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Self-esteem
Love and Belongingness

Love and Belonging
Needs






Safety and Security
Physiologic (survival)
M U L T I - E D U C A T I O N A L R E V I E W G R O U P E X P E R T S , I N C .

MAKATI* CAVITE * PAMPANGA * CABANATUAN* BAGUIO * TUGUEGARA* VIGAN * LUCENA * MORAYTA*
DAVAO *BACOLOD * KIDAPAWAN* ILIGAN * GENERAL SANTOS*BULACAN* ILOILO * CEBU*
MANILA HEAD OFFICE


CARE OF THE CLIENTS WITH PSYCHOSOCIAL ALTERATIONS MENTAL HEALTH NURSING

PSYCHIATRIC NURSING
An interpersonal process whereby the nurse assist an individual, family or community, to promote mental health, to prevent or cope with the experience of mental
illness and suffering and if necessary, to find meaning in these experiences

GENERAL CONCEPTS OF MENTAL HEALTH AND ILLNESS

MENTAL HEALTH
A state of emotional, psychological and social wellness
- Satisfying interpersonal relationships
- Effective behavior and coping
- A positive self-concept
- Emotional stability
State of adjustment with maximum effectiveness and satisfaction.
Fundamental for personal happiness
Contentment, achievement, optimism and hope
Absence of mental and behavioral disorder or disturbances

MENTAL ILLNESS
Ones view of an act
The reaction of others
Overall cultural context in which the acts occur
Often a matter of adjustment not a matter of a act


NEEDS
Organismic condition which exists within the individual which demands
certain activities
A state of tension which disrupts ones equilibrium
Produces a relative degree of discomfort
From metabolic processes, relationship with the environment and symbolic
behaviors.














*In Psychiatric Nursing: Safety is always a PRIORITY!

PERSONALITY DEVELOPMENT

PERSONALITY
Individuals internal and external adjustment to life.
Integration of behaviors that is lifelong
Integration of traits which can be investigated or described in order to
render and account of the unique quality of an individual
All that an individual is, feels and does consciously and unconsciously
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SIGMUND FREUDS PSYCHOSEXUAL THEORY
Psychoanatomically, personality has three basic
parts whose internal conflict and balance
produce behavior (Structures of Personality):






Postulated that the mind consist roughly of three overlapping
divisions/levels of awareness:









Personality development is equated to psychosexual development (libido)
Maturation of the sexual instinct is the last step in the maturation of
emotional development
Each stages interests become permanent parts of the personality
The stages of Psychosexual Development:


ERIK ERIKSONS PSYCHOSOCIAL THEORY

Psychosocial maturity
Everyone goes thru a developmental stage
featured by a developmental task that must be
successfully completed if the succeeding tasks are
being resolved in turn
There is interplay between the positive and
negative outcomes inherent in each task
Womb to tomb
The Psychosocial stages are:

AGE-GROUP AGE DEVELOPMENTAL TASK VIRTUE
Infant 0-18 mos Trust vs Mistrust Hope
Toddler 18 mos- 3 yrs Autonomy vs Shame and
Doubt

Will
Preschool 3-5 yrs Initiative vs Guilt Purpose
School Age 6-12 yrs Industry vs Inferiority Competence
Adolescence 12-18 yrs Identity vs Role
Diffusion/Confusion

Fidelity
Young Adult 18-25 (30) yrs Intimacy vs Isolation Love
Middle Adult 25 (30)-65 yrs Generativity vs Stagnation
Care
Maturity 65 yrs death Ego-Integrity vs Despair Wisdom


HARRY STACK SULLIVANS INTERPERSONAL THEORY

Personal interrelationships
Self-image and self concept organizes behavior
and is built as a result of his experience with
significant other persons and their reflected
appraisals
Emphasizes social factors
Maturation of inter-relational skills leads to
personality maturation
Stages of Interpersonal Model are:


PRINCIPLE
Id Pleasure
Ego Reality
Superego Moral
LEVEL DESCRIPTION
Conscious Involves experiences which can be recalled at will
without any effort
Preconscious Involves experiences which can be recalled at will
but with some effort
Unconscious Involves experiences which cannot be recalled at
will
STAGE AGE FOCUS MAJOR
CONFLICT
Oral Birth to 18 mos mouth,lips,tongue Weaning
Anal 18 to 36 mos Bladder Toilet training
Phallic
3 5 yrs

Genitals
Penis envy
Fear of castration
Oedipal complex
Latency 5-11 or 13 yrs
(puberty)
School work, sports
Genital 11-13 yrs Capacity for the intimacy
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STAGE AGE CHARACTERISTIC
Infancy Birth - 1 yrs Crying to establish contact with others
Childhood 1 - 6 yrs Language assists with learning to delay
gratification of needs
Juvenile 6 9 yrs Competition
Compromise
Cooperation
for developing relationships with peers
Preadolescence 9 -12 yrs Love assist in the development of
chum relationship with a person of the
same gender
Early Adolescence 12 -14 yrs With sexual desire in establishing
relationship with person of the opposite
sex;
Independence developed
Late Adolescence 14 21 yrs Interdependence is learned
Learns lasting sexual relationships

JEAN PIAGETS COGNITIVE THEORY
Motor activities involving concrete objects results in the
development of mental functioning (learning)
New operation building on already existing ones
Increasing integration and coordination
Maximal learning through the process of contemplative
recognition
Stages of cognitive development are:
STAGE AGE CHARACTERISTIC
Sensorimotor Birth 2 yrs Begins to form mental images
Object permanence: tangible objects do
not cease to exist just because they are
out of sight.
Develops sense of self as separate from
the environment
Preoperational 2 6 yrs Expresses now self with language
Understands symbolic gestures
Begins to classify objects
Concrete
Operational
6 12 yrs Thinking is still concrete
Begins to apply logic to thinking
Spatiality,Reversibility is being
understood and able to apply rules
Formal Operational 12 -15 yrs Think and reason in abstract terms
Further develops logical thinking and
reasoning
Now achieves cognitive maturity

LAWRENCE KOHLBERGS MORAL DEVELOPMENT
Moral development depends primarily on cognitive
development
Moral development goes hand in hand with
thinking and judgment
The Stages of Moral Development are:
SUMMARY OF PERSONALITY DEVELOPMENT
1. Development is a continuum
2. Behavior has meaning and is not determined by chance.
3. All behaviors should be goal-directed
4. The unconscious plays an active role in determining behavior.
5. The early years of life are extremely important for personality development
STAGE AGE CHARACTERISTIC
Pre conventional
(Egocentric
focus)

Toddler 7 yrs


Preschooler through
School age
Stage 1: Punishment avoidance
and obedient orientation

Stage 2: Instrumental Relativist
Orientation
Getting what you want by trade-off
Conventional
(Societal focus)

School age through
Adulthood

Adolescence and
Adulthood
Stage 3: Interpersonal
Concordance Orientation
Meeting expectations of others

Stage 4: Law and Order
Orientation
Fulfilling duties and upholding laws
Post-conventional
(Universal focus)
Middle-age or Older
Adult



Middle-age or Older
Adult
Stage 5: Social Contract Legalistic
Orientation
Sense of democracy and
relativity of rules

Stage 6: Universal Ethical
Principle Orientation
Self-selection of universal principles
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THEORETICAL FRAMEWORK OF CARE

THEORIES

1.Psychoanalytical Model
Behavioral disturbances stems from emotionally painful experiences
Repressed feelings lead to unresolved and unconscious conflicts in the
mind
Defense mechanism develop which produces the disturbed symptoms
Psychotherapy uncovers the roots of conflict through interviews in long-term
therapy
Ex. S. Frued

2. Developmental Model
Extended the work of Frued on personality development cross the lifespan
while focusing on social and psychological development in the life stages
Ex. E. Erikson and Jean Piaget

3. Interpersonal Model
Extended the theory of personality development to include the significance
of interpersonal relationship
Ex. H.S. Sullivan and H. Peplau

4. Behavioral Model
Behavior can be changed through a system of rewards and punishment
Response to behavior by therapists should be consistent
Ex. Pavlov and Skinner

5. Humanistic Model
Focuses on a persons positive qualities, his or her capacity to change, and
promotion of self-esteem
Ex. Maslows Hierarchy of Needs

6. Existential
A. Cognitive Model
Focuses on immediate thought processing-how a person perceives or
interprets his or her experience and determines how he or she feels and
behaves

B. Gestalt Model
Emphasizes identifying the persons feelings and thoughts in the here and
now

7.Medical-Biological Model
Behavior disturbance is an illness or defect
Illness is located in the body, either a neurostructurral defects, biochemical
alteration or genetics
Disease entities can be diagnosed, classified and labeled
Somatic therapies are used which includes:
o Electroconvulsive therapies
o Psychosurgery
o Bright Light Therapy
o Transcranial Magnetic Stimulation (TMS) or Repetitive Transcranial
Magnetic Stimulation (rTMS)

TREATMENT MODALITIES

1.Individual Psychotherapy
A method of bringing about change in a person by exploring his or her
feelings, attitudes, thinking and behavior
a confidential relationship between client and therapist that may occur in the
therapists office, outpatient clinic, or mental hospital

2. Couple therapy
An intervention involving two individuals sharing a common relationship (a
married or no married, homosexual or heterosexual pair) is a way of
resolving tension or conflict in a relationship

3. Family therapy
a method of treatment in which members gain insight into problems,
improve communication, and improve functioning of individual members as
well as the family as a whole

4. Group therapy
a method of therapeutic intervention based on the exploration and analysis
of both internal and external conflict and the group process
Members share a common purpose and are expected to contribute to the
group to benefit others and receive benefit from others in return
Major focus is the here-and-now experience
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Yaloms Therapeutic/Curative Factors

1. INSTILLATION OF HOPE is the first and often most important factor.
Patients receive hope from observing others who have benefited from the
group experience
2. UNIVERSALITY. Patients experience relief in knowing that they are not
alone and unique, but that others experience similar problems, feelings, and
concerns.we are all in the same boat
3. IMPARTING OF INFORMATION. Patients learn or are provided information
about areas related to their needs.
4. ALTRUISM. Patients experience themselves as helpful or useful to others.
5. CORRECTIVE RECAPITULATION OF PRIMARY FAMILY GROUP.
Patients renew previous dysfunctional family patterns and learn that these
patterns can be changed to meet their present needs effectively.
6. DEVELOPMENT OF SOCIALIZING TECHNIQUES. Patients are taught
appropriate social skills.
7. IMITATIVE BEHAVIOUR. Patients selectively model healthy behaviors of
the leader and other group members.
8. CATHARSIS. Patients are not only allowed to express them appropriately.
9. EXISTENTIAL FACTORS. Patients share feelings about ultimate
concerns of existence, such as death or isolation, and learn to accept that
there is a limit to their control of these issues.
10. COHESIVENESS. Patients experience feelings of being accepted, valued,
and part of a group experience
11. INTERPERSONAL LEARNING. Patients learn how their behaviours affect
others and more appropriate ways of relating in the supportive atmosphere
of the group.
PSYCHOPHARMACOLOGY

BASIC PRINCIPLES
A medication is selected based on the clients target symptoms
Many psychotropic drugs must be given in adequate for a period of time
before their full effect is realized
The dosage of medication is often adjusted to the lowest dose effective for
clients
Elderly persons require lower dosages of medication to produce therapeutic
effects and it may take longer for a drug to achieve its full therapeutic effect
Psychotropic drugs are often decreased gradually rather than abruptly
discontinued
Follow-up care is essential to ensure compliance with the medication
regimen, to make needed adjustments in dose and manage side effects


Anti-anxiety Drugs (Ang tunog ng BUS)
Most common drugs are benzodiazepines
- Diazepam(Valium), Lorazepam (Ativan), Chlordiazepoxide
(Librium), Clorazepate (Tranxene)
Buspirone (Buspar) is the first pure anxiolytic drug and acts as a partial
agonist at serotonin receptor sites.
Barbiturates may also be used for anxiety such as Phenobarbital
Propranolol (Inderal) is a beta-blocker effectively interrupts the physiological
responses of anxiety
Antihistamines Hydroxyzine (Iterax, Atarax) has a central cholinergic effect
and is good anti-anxiety agent



Caution client to avoid potentially hazardous activities because of
drowsiness
Warn the client of the danger of concurrent use of alcohol and other CNS
depressants
Avoid abrupt withdrawal
Do not give antacids concurrently
Do not take medications with meals
Watch for adverse reactions


Antipsychotic Drugs ( Ang kuwento ni THOR)
Classified either by chemical class, potency but more importantly by
typicality
Low-potency drugs causes more anticholinergic side effects whereas high-
potency drugs causes more EPS


NURSING INTERVENTION
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NURSING INTERVENTION
1.TYPICAL ANTIPSYCHOTIC DRUGS
Traditional drugs effective for
EFFECTIVE FOR WHAT TYPE OF SYMPTOM/S?_______
Examples are:
o chlorpromazine (Thorazine), thioridazine (Mellaril), haloperidol
(Haldol), fluphenazine (Prolixin)

2.ATYPICAL ANTIPSYCHOTIC DRUGS
EFFECTIVE FOR WHAT TYPE OF SYMPTOM/S?_______
No endocrine side effects Prolactin increase)
Potent antagonists of serotonin
Examples are:
o Clozapine (Clozaril, risperidone (Risperdal, olanzapine (Zyprexa),
quetiapine (Seroquel)

3.DOPAMINE SYSTEM STABILIZER (DSS)
EFFECTIVE FOR WHAT TYPE OF SYMPTOM/S?_______
DSS are thought to balance the dopamine systems by increasing dopamine
in brain areas in which dopamine is deficient and decreasing dopamine in
brain areas in which dopamine is overactive
Only example is:
o Aripiprazole (Abilify)


SIDE EFFECTS (pag wala sa tamang KATINUAN)

1. EXTRAPYRAMIDAL SIDE EFFECTS (EPSE)
a. Acute Dystonia
- Acute muscular rigidity and cramping, stiff thick tongue with
difficulty swallowing; torticollis, opisthotonus or oculogyric crisis
b. Pseudoparkinsonism
- Stooped, stiff posture with mask-like faces, a festinating gait,
cogwheel rigidity, drooling, bradykinesia, pill rolling tremors.
c. Akathisia
- Feeling of internal restlessness and inability to sit down
d. Tardive Dyskinesia
- Syndrome of permanent involuntary movements of the tongue,
facial and neck muscles, upper and lower extremities even truncal
musculature
- Manifested as tongue-thrusting and protrusion, lip-smacking,
blinking, grimacing

2. NEUROLEPTIC MALIGNANT SYNDROME (NMS)
Potentially fatal reaction to an antipsychotic drug; idiosyncratic
Characterized by rigidity, high fever, autonomic instability and maybe
confusion and muteness

3. ANTICHOLINERGIC EFFECTS
Orthostatic hypotension, dry mouth, constipation, urinary retention,
photophobia and sensitivity

4. ENDOCRINE CHANGES
Lactation in females; gynecomastia and impotence in males

5. AGRANULOCYTOSIS
Esp. for those taking clozapine
Decrease in white blood cell hence prone to infections



Check BP prior to administration
Periodic liver function test and blood counts
Observe for warning signs of adverse effects
Note complaints of sore throat, nosebleed, rash, fever or other signs of
infection
Warn client that drowsiness may occur until tolerance is developed
Teach the client to:
- Avoid alcohol
- Consult before taking other medications
- Precautions to avoid skin damage from photosensitivity
- High fiber diets, fluids, exercise and good oral hygiene



Anticholinergic and Dopaminergic drugs
Given to control EPSEs in clients taking antipsychotic drugs
A balance between acetylcholine and dopamine is required for normal
movement
NURSING INTERVENTION
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Balance is accomplished in three ways
1. Drugs used to increase dopamine (Dopaminergic)
2. Drugs used to decrease the level of Ach (Anticholinergic)
3. A combination of the above drugs

Dopaminergic drugs include:
- Carbidopa-levodopa (Sinemet), amantadine (Symmetrel),
bromocriptine (Parlodel), pergolide (Permax),
selegilline (Eldepryl)
- Common psychiatric side effects of dopaminergics: Confusion,
hallucinations, delusions, depression, anxiety, agitation
Anticholinergics used are:
- Benztropine (Cogentine), biperiden (Akineton), trihexyphenidyl
(Artane), dephenhydramine (Benadryl)
- Common side effects of anticholinergics: Mydriasis and blurred
vision, decreased secretions, , constipation, urinary retention and
increased heart rate

Antidepressant Drugs (Kuwento nina ANA at ELA)

1.SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRI)
Block reuptake of serotonin at specific serotonin receptor sites
Serotonin syndrome may appear in some clients
Indicated for depression, OCD, panic disorders
Examples are: Includes Paroxetine (Seroxat, Paxil), Sertraline (Zoloft),
Fluvoxamine (Luvox), Fluoxetine (Proxac)

__________
2.TRICYCLIC ANTI-DEPRESSANTS (TCA)
Blocks reuptake of serotonin and norepinephrine
Examples are: imipramine (Tofranil), Amitriptyline (Elavil), Clomipramine
(Anafranil), Amoxapine (Asendin), Doxepin (Sinequan)

__________
3.MONOAMINE OXIDASE INHIBITOR (MAOI)
Prevents the breakdown of dopamine, serotonin and norepinephrine
Examples are : Isocarboxacid (marplan), Phenelzine (Nardil),
Tranylcypromine (Parnate)
__________
Assess for the side effects and treat symptomatically
Do not give TCAs and SSRIs with or immediately with MAOIs
Monitor blood pressure
Avoid TYRAMINE-containing foods (aged cheese, wine, pickled and
preserved foods and alcohol) may lead to HPN crisis (for MAOI)
Teach clients to:
- Take medications with food
- Notify/consult before taking any other drugs
- Not to drive or operate machineries
- Advise that these drugs may not take effect until after 2 weeks


Antimanic Drugs (Ang kawad ng PLDT)
Normalizes reuptake of certain neurotransmitters but exact mechanism is
still unknown but there are theories which considers its action on the second
messenger system of the body
Standard drug of choice is Lithium Carbonate
o Effective serum level is 0.6-1.2 meq/L
o Effect of lithium takes 7-10 days
o SIDE EFFECT:
o Type of RELATIONSHIP of Na and Lithium:
In the absence of lithium alternative drugs are: Valporic acid (Depakote) or
carbamazepine (Tegretol)



Remind the client to take the medications regularly
Monitor salt and fluid intake
Report decreased in urine output
Monitor for signs and symptoms of toxicity
o Muscle weakness or twitiching, diarrhea, vomiting, hand tremors,
drowsiness (DVDMC)
Teach the client to:
- Avoid caffeine
- Take medications with meals
For Anticonvulsants
- Teach client not to drive until response had been determined
- Avoid alcohol and non-prescription drugs
- Do not stop the drug abruptly

NURSING INTERVENTION
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NURSING INTERVENTION
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Psychostimulants
Often termed indirectly acting amines because they act by causing release
of the neurotransmitters (NE, dopamine and serotonin) from presynaptic
terminals as opposed to having a direct agonist effects on the postsynaptic
receptors.
They also block the reuptake of these neurotransmitters
Most common example is Methylphenidate (Ritalin)
Most common side effects are anorexia, weight loss, nausea and irritability,
growth and weight suppression



Caffeine-free beverages are suggested
Taken after meals
Keep out of reach of children, 10-day supply can be fatal

Anticholinesterase
They target Ach deficiency. By attaching to and thus blocking ChE, these
four drugs substantially increase the amount of intrasynaptic Ach available
to cholinergic receptor..in short it INCREASES what neurotransmitter?
Tacrine (Cognex), Denazepil (Aricept)

THERAPEUTIC NURSE-CLIENT RELATIONSHIP

Therapeutic Use of Self
Nurses use themselves as a therapeutic tool to establish a therapeutic
relationships with clients and to help clients grow, change and heal
Self awareness
o A process by which the nurse gains recognition of his or her own
feelings, beliefs and attitudes
o JOHARI window

Nurse Client Relationship
It is the purposeful use of the nurses interpersonal skills directed towards
growth producing outcomes for clients.

CHARACTERISTICS
Frequently informal and spontaneous and occurs in various health care and
community settings.
Maybe formalized with counseling or individual psychotherapy
It is a professional relationship
- concepts of transference and counter-transference

COMPONENTS
1. TRUST
-Trust builds when the client is confident in the nurse and when the nurses
presence conveys integrity and reliability. Trust develops when the client
believes that the nurse will be consistent in his or her words and actions
and can be relied on to do what he or she says.

2. GENUINE INTEREST
-When the nurse is comfortable with himself or herself, aware of his or her
strengths and limitations, and clearly focused, the client perceives a
genuine person showing genuine interest.

3. EMPATHY
-Is the ability of the nurse to perceive the meanings and feelings of the
client and to communicate that understanding to the client.It is considered
one of the essential skills a nurse must develop.

4. ACCEPTANCE
-The nurse who does not become upset or respond negatively to a clients
outbursts, anger, or acting out conveys acceptance to the client.

5. POSITIVE REGARD
-The nurse who appreciates the client as a unique worthwhile human being
can respect the client regardless of his or her behavior, background, or
lifestyle. This unconditional nonjudgmental attitude is known as positive
regard and implies respect.

ROLES OF PSYCHIATRIC-MENTAL HEALTH NURSE
1. Nurse-Teacher
2. Mother Surrogate
3. Technical Nurse
4. Nurse-Manager
5. Socializing Agent
6. Counselor/ Nurse-Therapist

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PHASES (What are the major tasks in each phase?)

1. Preorientation/Preinteraction
2. Orientation
3. Working
4. Termination
(The longest and the most productive phase)

Therapeutic Communication

COMMUNICATION
The reciprocal exchange of information
Components
- Sender, message, receiver, feedback and the context
Models/ Types
o Verbal
Structural Model:
Sender, Message, Receiver, Feedback, Context
o Non-verbal

1. THERAPEUTIC COMMUNICATION (VERBAL)
o The process in which the nurse consciously utilizes the principles of
communication in a goal-directed professional framework.
o Best responses should focus on the general guidelines

GENERAL GUIDELINES
* Open-ended questioning is best used
* Here and now rather than the past
* What rather than why
* Orientation and presentation of reality
* Actual client behaviors and nursing observations rather than giving
inferences
* Maintenance of biologic integrity
* Nursing interventions rather than roles designated to other health
team members
* Sharing information and exploring alternatives rather than giving
actual solutions
(Ang ating CARE)

2. Components of NONVERBAL COMMUNICATION
a. Kinesics
b. Proxemics
c. Paralanguage
d. Touch
e. Silence


Therapeutic Milieu (What is the most important principle?)
It is the purposeful use of all interactions to assist clients in developing
interpersonal and social skills in a conductive physical and emotional
environment
Manipulates environmental stimuli to provide limits, protect clients and other
members of the therapeutic community and promote optimal functioning
(Role of the nurse?)


EVALUATING MENTAL FUNCTIONING
Mental Status Examination
Standardized nursing assessment procedure aimed at making a diagnosis
and determine intervention
Designed to determine present mental status
Assessed according to the ff. mental functions:

1.General Description
A.GENEREAL APPEARANCE:
Type, condition, and appropriateness of clothing (for age, season, setting),
grooming, cleanliness, physical condition, and posture

B. BEHAVIORS during the interview
Degree of cooperation. Resistance, or evasiveness

C. SOCIAL SKILLS
Friendliness, shyness or withdrawal

D. Amount and type of MOTOR ACTIVITY
Psychomotor agitation or retardation, restlessness, tics, tremors,
hypervigilance, or lack of activity

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2. Emotional State
A. AFFECT
Labile, blunted, flat, incongruent, or inappropriate affect

B. MOOD
Specific moods expressed or observed- euphoria, depression, anxiety,
anger, guilt, or fear

3. Thinking
A.THOUGHT CONTENT
Helplessness, hopelessness, worthlessness, suicidal thoughts or plans,
suspiciousness, obsessions, poverty of content, denial, or delusions

B. THOUGHT PROCESS reflected in speech
Ambivalence, circumstantiality, tangentiality, thought blocking, loose
associations, flight of ideas, perseveration, neologism or word salad

4.Experience
PERCEPTION: Hallucination

5.Sensorium and Cognition
A.SPEECH PATTERNS
Amount, rate, volume, tone pressure, mutism, slurring or stuttering

B. DEGREE OF CONCENTRATION AND ATTENTION SPAN

C. DEGREE OF CONSCIOUSNESS
To time, place, person, and level of consciousness

D. MEMORY
Immediate recall, recent, remote, amnesia, and confabulation

E. INTELLECTUAL FUNCTIONING
Educational level, use of language and knowledge, abstract vs concrete
thinking and calculation

F. INSIGHT
Degree of awareness of illness, behavior, problems, and their causes

G. JUDGMENT
Soundness of problem solving and decisions

Diagnostic Statistical Manual 4
TH
edition Text Revision (DSM-IV-TR)
Specific diagnostic criteria developed by the
American Psychiatric Association
Includes diagnostic criteria and description of
each category
Important for nurses to be familiar with this
system in order to communicate effectively and
efficiently with other members of the mental
health team
o Axis I - Psychiatric clinical diagnosis
o Axis II - Presence of mental retardation or personality disorders
o Axis III General medical conditions
o Axis IV Psychosocial stressor
o Axis V - Global assessment of functioning (GAF)

ANXIETY: A Central Concept

Stress
A generalized non-specific response of the body to any demands whether
positive or negative.
Damaging or unpleasant forms of stress is distress.
When stress is sufficiently great and reaches a point above the threshold of
an individual, frustration results
Response to Stress:
Fight or flight mechanism
Hans Selyes General Adaptation Syndrome
Stage I - Stage or alarm reaction
Stage II - Stage of resistance
Stage III - Stage of exhaustion

Anxiety
A feeling of severe discomfit or dread that arises from within the individual in
response to a threat, which is less visible and definable than fear, which has
a visible object or trigger.
Subjective experience detected by the objective behaviors that result from it.
Emotional pain.
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MERGE
NOTE
NOTE
Triggers autonomic relief behaviors aimed at eliminating anxiety.
Contagious; communicated from one person to another.

LEVELS OF ANXIETY
Mild (+1)
- Greater alertness to the environment occurs
- People may feel more energetic and motivated
- Behavior may be more efficient
Moderate (+2)
- Perceptual field begins to narrow
- Shuts out periphery; focused on central concerns
- Selective Inattention
Severe (+3)
- Perceptual fields is greatly reduced
- People generally focus on small details but maybe unable to focus
on the whole
- Inability to focus on events and environment
Panic (+4)
- Disruption of the perceptual field
- Disorganization of the personality
- Inability to control the self or environment
- Behavior purposeless and communication unintelligible
- Complete immobility maybe present

DRUG THERAPY
Antianxiety


Coping Responses

COPING MECHANISMS
- Any effort directed at stress management.
- It can be problem, cognitive or emotion focused

DEFENSE MECHANISMS
- Methods of attempting to protect the self and cope with basic drives
or emotionally painful thoughts, feelings or events
- Become counterproductive when used to the extreme

DEFENSE
MECHANISM

DEFINITION
Denial Unconscious refusal to admit an unacceptable idea or
behavior
Repression Unconscious and involuntary forgetting of painful ideas,
events, and conflicts
Suppression Conscious exclusion from awareness anxiety-producing
feelings, ideas and situations
Rationalization Conscious or unconscious attempts to make or prove that
ones feelings or behaviors are justifiable
Intellectualization Consciously or unconsciously using only logical explanations
without feelings or an affective component
Dissociation The unconscious separation of painful feelings and emotions
from an unacceptable idea, situation, or object
Introjection Unconsciously incorporating values and attitudes of others as
if they were your own
identification Process by which the person tries to become like someone
he admires by talking on thoughts, mannerisms or tastes of
that person
Compensation Consciously covering up for a weakness by overemphasizing
or making up a desirable trait
Sublimation Consciously or unconsciously channeling instinctual drives
into acceptable activities
Reaction
formation
A conscious behavior that is the exact opposite of an
unconscious feeling
Undoing Consciously doing something to counteract or make up for a
transgression or wrongdoing
Displacement Unconsciously discharging pent-up feeling to a less
threatening object, person or animal
Projection Unconsciously (or consciously) blaming someone else for
ones difficulties or placing ones unethical desires on
someone else
Conversion Unconscious expression of intrapsychic conflict symbolically
through physical symptoms
Regression Unconscious return to an earlier and more comfortable
developmental level
Fixation Immobilization of a portion of the personality resulting from
unsuccessful completion of tasks in a developmental stage

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CRISIS
Results in a period of severe disorganization resulting from the failure of an
individuals usual coping mechanisms, lack of usual resources, or both
Individual is in a state of disequilibrium
Self-limiting (4-6 weeks) and is precipitated by new or sudden situations
Occurs in all ages
Response is relative
Ineffective resolution leads to future crisis

FORMS/CATEGORIES
- Maturational/Developmental crisis
- Situational/Accidental crisis
- Adventitious/Social crisis



Short-term therapy focused on solving immediate problem
Cope with an immediate problem
- Does not go into cause or require insight
The goal is to return the client into pre-crisis level of functioning
Involves clarifying present situations and problems, mobilize internal and
external resources and teach new coping skills.

CRISIS INTERVENTION STRATEGIES
1. Focus on survival, safety and security
a. Assess for and prevent suicide, violence, decompensation, and
reactivation of serious medical or psychiatric problems
b. Validate reactions and feeling as normal
2. Reestablish equilibrium and stabilization
3. Focus on strengths and adaptive coping
a. Encourage use if adaptive coping and personal, spiritual, family and
community resources
4. Offer suggestions for concrete, specific problem solving
a. Focus on the here and now
5. Make provision for follow-up care
a. Arrange for monitoring for 2-3 months- the risk of suicide can persist

METHODS (STEPS) OF CRISIS INTERVENTION
1. An assessment of the individual and the problem
2. Planing of therapeutic intervention
3. Intervention
4. Resolution of the crisis
5. Anticipatory planning

GRIEF
Refers to the subjective emotions and affect that are normal response to the
experience of the loss

KUBLER-ROSS STAGES OF GRIEF
Denial
Anger
Bargaining
Depression
Acceptance



Acceptance
Provide opportunity for the persons to tell their story
Recognize and accept the varied emotions people express in a loss
Provide support for the expression of difficult feelings such as anger and
sadness
Encourage maintain established relationships
Acknowledge the usefulness of counseling for especially difficult problems

ANXIETY DISORDERS (Ang taong PAGOD)
Anxiety usually predominates and the person is usually in a state of conflict
Persistent or recurrent
Certain defense mechanism are used repeatedly in an attempt to control
anxiety
Anxiety maybe present despite the absence of triggers
Creates a significant impairment in socio occupational functioning
o Primary gain refers to the individuals desire to relieve anxiety in
order to feel better and more secure
o Secondary gain refers to the attention and support the individual
derives from others because of illness
REMEMBER
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NURSING INTERVENTION

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1.Generalized Anxiety Disorder
Excessive worry and anxiety
Difficulty in controlling the worry
Anxiety and worry is evident in
- restlessness, fatigue and irritability, diminished concentration,
muscle tension, disturbed sleep
Chronic feelings of nervousness and apprehension for no apparent reason

2.Panic Disorders
Recurrent, unexpected panic attacks followed by a month or more of worry
about having additional attacks, worry about the results of the attacks, and
behavioral changes related to the attacks

3.Obsessive-Compulsive Disorder
Obsessions are intrusive, inappropriate, recurrent, and persistent thoughts,
impulses, or images that are distressful or produce anxiety
compulsions are repetitive behaviors, such as hand washing, or mental
acts, such as counting, performed in response to an obsession

(What is the most common ritual?)

4.Phobic Disorder
Phobia is a persistent and irrational fear of a specific object, activity or
situation that results in a compelling desire to avoid the dreaded object or
situation
The fear is recognized as excessive and unreasonable in proportion to the
actual danger
Maybe primary or secondary
Categorized into:
- Agoraphobia
o Fear of being in public places wherein escape may be
difficult; fear of the fear
- Social phobia
- Specific phobia (e.g. Claustrophobia)

5.Acute Stress Disorders
Exposure to a traumatic event involving threat of death/injury to self or
others, or actual injury to self and others
Responses of horror, helplessness and fear
Dissociative symptoms immediately after
Avoidance of stimuli related to trauma
Increased arousal or anxiety
- Sleep disturbance, hypervigilance, easy startle
Re-experiencing or relieving the traumatic event
- distressing thoughts dreams
Impairment in socio-occupational functioning

6.Posttraumatic Stress Disorder
Same as that of ASD
Numbing of responsiveness
- Inability to recall aspects of the event
- Restricted affect
- Sense of foreshortened future
Survivor guilt
Occurs usually within 6 months after the event or even more (delayed)



To reduce anxiety
- Provide a calm and quit environment
- Ask patients to identify what and how they feel
- Encourage the patients to discuss feelings
- Help patients identify possible causes of their feelings
- Listen carefully for patients expressions of helplessness and
hopelessness
- Plan and involve patients in activities such as walking or playing
recreational games

For panic
- Remain with the client and provide safety
- Reduce environmental stimuli and approach always in a calm
manner
- Focus clients attention on a simple, repetitive task

For ritualistic behaviors
- Avoid interfering with the ritual
- Set rational limits on ritualistic behavior in terms of timing frequency
and location
REMEMBER
NURSING INTERVENTION
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- Structure simple activities or task for patients
- Encourage to participate in activities where clients can attain control
and success
- Recognize and reinforce non ritualistic behaviors

For ASD and PTSD
- Assure them that their feelings and reaction are typical reactions to
serious trauma
- Encourage safe verbalizations of feelings especially anger
- Encourage adaptive coping strategies, exercise, relaxation
techniques and sleep-promoting strategies
- Facilitate progressive review of the trauma and its consequences
- Encourage the patients to establish or re-establish relationship

SOMATOFORM DISORDERS
Involves physical symptoms without any organic or physiologic cause
Not under voluntary control
Symbolizes repressed and unresolved conflicts

1.Somatization Disorder
Chronic somatic complaints of long-duration
Complaints changes from one anatomic site to another
A complicated medical history is common

2.Pain Disorder
Prolonged and severe pain that seem unrelated to physical causes
Seems to correlate with psychological stress
May present with abuse of analgesics

3.Conversion Disorder
Loss of sensory or motor functioning that seems unrelated to physical cause
The physical problem is symbolic of underlying anxiety
Presence of la belle indifference

4.Hypochondriasis
Preoccupation with the belief that a serious illness is present despite
reassurance to the contrary and may interfere with daily life
Physical signs and symptoms are consistently misinterpreted to mean that
the clients is ill

5.Body Dysmorphic Disorder
Preoccupation with some imagined defect in physical appearance which is
out of proportion to any actual abnormality



Avoid reinforcing the symptoms
- do not focus on them to reduced secondary gain
- Do not attempt to persuade the client that the symptoms are not real
or that the client should give it up
Increase self esteem by involving clients in activities in which they can be
successful
Encourage to identify and explore feelings

DISSOCIATIVE DISORDERS
Sudden temporary change in consciousness, identity or motor behaviors
The repression of ideas that leads to amnesia and other forms of
dissociation is conceived as a way of protecting the individual from
emotional pain

1.Dissociative Amnesia
Inability to recall personal information
Loss of memory of important personal events that were traumatic or
stressful in nature

2.Dissociative Fugue
Sudden unexpected travel away from home or work with loss of memory
about the past
Assumption of partial/completely new identity

3.Dissociative Identity Disorder
Existence of 2 or more identities or personalities that take control of a
persons behavior

4.Depersonalization
Expresses feelings of detachment from or an outside observer of ones
body or mental processes
Unreality or self-estranged (derealization)
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Reduce external stress and demands on the client
Present reality
Reassure the client that memory will return
Encourage to explore and verbalize feelings
Set rational limits on behavior
Assist in the exploration or preceding event
Reduce the clients anxiety

SCHIZOPHRENIA
Occurs in the late adolescence and early adulthood
More common in lower socio-economic groups
High prevalence among family members and in twins

SCHIZOPHRENIA
A. Characteristic symptoms (at least two of the following):
Delusion
Hallucinations
Disorganized speech
Grossly disorganized or catatonic behavior
Negative symptoms
B. Social-occupations dysfunction: work, interpersonal, and self-care functioning
below the level
achieved before onset
C. Duration: continuous signs of the disturbance for at least 6 months
D. Schizoaffective and mood disorders not present and not responsible for the
signs and symproms
E. Not caused by substance abuse or general medical disorder
FOUR AS OF SCHIZOPHRENIA
1. Affective disturbances
2. Autism ( THE 4SUM?)
3. Associative looseness
4. Ambivalence

DSM-IV-TR FOR SCHIZOPHRENIA SUBTYPES
Paranoid Preoccupation with one or more delusions or frequent
auditory hallucinations (content frequently persecutory
and/or grandiose)
Disorganized All the following are prominent; disorganized speech,
disorganized behavior, flat or inappropriate affect
Catatonic At least two of the following are present:
A. Motoric immobility, waxy flexibility, or stupor
B. Excessive motor activity (purposely)
C. Extreme negativism or mutism
D. Peculiar movements, stereotype of movements,
prominent mannerisms, or prominent grimacing
E. Echolalia or echopraxia
Undifferentiated Characteristic symptoms (see criteria A) are present, but
criteria for paranoid, catatonic, or disorganized subtypes
are not met
Residual A. Characteristic symptoms (see box: DSM-IV-TR criteria
for Schizophrenia, criterion A) are no longer present;
criteria are unmet for paranoid, catatonic, or disorganized
subtypes
B. There is continuing evidence of disturbance, such as
the presence of negative symptoms or criteria A
symptoms, in an attenuated form (e.g., odd beliefs,
unusual perceptual experiences).

ETIOLOGY
Biological Theories
- Genetic component is present
- Dopamine hypothesis excessive dopaminergic activities in the
cortical areas causes acute psychotic symptoms
- Neurostructural changes
Developmental Theories
- Impaired interpersonal relationship with primary caregiver
- Poor ego boundaries, fragile ego and ego disintegration
Family Theories
- Schizophrenic mother
- Double-bind
Vulnerability-Stress Model
- Recognizes both biological and psychodynamic



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DSM-IV-TR
CRITERIA!

REMEMBER
DSM-IV-TR
CRITERIA!


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TYPES OF DELUSION
1. Persutory/paranoid delusion
2. Grandiose delusion
3. Religious delusion
4. Somatic delusion
5. Referential delusion
6. Nihilistic delusion

TYPES OF HALLUCINATION
1. Auditory
2. Visual
3. Tactile
4. Gustatory
5. Olfactory
6. Kinesthetic
7. Cenesthetic



General Principles for a therapeutic relationship
- Be calm when talking to patients
- Accept patient as they are but do not accept all behavior
- Keep all promises
- Be consistent
- Be honest
Maintain a safe and therapeutic environment
Meet the patients physiologic needs
Help patient maintain contact with reality
- Orient the patients to time and place if indicated
Reduce hallucinations and delusions
- Present reality without arguing
- Engage in conversations that are simple, direct, specific and
concrete
- Do not dwell on the content of delusions
Decrease withdrawal
- Engage in one relationships as tolerated by clients
- Engage in social activities
- Allow interpersonal distance if necessary
- Do not touch the patients without warning them
- Avoid whispering or laughing when patients are unable to hear all of
a conversation
- Avoid competitive activities with some patients
Encourage differentiation of self from others and the environment
Allow and encourage verbalization of feelings
Increased the clients self-esteem
- Provide opportunities to be successful
- Convey an attitude of respect
- Do not embarrass patients
- Reinforce positive behaviors
- Encourage participation in self-care activities

MOOD DISORDERS
1. Major Depression
2. Mania
3. Bipolar disorder

OTHER
1. Dysthymia
2. Hypomania
3. Cyclothymia
4. Seasonal Affective Disorder

MAJOR DEPRESSION
Abnormal extension and over elaboration of sadness and grief

ETIOLOGY
Biological theories of depression
- Genetics play a role in its occurrence
- Levels of norepinephrine and serotonin altered, decreased
availability in the CNS
- Endocrine changes
Psychological theories
- Object loss theory - Debilitating early life
experiences
- Aggression towards the self - Intrapsychic conflict
- Cognitive theory - Antipsychiatric model
- Learned helplessness

NURSING INTERVENTION
DSM-IV-TR
CRITERIA!

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ESCAPES FROM DEPRESSION
Complete hopelessness and inactivity
Soliciting or winning sympathy
Use of alcohol/substances
Frenzied activity
Excessive motor activity
Suicide



Maintain clients safety
Provide for adequate nutrition, hydration elimination, exercise and physical
hygiene
Help client have adequate rest and sleep
Provide a simple and structured schedule and environment
Develop trust
Offer sincere concern and empathy
Allow and encourage verbalization of feelings
Bolster self-esteem
- Accept patients where they are and focus on their strengths
- Point out even small accomplishments
- Reinforce decision making by patients
- Redirect clients conversation away from self-reproach and
derogation
- Involve patients in activities in which they can experience success
- Respond to anger therapeutically
Recognize dependence
- Make decisions for patients that they are not ready to make for
themselves
Spend time with withdrawn patients
Encourage increasing participation in social, recreational and occupational
activities
Never reinforce delusions or hallucinations

DRUG THERAPY
Antidepressants

Electroconvulsive Therapy (ECT)
Induction of grand mal seizures through the application of electrical current
to the brain to effect behavioral changes
Indicated for clients with major depression, acute manic states,
schizophrenics (catatonic), OCD and some personality disorders (anti-
social)
Exact mechanism of actions is still unknown
There are no absolute contraindications however relative contraindications
include:
- Cardiac problems
- Increased intracranial pressure
- Severe osteoporosis
- Acute and chronic pulmonary disorders
- Pregnancy (if with complication)
The side effects are headache, confusion and temporary memory loss
>>>Konti nalang. Ur almost done =) "Dattebayo!" (BELIEVE IT!)- Naruto
I do not know anyone who has gotten to the top without hard work. That is the recipe. It
will not always get you to the top, but it will get you pretty near. ~M. Thatcher
KEY FEATURES OF MAJOR DEPRESSIVE DISORDERS
At least a 2-week period of maladaptive functioning is present that is a clear
change from previous levels of functioning. Al least five of the following symptoms
must be present during that 2-week period, out of which must be (1) or (2):

1. Depressed mood
2. Inability to experience pleasure or markedly diminished interest in pleasurable
activities (Anhedonia)
3. Appetite disturbance with weight change (loss or gain of more than 5% of body
weight within 1 month)
4. Sleep disturbance
5. Psychomotor disturbance
6. Fatigue or loss of energy
7. Feelings of worthlessness or excessive or inappropriate guilt
8. Diminished ability to concentrate or indecisiveness
9. Recurrent thoughts of death or suicidal ideations

The mood disturbance causes marked distress or significant impairment in social
or occupational functioning, or both.
No evidence of a physical or substance-induced cause exists for the patients
symptoms or for the presence of another major mental disorder that accounts for
the patients depressive symptoms.
NURSING INTERVENTION
DSM-IV-TR
CRITERIA!

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MERGE
NOTE
Pre-ECT Post-ECT
Secure the informed consent
Keep client on NPO at least 4 hrs prior
Remove dentures, eyeglasses,
contact lenses etc.
Client must be asked to void prior
Remain with the client; safety precautions
Encourage client to verbalize feelings
Pre-medications maybe given as
ordered (Atropine sulfate,
succinylcholine [Anectine] )
Client is oxygenated
Turn head to the sides
Monitor vital signs
Stay with the patient until he is fully
awake
Reorientation
Provide a highly structured
schedule of routine activities to
minimize confusion


(Ang AMA ng PUSA)

SUICIDE
Direct self-destructive behavior; self-inflicted death
Influenced by a persons cultural beliefs, values and norms
Never a random act, whether done impulsively or with painstaking
consideration, the act has both a message and a purpose
More common in white persons and least common in black persons
Common among schizophrenics, depressed and alcoholic patients
More common in spring
More likely to occur in the early morning hours

LEVELS OF SUICIDAL BEHAVIOR
Suicidal gestures - non-lethal, self-injurious acts done to get attention
Suicidal ideations - thoughts of suicide
Suicidal threats - verbal statements
Suicidal attempt - actual implementation
Completed suicide - warning signs have been missed/ignored

COMMON EXPRESSIONS OF SUICIDAL PATIENTS
Cry for help - redemption
Escape - relief of pain
Heroism - retaliatory
Loss of self-esteem - reunion
Manipulation
Martyrdom
Rebirth
SAD PERSONS SCALE
S ex
A ge (<19 or >45)
D epression
P revious Suicide Attempt
E thanol (Alcohol) Abuse
R ational Thinking Impaired (judgment)
S ocial Support Lacking ( including recent loss of loved
one)
O rganized Plan
N o Spouse (single, divorced, widowed, separated)
S ickness especially Chronic
*This scale should be used as a guideline only:
use your judgment and dont neglect unspecified factors

ETIOLOGY
Psychodynamic Theories
- Instinct for life vs. instinct for death
- Aggression towards the self
- 3 Ps Pain, perturbation and pressure
Sociological Theories
- Social and cultural contexts influence ideations of suicide
Biological Theories
- There is decreased serotonin and its metabolites in patients who are
suicidal
Predisposing Factors Include:
- Psychiatric disorders (mood, substance, psychotic disorders)
- Personality traits (hostility, impulsivity, chronic depression)



Evaluate patients for suicidal risk (suicidal cues)
Note behaviors like making a will, saying goodbyes and giving away
prized possessions
Suspect suicidal ideation in the depressed
Inquire directly about frequency and content of suicidal ideation
Ask patients about the advantages and disadvantages of suicide
Evaluate the patients access to means of suicide
Develop a formal no suicide contract with patients
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MERGE
NOTE
Monitor closely and continuously
Encourage verbalization of feelings
Support patients reason to live

BIPOLAR DISORDERS
Individuals experience extremes in mood polarity
Manic-depressive
BIPOLAR DISORDERS
I. Manic Episode:
A. A distinct period of abnormal and persistent elevated, expansive, or
irritable mood that lasts at least 1 week or less if hospitalization is required.
B. At least three of the following symptoms must occur during the episode
(or four if the patient is only irritable).
1. Inflates self-esteem or grandiosity
2. Decreased need for sleep
3. Very talkative
4. Flight of ideas or subjective feeling that thoughts are racing
5. Distractability
6. Increase in goad-directed activity (social, occupational, educational,
or sexual) or psychomotor agitation
7. Excessive involvement in pleasurable activities that have a high
potential for personal problems (e.g. sexual promiscuity, spending
sprees, bad business investments)
C. Mood disturbance severe enough to cause problems socially,
interpersonally, or at work, or the person has to be hospitalized, to
prevent harm to self or others.
D. Not due to a substance

II. Bipolar disorders:
A. Bipolar episodes are divided into bipolar I and bipolar II. There are six
categories of bipolar I. In bipolar I, the patient must have a history of a
manic episode.
B. Bipolar II: The patient has experienced major depression and a
hypomanic episode (but not a manic episode)
ETIOLOGY
Psychodynamic theories
- Mania as a defense or a mask of depression
- Developmental: Mistrust and dependence
Biological theories
- Genetics is influential in bipolar disorders
- Excessive levels of neurotransmitters
-


Provide for patients physical safety and safety of those around him
Remind the client to respect distances between self and others
Use short simple sentences to communicate
Ask the clients to clear their messages and to decode metaphors, themes
and symbols used in speech
Provide the clients with a list of daily activities
Ensure that food and fluid needs are met
For patients too busy to eat
- Provide patients with foods that can be eaten on the run (finger
foods) because patients cannot sit ling enough to eat
- Provide high-protein, high calorie snacks
- Weight patients regularly
Reduce stimulation from the environment and others
- A quiet room maybe indicated to decreased environmental stimuli
- Remain quietly with the client rather than encouraging activities and
conversations
Channel clients need for movement into socially acceptable motor activities
- Goal-oriented activities are encourage
- Competitive sports activities are not allowed initially
- Mental activities will not be done by patients

AGGRESSIVE BEHAVIORS
PHASES OF THE AGGRESSIVE CYCLE
PHASE DESCRIPTION NURSING
INTERVENTIONS
Triggering
phase
Patients response are nonviolent
and present no danger to others
Convey emphatic support
Encourage ventilation
Escalation
phase
When verbalization and tension
reduction strategies fail and patients
become irrational (they begin to
swear,scream,threaten), the nurse
must take control of the situation.
Provide directions for the
client in calm firm voice
Tell the client to take time-
out for cooling
Show of force
Crisis
phase
Reached when the patient is
approaching an attack on the
Use involuntary seclusion,
restraints, or IM
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MERGE
environment, self, other patients, or
staff. Verbal limits are ineffective,
and external control by the staff is
essential.
medications (prn), if
ordered
Recovery
phase
Accusation, recriminations, lowering
of voice, decreased body tension,
change in conversational content,
more normal responses, relaxation.
Assess patient and staff
injuries
Evaluate patients progress
toward self-control
Postcrisis
depression
Crying, apologies, reconciliatory
interactions, repression of
assaultive feelings (which might
later appear as hostility, passive
aggression)
Process incident with
patient.
Discuss alternative
solutions to the situation
and feelings.
Facilitate reentry to unit
VICTIMS OF ABUSE AND VIOLENCE

CYCLE OF ABUSE AND VIOLENCE

Abuse is not constant nor it is random
There is an imbalance of power in a relationship
The honeymoon phase is what convinces the partner to stay in the
relationship

FORMS OF ABUSE WITHIN FAMILIES
1. PHYSICAL
-Inflicting or attempting to inflict physical injury or illness
-Withholding access to resources necessary to maintain health

2. NEGLECT
-failing or refusing to provide food, shelter, healthcare or protection for a
vulnerable elder

3. PSYCHOLOGICAL
-instilling or attempting to instill fear
-Isolating or attempting to isolate victim from friends, family, school or work

4. SEXUAL
-Coercing or attempting to coerce any sexual contact without consent
-Attempting to undermine the victims sexuality

5. ECONOMIC
-making or attempting to make the victim financially dependent

RAPE AND TRAUMA SYNDROME
Sleep disturbance, nightmares
Loss of appetite
Fear, anxieties, phobias and suspicions
Decreased activities and motivation
Disturbance in relationships
Self-blame, guilt and shame
Lowered self-esteem, worthlessness
Somatic symptoms



Reaffirm that they are worthwhile persons with dignity and rights, who is not
cause and deserve the rape
Convey to them that their anger is natural
Move at the victims pace and be supportive
Always give rationales and descriptions for any procedures
Protect the patients rights

TYPES OF ABUSE AMONG SPECIAL POPULATION
1. Domestic
2. Partner
3. Child
4. Elder



Honeymoon phase
Tension-building
phase
Period of
Violence
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NOTE
SUBSTANCE RELATED DISORDERS

Substance Abuse
-Pattern of pathologic use
o Inability to cut or stop use despite physical disorder known to be increased
by its use and despite the presence of complications
o Usually intoxicated throughout the day
- Impairment in functioning
o Legal difficulties and failure in obligations
o Behavioral changes
Substance dependence
- TOLERANCE
- WITHDRAWAL SYNDROME

ETIOLOGY
Psychoanalytic/Psychodynamic
- fixation or regression to the oral stage of development
Sociological
- Learned behavior encouraged by a subculture in which drugs are
easily available and its use is encouraged
Biochemical
- Physiologic dependence; readdiction or craving
TYPES EXAMPLES
CNS Depressants Alcohol
Baribiturates
Anxiolytics (Valium))
Inhalants
Opioids (Heroin, Morphine)
CNS Stimulants Amphetamine
Nicotine
Caffeine
Hallucinogens Psylocibin (in Psilocybe mushrooms)
Lysergic acid (LSD)
Phencyclidine (PCP)
Marijuana (Cannabis sativa)

Dual Diagnosis
The co-occurrence of psychiatric and substance use disorders

ALCOHOLISM
Alcohol
Genetic predisposition
Usually appears between the ages 20-40 however becoming common in
adolescents
BAL should be@ least _____ % considered intoxicated
More common in men than in women
Chronic use leads to Wernickes-Korsakoff syndrome

CAGE QUESTIONNAIRE
Have you ever felt you ought to Cut down on your drinking?
Have people Annoyed you by criticizing your drinking?
Have you ever felt bad or Guilty about your drinking?
Have you used alcohol as an Eye-opener?

SIGNS OF DRUG ABUSE
Sudden loss of interest or deterioration in school work fand other activities
Dropping old friends and associating with a new peer group
Secretive behaviors; spends a lot of time alone
Sudden and unexplained changes in mood, emotion and behavior
Physical signs such as pupil changes, slurred speech, needle marks,
photophobia etc.
- One must determine drugs use pattern of the client from information
provided by the client, family and friends:
1. Drugs being used
2. Quantity
3. Frequency
4. Length of use
- Analysis of blood and urine for substances



DETOXICATION PHASE
- Encourage participation in a treatment program and refer to
appropriate treatment resources
- Support the client through the detoxification or withdrawal
- Detoxification may take 2-3 weeks and should take place in an in-
patient setting
- Attend to clients physical problems
NURSING INTERVENTION
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REHABILITATIVE PHASE
- Assist clients to identify the stresses and conflicts and encourage
exploration of alternative coping strategies
- Assist the client to identify social support network
- Provide support to significant others
- Provide health teachings to clients

SEXUAL DISORDERS

1.Sexual Dysfunctions
Inhibition of the sexual
appetite or psycho-
physiological changes that
compromise the sexual
response cycle

The sexual response cycle:
- Phase 1: Appetitive
- Phase 2: Excitement
- Phase 3: Plateau
- Phase 4: Orgasm
- Phase 5: Resolution


TYPES OF SEXUAL DYSFUNCTION
Sexual desire disorder
- Hypoactive
- Sexual aversion disorder
Sexual arousal disorder
Orgasmic disorder
- Premature ejaculation
- Anorgasmia
Sexual pain disorders
- Dyspareunia
- Vaginismus
Predisposing factors
- Biological
- Psychosocial
- Relationship factors
2.Paraphilias (sexual perversions)
Sexual instinct is expressed in ways that are socially unacceptable and is
prohibited
Peaks between the age of 15 and 25 and decrease in incidence by age
Always enters the cycle of sexual perversion

PARAPHILIA
The following paraphilic activities last over a period of 6 months and cause
distress or impairment in social, occupational, or other important areas of
function:

EXHIBITIONISM
Recurrent, intense sexually arousing fantasies, sexual urges, or behaviors
involving exposing ones genitals to unsuspecting strangers.

FETISHISM
Recurrent, intense, sexually arousing fantasies, sexual urges, or behaviors
using nonliving objects.

FROTTEURISM
Recurrent, intense sexually arousing fantasies, sexual urges, or behaviors
involving touching and rubbing against a nonconsenting person.

PEDOPHILIA
Recurrent, intense sexually arousing fantasies, sexual urges, or behaviors that
involves sexual activity with a child or children generally 13 years of age or
younger.
The person is a least 16 years of age and at least 5 years older than the child
or children involved.

SEXUAL MASOCHISM
Recurrent, intense sexually arousing fantasies, sexual fantasies, urges, or
behaviors involving the act of being humiliated, beaten, restrained, or
otherwise made to suffer.

SEXUAL SADISM
Recurrent, intense sexually arousing fantasies, urges, or behaviors involving
acts in which the psychological or physical suffering of the victim is sexually
exciting to the person.
DSM-IV-TR
CRITERIA!

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VOYEURISM
Act of observing an unsuspecting person who is naked, in the process of
disrobing, or engaging in sexual activity.
3.Gender Identity Disorder
Homosexuality
Bisexuality
Transexualism (gender dysphoric disorder)

EATING DISORDERS

1.Anorexia Nervosa
Profound disturbance in body image and a relentless pursuit of thinness
often to the point of starvation
Weight phobia
Common in females; early adolescence
Refusal to maintain body weight at a normal BMI or it is less than 85% of
the DBW
Disturbance in the way in which ones body weight or shape is experienced
- self evaluation is based on body weight but is always in denial
- Amenorrhea (at least 3 consecutive cycles)
Other clinical features
- Most aberrant behaviors directed towards losing weight are in secret
- Refusal to eat with families or in public places
- Drastic reduction in total food intake with disproportionate decrease
in high carbohydrate and fatty foods
- There is actual preoccupation with food
- There are peculiar behaviors regarding food
- Associated with obsessive-compulsive behaviors, depression and
anxiety
- Markedly decreased interest in sex
- Overall prognosis is not good though some will spontaneous
recovery
TYPES
Restricting type
Binge eating/purging type

ETIOLOGY
Biological
- Decreased serotonin in CNS
- Presence of endogenous opiates for denial of hunger
Socio-cultural
- Society is focused on thinness and exercise
- More common in females
- Most frequent in developed countries
Common in professions such as modeling and ballet
Psychological
- Reaction to the demands for more independence in increased social
and sexual functioning
- There is lack of autonomy and selfhood
- Acts of extraordinary self-discipline
- Intrusive and unempathetic mother model

PHYSIOLOGIC SYMPTOMS
Hypothermia
Edema
Bradycardia
Hypersensitivity
Hypotension
Lanugo

TREATMENT
Hospitalizations
Individual (Weight-oriented)
Family therapy



Monitor caloric intake
Watch out signs of purging
Weigh client
Monitor activities
Plan for a realistic and healthy diet
Monitor nutritional and electrolyte status
For anorexia nervosa
- Increasing self-esteem is a primary objective
- Listen empathetically
- Engage clients in the food planning process
- Help identity and express bodily sensations
NURSING INTERVENTION
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- Identify non-weight related interest
- Improve social skills

2.Bulimia Nervosa
Consist of recurrent episodes of eating large amounts of food accompanied
by a feeling of out of control
There are feelings of guilt, depression and self-disgust after
There are recurrent compensatory behaviors: purging, fasting or excessive
exercise
They maintain normal body weight
Common in female; adolescence or early adulthood

ETIOLOGY
Biological
- Endorphin levels are increased
Psychological
- Parents maybe rejecting and neglectful
- Difficulties with adolescent demands
- Anorexics lacks ego strength while bulimic lacks superego control
TYPES
Purging
Non-purging

TREATMENT
Individual psychotherapy



For binge eating
- Create an atmosphere of trust
- Identify feeling associated with binging/purging behavior
- Improve self-esteem
- Teach about eating disorders
- Explore interpersonal relationships
DELIRUIM
Disturbance in consciousness accompanied by a change in cognition( e.g.,
memory deficit, disorientation, language disturbance, perceptual
disturbance)
Characterized by an acute onset and may last from hours to a number of
days and with a tendency to fluctuate during the course of the day
It is potentially reversible but can be life-threatening if not treated
Secondary either to a general medical condition or to effects of substances



Promote clients safety and structured environment
Manage the clients confusion(i.g., reorientation, approaching clients calmly
and speaking in a client low voice)
Promote sleep and proper nutrition
Keep the room lit to allay fears and prevent visual hallucinations
Monitor effects of medications

DEMENTIA
Altered mental state secondary to a cerebral disease
Usually irreversible, gradual in onset, progressive, degenerative
Characterized by a decreased intellectual function, personality change,
impaired judgment and often change in affect
Impairment in functioning is present

DEMENTIA
A. The development of multiple cognitive deficits manifested by both
1. Memory impairment (impaired ability to learn new information or to recall
previously learned
Information).
2. One (or more) of the following cognitive disturbances (As of Dementia):
a. Aphasia (language disturbance)
b. Apraxia (impaired ability to carry out motor functions despite intact
motor function)
c. Agnosia (failure to recognize or identify objects despite intact sensory
functioning
d. Disturbance or executive functioning (e.g., planning, organizing,
sequencing, abstracting)
B. The cognitive deficits in criteria A1 and A2 each cause significant impairment in
social or occupational functioning and represent a significant decline from a
previous level of functioning.
C. The course is characterized by a gradual onset and continuing cognitive
decline.
NURSING INTERVENTION
DSM-IV-TR
CRITERIA!

NURSING INTERVENTION
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(Ano ang alagang hayop ng taong may dementia?)

Alzheimer s Disease
Major cause of dementia in the elderly
Unknown etiology but some theories include
- Alterations in acetylcholine
Very strong genetic predisposition
Organic changes occur
- Brain atrophy, widening of sulcus and ventricles
- Neurofibrillary tangles and amyloid bodies
Stage 1
Agitated or apathetic mood
Attempts to cover up symptoms
Decline in personal appearance
Decline in recent memory
Decreased concentration
Depression
Disorientation regarding time
Disturbed sleep

Stage II
May last from 2-12 years
Confabulation (unconscious filling of memory gaps with fabricated facts and
experiences)
Continuous repetitive behaviors
Diminishing ability to understand or use language
Disorientation to person, place and time
Inability to recognize family members
Inability to retain new information
Incontinence of bowel and bladder
Socially unacceptable behavior

Stage III
Terminal stage (months to 5 years)
Compulsive touching and examination of objects
Deterioration in motor abilities
Non responsiveness
Severe decline in cognitive functions

DRUG THERAPY
Anti cholinesterase agents
Antipsychotic agents
- in low doses like haloperidol or risperidone

(Sino naman ang boyfriend ni LOLA?)



Remove any hazardous items or potential obstacles from the patients
environment to provide and maintain safety
Monitor food and fluid intake
Provide verbal and non-verbal communication that is consistent and
structured
State expectations simply and completely
Increase social interaction to provide stimulus for the patients
Encourage the use of community resources
Promote physical activity and sensory stimulations
Orient the patient to his surroundings
Monitor the environment
Encourage the patient to express feelings

Personality Disorder
formerly known as Character Disorder
an enduring pattern of inner experience and behavior that deviates markedly
from the expectations of the culture of the individual who exhibits it
CLUSTER A : odd or eccentric
1. Paranoid
2. Schizoid
3. Schizotypal
CLUSTER B: dramatic, emotional or erratic
1. Histrionic
2. Antisocial
3. Narcissistic
4. Borderline
CLUSTER C: anxious or fearful disorders
1. Avoidant
2. OC
NURSING INTERVENTION
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3. Dependent
ONS
1. Passive-aggressive

MENTAL DISEASES IN CHILDREN
Mental illness in the children and adolescents
Children are less able to verbalize feelings
Irritability maybe a predominant feature
Risk factors for childhood psychiatric disorders are
- Genetic and biological factors
- Adverse environmental influences
- Family and socio-cultural factors
- Stress experience
- Children can be motivated by their peers
- Negative effects of risk factors depend upon the severity of the risk
and the resiliency of the child
- Resilience is the ability to withstand problems of an undesirable
childhood

Mental Retardation
Below average intellectual functioning and impairment in adaptive skills that
is present before 18 years old
Arrested or incomplete development of the mind
Classified according to severity:
1. Mild
IQ level 50-55 to 69
2. Moderate
IQ level 35-40 to 50-55
3. Severe
IQ level 20-25 to 35-40
4. Profound
IQ below 20 or 25

(Diagnosed before___)
ETIOLOGY
>Chromosomal abnormalities > Genetic factors
>Complications of pregnancy >Perinatal factors
>Acquired childhood disorders

Pervasive Developmental Disorders
Autistic disorder
Retts disorder
Childhood disintegrative disorder
Aspergers disorder

AUTISTIC DISORDER
Disturbance in social relatedness
Common features
- Stereotypical behaviors -Peculiar preoccupations
- Delayed socialization and communication
Substantial percentage are mentally related
(Diagnosed before ___)

Attention Deficit And Disruptive Behavior Disorder
Attention deficit hyperactivity disorder
Conduct disorder
Oppositional defiant disorder

ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD or ADD)
Most common pediatric psychiatric disorder
Cardinal feature:
o Inattention
o Hyperactivity-impulsivity
o Impulsivity
(Diagnosed before___)
DRUG THERAPY
- Psychostimulants
- The Feingold diet elimination of artificial flavoring and colorings
and natural salicylates in food


Help the parents accept a diagnosis and plan a realistic approach to the
situation
Help shape family members and other peoples attitudes towards them and
accept them
Help in activities of daily living
Standards of acceptable behavior within the ability of the child should be
provided
REMEMBER
REMEMBER
NURSING INTERVENTION IN CHILDHOOD MENTAL DISORDERS
REMEMBER
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NOTE
NOTE
He should b taught to seek help when in difficulty to resist frustration and
achieve emotional control
Create a therapeutic environment

STIGMA
An attribute or trait deemed by the persons social environment as negative,
different and diminishing

ETHICAL DILEMMA
Exists when moral claims conflict with one another. It can be defined as:
o A difficult problem that seems to have no satisfactory solution
o A choice between equally unsatisfactory alternatives

PSYCHIATRIC REHABABILITATION
The process of helping the person return to the highest possible level of
functioning
The range of social, educational, occupational, behavioral, and cognitive
interventions used to increase the role performance of persons with serious
and persistent mental illness and to enhance their recovery

CARE OF THE CAREGIVER
ROLE STRAIN
When the demands of providing care threaten to overwhelm the caregiver
Characterized by:
- Constant fatigue unrelieved by rest
- Use of alcohol/other substances
- Social isolation
- Inattention to personal needs
- Inability/unwillingness to be helped by others
It may become a factor in the neglect or abuse of patients



Refer caregivers to knowledgeable health professional who can provide
information, support and assistance
Provide outlets for dealing with caregivers feelings
Help them seek and accept assistance from other people or agency and not
wait until they are exhausted
Provide support for a personal life
>uve finished this extra CHAKRA GREAT J OB!
REFERENCE:

Fortinash, K.M. & Holoday, P.A. (2008). Psychiatric Mental Health Nurisng
(4
th
ed.). St. Louis: Mosby/Elsevier.

Keltner, N.L.,Schwecke, L.H., & Bostrom, C. E. (2007). Psychiatric Nursing,
(5
th
ed.). St. Louis: Mosby/Elsevier.

Kozier, B., Berman, A., Snyder, S., & Erb, G., (2007). Kozier & Erbs
Fundamentals of Nursing: Concepts, Process & Practice (8
th
ed., Vol. 1).
Upper Saddle River: Prentice Hall.

Shives, L.R. (2008). Basic Concepts of Psychiatric-Mental Health Nursing (7
th
Ed.).
Philadelphia: /Walters Kluwer Health/Lippincott Williams & Wilkins.

Stuart, G.W. & Laraia M.T. (2005). Principles and Practice of Psychiatric
Nursing (8
th
ed.). St. Louis: Mosby/Elsevier.

Videbeck, S.L. (2008). Psychitric-Mental Health Nursing (4
th
ed. ).
Philadelphia: Lippincott Williams & Wilkins.

***Edited August 2011/MERGE_Psychiatric Nursing Team

Welcome to the Psychiatric Hotline
If you are obsessive-compulsive, please press 1 repeatedly
If you are co-dependent, please ask someone to press 2
If you have multiple personalities, please press 3,4,5 and 6
If you are paranoid-delusional, we know who you are and what you want. Just stay
on the line so we can trace the call.
If you are schizophrenic, listen carefully and little voice will tell you which number
to press
If you are depressed, it doesnt matter which number you press. No one will
answer
If you are delusional and occasional and occasionally hallucinate, please be aware
that the thing you are holding on the side of your head is alive and about to bite
off your ear.

NOTE: These are supplemental handouts only. MERGE Team still advice you
to have additional readings as necessary.
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