TABLE OF CONTENTS I. Psychiatric Nursing, 3 II. Basic Principles of Psychiatric Nursing, 3 III.3 Levels of Psychiatric Nursing (Levels of Health), 3 a.
Primary, 3 b. Secondary, 4 c. Tertiary, 6 IV. Criteria of Mental Health, 6 V. Components of Assessment of Mental Status, 6 VI. DSM V (Diagnostic and Statistical Manual for Mental Health, 7 VII. Conceptual Models of Psychiatric Treatment, 7 VIII. Psychosocial Theory of Eric Erikson, 7 IX. Psychosexual (Psychoanalytical) Theory of Sigmund Freud, 7 a. Freudian Theory Component, 8 X. Essential Elements of Nurse-Client Contact, 9 XI. Four Phases of Nurse-Client Contact, 10 a. Pre-interaction/Pre-orientation, 10 b. Orientation, 10 c. Working Phase,11 d. Termination, 11 XII. Therapeutic Communication, 11 a. Therapeutic Communication Techniques, 11 b. Blocks to Therapeutic Communication, 12 XIII. Behavioral Therapy, 13 A. Terminologies, 13 a. Classical Conditioning, 13 b. Operant Conditioning, 14 c. Behavioral Treatments, 16 XIV. Group Therapy, 16 A. Definition, 16 B. Types of Groups, 16 C. Advantage of Group Therapy, 17 D. Principles of Group Therapy, 17 E. Phases of Group Therapy, 17 XV. Defense Mechanisms, 18 XVI. Anxiety, 20 A. Definition, 20 B. Major Assessment criterion for Measuring Degree of Anxiety, 20 C. Potential Nursing Diagnosis, 21 D. Nursing Intervention, 21 1
XVII. Types of Anxiety Disorder, 22 A. Phobia and Panic Disorder, 22 B. Obsessive-Compulsive Disorder, 22 C. Post Traumatic Stress Disorder, 23 D. Anxiolytic/Anti-Anxiety Drugs, 24 a. Benzodiazepine, 24 b. Barbiturates, 24 c. Atypical Anxiolytics, 25 XVIII. Psychotic Disorder: Schizophrenia, 25 A. Assessment Finding: General Signs, 25 B. Prioritized Nursing Diagnoses for all types of Schizophrenia, 27 C. Five Types of Schizophrenia, 27 D. Principle of Care in Schizophrenia, 28 XIX. Antipsychotics, 28 A. Phenothiazine, 28 B. Butyrophenones, 29 C. Thioxanthenes, 29 D. Atypical Anxiolytics, 29 E. Six Common Anticholinergic Side Effects of Antipsychotics, 29 F. Acute/Common side Effect for Prolonged use of Antipsychotics,30 G. Anti-Extrapyramidal Medications, 31 H. Adverse Effects of Antipsychotic Drugs, 31 XX. Affective/ Mood Disorder, 31 A. Types I. Depressive Disorder, 31 a Antidepressants/ Thymoleptics, 34 i. Selective Serotonin Reuptake Inhibitors (SSRI), 34 ii. 2nd Generation Tricyclic Antidepressants (TCA), 35 iii. MAOI-Monoamine Oxidase Inhibitor, 36 iv. Electro Convulsive Therapy (ECT), 36 II. Bipolar Disorder, 38 a. Mood Stabilizers, 40 XXI. Psychosomatic/ Somatoform Disorder, 42 A. Psychosomatic Disorders, 42 B. Types of Somatoform Disorder/Psychosomatic Disorders, 43 XXII. Dissociative Disorder, 44 XXIII. Personality Disorders, 44 A. Cluster A: ODD/Eccentric, 45 a. Paranoid Personality Disorder, 45 b. Schizoid Personality Disorder, 45 c. Schizotypal Personality Disorder, 46 B. Cluster B: Dramatic/Erratic, 46 a. Antisocial Personality Disorder, 46 b. Borderline Personality Disorder, 47 2
c. Histrionic Personality Disorder, 47 d. Narcissistic personality Disorder, 47 C. Cluster C: Anxious/ Fearful, 48 a. Obsessive-Compulsive Disorder, 48 b. Dependent Personality Disorder, 49 c. Avoidant Personality Disorder, 49 d. Passive-Aggressive Personality Disorder, 49 XXIV: Cognitive/ Organic Mental Disorder, 49 A. Delirium vs. Dementia, 50 B. Types of Dementia C. Alzheimer’s Disease, 50 XXV. Eating Disorders, 55 A. Anorexia vs. Bulimia, 55 XXVI. Drug Addiction/Non-Alcoholic Substance Abuse, 57 A. Non-Alcoholic Abused Substances, 57 XXVII. Sexual Disorder/ Dysfunction, 59 XXVIII. Pervasive Developmental Disorder, 60 A. Autistic Disorder, 60 B. Attention Deficit Hyperactive Disorder, 61 C. Child Abuse, 61
PSYCHIATRIC NURSING • A specialized area of nursing practice employing theories of human behavior as its science and purposely use of self as its art. Includes the continuous and comprehensive services necessary for the promotion of optimal mental health, prevention of mental illness, health maintenance, management and referral of mental and physical health problems, the diagnosis and treatment of mental disorders and their sequela, and rehabilitation BASIC PRINCIPLES OF PSYCHIATRIC NURSING Accept and respect the client regardless of his behavior. Limit or reject the inappropriate behavior but not the individual Encourage and support expression of feelings in a safe and non-judgmental environment. Increase verbalization, decreases anxiety. Behaviors are learned. All behavior has meaning. INTERDISCIPLINARY TEAM PRIMARY ROLES • Psychiatrist: The psychiatrist is a physician certified in psychiatry by the American Board of Psychiatry and Neurology, which requires 3-year residency, 2-years of clinical practice, and completion of an examination. The primary function of the psychiatrist is diagnosis of, mental disorders and prescription of medical treatments. Psychologist: The clinical psychologist has a doctorate (Ph.D.) in clinical psychology and is prepared to practice therapy, conduct research, and interpret psychological tests. Psychologists may also participate in the design of therapy programs for groups of individuals. Psychiatric nurse: The registered nurse gains experience in working with clients with psychiatric disorders after graduation from an accredited program of nursing and completion of the licensure examination. The nurse has a solid foundation in health promotion, illness prevention, and rehabilitation in all areas, allowing him or her to view the client holistically. The nurse is also an essential team member in evaluating the effectiveness of medical treatment, particularly medications. Registered nurses who obtain a master’s degree in mental health may be certified as clinical specialist or licensed as advanced practitioners, depending on individual state nurse practice acts. Advanced practice nurses are certified to prescribe drugs in many states. Psychiatric social worker: Most psychiatric social workers are prepared at the master’s level, and they are licensed in some states. Social workers may practice therapy and often have the primary responsibility for working with families, community support, and referral.
Teaching pregnant women relaxation techniques Objective: to prevent complication in labor.S.•
Occupational therapist: Occupational therapist may have an associate degree (certified occupational therapy assistant) or a baccalaureate degree (certified occupational therapist). but in some instances persons with experience fulfill these roles. Vocational rehabilitation specialist: Vocational rehabilitation includes determining clients’ interests and abilities and matching them with vocational choices. as well as pursuit of further education if that is needed and desired.
3 LEVELS OF PSYCHIATRIC NURSING (Levels of Health) I. Client and Family Teaching (Health Teaching) 1. Primary Objective: PROMOTION & PREVENTION
A. Teaching adolescent in preventing contracting STDs CHLAMYDIA: #1 STD in the U. PID (Pelvic Inflammatory disease) #1 cause of sterility in women #1 Drug of choice Erythromycin 2nd drug of choice Cephalosporin 2. Occupational therapy focuses on the functional abilities of the client and ways to improve client functioning such as working with arts and crafts and focusing on psychomotor skills. Vocational rehabilitation specialists can be prepared at the baccalaureate or master’s level and may have different levels of autonomy and program supervision based on their education. The recreation therapist helps the client to achieve a balance of work and play in his or her life and provides activities that promote constructive use of leisure or unstructured time. perineal
. #1 Sign: Greenish & purulent urethral discharge. Recreation therapist: Many recreation therapists complete a baccalaureate degree. Clients are also assisted in job-seeking and job-retention skills. laceration (also can be prevented by Kegel’s exercise) fetal distress.
Oral Contraceptive. above) 4. hopeless. Herbal Medicines C.) Diet: Finger Food (high caloric.o. Conducting rape prevention classes is an example of primary level of prevention. Suicide = Mmajor depression. Secondary : Screening. despair. Autism: Aage of onset (3 y. Suicidal.o. Diagnosis & Immediate Treatment A. Alcoholics. B. powerless Prone: Mmale Age bracket prone for suicide #1. Conduct disorder: Aage of onset (6 y. dextroamphetamine (Dexedrine) 3.Stage I of labor (LAT-CAP) L atent C chest breathing A ctive A bdominal breathing T ransitionalent P ant blow breathing 3. Elderly (ego-despair) 3.o. Post partum depression (7 days/2-4 weeks) D. Psychosocial Support – family/friends/peers Needs most support (ASA): Addicts. Natural) Barrier . high CHO) Rx: Ritalin (Methylphenidate).CONDOM Oral . Anemics & Menses irregular) 4. Screening > Denver Development Screening Test (DDST) #1 test for PDD Pervasive Development Ddisorder (PPD) 1. Teaching couples on contraceptives BON (Barrier. ADHD: Aage of onset (6 y.) 2.not for M A M (Malnourished. Giving Vaccines II. Adolescent (identity crisis) 2.)
.Artificial Natural . Middle age men (40 y.o.
Avoid dark places C. abortion . No suicide contract – 24 hrs monitoring . disaster ex. When the patient verbalizes that the 2nd Gen TCA is working.ex. Developmental Maturation Crisis . tsunami In a DISASTER 1st assess/survey the scene
.Patient is required to verbalize suicidal ideas 3.Mid-life crisis. curtains 4. Suicide Prevention/Intervention Impending signs of Suicide 1. belts. Schizophrenia) 4. epidemic. World War I & II. less than 2-4 wks (telling a lie) Suicide Interventions: 1. so the nurse needs to be active and should direct the paient to activities that facilitate coping.Pregnancy .Most common: Ddeath of a loved one NSG DX: Ineffective Individual Ccoping/ Denial .B. Giving away of prized possessions 3. Case Finding (Epidemics)/Contact Tracing (STDs) D.Parenthood 2.
Types of Crisis: 1. Situational / Accidental crisis – . .Adolescence (identity crisis) . Crisis Intervention Objective: Tto return the client to its normal functioning or pre crisis level. Sudden elevation of mood/sudden mood swings 2. Adventitious – calamity. One-on-one supervision and monitoring 2. Duration: (4-6 wks)
Disorganization is a phase in the crisis state which is characterized by the feelings of great anxiety and inability to perform activities of daily living A patient in crisis is passive and submissive. murder. Non metallic/plastic/sharp objects: ex. Delusion of Omnipotence (divine powers) Used by SS (Suicidal. rape and fire 3.
anorexia & depression . K Calcium gluconate Naloxone (Narcan) Amicar (Aminocaproic acid) *(Neuroleptic Malignant #1 Cardinal Sign : High Dantrolene (Dantrium). Vocational Skills (Entrepreneur skills) C. Aftercare Support – follow-up. Emergency drugs and antidotes DRUGS/ DISEASE Heparin Warfarin (Coumadin) Mg Sulfate Nubain (best). Syndrome’s (NMS) Fever / Hyperthermia Bromocriptine (Parlodel) Effect: antiparkinsonian. anti-prolactin. Tertiary Objective: Rrehabilitation. which start upon admission A. Needed by: addicts & residual schizophrenia due to remission & exacerbation Action / Effect Anticoagulant Anticoagulant Anticonvulsants Narcotics Dissolves clot
.E.I. antipsychotic Hypertensive crisis (MAOI Antidepressant intoxication Ca channel blocker intoxication) Suffix:(-dipine) Anxiolytics. Morphine Fibrinolytic / Thrombolytic ANTIDOTES Protamine Sulfate Vit.Also use fine motor rehabilitation for Post M. & Post CVA B. -zolam tranquilizer Tensilon (Endrophonium): Anticholinesterase & Miotic Atropine Sulfate (ATSO4) Anticholinesterase intoxication. Occupational Therapy – . Pilorcarpine (Pilocar) intoxication : Miotic III.Usually use behavior modification for PDD (Pervasive Developmental Disorders). Sedatives – Sedative hypnotic/ Minor Flumazenil (Romazicon) Suffix: zepam.
delusion of persecution & delusion of reference (paranoid delusions) THOUGHT PROCESS: Ability to understanding abstract/symbols? Example: Mmagical thinking and animism of Schizotypal personality SPEECH: Coherency? Relevance? Meaning? Quality/Quantity? Example : Slurring of Speech ( alcoholism) and pressured speech (manic depression or bipolar disorder)
. balance between dependence and independence.responsible for decisions. 1953. includes social sensitivity (empathy) Growth. & self-actualization (by Maslow) which includes fully functioning person” (by Rogers) Autonomy: Iinvolves self. self-awareness. delusion of omnipotence ( schizophrenia). Labile Affect: Manic Depression or Bipolar Disorder THOUGHT CONTENT: Self-concept? Areas of concern? Themes? Obsessions? Delusions? Hallucinations? Example: Ddelusion of grandeur (manic). security and wholeness
COMPONENTS OF ASSESSMENT OF MENTAL STATUS SENSORIUM: Consciousness? Orientation? Attention? Concentration? Comprehension? Example: Disorientation & Confusion ( Dementia) APPEARANCE: Appropriateness? Grooming? Rigidity? Mannerisms? Example: Poor Grooming (Suicidal Patients. self-acceptance. 1995) • • • • Reality perception: Aability to test assumptions about the world by empirical thought. belongingness. and acceptance of the consequences of one’s action Positive attitudes toward self.CRITERIA OF MENTAL HEALTH (Jahoda. Schizophrenia and Manic Depression) AFFECT / MOOD: Appropriateness? Swing? Duration? Intensity? Example: Flat Affect: Schizophrenia & Major Depression. includes self-identity. development.determination. self. Staurt and Sundeen. Seen also in Parkinson’s Disease & Myasthenia Gravis.
• STAGES OF PSYCHOSOCIAL DEVELOPMENT: AGE Infancy (0-18 mo) Toddler (18 mo-3 yrs) Preschool Age (3-6 yrs) School Age (6-12 yrs) Adolescence (12-20 yrs) Early Adulthood (20-35 yrs) Middle Adulthood (35-65 yrs) Later years / Old Age (65 yrs) PSYCHOSOCIAL TASKS Trust vs. • Describes the human cycle as a series of eight EGO developmental stages from birth to death. diagnoses. Inferiority Identity vs. Isolation Generativity vs.Interpersonal relationships PSYCHOSOCIAL THEORY (Erik Erickson).Conscious human experiences BIOMEDICAL MODEL (Meyer. anxiety. Pavlov’s Theory: Classical Conditioning. etiologies. PSYCHOSOCIAL THEORY OF ERIC ERIKSON • Most commonly used theory by health professionals. Mistrust Autonomy vs. Kraeplin. Shame and Doubt Initiative vs. Focus-Psychosocial tasks EXISTENTIAL MODEL / HUMANISTIC MODEL (Rogers). defense mechanisms.Intrapsychic process (conflicts. impulses). INTERPERSOAL MODEL (Sullivan and Peplau). Frances). Focus – Disease approach. Despair
Most common task of 40 y/o includes developing responsibility over their own lives 76 y/o male who has a good ego integrity is preoccupied w/ death
. Focus: PSYCHOSOCIAL TASKS throughout the life cycle.learned behavior. syndromes. Role confusion Intimacy vs. Focus. Guilt Industry vs.0 BEHAVIORAL FRAMEWORK: Focus. Focus. Skinner’s Theory: Operant Conditioning.DSM V (Diagnostic and Statistical Manual for Mental Health) Axis I II III IV V Clinical Syndrome (S&Sx) Personality Disorders Pathological Disorders Environmental & Psychosocial stressors Global Functioning (assessment)]
CONCEPTUAL MODELS OF PSYCHIATRIC TREATMENT • • • • • • PSYCHOANALYTICAL/PSYCHOSEXUAL MODEL. (Freud). Focus. Stagnation Integrity vs.
memories and feelings that are repressed and not available to the conscious mind.PSYCHOSEXUAL (PSYCHOANALYTICAL) THEORY OF SIGMUND FREUD • • • Infancy: Oral Phase. logical and governed by REALITY PRINCIPLE. Electra Complex: Attachment of the girl to her father and jealousy toward the mother. it cannot be deliberately brought back into awareness unless in disguised or distorted form (dreams)
. helps repress unpleasant thoughts or feelings and can examine or censor certain desires or thinking.the thoughts. are remembered and easily recalled or available to the individual Subconscious – the Preconscious. composed of material that has been deliberately pushed out of conscious level. Schooler: Latency phase. not logical and governed by PLEASURE PRINCIPLE – and since it is usually painful and unacceptable to the individual. Stage of the Ego Preschooler: Phallic Phase. • • • Conscious – Composed of past experiences. can be recalled with some effort Unconscious – Composed of the LARGEST BODY OF MATERIAL. it cannot be deliberately brought unacceptable to the individual. Stage of the Strict Superego Adolescent: Genital phase
FREUDIAN THEORY COMPONENTS: 1. LEVELS OF AWARENESS: Conscious Subconscious Watchman of the Personality Unconscious The one who molds the personality Storage bin of traumatic & meaningful memories. Stage of the Superego (conscience) Attachment of the child to the parent of the opposite sex and jealousy toward the parent of the same sex Oedipal Complex: Attachment of the son to his mother and jealousy toward the father. True desires & motives are here. Stage of the Id Toddler: Anal Phase.
PRINCIPLE -Pleasure Principle
LANGUAGE “I want it when I want it. “I should not want that. “I want. The Ego says.seeking.” “Not now. The Ids says.” SUPEREGO: Psychoanalytic term for that part of the psyche that RESTRAINS. SYSTEMS OF PERSONALITY. prohibitive forces of the SUPEREGO and is directed by REALITY PRINCIPLE. primitive drives governed by the PLEASURE PRINCIPLE and is SELF. when I want it”. is self.critical.”
“I can wait.critical. The “I” that is shown to the environment and most in touch with REALITY and the MEDIATOR between the primitive. instinctive drives of the ID and the self.”
-Induces guilt undoing
“Thou shall not. It is not good to even wish for it. and is called the CONSCIENCE or EGO IDEAL.feeling part of personality. This is the thinking. I am not yet ready. what I want. 3 AGENCIES OF THE MIND: Three Elements of Personality Id FUNCTION -Animal instinct -Survival of the fittest -Balances (Mediator) the desire of the Id and Superego
The ego acts as the integrator of the personality. pleasure.2. perhaps next week. “I would want to have it if only I can afford it. controls. inhibits and prohibits impulses and instincts. The Superego says. the reservoir of INSTINCTS. EGO: Psychoanalytic term for that part of the psyche that is CONSCIOUS.”
IMBALANCE or ABNORMAL FUNCTIONING OF THE THREE ELEMENTS OF PERSONALITY ↑Id + ↓SE = Conduct Ddisorder and Antisocial Personality Disorder ↓Id + ↑SE = Obsessive Compulsive Disorder • • ID: Psychoanalytic term for that part of the psyche that is UNCONSCIOUS.”
ORIENTATION (INITIATION) Assessment of problems.CLIENT CONTRACT 1. Diet contract Eeating disorder The start of termination phase: “Good morning. date start & end. Roles of RN and patient 6. Goals / Expectations 8.” C.ESSENTIAL ELEMENTS OF A NURSE. Stage of testing. Confidentiality FOUR PHASES OF NURSE. Define responsibilities of nurse and client.Most difficult phase -. Purpose of a relationship 2. full name. Meeting location / time 3. shift.Stage of Self-Awareness Tto prevent Counter Transference #1 CORE VALUE OF Psychiatric Nursing B. expectations of clients Identify anxiety level of self and client Set goals of relationship. WORKING PHASE
Promote acceptance of each other Accept client as having value and worth as a unique individual. No suicide contract Mmajor depression = emergency TWO definitions of no suicide contract: A.CLIENT RELATIONSHIP (NCR) A. needs. Stress confidentiality.NCP is on going
. Pre-interaction/Pre-orientation (For the Nurse) . Contract – 2 famous psychiatric contracts: 1. Condition for termination 4. Names of RN and patient 5. Responsibilities of RN and patient 7.Counter transference phase . Establish boundaries of relationship. RN.Stage of resistance . . 24 hrs monitoring B. Vverbalization to the nurse of all suicide ideas 2. session.
solving techniques Maintain PROFESSIONAL.here and now Provide ACTIVE LISTENING and REFLECTION of feelings Use non.solving skills Increasing independence ο Help client develop alternative. symbols) utilized in a goal.oriented. fetal position when crying.
.The #1 Psychiatric Core Value is Consistency Ffor manipulative patients Be consistent to patient with: BAAAM COPS B orderline C onduct d/o A ntisocial O oral/eating disorder A lzheimer’s P aranoid A utistic S uicidal M anic Use therapeutic and problem. ο Regressive behaviors Discuss client’s feelings and objectives achieved THERAPEUTIC COMMUNICATION DEFINITION: Continuous. adaptive coping mechanisms
Personal biases (manifestation by counter-transference & vice versa) are seen during working phase
D. signals. TERMINATION Plan for termination of relationship early the relationship .verbal communication to support client Recognize blocks to communication and work to remove them FOCUS on client’s: Confronting and working through identified problems Problems. thumb sucking.verbal means (words.Stage of Separation Anxiety Signs & symptoms: Rregression: Ttemper tantrums. depression. etc. therapeutic relationship Keep interaction reality.
.Identification of the problem/exploration . dynamic process of SENDING and RECEIVING MESSAGES by various verbal or non.directed professional framework. apathy.Phase of prognosis Eevaluation Maintain boundaries Anticipate problems of termination: ο Increased dependency on the nurse ο Recall of previous negative experience. signs.rejection. . abandonment.
The most appropriate response of the nurse is to say. This approach provides reassurance for a patient in distress.” RN’s response to elaborate feelings includes statement like.”
*Ursula. comfort “I am here.” And continues being silent. service.” Includes statement like “Tell me about your feelings & I will stay w/ you.” “You seem angry. Offering of self – safety. ‘I don’t do anything right.
b. age 25. Reflection: (mirror of feelings) “It must be difficult for you.THERAPEUTIC COMMUNICATION TECHNIQUES a. perhaps you can do so at another time”. “Have you discussed this with your husband about how to cope with these problems? Tell me.”
When patient with symptoms of severe depression says to the nurse “I can’t talk. Clarification – used in neologism and word salad SAM (seen in Schizophrenia. Surrounded by broken glass. I have nothing to say. is found on the floor of the bathroom in the day treatment cleaning with moderate lacerations to both wrists. calling her name and telling her that the nurse is here to help her. My husband says. Elaboration/Exploration “Tell me more about your feelings”
“Everyone is on my back. The best way the nurse should do is to approach Ursula slowly while speaking in the calm voice.” Appropriate response for an 80 y/o who says. she sits staring blanking at her bleeding wrist while staff members call for an ambulance. You seem concerned. “It may difficult for you to speak at this time.” correct 5response of RN includes statement like. “I told my children that I’m ready to die.” – (Used in flight of ideas and looseness of association)
. Nobody in the family is senile. “I can’t be. Manic) “What do you mean by…?” (Used in Neologism and word salad) “I could not follow you. I will sit here beside you. This response will convey that the nurse is willing to wait for the patient’s readiness to engage in conversation. “It sounds as if you are shocked over the diagnosis.’ & my boss wants me to do things differently. Daughter of patient newly diagnosed w/ Alzheimer’s says. I will lead you to the group therapy session.
“There are spiders crawling on my back”. “I’m pregnant by God in heaven.. “What does the voice tells you?” “I know that Prof.Delusion..“The ground is watching us. “Do you have plans of suicide”? Pt says. (Patient: “I can’t believe I cannot go home today. Draper tried to rape me. “You believe something special happened to you?’
. The appropriate response of the nurse would be.”
A patient admitted to be listening to voices should be assessed by asking. “I’ll be better off dead. “I’d like to take you out & give you a good show. its only part of your illness”. Brilliant & charming patient says.then…mmmh… go on… yes…” g.” j. Therapeutic Silence h.” Appropriate response by the nurse includes statement like.”
Alcoholic pt with delirium tremens states. rape my mind. Validation – interpret Client: “I see a shadow.” Nurse: “You’re frightened. Hallucination. appropriate intervention includes clarify the meaning of the word. “What do you mean by a good show?”
e. Reality Orientation/Reality Testing .” best response by the RN is asking pt. Paraphrasing/restating – repeating Repeats the MAIN IDEA.” Best response of the RN includes asking questions like.”. Illusion & delusion Client: “Help! Help! There are spiders on my back!” Nurse: “I don’t see spiders but for you that is real.Nsg Dx: Altered Sensory Perception . Summarizing – recap Nurse: “Today you have described your understanding of how you feel when you are upset with your son.” Nurse: “You can’t believe that you can’t go home today?”)’ i.
f. “there are no spiders.& he’s still trying to rape me”. correct of RN includes questions like “Are you frightened being unable to control your thoughts?” Post-menopausal woman says. restate what the client says.. Giving Leads “Aha.
Non therapeutic silence/touch g. encourages further or broadened communication. Open-ended question / broad openings Questions NOT answerable by ‘YES’ or ‘NO’. everything will be all right.” is an appropriate response for a suspicious pt saying.” d. Closed Ended Question – questions answered by “yes” or “no” Note: Tthe only therapeutic closed-ended question Ssuicidal pt. “How are you?” “How’s your day?” “What are your favorite things?”
BLOCKS TO THERAPEUTIC COMMUNICATION a. Never use why – it demands an explanation and also anxiety provoking b.” e.” “Relax that is nothing to worry about. Belittling the patient – CHANGING THE SUBJECT f. “Are you planning to commit suicide?” – Confrontation c. OCD who checks door 10-15 times includes statement like.” / “You should not think that way. Agree/disagree – never argue with client “You are right in doing that. Stereotyping
. Advising – never advise because they are sometimes persona. “It sounds as if you have much anxiety.“It must be frightening to feel that way. opinions “I believe it would be better if you…” h. False Assurance “Ddo not worry” Tto patient who are dying & w/ incurable illness “You have the best doctor.”
k. “I think that my food is being poisoned” RN’s correct response of pt w/.
HPN ↓BP. condemned. Classical Conditioning (pairing of two stimuli in order to gain a new learning behavior – by Ivan Pavlov) 1. Desensitization – gradual exposure to the feared object -. • REINFORCER: Aa reward positively or negatively influences and strengthens desirable behaviors. Used in eating disorders and depression > Token economy is also effective for toddlers 2. • POSITIVE REINFORCER: Aa desirable reward produced by specific behavior (TV time after doing homework) • NEGATIVE REINFORCER: Aa negative consequence of a behavior (Spanking child for wetting the floor)
A. • TARGET BEHAVIOR: Aactivities that the nurse wants to develop or accelerate in the client. Negative Reinforcement (Punishment Orientation) Aversion Therapy/Aversion Technique Behavioral Treatments 1. Extinction B. Biofeedback – mind over matter. unwanted behavior • OPERANT BEHAVIOR: Aactivities that are strongly influenced by events that follow them. excessive. Ex. headache 5. Relaxation Technique – light stroking = labor . 2.#1 treatment for phobia 2. Acquisition (newly acquired behavior or the by product of classical conditioning).A. Flooding/. Guided Imagery (Child) & Visualization (Adult)
. TERMINOLOGIES • STIMULUS: Aany event affecting an individual • PROBLEM BEHAVIOR: Ddeficient. Operant conditioning – Burrhus Skinner .Purse Lip Breathing Exercise = COPD/CAL (Chronic Airflow Limitation) 4. palpitations. Positive reinforcement (Reward Orientation) Token Economy – use tokens as a source of reward.used in Behavior Modification 1.Implosive Therapy – sudden exposure 3.
8-10 patients are the optimal number of patients in a group. Verbalization: Members express feelings and group reinforces appropriate communication. Economical: Lless staff used.GROUP THERAPY A.
Unstructured 1. PRINCIPLES OF GROUP THERAPY 1.
Desired outcome of group therapy includes verbalization of feelings rather than acting them out
. With feedback group→ Corrects distortions of problems Builds self. 2. Format: Discussion flows according to group members’ concern 3.confidence Increases reality. Emphasis: Mmore on FEELINGS rather than facts C. 3. Responsibility for goal is shared by group and leader 2. Increased feelings of closeness→ Reduction on feelings of being alone.elected. ADVANTAGE OF GROUP THERAPY 1.image and self. 4. Goals: Nnot pre.determined Format: Cclear and specific Factual material: Ppresented Leader: Rretains control
2.testing opportunities Gives info on how one’s personality and behavior appear to others 4. DEFINITION: Psychotherapeutic processes that occur in formally organized groups designed to change maladaptive or undesirable behavior.
Knowledge of therapeutic modalities enhances the performance of nursing interventions during therapy. Provides attention to reality and provides development of insight into one’s problems by expressing own experiences and listening to others in groups D. Materials and topics are not pre. Leader: Nnondirective 5. TYPES OF GROUPS 1.
B. Structured Goals: Ppre.determined. With opportunities for practicing alternative behaviors and methods of coping with feelings 5.
taking on phase In a group therapy when one client says to another. Support: Members gain support from one another through interaction. sharing and communication. best action of the RN is to maintain distance from the pt. Change: Members have opportunity to try out new and desirable behaviors in group. “Maybe you’re someone else’s problems. 4.” this shows that they are in the working
3. E. acquaintance and interaction 2.2. “Leave me alone & get away from me. Initial Phase Formation of group Setting and clarification of goals and expectations Initial meeting. PHASES OF GROUP THERAPY 1. Termination Phase Evaluation of goals attainment Support for leave. Behavior indicating that goal is met after socialization in a group therapy includes participation of each group member telling the leader about specific problems
DEFENSE MECHANISMS REPRESSSION CONVERSION IDENTIFICATION SUBLIMATION RATIONALIZATION DISPLACEMENT SPLITTING SUPPRESSION DISSOCIATION/SYMBOLIZATION INTROJECTION COMPENSATION PROJECTION UNDOING REACTION FORMATION
. supportive setting to effect change. Working Phase Confrontation between members→ Ccohesiveness Identification of problems→ Pproblem. 3.taking
In group therapy if a client says. Activity: Provides stimuli to verbalization and expression of feelings.”.
REPRESSION Involuntary recall painful or unpleasant thoughts or feelings cause they are automatically & involuntarily pushed into one’s unconsciousness. To preserve one’s ego or self. suppress anger HPN DISSOCIATION Act of detaching of separating a strong emotionally #1 DM: Mmultiple personality= charged conflict from one’s consciousness. 21
. SYMBOLIZATION – unconscious. A woman raped found wandering a busy highway – traumatic amnesia. destruction of ego Ex. disease Ex. anemia. Voluntary forgetfulness or “I rather not talk about it. B12 P. Sexually abused as a child blocks the experience from her consciousness and is confused about inability to respond sexually. Imitator. CONVERSION Transferring of mental conflict or emotional anxiety into #1 DM: Ssomatic/somatoform physical symptom to release tension. B9 folic acid. Ex. SUPPRESSION – used selective Willingly or voluntarily putting unacceptable thoughts or inattention (moderate anxiety) feelings out of one’s mind with the ability to recall the thoughts or feelings at will. Engagement ring symbol of love. Mimics/simulates external behavior .REGRESSION INTELLECTUALIZATION DENIAL
FIXATION ACTING-OUT FANTASY
DEFENSE MECHANISMS Legend: DM means Defense Mechanism 1. IDENTIFICATION – external Unconsciously. FORGETFULNESS Bblackout (alcoholic intoxication) blocking (Alzheimer’s/Dementia) Mmemory gaps Cconfabulation = making story to fill in memory gaps also used by Wernicke’s Korsakoff’s = ↓ Vit. peripheral neuritis (tingling sensation) ↓ B6 Pyridoxine. Ex. phobias 3. B1-thiamine. A soldier experiences sudden blindness after witnessing his best friend dying from a grenade blast. like fashion & fads Ex. idea. right now!” 2. similar to role playing INTROJECTION – INTERNAL Attributing to oneself the good qualities of another. or act represents another through some #1 DM: Pphobias common aspect and carries the emotional feeling associated with the other. Ex. people use it to identify with the DM: Ppreschooler personality and traits of another. An object. Diarrhea before exam.
Ex. UNDOING OR RESTITUTION – Negation of previous consciously intolerable action or lower to higher experience to reduce or alleviate feelings of guilt. Yelling at a subordinate after being yelled at by the boss. Acting & dressing like Jesus Christ 4. Rationalization is justifying one’s actions
which are based on other motives. DM: Obsessive Compulsive Ex. DISPLACEMENT – higher to Mechanism that serves to transfer feelings such as lower frustration. Student hating her CI may act very courteously
.Projection is attributing to others one’s
unconscious wishes/fear. An aggressive person joins debate team (behavior modification)++ COMPENSATION The act of making up for a real or imagined deficiency with a specific behavior. it is all for the best. 7. Sending flowers after embarrassing her in public. Conscious or unconscious. Hx of drug addicts & alcoholics DM: Borderline (female) REACTION FORMATION Person exaggerates or overdevelops certain actions by #1 DM: Ppassive-aggressive displaying exactly the opposite behavior.
Ex. hostility or anxiety from one idea. -+ 5. “ingestion. Problem is not connected. Blaming others for own faults. Irrational/illogical excuses to escape responsibility. Conscious intent often altruistic. anyway. “scapegoat” 6. OVERCOMPENSATION. Modify the issue. RATIONALIZATION – object Most common ego DM.
PROJECTION – person #1 DM: Pparanoid
Ex. person or object to another. SPLITTING Viewing people as all good. Usually it is observed in paranoid patients. or personality disorder feeling from what he or she normally would show in a given situation. Person rejects unwanted characteristics of self and assigns them to others. Ex. attitude. problem is still present and connected Ex. Procrastinate Ex. Temporarily alleviates anxiety. internalization” Ex. actions and/or feelings with good acceptable reasons or explanation. It is usually seen among alcoholics. blames it on the poor lectures. Student fails an exam. traits and personality. SUBLIMATION Re-channeling of consciously intolerable or Socially Unacceptable Behaviors or impulses into personally or socially acceptable. Unconsciously used to justify #1 DM: Aanti-social disorder ideas. values & beliefs.DM: Ddepression transference
counter Incorporate feelings & emotions. It wasn’t worth it. An unattractive girl became a very good tennis player. and others as all bad Impulsive = poor self-control Ex.
9. incurable illness
towards her.OUT 10. Temporary flight from reality to ↓ anxiety.” is showing denial
FANTASY DM: Schizoid
Imagined events or mental images. needs. “You might have mixed my result with other patients. A 27 year old acts like a 17 y. Unconscious wish turned into reality Ex. and/or reality factors that are intolerable. Ex. MAJOR ASSESSMENT CRITERION FOR MEASURING DEGREE OF ANXIETY: Client’s ability to focus on what is happening to him in a situation. Person uses reasoning as a means to avoid confrontation. alcoholics = oral fixation The act of transferring emotional concerns into the intellectual sphere. INTELLECTUALIZATION
ACTING . on her first date with a fellow employee. DEFINITION: Effective subjective response to an imagined or real internal or external threat. Ex. Ex. temporary retreat to past levels of behavior that reduce anxiety.8. B. and increased motivation. Blocking the awareness of reality. diffuse apprehension or vague uneasiness. (permanent flight from reality: autism) ANXIETY
A. smoking at parties chronic regression Permanent or persistence into later life of interests and behavior patterns appropriate to an early age. DENIAL #1DM: Alcoholics. allow one to feel more comfortable. “What’s good about this. “Dear John” Letter the groom is trying to figure out with his room mate why his fiancée changed her mind – to avoid confronting her. is that after it I will look good & thin.” This shows that the teen is denying her chronic illness Cancer patient saying. “things will get better. Molested child wants to be comforted becomes psychologist = Oprah The unconscious refusal /avoidance to face thoughts. Wishful thinking.o. wishes. A. Daydreaming. increased attentiveness. Chain smokers. Ex. Without stressors Ex. 23
. Exaggeration of intellect. PTSD. Alert senses. soon”
14 y/o girl who is undergoing dialysis says. □ Perceived SUBJECTIVELY by the conscious mind is as a painful. □ Low / mild level of anxiety is healthy and helps in individual growth and development. feelings. but the causative conflict or threats is not in the conscious mind or awareness. □ Mild: The perceptual field is wide allowing the client to focus realistically on what is happening to him.
□ Moderate: Another word is selective inattention. The perceptual field narrows and the client is able to partially focus on what is happening if directed to do so and can verbalize feelings of anxiety. □ Severe: The perceptual field is significantly reduced and the client may not be able to focus on what is happening to him and may not be able to recognize or verbalize anxiety. All senses affected; decreased perceptual field; drained energy; Learning and problem-solving not possible. Start of sympathetic symptoms: tachycardia, palpitations, hyperventilation (brown paper bag to prevent Respiratory Alkalosis) and cold clammy skin. □ Panic: The perceptual field is severely reduced and the client experiences feelings of panic and dread. Client overwhelmed and helpless; personality may disintegrate → hallucinations and delusions. Pathological conditions requiring immediate intervention. Client may harm self or others.
A patient stating, “Sometimes I feel like I’m going crazy & losing control over myself,” is showing symptoms of panic attack
POTENTIAL NURSING DIAGNOSES □ Ineffective Individual Coping □ Anxiety C. NURSING INTERVENTION IMPLEMENTATON: □ Identify anxious behavior and anxiety levels and institute measures to decrease anxiety at a level where learning can occur. □ Provide appropriate environment where environmental stress & stimulation are low (First nursing action): • Structured, NON-STIMULATING, uncluttered • SAFE from physical exhaustion and harm. □ STAY. Do not leave client alone. Recognize if additional help is needed. Provide physical care if necessary. □ Establish PERSON-TO-PERSON relationship and maintain an accepting attitude: • ACCEPT client. Show willingness to LISTEN. • Encourage, allow EXPRESION OF FEELINGS at clients OWN PACE avoid forcing verbalization. □ Administer medication as directed and needed. The pharmacology therapy of choice is the ANXIOLYTICS-reduces anxiety so client can participate in psychotherapy. □Assist to cope with anxiety more effectively. Assist to recognize individual strengths realistically • Encourage measures to reduce anxiety: activities: relaxation techniques, exercises (DANCING, WALKING, JOGGING), hobbies, talking with support groups, desensitization treatment program • Provide individual or group therapy to identify anxiety and new ways of dealing with it and develop more effective coping interpersonal skills.
• If patient can be redirected back to the topic after he gets anxious while the RN gives discharge teaching, it is an indication that discharge teaching can be resumed.
TYPES OF ANXIETY DISORDER 1. Phobia 2. Obsessive Compulsive 3. Post Traumatic Stress Disorder (PTSD) 4. Generalized Anxiety Disorder (GAD) 5. Panic Disorder PHOBIA AND PANIC DISORDER A. Extreme anxiety and apprehension experienced by an individual when confronted with feared object/ situation; commonly begins in early twenty’s (young adult) as a result of childhood environmental factors characterized by ORDER & RIGIDITY; use compensatory mechanism of the psychoneurotic pattern of behavior and development of symptoms permits some measure of social adjustment. B. PRECIPITATING FACTOR: Pressures of decision-making regarding life-style in early adult period C. TYPES OF PHOBIA • Agoraphobia: Ffear of being alone, fear of open spaces or PUBLIC places where help would not be immediately available (trains, tunnels, crowds, buses)
A client with agoraphobia who is already able to go outside the house indicates a positive response to therapy.
Expected outcome for agoraphobia includes going out to see the mailbox
Social phobia: Ffear of public speaking or situations in which public scrutiny may occur Simple phobia: Ffear of specific objects, animals or situations
D. NURSING IMPLEMENTATION • Recognize the client’s feelings about phobic object/ situation
Specific precipitants are present with phobia
• • • •
Avoid confrontation and humiliation; Provide constant support (Stay with client during an attack) if exposure to phobic object or situation cannot be avoided Do not focus on getting patient to stop being afraid Provide relaxation techniques Implement behavioral therapy: SYSTEMIC DESENSITIZATION (the #1 treatment for PHOBIA) . Administer antidepressants as ordered
A. A psychiatric disorder characterized by persistent, recurring anxiety-provoking thoughts and repetitive acts; Unconscious control of anxiety by the use of rituals and thoughts 1. OBSESSION: Ppersistent, repetitive, uncontrollable thoughts 2. COMPULSION: Rrepetitive, uncontrollable acts of irrational behavior that serve NO rational purpose → rigidity, rituals, inflexibility; the development of rituals permits some measure of social adjustment B. ASSESSMENT FINDINGS: Rritualistic, rigid, inflexible; with difficulty making decisions and demonstrates striving at perfection; use verbal and intellectual defenses C. NURSING IMPLEMENTATION: Provide for physical safety (1st); meet physical needs Accept, allow ritualistic activity; DO NOT INTERFERE with it; (The best time to interfere with ritual is after client has completed it.) Accept behavior but set limits on length and frequency of the ritual. Offer alternative activities; support attempts to reduce dependency on the ritual; guide decisions Provide structured environment, minimize choices Provide socialization, group therapy Administer CLOMIPRAMINE (ANAFRANIL) as ordered A Tricyclic antidepressant used in phobias, anxiety and obsessive-compulsive disorder; SIDE-EFFECTS/ ADVERSE REACTIONS: Ttachycardia, cardiac arrest, dizziness, tremors, seizures, CONTRAINDICATIONS: Ppregnancy, hypersensitivity; Interactions/Incompatibilities: Hypertensive crisis, convulsions, with MAOIs POST-TRAUMATIC STRESS SYNDROME A. A disorder following exposure to extreme traumatic event (wars, rape, natural catastrophes) causing intense fear, recurring distressing recollections and nightmares B. ASSESSMENT: 2 Cardinal Sign: FLASHBACK & NIGHTMARES. Images, thoughts, feelings → intense fear and horror, sleep disturbances. Depression, or irritability or outburst of anger Exaggerated startle response; Poor impulsive control Avoidance; Inability to maintain intimacy; Hypervigilance C. PRIORITY NURSING DIGNOSIS: Altered Sleeping Patterns Altered Skin Integrity Ineffective Individual Coping D. NURSING INTERVENTATION Encourage VERBALIZATION about painful experience. Show empathy; be nonjudgmental; Help feel safe. Rational emotive-therapy; Allow to grieve Help client identify, label and express feelings safely Enhance support systems: Sself-help groups, family psychoeducation, and socialization.
In a rape victim, a statement like, “If I should not have worn that red panty, it wont happen to me”, shows denial Statement of a rape patient who is beginning to resolve trauma includes, “I’m able to tell my friends about being raped.” An RN needs further teaching about caring for a post-traumatic client when she keeps on asking the client to describe the trauma that caused patient’s distress after recovering from a PTSD.
GENERALIZED ANXIETY DISORDER A. Description 1. Generalized anxiety disorder is an unrealistic anxiety in which the cause can be identified.
The two major types of precipitating factors for anxiety are: treats to one biologic integrity and treats to one’s self-esteem. Anxiety is one of the defining characteristics of ineffective individual coping. A patient with anxiety disorder may exhibit difficulty in coping.
2. Physical symptoms occur B. Assessment 1. Restlessness and inability to relax 2. Episodes of trembling and shakiness 3. Chronic muscular tension 4. Dizziness 5. Inability to concentrate 6. Chronic fatigue and sleep problems 7. Inability to recognize the connection between the anxiety and the physical symptoms 8. Focus on the physical discomfort PANIC DISORDER 1. Description a. The cause usually can not be identified. b. Panic disorder produces a sudden onset with feeling of intense apprehension and dread. c. Severe, recurrent, intermittent anxiety attacks lasting 5 to 30 minutes occur. 2. Assessment a. Choking sensation b. Labored breathing c. Pounding heart d. Chest pain e. Dizziness f. Nausea g. Blurred vision h. Numbness or tingling of the extremities i. A sense of unreality and helplessness j. A fear of being trapped k. A fear of dying 27
muscle relaxant & anxiolytic Diazepam (Valium)* best for: Sstatus epilepticus . functional psychiatric disorders. Assist the client to change unrealistic thoughts to more realistic thoughts. relax muscles. Most commonly prescribed drugs in medicine Greatest harm: Wwhen combined with ALCOHOL I. A combination of behavioral and somatic approaches is effective in the management of anxiety. Used in neuroses. d. insomnia ACTION: Increases GABA (gamma amino butyric acid) USES: Major use to reduce anxiety. e. do not stop abruptly because of rebound grand mal seizure Midazolam (Dormicum) Prazepam (Centrax) Chlordiazepoxide (Librium)* 2nd drug of choice for delirium tremens Clonazepam (Klonopin) 28
. “I can no longer go further. psychosomatic disorders. trembling & says. inhibit convulsion. Administer anti-anxiety medications as prescribed
A client in panic disorder showing dilated eyes. Benzodiazepine Code: -ZEPAM/ZOLAM Action: Aanticonvulsant. Attend to physical symptoms b. the best for delirium tremens (alcohol & cocaine withdrawal) Estazolam (Prosom) Alprazolam (Xanax) Chlorazepate (Tranxene) Oxazepam (Serax)* the best in sundown syndrome (seen in Alzheimers) Advantage: Nnot hepatotoxic Lorazepam (Ativan)* 2nd drug for sundown syndrome Triazolam (Halcion)* Anti-insomnia Temazepam (Restoril)* Anti-insomnia Flurazepam (Dalmane)* Anti-insomnia. Ffeelings of impending doom 3. DO NOT modify psychotic behavior. Interventions a. c.” Should be accompanied in her room & RN should stay w/ her for a while
The goal of intervention in the care of the anxious patient is to enable him to develop his capacity to tolerate mild anxiety.
Therapeutic communication appropriate to patient showing signs of panic disorder includes providing a concrete direction
ANXIOLYTICS/ANTI-ANXIETY Another word: Sedatives/Hypnotics/Minor Tranquilizer For: Delirium. anti-anxiety. Uuse cognitive restructuring. Assist the client to identify the thoughts that aroused the anxiety and identify the basis for these thoughts. also induce sedation.L.
assistance w/ walking. Anxiolytic (addictive) Zolpidem (Ambien.Halazepam (Paxipam) Side Effects: #1 Vital sign to be monitored: Respiratory Rate due to its Lethal Side Effect. Milltown) Chloral Hydrate (Noctec) Hydroxyzine (Atarax. Iterax. Early decrease LOC Lethargic Late/Fatal decrease RR Respiratory Depression RR below 12 Avoid strenuous activities Antidote for Benzodiazepine intoxication: FLUMAZENIL (ROMAZICON). sensorium. Stillnox) sleeping aid
SIDE EFFECTS DROWSINESS (Do not drive. affect) Habituation and increased tolerance Withdrawal symptoms: high doses & prolonged use (>6mo) PSYCHOTIC DISORDER: SCHIZOPHRENIA
. Barbiturates Action: Uused as an anticonvulsant besides being a sedative Code: TAL / AL Secobarbital (seconal) Phenobarbital (luminal)* commonly used anticonvulsant barbiturate Methohexital (Brevital) Amobarbital (Amital) III Atypical Anxiolytics Meprobamate (Equanil. Antihistamine. NO alcohol) Mental confusion (Evaluate mood. Respiratory Depression 1. Vistaril)* anti emetic & antihistamine Diphenhydramine (Benadryl)* Antiparkinsons. an anxiolytic antagonist II.
Iincreased dopamine –coming from the substancia nigra 2. ASSESSMENT FINDINGS (GENERAL SIGNS) THE FOUR A’s of SCHIZOPHRENIA ACCORDING TO BLEULER
ASSOCIATIONS. Genetics 65% chances.
(+) POSITIVE SIGNS OF SCHIZOPHRENIA: Ddue to EXCESS DOPAMINE
Do you know HILDDA PI? Hallucination.if two parents are diagnose with schizophrenia 32. Ddouble-bind theory 2 kinds of information/communication 4. Disorientation & Agitation Paranoia & Insomnia
Schizophrenic patient says.5% chances.
Patient with 5 admissions in 2 yrs is considered a chronic schizo. Delusion. sensory perception and with deterioration & regression of psychosocial functioning. aloofness) AFFECT. A. neologism. Illusion.if 1 parent is diagnosed with schizophrenia 5. FLAT (Inappropriate or no display of feelings) #1 HALLUCINATION of Schizophrenia is Auditory.Definition: Ssevere impairment of mental & social functioning with grossly impaired reality testing. tomatoes are red…” is showing looseness of association
. Looseness of Association. Trauma PTSD 3. “Pretty red dress. Drug addicts and alcoholics: Hhigh probability for schizophrenia due to increase Delusions & hallucination DSM V Criteria for Schizophrenia: Characterized by both (-) & (+) symptoms & social / occupational dysfunction for at least SIX (6) months. LOOSE: Jjumping to different topics WITHOUT association or relevance AMBIVALENCE (Two opposing feelings toward others at the same time) AUTISM (withdrawal from environment and others) → magical thinking.
Anergia. delusion & hallucination) 5. PRIORITIZED NURSING DIAGNOSES FOR ALL TYPES OF SCHIZOPHRENIA: 1. Word Salad (incoherent mixture of words) 2. Neologism (creating NEW WORDS) vs. Proxemics( 7 feet away from the patient). Verbigeration (meaningless repetition of action words (Verb)) vs. Alteration in Thought Process. delusion of Persecution (#1 delusion of Paranoid Schizophrenia) . 2. Flight of Ideas (jumping from one RELATED topic to another): Ccommonly seen in MANIC patients. Risk for violence: Ddirected toward self or other (priority!!!) 2. Clang association (use of rhymes in sentences) vs. also in Schizophrenia. REMEMBER the 4 P’s: Projection (#1 defense mechanism). altered 4. Echolalia/Parroting & Echopraxia (Commonly seen in AUTISM)
B. Tangentiality (did not answer the stimulus/ question) 5. Circumstantiality (beating around the bush.g. Anhedonia NURSING DIAGNOSIS FOR NEGATIVE SYMPTOMS OF SCHIZOPHRENIA: 1. 5 (FIVE) TYPES OF SCHIZOPHRENIA: 1.
.(-) NEGATIVE SIGNS OF SCHIZOPHRENIA: Ddue to LACK OF DOPAMINE Remember your POOR A’s? Poor judgment. Passive Friendliness (#1 attitude therapy: Nno touching. no whispering & laughing) . . ideas of persecution and delusions. Sensory/perceptual alterations ( related to illusion. 1st stimulus correct response 2nd & following stimulus still responding to the 1st stimuli 4. Perseveration e. sees environment as hostile and threatening. Social isolation C. Thought process. Alteration in Content of Thought
OTHER NEGATIVE SYMPTOMS: All this signs & symptoms can also be seen in SAM (Schizophrenia. 3. answers but delayed) vs. Self-care deficit 3. PARANOID: Presenting sign is SUSPICIOUSNESS. Poor insight. Alzheimer’s & Manic) 1. Poor self care Alogia.
the patient should be involved in the plan of care. .” In order to encourage trust.Catatonic stupor – markedly slowed movement. Social Isolation – no group session when schizophrenic
Paranoid who is suspicious saying.Catatonic posturing. Self Care Deficit
3.bizarre or weird positions . Fluid & Electrolyte Imbalance 2.” The other staff members are laughing at my back. mutism. CATATONIC: With stereotyped position (catatonia) with waxy flexibility. “Someone has placed a transistor in my brain. MISTRUST) NURSING CONSIDERATION: 1. regression. “This place is meant for bugs & prison. laughing. “I don’t like to eat meat because animal produced foods are Poisonous”.Catatonic hyperactivity or excitability: PRIORITIZED NURSING DIAGNOSIS: 1. Developmental Stage FIXATION: Anal Fixation #1 Defense Mechanism: Regression & Fixation 4. Food: PACKED OR SEALED foods except canned goods: Nno metal 3. DISORGANIZED: Another word is Hebephrenic. shows suspicious paranoid type schizophrenia. bizarre mannerism. All behaviors are similar with toddlers since they are anal fixated.Catatonic negativism – resistance towards flexion & extension . Altered Nutrition less than body requirement 3.” correct interpretation shows paranoid delusion Statement like.Most dangerous/serious type of schizophrenia– may die from dehydration CATATONIC CHARACTERISTICS: . #1 Defense mechanism: Autism & mutism #1 Cardinal Sign of Catatonia – waxy flexibility (cerea flexibilitas) -Ssimilar in children with autism .
Developmental Stage FIXATION: ORAL PHASE (TRUST vs. Consistency to build trust 2.Catatonic rigidity – cementation/stone-like position .A patient who says. transient hallucinations (Auditory).” shows a paranoid delusion of schizophrenia. Characterized with inappropriate behavior: Ssilly crying. Schizophrenic says. UNDIFFERENTIATED or MIXED : Symptoms of more than one type of schizophrenia 32
Promote trust. Establishment and maintenance of therapeutic relationship: Engage in individual therapy.
2. Maintenance of safety: Protect from altered thought processes. RESIDUAL: No longer exhibits overt symptoms. The #1 drug of choice is Fluphenazine (Prolixin decanoate)
5. remove from areas of tension
Suspiciousness & paranoid patient is threatening to the staff. no more delusions but still has negative symptoms or odd beliefs or unusual perceptions. Respond to feelings.
Undifferentiated type chronic schizophrenia must be referred to a program promoting social skills due to functional loss deficit. so solitary activities are preferred over team activities. bastard. and not to delusions. who yells. group. “Everyone. Implementation of appropriate family. the action of an RN that shows a need for further teaching is when shegoes to the room of a pt. out of here. PRINCIPLES OF CARE 1. social or diversional therapies
Patients with schizophrenia need activities that do not require interaction. priority focus should be hyponatremia.” includes walking towards the pt & ask him who he is talking to. Do not argue.” Appropriate action of RN to a Schizophrenic who yells loudly. Encourage expression by verbalizing the observed.-
has delusions & disorganized behavior but DOES NOT meet the critieria for the above sub types alone. Validate reality.
Admission assessment of a Schizophrenic client reveals auditory hallucination. Offer presence-Tolerate long silences 4. and drinking more than 6 L of water daily for past weeks. Meeting of physical needs: May have to be fed / bathe initially 3.
Desired efficacy of treatment in schizophrenic patient who is mute & immobilized includes standing up when RN enters the room.
ANTIPSYCHOTICS Another word: Neuroleptic / Major Tranquilizers 33
. talks to wall and saying “Don’t talk to me.
Thioxanthenes Code: THIXENE
Chlorprothixene (Taractan Thiothixene (Navane)
IV. Non-psychiatric cases: Nausea and vomiting. Phenothiazine Code: AZINE Fluphenazine (Prolixin)* Acetophenazine (Tindal) Pherphenazine (Trilafon) Promazine (Sparine) Chlorpromazine (Thorazine)*#1 that causes photosensitivity/photophobia. intractable hiccups. to prevent constipation & contact dermatitis.
↓ delusion. Side effects: Ccauses also red orange urine In liquid form is usually put in a chaser Chaser: 60. taken with straw (bite straw & sip) Mesoridazine (Serentil) Thioridazine (Mellaril)* ceiling dose/day: 800 mg Adverse Effect: Rretinitis pigmentosa Prochlorperazine (Compazine)* #1 commonly used anti emetic
Compazine causes anticholinergic side effects
Trifluoperazine (Stelazine) II.
Antipsychotics can only decrease the positive symptoms of schizophrenia. pre-anesthesia. Butyrophenones Code: PERIDOL Haloperidol (Haldol.100 ml juice (prone or tomato). acute mania. Serenase)* #1 drug used for extreme violent behavior
Instruct patient taking Haldol to wear sunscreen
Droperidol (Inapsine) III.USES: Schizophrenia. hallucinations. looseness of association to decrease levels of dopamine in the substantia nigra
I. Atypical Antipsychotics Olanzapine (Zyprexia)
Code: DONE / ZAPINE or APINE
. but not the negative symptom such as ambivalence. depression and organic conditions.
” shows a correct understanding of a patient while taking Clozaril. Constipation Nursing Interventions: 1.take BP in supine. Urinary Retention – (Post Partum. Sounds of dripping water – faucet 3. Difference of BP 15-20 mm Hg below S/Sx: Ppallor. ↑exercise 4. Intermittent cold & warm compress 3. paraplegia) Nursing Interventions: 1. Fowler’s & standing position. Pan Photosensitivity (photophobia) Nursing Intervention:
.Clozapine (Clozaril) #1 that causes Agranulocytosis & Blood Dyscrascia
“I will need to monitor my blood level to continue my medication.↑ sympathetic reaction (don’t operate machinery). Provide Privacy – give bed pan 2. dizziness Nursing consideration: Slowly change position
Told patient to dangle feet first before standing
5. ↑ OFI 3. prune/pineapple/papaya juice/ fruits 2. Blurring of Vision . Prevent constipation ↑ fiber (residue) AG or roughage. Orthostatic Hypotension/Postural Hypotension .
Loxapine (Loxitane) Risperidone (Risperidone) #1 drug for Korsakoff’s psychosis Molindone (Moban) Aripiprazole (Abilify) newest antipsychotic drug SIX COMMON ANTICHOLINERGIC SIDE EFFECTS OF ANTIPSYCHOTICS (Anticholinergic effects are drug actions of antipsychotic drugs because they BLOCK MUSCARINIC CHOLINERGIC RECEPTORS) CODE: BUCO PanDan – anticholinergic S/Es 1. Mydriatic – pupil dilate sympa ↑ IOP don’t use in glaucoma 2. Autonomic Dysreflexia.
which is a result of neurological dysfunction of the Extrapyramidal System. finger fidgeting.1.
Patient is unable to remain still
Drug of Choice: CODE: CBA #1 Cogentin (Benztropine Mesylate) #2 Benadryl (Diphenhydramine Hcl) #3 Akineton (Biperiden Hcl) 2. cogwheel rigidity. long sleeves or/and umbrella
Patients taking antipsychotic should be instructed to wear wide brimmed hat when going outside
6. shuffling gait or festinating gait. Use sun glasses. Akathisia –another word: Mmotor restlessness 1-6 wks Signs of motor restless: Foot tapping.
Patients taking with prolonged antipsychotic medications should always be assessed for symptoms of extrapyramidal symptoms. Other signs: Mmask-like face. flat affect. (2) chewing gum.
1. jaw and throat spasm (dysphagia) 2-5 days Drug of Choice: CODE: CBA #1 Cogentin (Benztropine Mesylate) #2 Benadryl (Diphenhydramine Hcl) #3 Akineton (Biperiden Hcl)
3. neck shoulder. can’t sit down for more than 15 minutes and pacing back & forth. Pseudoparkinsonism . (3) sips of water
ACUTE/COMMON SIDE-EFFECTS FOR PROLONGED USED OF ANTIPSYCOTICS Extrapyramidal Symptoms (EPS) Common Signs & Symptoms: Definition of EPS: Rreversible side effect (except TARDIVE DYSKINESIA).another word: Ddrug-induced Parkinsonism – #1 sign: Ppill-rolling tremors. Dan Dry mouth/ Xerostomia Prioritized Nursing Intervention: Give (1) ice chips. sun block. Dystonia – #1 cardinal Sign: Ooculogyric crisis = involuntary rolling of eyeballs.
also an ANTI VIRAL 4.DRUG OF CHOICE: #1 Artane (trihexyphenydyl) #2 Amantadine ( Symmetrel) can also be used in Chicken pox.EPS MEDICATION
CODE: PACABBA . Cogentin. sweating. which is a medical emergency. tachycardia. protrusion of the tongue. tongue rolling. puckering of cheeks. LIFE-THREATENING : (EXTREME EMERGENCY): #1 Cardinal Sign is High fever. Elevated blood pressure and diaphoresis are indicative of Neuroleptic malignant
syndrome. incontinence. tachypnea.Usually they are anticholinergic & antiparkinsonian drugs Procyclidine (kemadryl. --administer Artane. renal failure. Tardive Dyskinesia – Starts with T: TONGUE (tongue rolling & tongue protrusion) lip smacking. stupor. and drooling of saliva. facial grimacing. tongue thrusting. Antiparkinsonian drug
5. kemadrin) Artane ( trihexyphenydyl) Cogentin (Benztropine mesylate) Akineton (biperiden Hcl) Bromocriptine (Parlodel) Benadryl (Diphenhydramine) Amantadine (Symmetrel) ADVERSE EFFECT OF ANTIPSYCHOTIC DRUGS: Neuroleptic Malignant Syndrome RARE. ventilation. This is an EMERGENCY!!!
Symptoms of tardive dyskinesia include fly catcher’s mouth. hyperkalemia. tremors. muscle rigidity (Discontinue all drugs STAT.
ANTIDOTE: Dantrolene (Dantrium) or Bromocriptine (Parlodel) Bromocriptine is both an Antiparkinsons & Anti prolactin
AFFECTIVE / MOOD DISORDERS
Akinesia – absence of kinetic movements ANTI. vermicular or vermiform tongue rolling irreversible. hydrotherapeutic measures). renal dialysis. hydration. nutrition. Benadryl.
irritability. while in manic patient. anxiety. DEPRESSIVE DISORDERS: Depressive episode with no manic episodes 1. withdrawal. anorexia. Dysthymia: Cchronic depressive mood problems occurring in the absence of a major depressive or organic or psychotic diagnosis. a pathologic grief reaction experienced by an individual who does not mourn • The term depression is used in varied ways: a sign. chest pain. low self-esteem. oldest and most frequently described psychiatric illness. insomnia. constipation. Major depression. Behavioral: Altered activity level. DIFFERENTIATION/CATEGORY: Moderate Depression – crying at night . psychomotor retardation. severe. loss of interest. denial of feelings b.MODELS OF CAUSATION: Genetic. sense of worthlessness. backache.
Depression in children results to anhedonia (energy loss & fatigue. headache. over-dependency. ambivalence.both of them have the same characteristics • BEHAVIORS COMMONLY ASSOCIATED WITH DEPRESSION a. Biological: Ddecreased serotonin and norepinephrine *. recurrent: Rrepeated episodes of major sadness or depression separated by long intervals. moderate. hostility is turned towards the environment. experiential. vomiting.
In a depressed patient. abdominal pains* c. inability to concentrate. emotional state. symptom. behavioral variables DEPRESSION: An abnormal extension or over elaboration of sadness and grief. Personality disorganization. Learned helplessnesshopelessness. helplessness. single episode 2. self-blame d. hostility is turned towards the self. bitterness. Behavioral: Lloss of positive reinforcement. indecisiveness. depression less than 2weeks *Major Depression – Severe depression for more than 2 weeks * . weight change. syndrome. Affective: Anger. Life stressors. dizziness. occurring in clusters or increasing with age* 3.Dysthymia – painful depression for 2 years *Severe Depression – Crying at early morning. • May be mild. agitation. reaction. Aggression turned inward. Objects loss. Suicidal Behavior A. Cognitive: Hhopelessness. and Integrative: chemical. Physiological: Ffatigue. Manic-Depressive (Bipolar) Disorders. disease or clinical entity. Major depression. poor hygiene. apathy. TYPES: Depressive Disorders. decreased interest in previously enjoyed activities) like playing alone during recess. hopelessness. with (uncommon) or without psychotic features I. pessimism. Cognitive: Confusion.
Elderly (ego-despair) 3. no friend. SAD – Seasonal Affective Disorder – common on winter season (Nov. Constipation* PREDISPOSING FACTORS: 1. or relationship. Psychomotor retardation (slow mov’t) 9. for 2 weeks: 1. difficulty. Middle age men (45 y.. retired 6 yrs ago. Adolescent (identity crisis) 2. In general the purpose or reason for suicide is to escape. above) 4. Loss of interest or pleasure ambivalence (fear of death vs.• DIAGNOSTIC CRITERIA FOR MAJOR DEPRESSION: At least five of the following. Post partum depression (7 days/2-4 weeks)
Suicide and Self-destructive Behavior Suicide is never a random act. Intervention for pt with seasonal affective disorder (SAD) during a depressed mood includes the use of broad spectrum light in high activity area. avoiding being a burden to others. e. no hobby. to get away or end an intolerable situation. no money & has history of alcohol abuse is at risk for suicide
6. or to avoid punishment or exposure of socially or personally unacceptable behavior. most of the day.o.-Feb. Fatigue or loss of energy (anemia) 10. Early morning depression 6. Caucasians/Afro-Americans/Asians* 5. Feelings of worthlessness & 2. crisis.g.) or intimate months
Seasonal depression occurs during winter and fall this is due to abnormal melatonin metabolism. Loss of loved one (situational crisis) 3. Insomnia* 8. Incurable Illness* 8. Weight loss or gain 5. This produces high intensity color like broad day light. Post partum depression 9.
. Also instruct the pt that the light source must be 3 ft away from the eye
4. nearly daily. fear living) * (ANHEDONIA)* 7. History of suicide* 4. Schizophrenia* Prone: Mmale Age bracket prone for suicide #1. Alcoholics/Drug addicts*
A 66 y/o American men. Whether committed impulsively or after painstaking consideration the act has both a message and a purpose. resolving an untenable family situation. Flat affect* 11. Annulled & Divorced 2. escaping a terminal illness. Self care deficit* 3. Protestants 7. Single.
A complete suicide is the most violent self-destructive behavior. Typical behavior are biting one’s nails. loss of job. temper outbursts. or the loss of or threat of their spouse. People who have attempted suicide before 2. decline in school or work performance 3. separated or widowed People who are confused about their sexual orientation People who have experienced a recent loss: divorce. Suicidal attempt – a strong and desperate call for help involving a definite risk. Demographic Variables – suicide rates are higher among the following: 1. money or social position 3. Suicidal gesture – more serious warning signal than a threat that maybe followed a suicidal act that is carefully planned to attract attention without seriously injuring the subject 4. gambling. if violent. self-mutilation 2. Some. Cognitive styles of suicidal patients: 1. smoking. Levels of self-destructive behavior: 1. Suicidal threat – a threat more serious than a casual statement of suicidal intent and accompanied by behavioral changes. Eskimos and Native Americans 6. job. they do not obtain the results they hope for. pulling one’s hair scratching or cutting one’s wrist. Single people Divorced. loss of social status or who are facing the threat of criminal exposure 5. 2. people cannot express their needs or feelings to others. For them. Ambivalence. Caucasians. Those with physical illness. particularly when the illness involves an alteration of body images or lifestyle 5. mood swings. 3. form of communication.g. People who are depressed or recovering from depression or a psychotic episode 4. They have 2 conflicting desires at the same time: T to live and to die. or when they do.Self-destructive behavior is action by which people emotionally. 4. loss of prestige. Ambivalence accounts for the fact that a suicidal person often takes lethal or near-lethal action but leaves open the possibility for rescue. e. Those who abuse alcohol or drugs
. People who have experienced the loss of an important person at some time in the past or the loss of both parents early in life. 2.g. Chronic self-destructive behavior – e. suicide becomes a clear and direct.. Protestants or those who profess no religious affiliation
Clinical variables: 1. socially and physically damage or end their lives. Communication.
no history of attempts or recent serious loss. has satisfactorily support network. 1. Those who are recovering from a thought disorder combined with depressed mood and / or suicidal ideation ( hallucinations that tell them to kill or harm themselves) Management – people bent on suicide almost always give either verbal or nonverbal clues of their intent. A lethality assessment scale (Table 2) is an attempt to predict the likelihood of suicide. and is in close contact with significant others Person has considered suicide with low lethal method. no alcohol problems. They are crying out for help. or has plan with low lethal method . history of low lethal attempts.6. They actually make a powerful attempt to communicate to others their hurt ad desperation. is weighing the odds between life and
. basically wants to live
Low risk of immediate suicide
Moderate risk of immediate suicide
Has considered suicide with high lethal method but no specific plan or threats. has satisfactorily social support network. with dysfunctional family history and reliance on Valium or other drugs for stress relief. Table 2: Lethality Assessment Scale Key to Scale 1 Danger to Self No predictable risk of immediate suicide Typical Indicators Has no notion of suicide or history of attempts.
a. is cut off from resources. Implement basic suicide precautions: • • Check on the client at least every 15 minutes or require the client to remain in public places Stay with the client while all medications are taken
High risk of immediate suicide
Has current high lethal plan. has a close friend but is unable to communicate with him or her a drinking problem. is depressed and wants to die Has current high lethal plan with available means. such as unemployment or divorce or failure in school age more in elderly and adolescents
Very high risk of immediate suicide
General guidelines – the general task of the nurse is to work with the client to stop the constricted processing of suicidal thinking long enough to allow the client and the family to consider alternatives to suicide. Talk about suicide openly and directly c. history of previous attempts. history of high lethal suicide attempts. and is threatened with a serious loss. Take only threat seriously b. is depressed and uses alcohol to excess. obtainable means.
maximum suicide precautions mean: • • • • Provide one-to-one nursing supervision.acceptance f. Make the search in the client’s presence and ask for the client’s assistance while doing so Check articles brought in by visitors Allow the client to have regular food tray but check whether the glass or any utensils are missing when collecting the tray Allow visitors and telephone calls unless the client wishes otherwise Check that visitors do not potentially dangerous objects in the room
d. Decide if a no-harm. no suicide contract will be used k. Do a body examination u. Be prepared to deal with family members who may be confused. Evaluate the plan developed in collaboration with the client and arrange for appropriate follow-up r. the most pressing need is h. In addition to the above. Assume a nonjudgmental. robe belts. Work with other team members to evaluate the issues fully t. The answer will shed light on the meaning suicide has for this patient and may provide information that can lead to other helpful interventions j. Ask why the client chose to attempt suicide at this particular moment. Do not make unrealistic promises m. and work to assists the client toward self. Recognize that people can and have hanged or strangled themselves with shoelaces. The nurse must be in the room with the client at all times Maintain the client’s safety in the least restrictive manner possible Do not allow the client to leave the unit for test or procedures Serve the client’s meals in an isolation tray that contains no glass or metal silverware
e. angry or uninterested p. Encouraged the client to continue daily activities and self-care as much as possible n. in the client’s view. Expect that the client will be experiencing shame. Be careful not to encourage staff behaviors that give clients or staff members a false sense of security l. Evaluate the client’s need for medication q. caring attitude that does not engender self-pity in the client i. etc.
.• • • • •
Search the client’s belongings for potentially harmful objects. brassiere straps. pantyhose. Monitor your personal feelings about the client and decide how they may be influencing your clinical work s. Find out what. Relieve the client’s obvious immediate distress g. Decide with the client which family members and friends are to be contact and by whom o.
Delusion of Omnipotence (divine powers) Used by SS (Suicidal. hanging. Giving away of prized possessions* 3. Do not leave the patient for the 1st 24 hrs. jumping from a very high place/building. Low-risk = slashing of the radial pulse (more o females) 2. it means that the patient is from depression and is in danger of committing suicide. One-on-one nursing monitoring/intervention (never leave the client)* 2. No metallic objects 44
. In between nursing shifts RATIONALE: Nnurses at this time are very busy NURSING DIAGNOSIS: (common) Risk/Potential for Injury Directed to Self STEP BY STEP PRIORITIZE NURSING INTERVENTIONS: 1. Early in the morning RATIONALE: Tthe depression at this time is HIGH 2. less than 2-4 wks ( telling a lie) • Suicidal attempts are common when client is strong enough to carry out a suicidal plan. c) SUICIDAL ATTEMPTS: Aany self-directed actions taken by the individual that will lead to death if not interrupted. Sudden elevation of mood/sudden mood swings*
recovering When a depressed patient suddenly becomes cheerful. High-risk = drowning. Offering of self (best therapeutic communication)* 4.2 LETHAL METHODS OF SUICIDE: 1. overdose of tranquilizer (Midazolam & Dormicum)
SUICIDAL BEHAVIORS: SUICIDAL GESTURE: Ddirected toward the goal of receiving attention rather than actual self-destruction. (No suicide contract)* 3. When the patient verbalizes that the 2nd Gen TCA is working. usually 10-14 days after start of medication. and has the means readily available. b) SUICIDAL THREAT: Ooccurs before the overt suicidal activity takes place: “Will you remember me when I am gone.” “Take care of my children”. and after ECT
USUAL TIME FOR SUICIDE: 1.
Best question to be asked after a patient who recovers from an overdose of pills includes asking “Do you still want to end your life?”
IMPENDING SIGNS OF SUICIDE: 1. gun shot.
2. Schizophrenia) 4. A most suicidal person has made a specific plan.
Avoid religious music (increases guilt) and love songs = non-suggestive song is needed 8.
Assess attempt for suicide in a 16 y/o girl who is eating & sleeping poorly since break-up and saying. Needs stimulus – bright room Rationale: to see suicidal acts 7. SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs)
. Decrease social withdrawal: Ssit with client during quiet times.” My life is ruined now. Support self-esteem: Warm and consistent care Being patient with client’s slowness Simple tasks that increase success and self-esteem and imply confidence in capabilities Example: Self care activities that will not easily tire the patient.
9. introduce to others when ready
The priority focus for a suicidal patient in the ER with a slash in her wrist is her physiologic homeostasis. Check for impending signs of suicide = sudden elevation of mood. elimination Promote self-care whenever appropriate / possible 16. Providing an activity that serves as an outlet for these aggressive feelings will make the patient feel less guilty. Rationale: Depressed patients have fatigue.‘’ Your daughter will go on to view suicide as a way of coping.”
Depressed patients usually turn their hostile feelings towards themselves. rest. #1 – sudden mood swings
A female patient who becomes euphoric for no apparent reason shows a behavior that indicates recovery from depression. Check under the tongue & pillow 12.”
ANTIDEPRESSANTS or THYMOLEPTICS I. TCA 3rd MAOI 4th ECT (last resort) 15. 17. #1 Attitude Therapy: Kind Firmness 14. Join group therapy
During family therapy. Activities focus on self-care 10. No sharp objects 6. a mother asks. which increases the risk for suicide. “How long will my daughters have suicidal thoughts?” appropriate response of the RN. Meet physical needs: Promote eating. between shift & during endorsement 13. Step by step Tx: ANTIDEPRESSANT another word is THYMOLEPTICS 1st SSRI (Selective Serotonin Reuptake Inhibitor) A 2nd Second Gen.5. Monitor in giving medication – do not leave patient after giving medication for 30 minutes. Monitor patient in CR.
Code: PRAMINE/TRYPTILLINE Clomipramine HCl (Anaframil) #1 for OCD* Imipramine (Tofranil)* the best drug for enuresis Amitryptilline (Elavil) Protryphilline (Vivactil) Maprotilline (Ludiomil) Norpramine (Desipramine) #1 antidepressant for elderly depression. Weight Loss 2. Code: XETINE/ODONE Fluoxetine HCl (Prozac) – dry mouth (xerostomia) Paroxetine HCl (Paxil) Trazodone (Desyrel)) – adverse effect: Ppriapism (prolonged use) Nefazodone (Serzone) Fluvoxamine (Luvox) Sertraline (Zoloft) – causes GI upset (diarrhea. Give meds in single AM dose
Antidepressants are best taken after meals
II. SECOND GENERATION TRICYCLIC ANTI DEPRESSANT Action: Increases norepinephrine and/or serotonin levels in CNS by blocking their uptake by presynaptic neurons or it balances Serotonin & Epinephrine levels. Warm milk/banana (active substance: tryptophan) 3. Ffor insomnia: a. Wwarm bath (systemic effect) 2. insomnia): always with meals Venlafaxine (Effexor) Citalopram (Celexia) Common Side Effects: 1.Usually the FIRST LINE of drug. RATIONALE: Ffewer anticholinergic S/E Nortryptilline (Pamelor. Aventyl) Trimipramine ( Surmontil) Buproprion (Wellbutrin) 400 mg/day*(ceiling dose) EXCESS INTAKE: Ggrand mal seizure Doxepine (Sinequan) 46
. Massage b. Insomnia (single am dose) Nursing Considerations: 1. Effect: 2-4 wks. RATIONALE: FEWER SIDE EFFECTS Action: Balance Serotonin – gradual effect (usually 2 weeks) Effect: 2 wks. Induce sleep thru: 1.
sausage. avocado. raisins (all over ripe fruits except apricot) 7. Sedation (at night) 2. MAOI – MONO AMINE OXIDESE INHIBITOR ACTION: Psychomotor stimulator or psychic energizers. NOREPINEPHRINE. bologna. papaya.
III. the nurse must anticipate the physician to discontinue TCA after two weeks and start on Parnate.
2. Coffee. Pickled herring
Foods contraindicated in MAOI therapy includes figs. Nursing intervention before giving the drug includes checking the BP.Amoxapine (Asendin) Common Side Effects: Nursing Consideration: 1. Canned foods such as sardines. sausage. Red wine (alcohol) 4. licorice. .
Cheddar cheese and Swiss cheese are high in tyramine and should be avoided. Food safe to give includes fresh fish. serotonin) → CNS stimulation Effect: 2 weeks CODE: PAMMANA Parnate (tranylcypromine) Marplan (Isocarboxacid) Mannerix (Moclobemide) *the newest MAOI Nardil (Phenelzine SO4) CONTAINDICATIONS: TYRAMINE + MAOI = HYPERTENSIVE CRISIS 1. Cream. Soy sauce 5. Give meds at night
# 1 adverse effect – cardiac dysrhythmias #1 screening test before taking TCA – ECG
When a depressed client taking TCA shows no improvement in the symptoms. Yogurt. soy sauce & catsup 3. Weight gain 1. 8. chicken liver. Organ meats (chicken gizzard & liver) & Process foods (salami/bacon) ↑ Na 3. Cheese burger 6.
. sauerkrauts. Yogurt. Tyramine rich-food. OTC decongestants 10. Mayonnaise 9. meat tenderizer. high in Na & cholesterol Hypertensive Crisis 1. Banana. Aged cheese (except cottage cheese. cream cheese). Pickled foods. sour cream. Italian green beans. chocolate. Chocolate . margarine. yeast. yeast. block oxidative deamination of naturally occurring monoamines (epinephrine.
PPPP – Post MI. Safer for elderly.Before ECT a major depressed client undergo the ff meds: 1. gain (stimulate thalamic/limbic appetite)
Contraindicated: 1. 80 % improvement rate of major depressive episode with vegetative aspects . Then.
ECT’s mechanism of action is unclear at present
Advantages: Quicker effects than antidepressants. .Best therapy for major depression (last resort) . Verapamil (Calan) 2. Headache ↑ 02 demand.Invasive . confusion/disorientation – (usually 24 hours) 3. weakness of lumbosacral spine
.Induction of 70-150 volts of electricity in).6-12 treatments. Wt. it is followed by a grand-mal seizure lasting 30-60 secs. pacemaker. ↑ cerebral hypoxia 4. pregnant women 2. degenerative disorder 3. MAOi – 2 wks 4. Brain tumor. Phentolamine (Regitine) also the #1drug for Pheochromocytoma (tumor in the medulla) IV. Muscle spasm 5. SSRi (Selective Serotonin Reuptake Inhibitor inhibitor) –2 wks 2. ECT (last resort) Side Effects: 1. ELECTROCONVULSIVE THERAPY (ECT) ECT is passing of an electric current through electrodes applied to one or both temples to artificially induce a grand mal seizure for the safe and effective treatment of depression. Post CVA. Neurologic problem Alzheimer’s.Antidote: CALCIUM CHANNEL BLOCKERS (-DIPINE) 1. Temporary RECENT Memory Loss – ANTEROGRADE amnesia Intervention: Rre-orient client to 3 spheres 2.5-2secs. “every other day” . Antidepressants TCA 2nd Generation – 2-4 wks 3.
Methohexital (barbiturate Na) minor tranquilizer also an anticonvulsant c. Risk for Injury 3. Side rails up 4. No contact lenses it may adhere to the cornea 5.A. VS q 5 min until stable. 2. Risk for Airway Obstruction/aspiration 2. Observe for respiratory problems Remain with client until alert. Side-lying (#1 Position) 3. Atropine sulfate – anticholinergic PRIMARY purpose – to dry secretions and prevent aspiration SECONDARY purpose – to prevent bradycardia (vagolytic) b. after ECT side-lying 9. Before ECT supine position. if not a guardian may sign the consent forms. Informed Consent – if client is coherent. LOC 8. check RR 12 less. person (nurse). REORIENT: Ttime. to focus ABC. No metallic objects 3. Reassure regarding confusion and memory loss. Side-lying after removal of airway. Same RN before & after. Succinylcholine (Anectine) – muscle relaxant 7. Impaired/Altered Cognition/LOC Nursing Intervention 5 S in Seizure 1. Safety (#1 objective) 2. Phenobarbital (Luminal).
. place (unit). Give following medications BEFORE ECT: a. Legal/Pre-Nursing Responsibilities: Preparation: Similar to preparing a client for surgery: 1. Have patient VOID before giving ECT Nursing Diagnosis: 1. Wash & dry hair
6. Stimulus ↓ (no noise & bright lights) 5. Priority vs. Support the head with a pillow AFTER the seizure
FIRST & TOP priority: Ensure a patent airway. No nail polish to check peripheral circulation 4.
humorous. irritability. expansive. BIPOLAR DISORDERS: With one or more manic episodes. inflated self-esteem* b. Delusion of Grandeur – over self-worth. denial of realistic danger. lack of judgment. lack of shame. grandiosity. Affective: Eelation/ euphoria. manic: Mmost recent or current behavior displaying overactive. inadequate nutrition. depressive: Mmost recent or current behavior displaying major depression 2. • MANIA: Mood that is elevated. Easily Agitated 9. MANIC EPISODE: Neurotransmitter imbalance: * 1. flight of ideas. Insomnia 3. expansiveness. Tell manic pt to speak more slowly to make a sense if he keeps on moving one subject to
6. agitated behavior 3. Serotonin
BEHAVIORS COMMONLY ASSOCIATED WITH MANIA a. provocativeness. argumentative* DIAGNOSTIC CRITERIA FOR A MANIC EPISODE: At least 3 of the following for at least 1 week: 1. with or without a major depressive episode 1. Hyperactive & Distractibility 8. Excessive involvement in pleasurable activities without regard for negative consequences 5. Behavioral: Aggressiveness. Bipolar. distractibility. Cyclothymania: Nnumerous occurrences of abnormally depressed moods over a period of at least 2 years 5. intolerance of criticism. lack of guilt. or irritable Manic behavior is a defense against depression since the individual attempts to deny feelings of unworthiness and helplessness. Manipulative
. * d. mixed: Rrapid intermingling of depressed and manic behavior 4. poor grooming. excessive spending. Cognitive: Ambitiousness. Flight of ideas 4. Norepinephrine 2. weight loss* c.B. Bipolar. Bipolar. hyperactivity. Flight of ideas – talkative/pressured speech/pressure to keep talking
another. Physiological: Dehydration. needs little sleep. inflated self-esteem RATIONALE: Aa defense to mask feelings of depression & inadequacies 2.
strenuous activities & Increase perspiration!! ACCEPTABLE ACTIVITIES: Bbrisk walking. raking leaves.
Encourage rest: Ssedation PRN. Violent/aggressive/hypersexual 13. Encourage OFI: Bbecause of Lithium and increased metabolism 12. short PM naps 7. Increased Metabolism 11. non-argumentative manner 4. give finger foods: potato chips. Provide consistent care 3. constructive. do not touch 11. walking with staff) Meet nutritional needs: Hhigh-calorie FINGER FOODS and fluids to be carried while moving.. competitive is not safe. Fluid Volume Deficit
NURSING INTERVENTIONS: 1. scrabble. Set limits of behavior/external controls *One staff to provide controls *Do not leave alone in room when hyperactivity is escalating *Explain restrictions on behavior *Do not encourage performance/jokes *Approach in a calm. “My wife hasn’t eaten or slept for days. bingo.10.
10. bread. 9 Productive activities: Ggardening. tearing newspaper. SHORTCUT: ALL HIGH CALORIC & HIGH CARBOHYDRATE DIET or ALL BAKERY PRODUCTS!!!
Tuna sandwich & apple are appropriate food for bipolar manic A Husband of 36 y/o bipolar manic type says. and sandwich. Avoid CONTACT SPORTS: Bbasketball. Prone to become fatigue. Poor impulse control – impulsive 12. so. Pressured speech NURSING DIAGNOSIS: 1.. gym. Avoid ACTIVITIES that increases attention span such as chess.” The RN should place a priority focus on physical condition. collected. raisin. household chores. finger painting.
Activity for Manic Bipolar includes raking leaves (quiet physical. reject behavior 2. Risk/ Potential for Injury directed to others /or to self 2. 8. Check Lithium intoxication
. Less environmental stimulus: Nno bright lights. Fluid & Electrolytes Imbalances 3. productive) to increase self-esteem. punching bag. Accept client. Distract and redirect energy: Cchoose physical activities using large movements until acute mania subsides (dancing.
REMEMBER don’t touch the patient Touching the patient may increase AGITATION. ACTS by reducing adrenergic neurotransmitter levels in cerebral tissue through alteration of sodium transport → affects a shift in intraneural metabolism of NOREPINEPHRINE Action: ↓ hyperactivity and balance or stabilize the mood Effect: 1 wk.6 – 1. Disturbing the Group Session 1. Lithane.2 mEq (NCLEX) 52
. Swearing 1. Move to the door fast and call the crisis management team D. Physical violence MOOD STABILIZERS (ANTIMANIC DRUGS): LITHIUM For: (Mood disorder specifically Mania (Bipolar Disorder) USES: Elevate mood when client is depressed. Setting of limits – “matter of fact” (#1 Attitude therapy for manipulative patients)
Patient in acute manic phase begins to disrobe. immediate action is to place pt in seclusion. 2. Give avenues for verbalization/expression vs. Violent Patients 1.
C. “Staff 1 st used a lesser means of control for less success. appropriate nursing action includes removing patient from group meeting & accompany him to his room
B. Separate the patient from the group.” Shows a documentation that indicates a pt’s right is being safeguarded during aggressive reactions.5-1. used in acute manic. dampen mood when client is in manic.S Therapeutic Serum Level: = 0. bipolar prophylaxis. Aggressive Reaction 1.SELECTED SITUATIONS AND INTERVENTIONS: A. CODE: LITH Lithium CO3 – Eskalith. Lithobid Lithium Citrate – Cibalith . Decrease environmental stimulation
A pt who is pt watching TV suddenly throws the pillows & chair. Setting of Limits 2.5 mEq (local/CGFNS) = 0.
. if longer than 2 hours. ↑ OFI – 3 L /day. Long-term: q 2-3 months. CARDIAC. and THYROID status obtained.
A patient who is talking lithium must be placed in a normal sodium (3 gms. airway. MANNITOL (Osmitrol) osmotic diuretics Action to ↑ urine output. Early/Initial/Mild: 1. Antidote: 1. If patient forgets a dose. Avoid strenuous exercise/activities gym works 4.5. MNGT. Decrease Na = ↑ Lithium intoxication MORE dangerous!!!! AVOID the 2 dangerous “D”: diuretics & dehydration Avoid diuretics to prevent hyponatremia Avoid strenuous exercise/activities gym works Avoid sauna baths (EXCESSIVE PERSPIRATION) Avoid caffeine because it is a diuretic Stages in Lithium Intoxication I. For hypernatremia AVOID Na CO3 7. NEVER DOUBLE A DOSE!!!
Nursing Considerations: 1. DIAMOX (ACETAZOLAMIDE) carbonic anhydrase inhibitor (for open angle glaucoma) 2.) . Avoid caffeine because it is a diuretic 6. .a. 12 hours after the last dose. Increase Na = ↓ Lithium effect For hypernatremia AVOID Na CO3 Avoid taking soda and/or soda drinks
When the lithium level falls below 0. ↓ cerebral edema 3. Early in therapy: Serum levels measured q 2-3 times per week. the patient will manifest signs and symptoms of
B. dialysis for severe intoxication 4. Avoid sauna baths 5. ↑ Na – 3mg/day A. Before extracting Lithium serum level Lithium fasting 12 hrs check vital signs 2. he may take it if he missed dosing time by 2 hours. Avoid diuretics to prevent hyponatremia 3. Before lithium is begun baseline RENAL. high fluid diet (3 L of water). skip the dose and take the next dose. OF OVERDOSE: Induce emesis / lavage. This is done to facilitate excretion of lithium from the body. Avoid taking soda and/or soda drinks 8.
• The way an individual reacts to stress depends on his physiological and psychological make-up. Oliguria. PSYCHOPHYSIOLOGIC DISORDER: with real symptoms! Physical symptoms whose etiologies are in part precipitated by psychological factors and may involve any organ system. Dermatitis Nervous: Chronic fatigue. vomiting & anorexia .5 mEq 1. • Synergistic relationship exists between repressed feelings and overexcited organs. Tachycardia Gastrointestinal: Peptic Ulcer. • Emotional stress may exacerbate or precipitate an illness. Nnystagmus.Diarrhea . ulcerative colitis. Flushing. olfactory & visual hallucination 2. CONVERSION and INTROJECTION. • Somatoform disorders result in impaired social. • • • • • Cardiovascular: Hypertension.4 mEq Symptoms are 2x the initial signs III. Perspiring. PROJECTION. • Structural changes may take place and pose threat to life. Colic Respiratory: Asthma. Anuria) ARF (Kidney problem) Lithium is nephrotoxic & teratogenic 3. Hyperventilation..6 – 2.Abdominal cramps hypocalcemia metabolic alkalosis (Prolong vomiting metabolic acidosis) II. Exhaustion
. Grand Mal Seizure Cerebral hypoxia ↓LOC COMA
PSYCHOSOMATIC / SOMATOFORM DISORDERS A. Common colds.Gross hand tremors .Nausea. occupational and other areas of functioning. Moderate: 1. tactile. PSYCHOSOMATIC DISORDERS: Wwithout any organic or REAL physiological “OBJECTIVE” symptoms. Hay fever Skin: Blushing. • Defense mechanisms include REPRESSION. Severe: ↑ 2. Migraine headaches. POA (Polyuria.
Help to work through problems and learn new coping mechanism. deafness. Reinforces maladjusted behavior. b. SYMBOLISM: Symptom has symbolic value to client. Secondary gain. 2. paralysis or any other physical conditions but with no organic basis. Allow client to feel in control • Let client meet dependency needs. Control environment Don’ts: Confront client with his illness.• • •
Endocrine: Dysmenorrhea. REPRESSION: Keeps internal need or conflict out of awareness. • Help to express feelings. Client derives primary and secondary gains from the physical symptoms. Can take the form of blindness. #1 Sign is “DOCTOR SHOPPING”: Inability to accept reassurance even after exhaustive testing activities as going from doctor to doctor to find cure. NURSING INTERVENTION: Do’s: Divert attention from symptom. TYPES OF SOMATOFORM DISORDERS / PSYCHOSOMATIC DISORDERS 1. Hyperthyroidism Musculoskeletal: Cramps Others: Obesity. 2. attention. ASSESS FOR: TWO GAINS IN CONVERSION DISORDER Primary gain. CHARACERISTICS: #1 Sign “ Labelle Indifference” a. CONVERSION DISORDER: Presence of physical symptoms with NO identified physical etiology. hyperemesis gravidarum
NURSING CARE: Holistic or TOTAL – physical and emotional Understand that PHYSICAL SYMPTOMS ARE REAL and that the client is not faking and the TREATMENT OF PHYSICAL PROBLEMS DOES NOT RELIEVE EMOTIONAL PROBLEMS Develop nurse-client relationship: • Respect the client and his problems. Feed into secondary gains through anticipating client needs. HYPOCHONDRIASIS Preoccupation with an imagined illness with no observable symptoms and no organic changes. Reduce pressure on client. Provide social and recreational activities. (Not connected to the primary gain) Additional advantages: Ssympathy. signs of severe regression 55
. avoidance. ASSESS FOR • Preoccupation with body functions or fear of serious disease misinterpretation and exaggeration of physical symptoms • Adoption of sick role and invalid life-style.
Client attempts to deal with anxiety by BLOCKING certain areas out of the mind or deeply REPRESSING traumatic events. Projection. DEFINITION: Psychiatric disorder involving disruption in the usually integrated functions of consciousness.• Lack of interest in environment history of repeated absences from work • If the client is MALINGERING: Ddeliberately making up illness to prolong hospitalization. memory. o Help client refocus on topics other than the illness. or perception of the environment. and Introjection
DISSOCIATIVE DISORDERS A. • Prepare for. supportive approach but NOT focusing on the illness. assist in complete medical workup to reassure client and rule and medical problems • Psychotherapy. each of which controls the behavior while in the consciousness C. o Provide diversionary activities that build self-esteem. lifestyle. ‘faking illness’ Nursing Intervention: • Show acceptance of the client. family therapy and group therapy:
A combination of somatic and behavioral treatment modalities facilities treatment of the disorder. and interpersonal relations • Reduce anxiety-producing stimuli 56
. ASSESSMENT FINDINGS: • AMNESIA: Sselective or generalized and continuous loss of memory • FUGUE: Sstate of dissociation involving amnesia and actual PHYSICAL FLIGHT – transient disorientation where client is unaware that he has traveled to another location (Client does not remember period of fugue. A condition NOT of organic origin and usually occurs as a result of some very painful experience B. as if self is NOT REAL • DISSOCIATIVE IDENTITY DISORDER ( MULTIPLE PERSONALITY): Donated by two or more personalities. identity. NURSING IMPLEMENTATION: • Assess what form the dissociative disorder is manifesting and degree of interference in ADL.
o Meet physical needs giving accurate information and correcting misconception. o Demonstrate friendly.) • DEPERSONALIZATION: Aalteration in perception or experience of self. o Assist client understand how he uses illness to avoid dealing with his problems. sense of detachment from self. DEFENSE MECHANISMS IN SOMOTOFORM DISORDERS: Denial. Conversion. or by PSYCHOLOGICAL RETREAT from reality.
Schizotypal 2. Freudian fixation
GENERAL CHARACTERISTICS: 1. Schizoid c. Obsessive Compulsive CLUSTER A: ODD / ECCENTRIC A. antidepressant
Most appropriate intervention for Dissociative Personality Behavior includes encouraging to chart alternative personality. PREDISPOSING FACTORS & CAUSATION 1. Minor stress poor tolerance mood disturbance 4. neurologic defects & congenital predisposition 2. Antisocial d. Not caused by physiological pattern . Paranoid Personality Disorder
. Development of maladaptive behavior 3. Cluster A Disorders: Odd / Eccentric a.
PERSONALITY DISORDERS A. Cluster B Disorders: Dramatic / Erratic a. painful experiences o Hypnosis. Denial 2. Maladaptive behavior inflexible 3. Avoidant c. Narcissistic c. Passive Aggressive d. Dependent b.• •
Redirect client’s attention away from self. Cluster C Disorders: Anxious/ Fearful a.Attitude can be changed .Immature . cognitive restructuring o Behavioral therapy o Psychopharmacology: Anti-anxiety. DEFINITION: Borderline state of personality characterized by defects in its development or by pathologic trends in its structure. Histrionic b. in reality 5. increase socialization / diversional activities Support modalities of treatment: o Abreaction: aAsssisting in the recall of past.do not adjust to environment 3 CLUSTERS OF PERSONALITY DISORDERS 1. Biological predisposition malnutrition. Borderline 3. premorbid personality of individuals resembling the compensatory mechanisms associated with the pathologic counterpart. Paranoid b. B.
more interested on objects Shy.Flat affect indifferent to praise . Passive Friendliness no eye contact.Socially distant. non whispering 2. dreaming. over elaborate speech . detached. friends. e.Similar with schizophrenia CHARACTERISTICS: .avoids close relationships with family. cold and detached #1 NURSING DIAGNOSIS: Social Isolation\
C.suspicious.Magical thinking.Peculiarity in speech but no looseness of association .Loneliness suspicious/mistrust pathologic jealousy.15-40 y.Functional when works alone.. aloof.o. Consistency 3. Antisocial Personality Disorder . low IQ . Schizotypal Personality Disorder .Odd. hypersensitive #1 DEFENSE MECHANISM: Projection #1 NURSING DIAGNOSIS: Social Isolation #1NURSING CONSIDERATION/INTERVENTIONS: 1.may develop into schizophrenia or other psychotic disorders . mo touch. Schizoid Personality Disorder CHARACTERISTICS: . superstitiousness. unattached. telepathy .Diminished affective (blunted/inappropriate affect) and intellectual skills. introverted since childhood but with fair contact with reality Autistic thinking.g. emotional detachment. Proxemics: 7 feet away from the patient B.Frequent part of vagabond or transient groups of society #1 NURSING DIAGNOSIS: Social Isolation CLUSTER B: DRAMATIC/ ERRATIC A. lowest IQ . avoidance of meaningful interpersonal relationships. mostly in males .introvert.Cold/aloof limit social contact=social anxiety . peers . odd and eccentric. vague. humorless . loner.History of conduct disorder (6-11 yo)
.Withdrawn.Ideas of reference or delusion of reference .CHARACTERISTICS: Code (MOST OF THEM STARTS WITH LETTER “P”) . no laughing/giggling. eccentric. distrustful oral fixation . .
irresponsible .coprolalia (bad words) . disregard for right of others. cheats.
Efficacy of treatment is achieved for an antisocial if the patient is able to respect nurse’s & other patients boundaries. immature. manipulative .
2. reckless. authority figures .
NURSING INTERVENTION/CONSIDERATION: 1.Self-mutilation & suicidal
Therapeutic measure to prevent self-mutilation in borderline includes behavioral contract.Impulsive.Underdeveloped superego. .Impulsive. lack of guilt. cheats. physical/sexual abuse (18 months) low ego Unfulfilled need of intimacy CHARACTERISTICS: . steals.
Setting of limits prevent the patient from manipulating the nurse. does not say please.THEORIES: Ggenetic/hereditary Physical/Sexual abuse Low socioeconomic status maladaptive behaviors CHARACTERISTICS: . smooth talker
Antisocial patients have low tolerance to frustration. aggressive. destroys . intellectual. SETTING OF LIMITS – “matter of fact.” voice not high nor low. unable to learn from experience or punishment . unstable . dysfunctional family Trauma.Life-long disturbances that conflict with laws and customs . Borderline Personality Disorder .#1 Defense Mechanism: Rrationalization .Steals.Appears charming.Unable to postpone gratification. Consistency is a must regarding rules & regulation.lack remorse .
unit privilege Positive outcome for antisocial personality disorder includes adherence to rule of hospital Interventions that can be appreciated by antisocial include exchanging tokens for any
B.Low self-esteem . rapes. conscience and remorse. lies . unlawful.Randomly acting out aggressive egocentric impulses on society.hates rule/regulations.Mostly in females THEORIES: Ffaulty parent-child relationship. self-destructive.
wants to be the center of attention . manipulation. Borderline personality with a history of cutting her wrist shows an intense & a changeable affect during the middle phase of nurse-pt relationship.The purpose of behavioral contract in borderline is to limit use of unhealthy defense mechanisms
.Labile emotion. “I ran around the block rather than cutting myself”.” This statement is shown in a patient with borderline behavior. . “The policy of the unit is that.#1 DEFENSE MECHANISM: Ssplitting
“You’re the only nurse who understands me. brief.’”
C. . ‘You can’t leave in the unit in 1st 24 hrs. vain with behavior directed toward gaining attention to self. physical fights and temper tantrums
A borderline patient indicates an improvement when she state. shopping.Emotionally unstable.Disturbance in self-concept: Iidentity . “You’re a phony.Extroverted. Positive: Ccreative.Usually Men .Marked mood swings and impulsive unpredictable behavior with potential for self-destruction.More common in women. dramatic. “I’ll ensure what is necessary will be done to you
Intervention for borderline d/o includes setting of limits through saying. sex. manipulative.Exaggeration of emotion. Style of speech is excessively impressionistic . Sexually seductive or provocative .Emotional.Identity disturbance with chronic feelings of emptiness (Anhedonia) . substance abuse) . Narcissistic Personality Disorder .
. theatrical . 2-3 % of the population THEORY: Llacks Electra complex (no father figure) Papa’s girl
CHARACTERISTICS: . uses somatic complaints to avoid responsibility D.Manipulative. unstable interpersonal relationships with impulsiveness.Unpredictable behavior (gambling. I want to be just like you.Another: Mmetrosexual
. imaginative . Histrionic Personality Disorder . The patient says.Intense.” This statement shows Transference A patient borderline state. "You’re a smart nurse.” Best response of the nurse will be. You don’t know what happened to me.
envies other. rules and organization STEP TO STEP PRIORITY NURSING DIAGNOSIS: Altered Sleeping Patterns Altered Skin Integrity Ineffective Individual Coping
PRIORITY NURSING INTERVENTIONS: 1.Obsession – irresistible thought. Repression. success. beauty .CHARACTERISTICS: .Exaggerated or grandiose sense of self-importance . Give appropriate time to do rituals to decrease anxiety
. grandiosity. Symbolization # 1 Ritual: handwashing Other Ritualistic behaviors: 4 C’s: Controlling perfectionism Collects or hoarding Cleaning Checking
• • • •
Rigid. with strong need for attention and admiration from others CLUSTER C: ANXIOUS / FEARFUL A. Compulsion – irresistible action THEORIES: Genetic: Serotonin imbalance Anal fixation strict toilet training Overpowering mother CHARACTERISTICS: Cardinal Signs: RITUALISTIC #1 DEFENSE MECHANISM: Undoing.Boastful. superiority complex .More in women . perfectionist. lack of empathy -Overblown sense of importance.Vanity in personal appearance .Excessive admirations. cold affect Driven by obsessive concerns Sets high standards for self and others Preoccupied with details. Obsessive –Compulsive Personality Disorder . arrogant.preoccupied with fantasies: Ppower. egotistical. over-conscientious. inflexible.
good follower .
C. I love you & I’ll never do it again.Over sensitive to rejection/criticism 62
. helpless when alone. get these red flowers.”
CHARACTERISTICS: . TX: Tricyclics – antidepressants balance serotonin and norepinephrine Effects: 2-4 wks. preoccupied with fear of being alone .Fails to make decisions and accept responsibility→ induces others to take responsibility
A pt with Dependent personality who shows ineffective decision making should have setting of limits & make behavioral contract on its daily activities. Question most likely to elicit response for treatment of compulsive hand washing includes asking “how much has the symptom interfered with your daily activities?”
2. “I have a car key & money hidden outside the house.Most common personality disorder for Acute wife battering syndrome .lacks self-confidence. inferiority complex .” Battered wife should be referred to shelter Batterers are violent. Avoidant Personality Disorder CHARACTERISTICS: .avoid open forum .In OCD. “Mama. intervention includes giving an extra ½ hr to the pt to do the ritual before starting the task. Setting of limits avoid manipulative and controlling behaviors 4. timid.Shy. Dependent Personality Disorder . low self-esteem.Lacks self-confidence. helpless.Submissive. pls. Do not abruptly stop rituals 3. loving & remorseful (dual personality) Wife batterer has low-self esteem Honeymoon episodes in acute wife battering syndrome showing statement
reconciliation includes. Clomipramine (Anaframil) #1 drug of choice for OC Imipramine (Toframil) 2nd drug of choice
An oriented group therapy is indicated for OCD
B. clinging .Co-dependency enabling
Statement of pt that indicates ability to care for self after being victim of domestic violence includes a statement like.
loner.insecure backbiter plastic . depression. COGNITIVE/PSYCHIATRIC DISORDERS • With organic etiology • With deficits in COGNITION and MEMORY • Effects: Cchanges in levels of functioning and disturbed behavior • MOST COMMON AREAS OF DIFFICULTY (JOCAM) J – Judgment (impaired) O – Orientation (confused/disoriented.Depression.Withdrawn. anger are common . withdrawn) M. illusion/hallucination) C – Confabulation (filling in memory gaps) A – Affect (mood changes. cant finish a task
Patients with passive-aggressive personality expresses anger through passivity. anxiety. Passive Aggressive Personality Disorder CHARACTERISTICS: . rejection and failure are a possibility C. lacks self-confidence.
#1 Defense Mechanism: Rreaction formation .. with feelings of discomfort/timidity when with others -Unwilling to get involved with others and in situations where negative evaluation.
COGNITIVE / ORGANIC MENTAL DISORDERS I.loves to procrastinate.Social withdrawal = inept . tearful.
Goal of nurse in Passive Aggressive Personality includes verbalization of anger when needed Goal of Care for Passive Aggressive includes verbalization of feelings of anger when the need arises.Memory (Impaired especially for names and recent events – compensated by confabulation and circumstantiality)
DELIRIUM VERSUS DEMENTIA Delirium Acute in onset Dementia Chronic / Gradual in onset
common in men and earlier in onset. but with frontal lobe symptoms (personality changes) and reactive gliosis. meningitis. gait disturbance. Misinterpretations or hallucinations * Can have sleep – wake cycle disturbances * Changes in psychomotor activity * May experience anxiety. Vascular/Multi-infarct Dementia: Ppatchy cognitive deterioration (dependent on infarct site) appearing within 1 years of vascular injury. irritability. euphoria.
irreversible #1 Sign: Progressive memory Loss Causes: Uunknown
TYPES OF DEMENTIA Pick’s Disease: Similar picture to DAT. fear. Huntington’s Disease: Autosomal dominant (chromosome 4) disorder with both motor (chorea. sepsis such as (idiopathic) Encephalitis.Reversible #1 sign: Clouding of consciousness Or grand mal / tonic-clonic seizure Causes: Hyperthermia. drug induced Withdrawal (alcohol & cocaine withdrawal) SYMPTOMS OF DELIRIUM * Difficulty with attention * Easily distractible * Disoriented * May have sensory disturbances such as illusions. slurred speech) & cognitive changes (dementia)
The primary need of a patient with Alzheimer’s is Reorientation.Creutzfeldt-Jacob Disease: Dementia due to prions (infectious particle without DNA or RNA). Aphasia – sensory-inability for speech and communication Predisposing/Contributing Factors: Psychiatric Mental Health Nursing 3rd edition by Mary C. treated with L-dopa
Nursing care for the patient with dementia is geared towards maintaining existing functions by minimizing regression.
ALZHEIMER’S DISEASE Degenerative disease of the central nervous system characterized by premature senile retardation. Multi-infarct dementia is the second most common cause of non – traumatic dementia. Degenerative disorder of the cerebral cortex. the percentage increases to half. Parkinson’s Disease: Dopamine in the basal ganglia & extra-pyramidal system causes tremors (pill-rolling & resting). may begin at 40-65. rapidly progressive from vague somatic complaints to ataxia. ex. bradykinesia. cogwheel rigidity.
4 CARDINAL SIGNS OF ALZHEIMER’S 1. shuffling gait. Onset: Usually after 65 (2-4%).
The etiology of Alzheimer’s disease is unknown
The most common non. Agnosia – sensory–inability to recognize objects/subjects
Patient with agnosia is unable to recognize persons. Apraxia – sensory-inability for purposeful mov’t. (pg 342-343)
. Progresses to depression & dementia. Amnesia – 1st amnesia to appear: Aanterograde amnesia –recent memory 2nd amnesia to appear: Retrograde – past Tx: Reminiscing Group Therapy 4. mask-like fascies.traumatic cause of dementia is Alzheimer’s disease at 65. may die within 2 yrs or 8-10 yrs if with total care. by 85. Tremors 3. dementia then death. Townsend Exact cause unknown but several hypothesis were introduced.
1st to forget: Tthe name of an object 2nd to forget is the function of an object 2.
Place an alarm signal to know that the pt is attempting to exit in a dementia client who used to wander away from acute facility. progressive. 10% of the population has Alzheimer’s. The main pathology is the of presence of senile plaques that destroys neurons leading to decreased acetylcholine. NATURE: Gradual.
“How many glasses of water did you drink today?” - Anterograde amnesia.
. The patient can compensate for the memory loss but the family may notice personality changes and mood swing. Symptoms worsen in the evening known as “SUNDOWNING. and other symptoms & dementia. Sleeping becomes a problem. In the late stages of Alzheimer’s disease it is better to go along with the patient’s reality rather than confront him with logical reasoning. paranoia. 4) Head Trauma: Head injuries 5) Genetic Factor: Pattern of inheritance THREE STAGES OF ALZHEIMERS Early stage (Forgetfulness Stage: Mild) The first symptom of Alzheimer’s disease is Progressive memory loss. * Response of nursing assistant to an Alzheimer’s patient that Needs Further Teaching includes a statement like. The individual may not recognize family members. Individual may be unable to recall major life events even the name of spouse. The patient may notice difficulty balancing his checkbook and may forget where he put things. Middle stage (Wandering Stage/Sundown syndrome) The patient is increasingly disoriented and completely unable to learn and recall new information. and an impaired judgment. and the individual is aware of the intellectual decline. disorientation to time. and year. personality changes. Recent memory is affected including the ability to learn new information. He may wander or become agitated or physically aggressive. season. 3) Alterations in the Immune System: Aantibodies are being produced in the brain which causes a reaction against self it is called autoimmune. Asking close ended simple questions that relate to his reality is non-threatening and calming. He’s unable to speak intelligibly. memory loss. He may have bladder incontinence and may require assistance with activities of daily living. Managing daily living activities becomes progressively more difficult. Findings that are observed in the early stages of Alzheimer’s disease are inappropriate affect. Early Confusion: Symptoms of confusion begins and concentration may be interrupted. This is followed by disorientation. He’s totally incontinent of bowel and bladder. forget names. Individual may forget major event in personal history such as birthday of his/her child: experience declining activity to perform task. Disorientation in the surroundings is common and the person may be unable to recall the day. Forgetfulness: loose things.1) Acetylcholine Alteration: Ddecrease in acetylcholine reduces the amount of neurotransmitter which results in disruption of cognitive process. Late stage (Kluver Bucy like Syndrome) The patient may be unable to walk and is completely dependent on caregivers. Note that the nurse’s response in a way that is congruent is the main concern. 2) Accumulation of Aluminum: Sstudies show that aluminum accumulates in damaged areas of the brain. He may even be unable to swallow and is at risk for aspiration. There may be problems of immobility. language difficulty. individual may deny memory loss. short-term memory loss.
frequent contacts. patients plan and lead activities rather than the staff. TV & radio remote 15. Allow REMINISCING of past life / exploits / achievements. Avoid afternoon naps. 3) Keep bed in unelevated position with soft padding if client has history of seizure and keep the rails up. Tel #. Bed of confused Alzheimer’s patient must always have its side rails up.
Reminiscing helps lessen the patient’s loneliness. Decrease environmental stimulus. Diagnosis.
4) Assign room near nurses’ station.Nursing Diagnosis: Risk for trauma Nursing Intervention: 1) Milieu Therapy is needed: a CONSISTENT UNCHANGING & FAMILIAR ENVIRONMENT IS NEEDED to decrease chances of disorientation & confusion. provide an area in which the client is safe to wander. 6) Keep dim light on at night. 7) If patient is a smoker. avoid caffeine. Millieu therapy involves scientific manipulation of the improvement patient’s behavior
2) Store frequently used items within reach. Address. structured environment. Wear the Medical Alert Bracelet – (name. 8) Frequently orient patient to time. ↓ choices Consistency and ROUTINE in care to increase security. summarizing. 10. Medication) 14. Provision of simple. 12. repeating. 5) Assist patient with ambulation. stay with him/her at all times.
provided with A confused Alzheimer’s patient who gets out of bed several times must be a safe environment like placing a hand rails for the patient to hold. reinforce reality-oriented comments Ample time and patience to allow client to talk / complete tasks using associative patterns to improve recall: simplicity. Clock
environment that can influence In milieu therapy. 9) If patient is prone to wander. Family counseling about Alzheimer’s disease includes checking that pt is wearing ID bracelet when going out at all times 11. focusing.
13. REMEMBER THE 3 C’s for Alzheimer’s to DECREASE DISORIENTATION: Color. place and situation. Calendar. Soft restrain may be required if the client is disoriented and hyperactive as ordered by the physician.
If he doesn’t understand you. Speak slowly and do not shout. Talk about real people and real events. In caring for elderly w/ Alzheimer’s use short & simple words & face him while you are talking. 5) Use soft tone. 5) ADLs should follow home routine as closely as possible. Sensory stimulation for elders helps to increase pt’s arousal 2) Keep explanation simple and use face-to-face interaction. 4) Monitor for medication side effects.
Nursing Diagnosis: Self-care deficit Nursing Intervention: 1) Identify self-care deficit and provide assistance. Move slowly and maintain eye contact. repeat yourself using the same words. 3) Provide guidance and support for independent actions by talking the patient through the task. calm manner when speaking to a person with Alzheimer’s disease. simple sentences. Don’t a hurried tone. . Urinary incontinence in patient with Alzheimer’s can be controlled by decreasing fluid intake at night time 2) Allow plenty of time for the patient to perform task.
.Nursing Diagnosis: Altered thought process Nursing intervention: 1) Frequently orient the patient to reality. safety and security. Give foods high in carbohydrates to an Alzheimer’s who refuses to eat his meal
In an Alzheimer’s caregiver class. 7. Your nonverbal communication is more important than your actual spoken message. 4) Provide structure schedule of activities that does not change from day to day. and a slow. 6) Provide client’s nutritional needs. which will make the patient feel stressed. 3) Discourage rumination of delusional thinking. the nurse tells the student that the reason why pt’s do not take a bath is that they cant remember anymore if they have taken the bath already.
Monitor for flu – like symptoms. SUMMARIZED DRUGS USED TO TREAT DEMENTIA NAME DOSAGE RANGE AND ROUTE 40 – 160 mg orally per day divided into 4 doses NURSING CONSIIDERATION Monitor liver enzymes for hepatotoxic effects. However. have been approved by the Food and Drug Administration to improve cognitive function in patients with mild to moderate Alzheimer’s disease. Complication: MS Brunner and Suddarth (pg 158) 1) Infection 2) Malnutrition
Best Drug: Anticholinesterase:I increases ACH (acetylcholine) levels MS Brunner and Suddarth (pg 160) Tacrine hydrochloride (Cognex) Donezepil (Aricept) Rivastigmine (Exelon) DRUG STUDY: No cure or definitive treatment exists for Alzheimer’s disease.Screening Test: MS Brunner and Suddarth (pg 160) 1) Electroencephalography 2) Computed tomography 3) Magnetic Resonance Imaging Confirmative Test: MS Brunner and Suddarth (pg 160) Cerebral biopsy after death. and donepizel (Aricept).
. three drugs. Tacrine hydrochloride (Cognex)-monitor patient for liver toxicity Tacrine hydrochloride (Cognex)-enhances acetylcholine uptake in the brain. tacrine (Cognex). thus maintaining memory skills for a period of time. rivastigmine (Exelon).
Test stools periodically for GI bleeding. Research has shown that ginkgo produces arterial. increased catecholamines. Medical: Ggenetic predisposition. a plant extract.
3 – 12 mg orally per day divided into 2 doses
16 – 32 mg orally per day divided into 2 doses
Monitor for nausea. leading to improved tissue perfusion and blood flow. and insomnia. Behavioral: Aattention-seeking by rejecting foods.
BEST HERBAL DRUG FOR ALZHEIMERS: Enhancing memory with ginkgo biloba Ginkgo biloba. vomiting. loss of appetite. Family interaction: Aambivalent feelings towards mother. Adverse effects are uncommon but may include GI upset or using anticoagulants. Monitor for nausea. 3. Controlling intake and weight gain is a way the client establishes a sense of control over her life. manipulation to gratify needs 2. EATING DISORDERS #1 CAUSE: Unknown #1 Personality Disorder of Eating Disorders: Obsessive Compulsive Personality THEORIES OF CAUSATION: 1. Psychoanalytic: Rregression to oral and anal developmental stage to avoid adolescent sexuality and independence 4. diarrhea. lack of personal boundaries and independence. rigidity. The issue of CONTROL is a central one for the client with anorexia nervosa.Donepezil (Aricept)
5 – 10 mg orally per day
Monitor for nausea. vomiting. and syncope. hypothalamus dysfunction
. It is believed that symptoms are caused by stressor that the adolescent perceives as a loss of control in some aspect of her life. venous. overprotection. use of anorexia to avoid interpersonal conflicts. abdominal pain. and capillary dilation. contains several ingredients that many believe can slow memory loss in people with Alzheimer’s disease. and loss of appetite. dizziness.
fluctuation of body weight There is ACCEPTANCE . bradycardia.chipmunk face #1 Cause of death: cardiac dysrrhythmia --.Patient’s with eating
disorders are usually high achievers. electrolyte imbalance Hyperactivity.carbohydrate.↓ 15-20% ideal weight Defective defense mechanism: Denial Poor to fair prognosis
CHARACTERISTICS . which makes it difficult for the nurse to convince them to eat.introvert . difficulty accepting nurturance & caring Feelings of loneliness and isolation Hypotension.good prognosis acceptance . Leukopenia Skin problem: Hyperkeratosis (overgrowth of Complications: horny layer of epidermis) .strenuous exercise . ↑ caloric fast foods .All are females .4 % are Boys .
Resistance to treatment.loves to cook -abuses laxatives/enema . perfectionist and preoccupied with food.Bulimic patients are usually aware of their abnormal behavior.dental carries .hoards/collects food .vegetarian . Hypokalemia ECG ST segment depression
. Constipation.ANOREXIA .Binge/purge syndrome Binge eating: Eating increased amounts of high calorie food in a short period of time. hypoglycemia.Adolescent 11-17 yo .Amenorrhea lanugo
. CHARACTERISTICS .esophageal varices .young adults . amenorrhea Reduced metabolism. hypothermia Secondary sexual organ atrophy. reduced hormonal functioning.
OTHERS: Refusal to take meals → dramatic weight loss
Anorexic patients usually suppress their appetite. -2 binge-eating episodes or more per week for 3 months .callous finger Complications: .
Long term treatment for anorexia/bulimia includes outpatient family therapy sense of control over herself is a positive outcome in eating disorder. F/E imbalance 2.
STEP BY STEP NURSING DIAGNOSIS: 1. attainable short-term goals Provide support is developing better outlets for emotional expression. type of foods. Caring and nurturance when possible c. Altered Body Image
Change of body image causes difficulty in self-esteem. Provide education 1) on growth & development and normal nutrition 2) Limit setting: Bbased on weight gain or loss. prevents the patient from inducing vomiting. gain less than 100 g. use behavioral contract to enforce limits 2. Encourage outside interests not related to food Provide teaching on therapeutic diet: Bbalanced. Loss – complete bed rest. amenorrhea • Interpersonal relationships PROVIDE A STRUCTURED ENVIRONMENT that offers safety and comfort and helps DEVELOP INTERNAL CONTROL→ reduces need to control by self-starvation. Fluid volume deficit – hypovolemic shock 3. F/E imbalance 2. time and place of eating. Feedings: Ooral. more than 200 gmay ambulate in the hospital • Eating patterns: Aamount. hypotension. weighing 3x a week: Ssame time.
• Presence of anemia. monitor hydration and electrolytes
An anorexic patient with high urine specific gravity must be encouraged to have an increase fluid intake
b. grant or restrict privileges.with bathroom privileges. DIETARY THERAPY → restoration and stabilization of nutritional and fluid balance a. ASSESS AND EVALUATE: • Weight and % of normal body weight loss. whether food is forced or followed by vomiting. Limit activity based on weight gain: For wt. Provide surveillance 30 min. IV or tubes. bradycardia. 5. 4. Fluid volume deficit – hypovolemic shock 3.& Prominent U wave
STEP BY STEP NURSING DIAGNOSIS: 1.Altered Nutrition less than body requirement
NURSING INTERVENTION FOR EATING DISORDERS 1. 6. Altered Nutrition less than body requirement 4. calories restriction to effect WEIGHT GAIN (1-2 pound per week)
. clothing and weighing scale. to 1 hr after meals
• Preventing the patient from using the bathroom for 2 hours after eating. Help client accept eating problem and set realistic.
social. psychological. and cognitive symptoms indicating that a person persists in using the substance. & 3) Praise/reinforce compliance
Best discharge plan for anorexic teen includes attending a support group
DRUG ADDICTION/NONALCOHOLIC SUBSTANCE ABUSE SUBSTANCE ABUSE TERMS AND DEFINITTIONS TERMS Psychoactive substance DEFINITIONS A substance that affects a person’s mood or behavior Continued use of a psychoactive substance despite the occurrence of physical. behavioral. whereby withdrawal symptoms occur if the drug is not used
. Instruct and support in behavioral modification program: 1) Control speed of eating – chewing food well. accept lapses (behavior modification) 8.7. or occupational problems A range of physiologic. Offer PRAISE for progress. ignoring serious substance-related problems The body’s physical adaptation to a drug. 2) Self monitoring w/ food diary.
obsession with the drug. It also refers to the decreasing effect of the drug. impaired thinking. decreased tolerance. neglect of personal needs. and physiologic deterioration
Concurrent use of multiple drugs
An altered physiologic state resulting from the use of a psychoactive drug Accidental or deliberate consumption of a drug in a dose larger than is ordinarily used. resulting in a serious toxic reaction or death Tolerance is the need for the increasing amount of a substance to produce its desired effect. loss of control.Psychological dependence
The emotional need or craving for a drug either for its effect or to prevent the occurrence of withdrawal symptoms A compulsion. unkept promises to stop usage. A state whereby the effect of a drug is decreased and greater amounts are required to achieve the desired effect because the person has become tolerant to a similar drug
. and progressive pattern of drug use. characterized by behavioral changes.
Any factor that increases the likelihood of an event occurring The ability of one drug to increase the activity of another drug when taken at the same time Any use of a drug that deviates from medical or socially acceptable use
The coexistence of a major psychiatric illness and a psychoactive substance abuse disorder An acute situation in which a person experiences a period of memory loss for actions as a direct result of using drugs or alcohol Discontinuation of a substance by a person who is dependent on it The process of withdrawing a person from an addictive substance in a safe manner The amount of a drug that produces a poisonous effect The tendency to relapse into a former pattern of substance use and associated behaviors
The return to a normal state of health. needle marks on arms along path of a vein (wearing of long. abdominal cramps. and spiritual arenas of a person’s life
A. yawning. marital failures. violent acting out ● Physical Examination: Mmalnutrition.sleeves). misinterpretation of stimuli ● Defensive Coping related to denial of problem. projection of responsibility or blame. intake of mind-altering substances. intellectual. personality change. nasal discharge with nasal septum perforation (cocaine) ● Social: Inability to maintain ADL and fulfill role responsibilities and obligations B. ASSESSMENT FINDINGS ● History. whereby the person does not engage in problematic behavior and continues to meet life’s challenges and personal goals Complete abstinence from drugs while developing a satisfactory lifestyle Voluntarily refraining from activities or the use of substances that cause problems in the physiologic. stealing to support habit. POTENTIAL: ● Altered health maintenance/nutrition related to chemical dependence. lack of interest in food ● High Risk for Violence: Ddirected toward self or others related to feelings of suspicion or distrust. diaphoresis. rhinorrhea 10 hours after the last opiate injection. social. Academic or job failures. rationalization of failures NON-ALCOHOLIC ABUSED SUBSTANCES DRUG OPIATE or SX OF ABUSE/ INTOXICATION Euphoria → SX OF WITHDRAWAL Chills and TREATMENT Naloxone (NARCAN)
. lacrimation. psychological. NURSING DIAGNOSES.
meth. and temperature. dilated pupils. 3. RP. Grandiosity Hypervigilance. and weight loss/anorexia Fatigue Anxiety Depression ↑ BP and PR Tachycardia Tremors Convulsions Delirium Hallucinations Anxiety Insomnia Depression Fatigue Apathy Disorientation Irritability Altered sleep Sodium bicarbonate → excretion Activated charcoal. irritability. Ice. muscle spasm (legs). rhinorrhea. diaphoresis. 2. junk. abdominal pain.
Demerol Morphine Codeine Nalbuphine
HEROIN. crystal. respiration. decreased selfesteem. Temp Hyperactivity. smack. pink ladies) Phenobarbital Nembutal STIMULANTS (Upper. 4. weakness. speed.
Anxiety → Sadness → Insomnia
Narcotic Withdrawal causes muscle ache.Horse and Fine China)
Marked respiratory depression PinpointPupils . Crank Amphetamines Dexedrine
Slurred speech Respiratory depression ↓ BP and PR Ataxia/ impaired coordination Drowsiness Seizures. use gastric lavage
. . Hyperpyrexia Ventricular dysrhythmia
Lacrimation (Watery eyes) RUNNY NOSE YAWNING ↑ BP Dilated pupils Cramps Muscle SPASM Nausea.(Horse. gastric lavage
ANXIOLYTICS: Minor tranquilizers Valium Librium Barbiturates(Downes. pills. VOMITING Panic. depression
the #1 antidote for Opioids or Narcotic intoxication METHADONE for Heroin Withdrawal :
1. rainbows. anxiety 1st 12-72 hrs: -sleep disturbances.
Activated charcoal. tremors.NARCOTICS:
A CNS depressant can cause decreased blood pressure. Uppers. piloerection. Smack. diarrhea. pulse. pep. PR. Coma ↓ Memory Euphoria Agitation ↑ BP. VS changes.
Personality changes. Dilated pupils
Cocaine is characterized by. Amino acid therapy is utilized to facilitate restoration of depleted neurotransmitters. Inhaled) “Coke” “Crack” “Snow” “Blow” “Lady” “Powder”
Nasal septum perforation Irritability. Fatigue joint. vivid dreams and hypersomnia or insomnia and psychomotor agitation. Seizure Coma. Mania. Psychosis similar to paranoid schizophrenia None
Cocaine use leads to dopamine deficiency. Agitation Convulsions Coma Cannabis #1 sign RED EYES Derivatives: (irritated conjunctiva) Marijuana (mary jane.Methamphetamine
Euphoria. Inhaled) Angel dust. Hog. Conjunctival Hash. Injected. Temp Delirium. grass. Appetite suppression. Injected. Insomnia. Antisocial behavior
Cocaine (Oral. Pot. rocket fuel)
Hallucination Incoherence ↑ confusion Dilated pupils ↑ BP.
Hallucinogens: LSD (acid) (PCP :Oral. weed. Weed) Congestion ↑ appetite Euphoria Relaxed inhibition Dilated pupils Psychosis
Small doses of Valium
Hyperactivity Insomnia Dry mouth Sexual arousal Visual hallucinations
Most effects wear off in 58 hr ‘ talk down’ client
Another word for alcohol is “Booze” “Brew” GENERAL PRINCIPLES OF CARE: ALCOHOL DETOXIFICATION 3 A’s = Alcohol Withdrawal Aversion Therapy (Punishment)
shaving cream. Nausea & Vomiting 2. astringent. cough syrup/elixir. Diarrhea 3. Maintenance Phase = 250 mg & ↓ >Prohibited Household items with alcohol: mouthwash.” shows denial
CAGE SCREENING QUESTION FOR AN ALCOHOLIC C cut down alcohol (Do you need to cut down alcohol?) A annoyed (Are you annoyed when someone will ask you “Are you an alcoholic?) G guilty (Are you guilty of taking too much alcohol?) 79
. How much alcohol have you taken for the last 24-48 hrs?
In a detoxification unit. fruitcake.”
> Screening Questions for alcohol abuse: 1. and toner. Goal in alcohol detoxification includes maintaining maximum physical integrity during withdrawal period.
Effect of Antabuse with Alcohol 1. acetone/nail polish
Cough medicines and other over-the-counter medicines are alcohol-based and may cause antabuse reaction when it is combined with antabuse. “I can quit whenever I want.Antabuse (Disulfiram) = no effect unless mixed with alcohol Action: Iinhibit Antabuse effect Acetaldehyde dehydrogenase > Dosage: Acute phase = 500 mg in 1st 2 wks. the nurse asks the pt when was the last time he drink alcohol to determine the onset of alcohol withdrawal syndrome. Antabuse may worsen renal damage thus it is contraindicated for patients with renal problems.” Is a statement like.“ The group activity may not seem helpful to you but you can help them. vinegar. When was the last time you have taken alcohol? 2. Statement of a pt who is alcoholic and undergoing detoxification saying. “I don’t want to attend group meeting. Abdominal cramps > Short term objective for an alcoholic: Tto stop/cut denial Long term objective: Abstinence (similar with STD/HIV/AIDS) > # 1 group therapy for Alcoholics (12 step recovery program – AA (Alcoholic Anonymous) for victims of alcoholics: AL-ANON for alcoholic teens: ALATEEN
Correct response of an RN to alcoholic patient who says. Intense headache 4. I don’t need their alcoholic advice.
Visual hallucination Intervention: > Use lampshade to ↓ shadow (illusions)
. Wernicke’s Aphasia / Receptive Aphasia: Pproblems in interpretation (temporal lobe) B.2 – severe alcohol intoxication > 4 Common Complications with History of Alcoholism 1.
Wernicke’s’ psychosis is due to thiamine deficiency. B1 (thiamine) (Sx: Ttingling sensation/numbness of extremities: Aavoid electric blankets!)
syndrome. Hallucination – #1 hallucination of Alcohol withdrawal is TACTILE
Nursing diagnosis for patient with delirium tremens who says. Korsakoff’s Psychosis – irreversible (the best drug is Risperidone (Risperdal): Iit has Decrease extrapyramidal symptoms (EPS) 4 Stages of Alcohol Withdrawal I. Confabulation or making up of stories is one of the initial manifestations of Korsakoff’s
Two categories of Wernicke’s Korsakoff’s: A. Gastritis inflammation 3. Pancreatitis 4.E eye opener (stimulant) Do you use an eye opener early in the morning to decrease the after effects of alcohol? 3 Stages of Alcohol Intoxication I.15-0.04 -0. Wernicke’s Korsakoff’s peripheral neuritis lack of Vit.08-0. Alcohol Serum Level = 0.1 or 100 mg/dl > slurring of speech > Fruity odor similar to ketoacidosis > Legal intoxication III. diaphoresis. restlessness.05% > unsteady gait > ↓ social & sexual inhibition II. tachycardia. hyperventilation &
Symptoms of alcohol withdrawal is observed when the cup rattles to the side when the patient stirs his coffee
II. Early/Initial – Fine tremors. “There are bugs in my bed crawling over me” is Altered Thought Process
2. ASL = 0. Liver Cirrhosis 2. ASL = 0.
restlessness.↑ ICP 5. High pitch cry/projectile 3. which frequently occur in alcohol withdrawal syndromes.Leaving a light on the patient’s room will decrease visual hallucinations.
Shadow stimulates hallucination don’t leave the patient (Offering of self)
episodes. hallucinations and elevated vital signs. Headache & Aura.
Observation indicating a need to be included during endorsement to next shift in an alcoholic patient in the ER include observations of becoming fearful (delirium tremens)
DRUGS CAUSING DELIRIUM Anticonvulsants Anticholinergics Antidepressants Antihistamines Antipsychotics Aspirin Barbiturates Benzodiazepines Cardiac glycosides Cimetidine (Tagamet) Hypoglycemic agents Insulin Narcotics Propranolol (Inderal) Reserpine Thiazide diuretics
MOST COMMON CAUSES OF DELERIUM
. Assigning a staff to the patient promotes safety especially during withdrawal
III. illusions. Delirium Tremens Active Seizure = Grand mal/Tonic-Clonic
Delirium tremens is initially manifested by anxiety. Epigastric pain (early sign in eclampsia) 2. Pre-seizure/RUM FITS Impending signs of Seizure 1. Eye pain/periorbital pain (scotomas) usually in eclampsia 4. Restlessness cerebral hypoxia = ↓ 02 & glucose IV.
hypo. head injury. and hypnotics Reactions to anesthesia. HIV. Librium (Clordiazepoxide)
Positive) outcome of Librium in alcoholic depressed woman includes an observation that client can pick an object on floor w/ smooth coordination
3. thyroid or glucocorticoid disturbances. Phenytoin (Dilantin) best anticonvulsant for children SE: Ggingival hyperplasia & red orange urine Intervention: Mmassage the gums & use soft bristle toothbrush Adverse Effect: Blood dyscrasia. niacin. Klonopin (Clonazepam) 4. lithium. pneumonia Cerebral: Mmeningitis.000active bleeding Special Considerations: The only COMPATIBLE I. paint solvents.000. syphilis Intoxication: Aanticholinergics. alcohol. prescription medication or illicit (street) drugs
COMMONLY USED ANTICONVULSANTS 1. thiamine or vitamin B12 deficiency. cardiovascular shock. sleep deprivation. Carbamazepine (Tegretol): Anticonvulsant trigeminal neuralgia (tic douloureux) A/E: Agranulocytosis/neutropenia – S/Sx: Ssore throat Neutrophils 54-56 % 82
. encephalitis.thrombocytopenia S/SX: Bbleeding of the gums Lab test: Pplatelet count = 150. sedatives.Physiologic or metabolic
Hypoxemia. electrolytes disturbances. brain tumor. urinary tract infection. vitamin C. if ↓100. Solution for Phenytoin (dilantin) is NSS (Normal Saline Solution) 5.V. or protein deficiency.or hyperglycemia.000-400. Valium (Diazepam) best drug for delirium tremens 2. and exposure to gasoline. dehydration. renal or hepatic failure. and hypnotics Withdrawal: Aalcohol. insecticides. and related substances Systemic: Ssepsis. sedatives.
will ↑ respiratory depression if barbiturates have also been used METHADONE – drug substitute used for acute withdrawal and long-term maintenance. 1. or children and other nonconsenting individuals. Antidepressants block the ‘high’ from stimulant abuse G. temperature. LOC D. FETISHISM: Sexual gratification from an inanimate object (usually clothing material) substituted for the genitals 3. protect from injury
A pt taking phencyclidine (PCP). and decreasing stimuli. Check for trauma. Prevent and control seizures. multivitamins. Keep in calm. pulse. DRUG OF CHOICE when in doubt the substance used because NALOPHINE (NALLIN). which is administered under supervision. Valproic Acid (Depakene/Depakote) therapeutic serum level: 40-100 mcg. quiet environment E. Monitoring: BP. SEXUAL DISORDER: Ddeviations in sexual behavior. staying w/ the pt.
GENERAL PRINCIPLES OF CARE: DETOXIFICATION/OVERDOSE A. high-protein. public transportation) 4. sexual behaviors that are directed toward anything other than consenting adults or are performed under unusual circumstances and are considered abnormal B. respiration. Detoxify / treat overdose NALOXONE (NARCAN) – Pure antagonist to narcotics-induces withdrawal and stimulates respiration. thiamine and folic acid help decrease withdrawal symptoms. EXHIBITIONISM: Sexual gratification from exposing genitalia 2. a partial antagonist to narcotics. changes an illegal to a legal drug. Start IV line C. FROTTEURISM: Sexual gratification from toughing or rubbing against a nonconsenting person (usually in crowds.
Administer ordered drugs. high-vitamin
SEXUAL DISORDERS / DYSFUNCTION A. Maintain airway: Iintubation (keep airway on hand). Nutrition: Hhigh-calorie. appropriate nursing intervention includes seclusion. MASOCHISM: Sexual gratification from self-suffering used as an accompaniment of the sexual act or substitute for it
. Adverse Reaction: Hepatotoxic (assess SGPT or ALT) 7. shouts & walks back & forth. Ethosuccimide (zarontin)
Chlordiazepoxide (Librium).6. suction B. the pain to self or partner. PARAPHILIA: Sexual fantasies or urges that are directed toward nonhuman objects.
Anxiety related to threat to security and fear of discovery 2.# 1 screening test – DDST (Denver Developmental Screening Test) . 2. GENERAL PRINCIPLES OF CARE Acceptance NOT of the behavior but of the client who is in emotional pain Protection of the client from others Setting limits on the sexual acting out Supporting of self-esteem: Aavoidance of punitive remarks or responses Provision of diversional activities PERVASIVE DEVELOPMENTAL DISORDERS CODE: ACA Autism. Ccatatonic
. SADISM: Sexual gratification from inflicting pain or cruelty to others used as an accompaniment of the sexual act or a substitute for it 7. Llikes to follow bright moving objects 4. Blank stare 2. VOYEURISM: Sexual gratification from watching the sexual play / act of others 9.talented in music or math . Rrepetitive movement: head banging padded room/helmet 3. AUSTITIC DISORDER A. Attention Deficit Hyperactive Disorder (ADHD). NURSING DIAGNOSES 1. Sexual dysfunction related to inability to achieve sexual satisfaction without the use of paraphilic behaviors 5.mostly males . D. 1.5. 5. 3. acquired or lifelong inhibition or interference with any of the phases of the sexual responses which may be due to psychogenic factors alone or psychogenic and biologic combined. PEDOPHILIA: Sexual gratification from children 6.Autism is usually diagnosed during the toddler stage. Potential for injury / violence related to sexual behavior and retaliation for sexual behaviors E. Anxiety related to conflict between sexual desires social norms 3. A type of developmental disorder for an unknown. 4. ZOOPHILIA: Sexual gratification from animals C. Conduct Disorder. SEXUAL DYSFUNCTION: Generalized or situational. probable underlying problem: failure to develop satisfactory relationships with significant adults . TRANSVESTISM: Sexual gratification from wearing clothes of the opposite sex 8. Potential for infection related to frequent changes in sexual partners or sadistic or masochistic acts 6. Sexual dysfunction related to actual or perceived sexual limitations 4. CHARACTERISTICS: 1.
if necessary. Poor communication skills. Prevent acts of self-destructive behavior 5. Behavior modification in an autistic child enables the nurse to modify the child’s maladaptive behavior. Easily agitated by noise & color (orange/yellow) B. Withdrawal from reality. Ttemper tantrums 6. steering mechanisms due to profound interference in intellect 5. Poor interpersonal relations. never leave alone. Set consistent and firm limits for his behavior 3. routine ADL in familiar environment 2. Cclings to inanimate objects B. group. Accept the client’s need to push but still maintain regular contact. turns to inanimate objects and self-centered activities for security 4. Provide consistent. Hyperactive could not sit and stay in 15 minutes 2.
ATTENTION-DEFICIT HYPERACTIVITY DISORDER (ADHD) A. consistent care giver. NURSING DIAGNOSIS: Potential for Injury D. ASSESSMENT FINDINGS: 1. ● Psychotherapy: Pplay. Autistic thinking. individual therapy
Primary treatment goal to facilitate the recovery of an autistic child should include playing with blocks not with balls . in ego system formation: Iinability to distinguish between self and reality / environment → speaks of self in the third person 2. NURSING IMPLEMENTATION: 1. 3. and always provide safety. ↑ Serotonin . consistent loving home care is still favored over hospitalization. Provide appropriate therapy: ● Removal from home. Make physical contact on a regular basis. Personality alteration – adaptive. Association looseness. SEVERE AUTISM – Severe apathy. handwriting not legible 4. inhibitory. Ambivalence. Poor intellectual functioning C. 4.
Occupational Therapy #1 behavior modification #2
Pharmacology: Tranquilizers and amphetamines to reduce symptoms
Caring autistic children requires specialized skills. ↑metabolism fatigue 3. ASSESSMENT 85
.5. Poor grasp of reality. Lacks meaningful relationship with outside world. Disturbance in sense of self-identity. Disruptive behavioral disorder evident before 7 years old and lasting at least 6 months and characterized by hyperactivity and inattentiveness THEORIES: ↑ Norepinephrine.#1 Screening Test DDST CHARACTERISTICS: 1.
attainable goals Provide firm. Easily agitated by noise & color (orange/yellow) NURISNG IMPLEMENTATION: Set realistic. 2. DIET: ↑caloric content – finger foods 3.5. Excessive impulsiveness 4. ↑metabolism fatigue 3. #1 Therapy: Occupational Therapy using behavior modification 2.” indicates efficacy of the drug. DEFINITION: Physical abuse and emotional neglect. a drug for ADD/ADHD enhances catecholamine effect. insomnia and suppression of appetite.
Psychostimulant – to increase attention span 2.
CHILD ABUSE A.
C. Do not mix Caffeinated food/drinks with ACA/alcohol 5. 3. may include sexual abuse B. ASSESSMENT:
. Short attention span 3. consistent discipline with opportunities to experience satisfaction and success Provide a structured environment● With a balance of energy expenditure and quiet time ● With learning experience utilizing child’s ability ● With exercise in perceptual-motor coordination ● With LESS STIMULATION
The priority needs of the child with ADHD are safety and provision of inadequate nutrition. handwriting not legible 4. Stratera ( Atomoxetine) newest psychostimulant!! Contraindication: Ddo not give below 6 yo hepatotoxic SGPT
Stratera. CAUSE: Exact-unknown. Present in all socioeconomic levels C.
4. Dextroamphetamine (Dexedrine) 3. “My son is able to accomplish his task better. Administer drugs as ordered: RITALIN (methylphenidate) or dextroamphetamine sulfate
5. the drug of choice for ADHD causes growth suppression. Severe inattentiveness with or without hyperactivity 2.
1. Pemoline (Cylert) very hepatotoxic!!! 4.
Catching attention of a child with ADD includes getting him to look at his mom & give him simple directions. Tx: 1. 1. RITALIN (Methylphenidate: BEST GIVEN AFTER BREAKFAST) Always with meals
Ritalin. Vitamin B Complex ↑ appetite 4. Statement like. Squirming and fidgeting Hyperactive could not sit and stay in 15 minutes 2.
therefore the nurse has to deal with her feelings first. disturbance on parent-child interaction (Absence of PROTEST on admission of a toddler is a sign of abuse. and can do 6) With inadequate resources and support system
Abusive parents usually have low-self-esteem and has little social involvement.
Notify the legal authorities about reports of a battered 7 y/o girl is part of the responsibilities of an RN
D. Child abuse is common in the lower socio-economic class. cause of injury. POTENTIAL NURSING DIAGNOSES 1) Impaired Skin Integrity 2) Infective Family Coping E. dependent. NURSING IMPLEMENTATION • FIRST: Meet physical needs. STDs • History: Parents who were abused as kids ○ Other characteristics of abusive parents: 1) Tend to be young. immature. 20 Low in self. lacerations. which are lacking in abusive parents. TAKE PICTURES)
• • •
EMOTIONAL SUPPORT to child: PLAY THERAPY to express feelings.esteem 3) Lacks identity 4) Expect child to provide them with love and care (PERSONAL ROLE THEORY of causation) 5) With incorrect concept of what the child is. In working with the mother of abused child. location. The interaction between the abuse child and a mother provides a clue to the kind of relationship that this child has with his mother. therapeutic use of self requires self awareness initially.) ● Inconsistency of declaration of the type.● Obvious physical injuries. discovery of undeclared / unreported fractures ● Malnutrition / failure to thrive / emotional neglect ● Sexual abuse signs: Ggenital bruises. Attendance to a parenting class is a step towards learning parenting skills. treat injuries • MANDATORY: REPORTING of suspected cases to appropriate agency (SAVE EVIDENCES. NONJUDGMENTAL ATTITUDE toward parents ROLE MODELING for parents who are encouraged to care for child DOCUMENTATION of ACTUAL FINDIGNS not interpretation nor opinion
clothes. fecal or urine smell. or other health hazards in the elder’s living environment Rashes.• POSSIBLE INDICATORS OF ELDER ABUSE Physical abuse indicators • • • • Frequent. sores. or denial of their existence Disorientation or grogginess indicating misuse of medications Fear or edginess in the presence of family member or caregiver
Psychological or Emotional abuse indicators • • • • Helplessness Hesitance to talk openly Anger or agitation Withdrawal or depression
Financial abuse indicators • • • • • • Unusual or inappropriate activity in bank accounts Signatures on checks that differ from the elder’s Recent changes in will or power of attorney when elder is not capable of making those decisions Missing valuable belongings that are no just misplaced Lack of television. unexplained injuries accompanied by a habit of seeking medical assistance from various locations Reluctance to seek medical treatment for injuries. or personal items that are easily affordable Unusual concern by the caregiver over the expense of the elder’s treatment when it is not the caregiver’s money being spent
Neglect indicators • • • Dirt. or lice on the elder Elder has an untreated medical condition is malnourished or dehydrated not related to a known illness 88
squandering. unresponsive Lack of toilet facilities. problems. or to see anyone without the presence of the caregiver Attitudes of indifference or anger toward the elder Blaming the elder for his or her illness or limitations Defensiveness Conflicting accounts of elder’s abilities.
. living quarters infested with animals or vermin
Warning indicators from caregiver • • • • • • Elder is not given opportunity to speak for self. refusing needed medical attention . or giving away money while not paying bills Inability to manage activities of daily living such as personal care. substance use Failure to keep needed medical appointments Confusion. and so forth Previous history of abuse or problems with alcohol or drugs.•
Indicators of self-neglect • • • • • • Inability to manage personal finances. housework Wandering. to have visitors. isolation. shopping. memory loss. such as hoarding.