abilify) Side Effects  Headache  Anxiety  Nausea Patient Teaching  Adhering to medication regimen  Antidepressant Drugs SSRIs; TCAs; MAOIs Uses: Major depression, panic disorder and other anxiety disorders, bipolar depression, psychotic depression Action: Interact with the monoamine neurotransmitter systems in the brain, particularly the neurotransmitters norepinephrine and serotonin ANTIDEPRESSANTS - MOOD ELEVATOR  USES: major depressive illness, panic, anxiety, bipolar, and psychotic depression.  Used primarily to treat the related symptoms of dysphoria, anhedonia, reduced energy level, change in appetite and sleep, hopeless feelings, and suicidal ideations.  Interact with two monoamine neurotransmitters:  Norepinephrine

Serotonin

4 Groups of Anti depressants  Tricyclic and the related cyclic antidepressants.  Selective serotonin reuptake inhibitors ( SSRIs)  Monoamine oxidase inhibitors (MAOIs)  Other antidepressants or non tricyclic 1. Cyclic compounds (1950)  Effects: ◦ Sedative/ hypnotic ◦ Treatment of depression associated with organic illness and addiction ◦ Amoxapine – with neuroleptic effects ◦ Clomipramine – OCD  Contraindications: ◦ Alcohol intake ◦ Dementia ◦ Suicidal clients ( toxic in overdose) ◦ Cardiac disease ◦ Multiple concominant medications ( TCA drug indications) ◦ Daytime sedation, urinary retention, or constipation Teachings: ◦ Elderly – ½ of adult dosage. ◦ Alcohol – sedation and ataxia ◦ Suicidal precaution 2. MAOIs –Monoamine Oxidase Inhibitor- Effects: Reduces atypical depression ( with weight gain and hypersomnia) or refractory depression in compliant patients. Side effects: 1. hypertensive crisis - if taken with foods containing tyramine ( amino acids) or sympatomimetics Drug interactions: potentially fatal with Other MAOIs SSRIs – serotonin syndrome Meperidine ( Demerol) Buspirone (Buspar) Dextromethorpan General anesthetics ◦ Toxic effects: Cardiac toxicity, and are toxic in overdose ◦ Contraindications: Noncompliant or poorly motivated patients, insomnia, agitation.

 Teachings:
Avoid foods with tyramine: (cheese, liver, avocados, figs, anchovies, yeast extract, deli meats, herring, beer, red wine, ale, chocolate, protein extracts, and stimulants, diet pills, cold and decongestant medications, nasal sprays.) ◦ Never Combine with SSRI 3. SELECTIVE SEROTONIN REUPTAKE INHIBITORS - SSRIs (1987) 1. SSRI Antidepressant Drugs  Serotonin systems fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), citalopram (Celexa), escitalopram (Lexapro)  the first of choice in treating depression. ◦ Treatment for anxiety disorders: OCD, PTSD, and panic disorder, eating disorder, enuresis  Teachings: ◦ Effects not seen for 10-21 days- it will take weeks longer. ◦ Relief not immediate but will be experienced – do not discontinue prematurely. ◦

Patient     OTHERS:

Teaching Take in the morning Take with food Propanolol given for akathisia TCA Antidepressant Drugs imipramine (Tofranil), desipramine (Norpramin), amitriptyline (Elavil), doxepin (Sinequan), clomipramine (Anafranil)

2. SEROTONIN NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIs)- decreased activity of
norepinephrine a. Venlafaxine ( effexor)- mild sedation and anticholinergic symptoms- depressed, sleeping excessively and little energy b. Nefazodone(Serzone) c. duloxetine ( Cymbalta) 3. NOREPINEPHRINE DOPAMINE REUPTAKE INHIBITOR (NDRI) a. )- inhibits norepinephrine, serotonin, and dopamine b. Bupropion (wellbutrin, Zyban) – depression c. Zyban – nicotine addiction 4. ALPHA 2 ANTAGONIST ( NaSSA) a. Mirtazapine (Remeron) boosts norepinephrine/noradrenaline and serotonin by blocking the a2adrenergic presynaptic receptors, histamine receptor is also blocked – sedative effect. Indicated for depression 5. SEROTONIN 2 ANTAGONIST/REUPTAKE INHIBITORS (SARI) a. Trazadone ( Desyrel)- blocks serotonin 2A receptor potentially and blocks serotonin reuptake pump less potentially. b. Indication: insomnia, anxiety, depression 3. MOOD STABALIZING DRUGS / ANTI-MANIC USE: Bipolar Affective Disorder by stabilizing mood and treating acute mania. • Lithium normalizes the reuptake of neurotransmitter i.e. norepinephrine, serotonin, acetylcholine and dopamine. • Side effects: excessive thirst, metallic like taste( sugarless throat lozenges) Effects: • Mood disorders: mood swings, excitement, elation, flight of ideas, violent/self destructive behavior. • Manic episodes – Bipolar disorder –maintenance Toxic effects: severe diarrhea, vomiting, drowsiness, muscle weakness, lack of coordination – renal failure, coma, death. Management: 1. Food; and propranolol for hand tremor. 2. Fluid intake 2-3 liters/day, balanced diet with normal sodium intake. 3. Effectiveness—it takes 2-3 weeks 4. Having monthly blood levels drawn 12 hours after last dose (maintain therapeutic levels between 0.5–1.5 mEq/L) b. ANTICONVULSANT – Anticonvulsant – Carbamazepine ( Tegretol), Valproic acid ( Depakote, Depakene) lamotrigine (Lamictal), gabapentin (Neurontin) • are effective mood stabilizer.

• •

Daily dosage: 900-3,600 mg; serum lithium level @ 1.0 -1.2 mEq/L.

• Cause a decrease in the catabolism of GABA, resulting in increased
concentration of GABA in the CNS. Serum drug levels, obtained 12 hrs of last dose for therapeutic levels. Effects: o Treatment of bipolar disorder, acute mania, aggressive behavior o Reduction in mood swings o Maintenance – bipolar and seizure disorder

ANTIANXIETY/ Anxiolytics – minor tranquilizers a. Bipolar, mood stabilizers b. short term basis to decrease anxiety ,insomnia, OCD, PTSD, and alcohol withdrawal. c. Used to reduce the manifestations of anxiety: trembling, sweating, chest pain, dizziness, fear of losing control or dying, feeling of panic BENZODIAZEPINES – benzodiazepines; buspirone (BuSpar), Alprazolam (Xanax), Lorazepam( Ativan), Diazepam (Valium), Chlordiazepoxide (Librium), flurazepam (Dalmane), Ams Triazolan ( Halcion) for relieving anxiety, anticonvulsant and muscle relaxant.  Actions: mediate the actions of the amino acid GABA.  Indications: panic and generalized anxiety, alcohol detoxification and withdrawal, skeletal muscle spasms.  Single dose: induce sedation --- long term may lead to dependence on the drug.  Clonazepam: also as anti -convulsant.

 Teaching:
Short term basis or results in drug dependence Avoid alcohol and other CNS depressants. Impairs ability to drive or operate machineries. Not to be taken – prior or current drug dependence. ◦ Discontinuation à Withdrawal. NON BENZODIAZEPINE Buspirone ( BuSpar) – acting as a partial agonist at serotonin receptors. Intended Effects: Decreased anxiety Generalized Anxiety Disorders, (anxiety, difficulty to concentrate, tension, insomnia, restlessness, irritability and fatigue. Augmented antidepressant therapy Zolpidem( Ambien) – (short treatment) for sleep, treating anxiety disorders without the CNS depressants . STIMULANTS Amphetamines – 1930, used for psychiatric treatment, CNS stimulation Indication: ADHD in children and adolescents, residual ADD in adult, narcolepsy. Drugs: Methylphenidate (Ritalin), pemoline (Cylert), dextroamphetamine (Dexedrine), Nortriptyline (Pamelor)-best result. Mechanisms of actions:  Amphetamines and methylphenidate – indirectly acting amines, they act by releasing the neurotransmitters from presynaptic Pemoline – affects dopamine, less effect on the sympathetic NS. Side effects:  Anorexia, weight loss, nausea and irritability  Growth and weight suppression  Management:  Avoid caffeine, sugar, and chocolate to lessen the side effects.  Drug holidays – usually weekends, holidays, summer vacation. Stimulant Drugs methylphenidate (Ritalin), pemoline (Cylert), dextroamphetamine Uses: ADHD, residual ADD in adults, and narcolepsy Action: Cause release of neurotransmitters ◦ ◦ ◦ ◦

 Stimulant Drugs Side Effects  Anorexia  Weight loss  Nausea  Irritability Patient Teaching  Avoiding caffeine, sugar, and chocolate  Taking after meals  Long-term use can cause dependency  Disulfiram Antabuse Uses: Aversion therapy for treatment of alcoholism Action: Causes an adverse reaction when alcohol is ingested  Disulfiram Side Effects  Fatigue  Drowsiness  Halitosis  Tremor  Impotence Patient Teaching  Avoiding alcohol (including products such as shaving cream, aftershave, cologne, many OTC medications)  Family should never administer without the person's knowledge  Cultural Considerations Ethnic backgrounds influence responses to some psychotropic medications:  African Americans respond more rapidly to antipsychotic and tricyclic antidepressant medications than do whites and have a greater risk of side effects  Asians metabolize antipsychotic and tricyclic antidepressants more slowly, requiring lower doses to produce the same effects  Hispanics require lower doses of antidepressants than whites to achieve desired effects  Asians and African Americans require lower doses of lithium than whites to produce desired effects  Self-Awareness Issues  Viewing chronic mental illness as having remissions and exacerbations, just as chronic physical illnesses do Remaining open to new ideas that may lead to future breakthroughs · Understanding that medication noncompliance is often part of the illness, not willful misbehavior HERBAL SUPPLEMENTS 1. St John’s Wort and Kava – hypericum perforation L – 2. KAVA – PIPER Methysticum Plant - anxiety reduction Nutritional Therapies and Supplements: 1. Melatonin – (pineal gland) – treatment of insomnia and jetlag. 2. , Dimethylaminoethanol (DMAE)- ADHD, Alzheimer’s d., Huntinggton’s chorea, & Tardive Dyskinesia 3. lecithin – precursor of acethylcholine – improve memory and treat dementia. OTHER BIOLOGIC TREATMENTS: I. ELECTROCONVULSIVE THERAPY an electrical current - produce a gradmal seizure  It causes changes in monoamine neurotransmitter systems – similar to anti- depressants.  Most clients require 6-10 treatments --- 20-25 treatments.  Maintenance ECT – after initial therapy, q 6 weeks to 6 months. Indications: 

     Types:

Major depression – medications are ineffective; high suicidal potential; dehydration; stupor; catatonia; delusions; Recurrent major depression Severe mania – not controlled by medications Schizophrenia – catatonic Movement disorders refractory to treatment -- e.g. Parkinson’s disease, neuroleptic malignant syndrome, tardive dyskenesia. ◦

Medications: 1. ATROPINE ; prototypical anticholinergic ◦ Used: Inhibition of salivation and respiratory tract secretions – minimize aspiration. 2. Succinylcholine – ( Anectine) – ultra short neuromuscular blocker. ◦ Prevents the musculoskeletal complications from induced convulsions. 3. Methohexital (Brevital) – anesthesia – short acting barbiturate; ◦ Induces a light coma preceding delivery of ECT.  Preparation for ECT: ◦ Pre treatment evaluation: physical exam, laboratory work – CBC, blood chemistries, urinalysis) baseline memory abilities. ◦ Explain – confusion and disorientation upon awakening. ◦ Consent – family members, and facility legal staff should be involved. ◦ No benzodiazepines and barbiturates – no sedation at night – It increases the seizure threshold. ◦ A trained electrotherapist and an anesthesiologist should be available.  Nursing Responsibilities: ◦ NPO – 8 hrs. prior to ECT. ◦ Atropine as per ordered given 1 hr. prior to treatment/ IV immediately preceding treatment. ( reduces secretions and subsequent risk of aspirations) ◦ Voiding prior to treatment ◦ Hairpins and dentures should be removed. ◦ V/ital signs – baseline ◦ Reduce anxiety.  Procedure During ECT: ◦ IV line inserted. ◦ Electrodes are attached- held in place by a rubber strap. ◦ Bite-block is inserted / mouth. ◦ Methohexical ( Brevital or other short acting barbiturates) – causes immediate anesthesia – preempting the anxiety associated with waiting for the “ jolt to hit” and the anxiety caused by succinylcholine ( w/c causes paralysis but not sedation, thereby leaving the patient conscious but unable to breathe)  After ECT; ◦ Typical post anesthesia nursing care. ( the client recovers quickly from the brief procedure: V/S and observation are important. ◦ Upon recovery – provide fluids and food. ◦ Assist in walking until stable. ◦ Remain with client until alert ◦ Re-orientation, reassure regarding memory loss( confusion) --- time, place, person ◦ Administer O2/ suction if necessary. ( before and after the treatment) ◦ Benzodiazepine – PRN ( awake agitated)  Side Effects Of ECT: ◦ Memory loss for recent events. ◦ Difficulty learning new information ◦ Headaches, weight gain, hypertension, occasional cardiac arrhythmias

Unmodified ECT - no medications are given prior to treatment. Modified ECT - with medications prior to treatment.

PSYCHOANALYTIC THEORIES  Pioneered by Sigmund Freud (1856–1939) in Vienna  All human behavior is caused and can be explained  Personality components conceptualized as id, ego, and superego  Behavior motivated by subconscious thoughts and feelings;  Treatment involving analysis of dreams and free association  Ego defense mechanisms  Psychosexual stages of development  Transference and countertransference  Libido – inner drive  Parts of body –focus of gratification  Unsuccesful resolution – fixation  Deviations in behavior result from unsuccessful task.  Behavior is motivated by anxiety

 0-18 mos ;oral – mouth – trust and discriminating  18 mos. – 3 years ; anal – bowels – holding on or letting go
Negativism and toilet training age 3 -6 years phallic ; genitals –exploration and discovery ( inc. sexual tension) Gender identification and genital awareness  Oedipus and Electra complex //  Castration anxiety and penis envy  6-12 years –latency (quiet stage) sexual energy diverted to play. Institution of superego… control of instinctual impulses  12 – young adult – genital ; reawakening of sexual drives –relationships  Sexual maturation  Sexual identity ,ability to love and work  DEFENSE MECHANISMS • unconscious intrapsychic adoptive efforts to resolve emotional conflict and cope with anxiety • automatic • pathology is determined by the frequency of use DEFENSE MECHANISMS  DENIAL – failure to acknowledge an intolerable thought , feeling, experience or reality  DISPLACEMENT – redirection of emotions or feelings to a subject that is more acceptable or less threatening  PROJECTION – attributing to others one’s feelings, impulses , thought or wishes  UNDOING – an attempt to erase an act , thought , feeling or desire  COMPENSATION – an attempt to overcome real or imagined shortcoming  SYMBOLIZATION – a less threatening object or idea is used to epresent another  SUBSTITUTION – replacing desired , impractical , unattainable object with one that is acceptable  INTROJECTION – a form of identification in which there is a taking into oneself the characteristic of another(love object)  REPRESSION – unacceptable thoughts is kept from awareness(unconscious)  SUPPRESSION- consciously putting a disturbing thought or incident out of awareness  REACTION FORMATION expressing attitude directly opposite to unconscious wish or fear  REGRESSION – returning to an earlier developmental phase in the face of stress  DISSOCIATION – detachment of painful emotional conflicts from consciousness  CONVERSION – emotional problems are converted into symptoms  FANTASY – conscious distortion of unconscious feelings or wishes  IDENTIFICATION – conscious patterning of one’s self from another person  INTELLECTUALIZATION - over use of intellectual concepts by an individual to avoid expression of feelings  RATIONALIZATION – justifying ones actions which are based on other motives 

SUBLIMATION - rechanneling of unacceptable instinctual drives with one hat is acceptable their psychoanalytical developmental level.

 George Eman Vaillant's (1977) categorization, defenses form a continuum related to
Vaillant's levels are:  Level I - psychotic defenses (i.e. psychotic denial, delusional projection)

Level II - immature defenses (i.e. fantasy, projection, passive aggression, acting out)  These mechanisms are often present in adults and more commonly present in adolescents. Fantasy Projection: Hypochondriasis: Passive aggression: Acting out: Idealization: Level III - neurotic defenses (i.e. intellectualization, reaction formation, dissociation, displacement, repression)

 Level IV - mature defenses (i.e. humour, sublimation, suppression, altruism, anticipation)
DEVELOPMENTAL THEORIES Erik Erikson (1902–1994) Described eight stages of psychosocial development • EGO as rational part of the personality • Growth at social setting of the family and its cultural heritage • Stages – span the full life cycle • Healthy personality • Social determinants of personality • CONFLICTS- roles of society vs. individual • Individual – strengths and weaknesses • FAILURES- rectified at later stage

 Jean Piaget (1896–1980)

Described cognitive and intellectual development in children in four stages:  Sensorimotor,  Preoperational,  Concrete Operations,  Formal Operations  Piaget’s Cognitive Development  Human adapt to their environment psychologically.  Schema – refer to the cognitive structure or framework of thought.  Schemata – categories that form in mind to organize and understand the world. • Assimilation – incorporate new ideas, objects, and experiences into a framework of one’s thoughts. • Accommodation – refers to the ability to change the schema in order to introduce new ideas, objects and experiences.

INTERPERSONAL THEORIES  Harry Stack Sullivan (1892–1949)

 Established Five Life Stages of personality development that included the significance
 of INTERPERSONAL RELATIONSHIPS - Infancy; Childjood, Juvenile, Preadolescence, Adolescence Described Three Developmental Cognitive modes: Prototaxic, Parataxic, Syntaxic Believed that Unsatisfying Relationships were the basis for all emotional problems behavior is motivated by avoidance to anxiety and attainment of satisfaction.

  Described the concept of Therapeutic Milieu Or Community

Interpersonal Theories (cont’d

Hildegard Peplau (1909–1999)  Leading nursing theorist and clinician: developed the nurse–patient relationship with phases and tasks  Identified roles of the nurse: stranger, resource person, teacher, leader, surrogate, counselor  Described four levels of anxiety (mild, moderate, severe, panic)  She proposed:  Nurses must promote the np relationship – trust & foster helathyrelationship  Therapeutic use of self –promotes healing  Therapeutic relationship – patient’s neds  Humanistic Theories HUMANISTIC THEORY Abraham Maslow (1921–1970)  Hierarchy of needs: basic physiologic needs, safety and security needs, love and belonging needs, esteem needs, self-actualization Carl Rogers (1902–1987)  Client-centered therapy  Concepts of unconditional positive regard, genuineness, and empathetic understanding  Behavioral Theories Carl Rogers person-centered or client-centered therapy of, which is centered on the clients' capacity for self-direction and understanding of his/her own development (Clay, 2002).  Use of empathy in the therapeutic process  Unconditional positive regard  Genuiness  self-awareness and personal responsibility.  “Here and now Ivan Pavlov (1849–1936) B. F Skinner (1904–1990) . • Behaviorism focuses on behaviors and behavior changes rather than on explaining how the mind works (actions) • All behavior is learned( inc. mental illness) • Behavior has consequences (reward or punishment) • Rewarded behavior tends to recur • Behavioral Theories (cont’d) • Positive reinforcement increases the frequency of behavior • Removal of negative reinforcers increases the frequency of behavior • Continuous reinforcement is the fastest way to increase behavior; random intermittent reinforcement increases behavior more slowly but with longer-lasting effect • Treatment modalities based on behaviorism include behavior modification, token economy, and systematic desensitization  Existential Theories( Frankl, Perls, Mary )

 Cognitive therapy focuses on immediate thought processing and is used by most
existential therapists • Centers on present experiences. • Alienation from self – deviant behavior • People – free choices of behavior. • Nurse – works to restore “full life” from state of “self alienation” Albert Ellis  Rational emotive therapy: people make themselves unhappy through “irrational beliefs and automatic thinking”—the basis for the technique of changing or stopping thoughts Viktor Frankl  Logotherapy: life must have meaning and therapy is the search for that meaning

 Existential Theories (cont’d) Frederick “Fritz” Perls  Gestalt therapy emphasizes self-awareness and identifying thoughts and feelings in the here and now Frederick Perls –It emphasizes personal responsibility; The goal of Gestalt phenomenological exploration is awareness, or insight. Other approaches to humanistic counselling and therapy include Gestalt therapy, humanistic psychotherapy, depth therapy, holistic health, encounter groups, sensitivity training, marital and family therapies, body work, and the existential psychotherapy of Medard Boss - crisis intervention, to help persons with post-traumatic stress disorders, alcohol and drug abuse, depression, or anxiety disorders; with adults in a poverty program; with seriously mentally ill individuals with psychotic disorders; and those with borderline personality disorders. - Client's Verbal Behavior Or Language.

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Nonverbal Behavior. Self-Dialogue. Enactment And Dramatization. Guided Fantasy. Dream Work. Awareness Of Self And Others. Avoidance Behaviors. ] Homework.

William Glasser  Reality therapy focuses on the person’s behavior and how that behavior keeps the person from achieving life goals Existential theorists believe that deviations occur when the person is out of touch with self or environment; thus, the goal of therapy is to return the person to an authentic sense of self. Kohlberg – MORAL DEVELOPMENT/ THINKING/ JUDGEMENT  Pre-conventional (0-6)  Punishment And Obedience  Obedience To Rules To Avoid Punishment  Conventional ( 6-12 )  Mutual Interpersonal Expectations , relationships And Conformity  Social System And Conscience Maintenance  Being Good Is Important Self Respect Or Conscience  POST –CONVENTIONAL (12 – 18 Y)  Prior Right Or Social Contract  Universal Ethical Principle  Abide For Common Good  Rational Person-validity Of Principles-and Become Committed To Them  Inner Control Of Behavior Understanding The Equality Of Human Rights And Dignity Of Human Beings As Individuals SULLIVANS INTERPERSONAL THEORY Certain Goals Must Be Accomplished, If This Goals Are Not Accomplished At A Certain Stage,…. Personality Will Be Weakened….Factors In Each Stage Persists As A Permanent Part Of Personality…. Each Stage Has Major Traumas And Frustrations That Must Be Overcome …….Successful Resolution Of Conflicts Associated With Each Stage Is Essential To Development….. Unresolved Conflicts Remain In The Unconscious And May, At Times, Result In Maladaptive Behavior  CRISIS INTERVENTION  Four stages of crisis:  Exposure to stressor

 Increased anxiety when customary coping is ineffective  Increased efforts to cope  Disequilibrium and significant distress  Types of crises:  Maturational  Situational  Adventitious Crisis state lasts 4–6 weeks. Outcome is either return to previous functioning level, improved coping, or decreased coping. Crisis intervention techniques are authoritative and facilitative. A balance of both types is most effective. Group Therapy Stages of group development  Pregroup stage  Initial stage  Working stage  Termination stage  Group Therapy (cont’d)  Group leadership  Therapy groups and education groups: formal leader  Support groups and self-help groups: no formal leader Effective group leaders focus on group process as well as group content  Group roles  Growth-producing roles: information-seeker, opinion-seeker, information-giver, energizer, coordinator, harmonizer, encourager, and elaborator  Growth-inhibiting roles: monopolizer, aggressor, dominator, critic, recognition-seeker, and passive follower  Group Therapy (cont’d) The therapeutic results of group therapy (Yalom, 1995) include the following:  Gaining new information or learning  Gaining inspiration or hope  Interacting with others  Feeling acceptance and belonging  Becoming aware that one is not alone and that others share the same problems  Gaining insight into one’s problems and behaviors and how they affect others  Giving of oneself for the benefit of others (altruism)  Psychiatric Rehabilitation Involves providing services to clients with persistent and severe mental illness in the community May involve medication management, transportation, shopping, food preparation, hygiene, finances, social support, vocational referral  Psychosocial Interventions Psychosocial interventions are nursing activities that enhance the client’s social and psychological functioning and promote social skills, interpersonal relationships, and communication. These interventions are used in mental health and other practice areas.  Self-Awareness Issues  No one theory or treatment approach is effective for all clients.  Using a variety of psychosocial approaches increases nurse effectiveness.  The client’s feelings and perceptions are most influential in determining his or her response. COGNITIVE BEHAVIORAL THERAPY( Albert Ellis) - Cognition, emotion and behaviors are integrated and holistic - Cognition - internal process of perception, memory and judgment, though which an understanding of self and the worls is developed.

AIMS: to change or reframe an individual’s cognitions that result in a new view of self and environment. --- restructure how a person perceives events in his or her life to facilitate behavioral and emotional change. - Effective: depressions, OCD, dchizophrenia, Axis I Models of Perception: - EVENT à Perception à Mood State à Feelings à Thoughts à beliefsà Event COGNITIVE PROCESS - COGNITIVE TRIAD –thoughts about oneself, the world, and the future. - COGNITIVE DISTORTIONS- are automatic thoughts and are generated by organizing distorted information and or inaccurate interpretation of a situation. - SCHEMA ; individual’s life rules that act as a sieve or filter. They allow only information compatible with the internal picture of self and the world to be brought to the person’s awareness. - CBT – collaborative therapeutic relationship- a mutual trust develops through promoting patient’s strengths and control over their own lives.----- assumes innate ability to solve problems--- engage in self care, independent of professional assistance. STEPS: 1. Engagement and Assessment: 2. Interventions a) Negative beliefs – self talk b) Bibliotherapy – use of books that offer alternative thoughts & responses, journaling diary 3. Evaluation and Termination RATIONAL EMOTIVE BEHAVIORAL THERAPY Is a psychotherapeutic approach which proposes the unrealistic and irrational beliefs cause many emotional problems . - Basic Framework: ABCDE • Activating event - that triggers automatic thoughts and emotions; enternal or internal, emotion, thought /expectations • Beliefs – that underlie the thoughts and emotions

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2.

Effective outlook – developed by disputing or challenging negative belief systems - Five themes of Irrational Belief; a) A demand: “This must happen.” b) Absolute thinking; All or nothing at all c) Catastrophizing: exaggerating negative consequences of an event. d) Low frustration tolerance: everything should be easy e) Global evaluations of human worth: “ People can be rated and some are better than others” INTERVENTIONS: REBT a) Role playing, assertion training, desensitization, humor, operant conditioning, suggestion, support and other interventions. b) 2 Basic Forms • General – teaches rational and healthy behavior • Preferential – includes general, with emphasis a profound philosophic change.( creative, scientific,and skeptical thinkers.

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Consequences of this automatic process Dispute or challenge – unreasonable expectations

HUMANISTIC THEORY -based on the views of human potential for goodness - focus: one’s ability to learn about oneself, acceptance of oneself and exploration of personal capabilities - "positivist" and "empiricist" approaches. - emphasis on the actual experience of persons

-it stresses a phenomenological view of human experience, seeking to understand human beings and their behavior by conducting qualitative research. Abraham Maslow, emphazising a hierarchy of needs and motivations; Needs and motivations Rollo May existential psychology of acknowledging human choice and the tragic aspects of human existence; -

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