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MULTI- EDUCATIONAL REVIEW GROUP EXPERTS, INC.

P
MAKATI* CAVITE * PAMPANGA * CABANATUAN* BAGUIO * TUGUEGARA* VIGAN * LUCENA * MORAYTA*
S DAVAO *BACOLOD * KIDAPAWAN* ILIGAN * GENERAL SANTOS*BULACAN* ILOILO * CEBU*
MANILA HEAD OFFICE
Y
C CARE OF THE CLIENTS WITH PSYCHOSOCIAL ALTERATIONS – MENTAL HEALTH NURSING

H 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
I illness and suffering and if necessary, to find meaning in these experiences

A GENERAL CONCEPTS OF MENTAL HEALTH AND ILLNESS  From metabolic processes, relationship with the environment and symbolic
behaviors.
T MENTAL HEALTH
SA
 A state of emotional, psychological and social wellness
R - Satisfying interpersonal relationships
- Effective behavior and coping Self-esteem
I - A positive self-concept
- Emotional stability
 State of adjustment with maximum effectiveness and satisfaction. Love and Belongingness
C
 Fundamental for personal happiness
 Contentment, achievement, optimism and hope Love and Belonging
 Absence of mental and behavioral disorder or disturbances Safety and Security
Needs
N
MENTAL ILLNESS
Physiologic (survival)
U  One‟s view of an act
 The reaction of others
 Overall cultural context in which the acts occur *In Psychiatric Nursing: Safety is always a PRIORITY!
R  Often a matter of adjustment not a matter of a act
REMEMBER

PERSONALITY DEVELOPMENT
S
NEEDS PERSONALITY
I  Organismic condition which exists within the individual which demands  Individual‟s internal and external adjustment to life.
certain activities  Integration of behaviors that is lifelong
N  A state of tension which disrupts one‟s equilibrium  Integration of traits which can be investigated or described in order to
 Produces a relative degree of discomfort render and account of the unique quality of an individual
G  All that an individual is, feels and does consciously and unconsciously

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SIGMUND FREUD’S PSYCHOSEXUAL THEORY ERIK ERIKSON’S PSYCHOSOCIAL THEORY

 Psychoanatomically, personality has three basic
P parts whose internal conflict and balance  Psychosocial maturity
produce behavior (Structures of Personality):  Everyone goes thru a developmental stage
S featured by a developmental task that must be
successfully completed if the succeeding tasks are
Y PRINCIPLE being resolved in turn
Id Pleasure  There is interplay between the positive and
C Ego Reality negative outcomes inherent in each task
Superego Moral  “Womb to tomb”
H  Postulated that the mind consist roughly of three overlapping  The Psychosocial stages are:
divisions/levels of awareness:
I AGE-GROUP AGE DEVELOPMENTAL TASK VIRTUE
LEVEL DESCRIPTION Infant 0-18 mos Trust vs Mistrust Hope
A Conscious Involves experiences which can be recalled at will Toddler 18 mos- 3 yrs Autonomy vs Shame and
without any effort Doubt Will
T Preconscious Involves experiences which can be recalled at will Preschool 3-5 yrs Initiative vs Guilt Purpose
but with some effort School Age 6-12 yrs Industry vs Inferiority Competence
R Unconscious Involves experiences which cannot be recalled at
Adolescence 12-18 yrs Identity vs Role
will
Diffusion/Confusion Fidelity
I Young Adult 18-25 (30) yrs Intimacy vs Isolation Love
 Personality development is equated to psychosexual development (libido) Middle Adult 25 (30)-65 yrs Generativity vs Stagnation
C  Maturation of the sexual instinct is the last step in the maturation of Care
emotional development Maturity 65 yrs –death Ego-Integrity vs Despair Wisdom
 Each stage‟s interests become permanent parts of the personality
 The stages of Psychosexual Development:
N HARRY STACK SULLIVAN’S INTERPERSONAL THEORY
STAGE AGE FOCUS MAJOR
U CONFLICT  Personal interrelationships
Oral Birth to 18 mos mouth,lips,tongue Weaning  Self-image and self concept organizes behavior
R Anal 18 to 36 mos Bladder Toilet training and is built as a result of his experience with
Phallic Penis envy significant other persons and their reflected
S 3 – 5 yrs Genitals Fear of castration appraisals
Oedipal complex  Emphasizes social factors
I Latency 5-11 or 13 yrs School work, sports  Maturation of inter-relational skills leads to
(puberty) personality maturation
N Genital 11-13 yrs Capacity for the intimacy  Stages of Interpersonal Model are:

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STAGE AGE CHARACTERISTIC understood and able to apply rules

Infancy Birth - 1 ½ yrs Crying to establish contact with others Formal Operational 12 -15 yrs Think and reason in abstract terms
P Childhood 1 ½ - 6 yrs Language assists with learning to delay Further develops logical thinking and
gratification of needs reasoning
S Juvenile 6 – 9 yrs Competition Now achieves cognitive maturity
Compromise
Y Cooperation LAWRENCE KOHLBERG’S MORAL DEVELOPMENT
for developing relationships with peers Moral development depends primarily on cognitive
C Preadolescence 9 -12 yrs Love assist in the development of development
“chum” relationship with a person of the  Moral development goes hand in hand with
H same gender thinking and judgment
Early Adolescence 12 -14 yrs With sexual desire in establishing  The Stages of Moral Development are:
I relationship with person of the opposite STAGE AGE CHARACTERISTIC
sex; Pre conventional Toddler – 7 yrs Stage 1: Punishment avoidance
A Independence developed (Egocentric and obedient orientation
Late Adolescence 14 – 21 yrs Interdependence is learned focus)
T Learns lasting sexual relationships Preschooler through Stage 2: Instrumental Relativist
School age Orientation
R JEAN PIAGET’S COGNITIVE THEORY “Getting what you want” by trade-off
 Motor activities involving concrete objects results in the Conventional School age through Stage 3: Interpersonal
I development of mental functioning (learning) (Societal focus) Adulthood Concordance Orientation
 New operation building on already existing ones Meeting expectations of others
C  Increasing integration and coordination Adolescence and
Adulthood Stage 4: Law and Order
 Maximal learning through the process of contemplative
Orientation
recognition
Fulfilling duties and upholding laws
 Stages of cognitive development are:
N STAGE AGE CHARACTERISTIC
Post-conventional Middle-age or Older Stage 5: Social Contract Legalistic
(Universal focus) Adult Orientation
Sensorimotor Birth – 2 yrs Begins to form mental images Sense of democracy and
U Object permanence: tangible objects do relativity of rules
not cease to exist just because they are
R out of sight. Stage 6: Universal Ethical
Middle-age or Older
Develops sense of self as separate from Principle Orientation
S the environment
Adult
Self-selection of universal principles
Preoperational 2 – 6 yrs Expresses now self with language SUMMARY OF PERSONALITY DEVELOPMENT
I Understands symbolic gestures 1. Development is a continuum
Begins to classify objects 2. Behavior has meaning and is not determined by chance.
N Concrete 6 – 12 yrs Thinking is still concrete 3. All behaviors should be goal-directed
Operational Begins to apply logic to thinking 4. The unconscious plays an active role in determining behavior.
G Spatiality,Reversibility is being 5. The early years of life are extremely important for personality development

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THEORETICAL FRAMEWORK OF CARE B. Gestalt Model

 Emphasizes identifying the person‟s feelings and thoughts in the “here and
P THEORIES now”

S 1.Psychoanalytical Model 7.Medical-Biological Model

 Behavioral disturbances stems from emotionally painful experiences  Behavior disturbance is an illness or defect
Y  Repressed feelings lead to unresolved and unconscious conflicts in the  Illness is located in the body, either a neurostructurral defects, biochemical
mind alteration or genetics
C  Defense mechanism develop which produces the disturbed symptoms  Disease entities can be diagnosed, classified and labeled
 Psychotherapy uncovers the roots of conflict through interviews in long-term  Somatic therapies are used which includes:
H therapy o Electroconvulsive therapies
 Ex. S. Frued o Psychosurgery
I o Bright Light Therapy
2. Developmental Model o Transcranial Magnetic Stimulation (TMS) or Repetitive Transcranial
A  Extended the work of Frued on personality development cross the lifespan Magnetic Stimulation (rTMS)
while focusing on social and psychological development in the life stages
T  Ex. E. Erikson and Jean Piaget TREATMENT MODALITIES

R 3. Interpersonal Model 1.Individual Psychotherapy

 Extended the theory of personality development to include the significance  A method of bringing about change in a person by exploring his or her
I of interpersonal relationship feelings, attitudes, thinking and behavior
 Ex. H.S. Sullivan and H. Peplau  a confidential relationship between client and therapist that may occur in the
C therapist‟s office, outpatient clinic, or mental hospital
4. Behavioral Model
 Behavior can be changed through a system of rewards and punishment 2. Couple therapy
 Response to behavior by therapists should be consistent  An intervention involving two individuals sharing a common relationship (a
N  Ex. Pavlov and Skinner married or no married, homosexual or heterosexual pair) is a way of
resolving tension or conflict in a relationship
U 5. Humanistic Model
 Focuses on a person‟s positive qualities, his or her capacity to change, and 3. Family therapy
R promotion of self-esteem  a method of treatment in which members gain insight into problems,
 Ex. Maslow‟s Hierarchy of Needs improve communication, and improve functioning of individual members as
S well as the family as a whole
6. Existential
I A. Cognitive Model 4. Group therapy
 Focuses on immediate thought processing-how a person perceives or  a method of therapeutic intervention based on the exploration and analysis
N interprets his or her experience and determines how he or she feels and of both internal and external conflict and the group process
behaves  Members share a common purpose and are expected to contribute to the
G group to benefit others and receive benefit from others in return
 Major focus is the “here-and-now” experience

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NOTE
Yalom’s Therapeutic/Curative Factors  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
P 1. INSTILLATION OF HOPE is the first and often most important factor.  Psychotropic drugs are often decreased gradually rather than abruptly
Patients receive hope from observing others who have benefited from the discontinued
S group experience  Follow-up care is essential to ensure compliance with the medication
regimen, to make needed adjustments in dose and manage side effects
Y 2. UNIVERSALITY. Patients experience relief in knowing that they are not
alone and unique, but that others experience similar problems, feelings, and
C concerns.we are all in the same boat Anti-anxiety Drugs REMEMBER (Ang tunog ng BUS)
3. IMPARTING OF INFORMATION. Patients learn or are provided information  Most common drugs are benzodiazepines
H about areas related to their needs. - Diazepam(Valium), Lorazepam (Ativan), Chlordiazepoxide
4. ALTRUISM. Patients experience themselves as helpful or useful to others. (Librium), Clorazepate (Tranxene)
I 5. CORRECTIVE RECAPITULATION OF PRIMARY FAMILY GROUP.  Buspirone (Buspar) is the first pure anxiolytic drug and acts as a partial
agonist at serotonin receptor sites.
A Patients renew previous dysfunctional family patterns and learn that these
 Barbiturates may also be used for anxiety such as Phenobarbital
patterns can be changed to meet their present needs effectively.  Propranolol (Inderal) is a beta-blocker effectively interrupts the physiological
T 6. DEVELOPMENT OF SOCIALIZING TECHNIQUES. Patients are taught responses of anxiety
appropriate social skills.  Antihistamines Hydroxyzine (Iterax, Atarax) has a central cholinergic effect
R 7. IMITATIVE BEHAVIOUR. Patients selectively model healthy behaviors of and is good anti-anxiety agent
the leader and other group members.
I 8. CATHARSIS. Patients are not only allowed to express them appropriately. NURSING INTERVENTION
9. EXISTENTIAL FACTORS. Patients share feelings about “ultimate
C  Caution client to avoid potentially hazardous activities because of
concerns” of existence, such as death or isolation, and learn to accept that drowsiness
there is a limit to their control of these issues.  Warn the client of the danger of concurrent use of alcohol and other CNS
10. COHESIVENESS. Patients experience feelings of being accepted, valued, depressants
N and part of a group experience  Avoid abrupt withdrawal
11. INTERPERSONAL LEARNING. Patients learn how their behaviours affect  Do not give antacids concurrently
U others and more appropriate ways of relating in the supportive atmosphere  Do not take medications with meals
 Watch for adverse reactions
of the group.
R
PSYCHOPHARMACOLOGY REMEMBER ( Ang kuwento ni THOR)
S Antipsychotic Drugs
 Classified either by chemical class, potency but more importantly by
BASIC PRINCIPLES
I  A medication is selected based on the client‟s target symptoms
typicality
 Low-potency drugs causes more anticholinergic side effects whereas high-
 Many psychotropic drugs must be given in adequate for a period of time
N before their full effect is realized
potency drugs causes more EPS
 The dosage of medication is often adjusted to the lowest dose effective for
G clients

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1.TYPICAL ANTIPSYCHOTIC DRUGS - Manifested as tongue-thrusting and protrusion, lip-smacking,

P  Traditional drugs effective for blinking, grimacing
 EFFECTIVE FOR WHAT TYPE OF SYMPTOM/S?_______ WOF
S  Examples are: 2. NEUROLEPTIC MALIGNANT SYNDROME (NMS)
o chlorpromazine (Thorazine), thioridazine (Mellaril), haloperidol  Potentially fatal reaction to an antipsychotic drug; idiosyncratic
Y (Haldol), fluphenazine (Prolixin)  Characterized by rigidity, high fever, autonomic instability and maybe
confusion and muteness
C 2.ATYPICAL ANTIPSYCHOTIC DRUGS
 EFFECTIVE FOR WHAT TYPE OF SYMPTOM/S?_______ 3. ANTICHOLINERGIC EFFECTS
H  No endocrine side effects Prolactin increase)  Orthostatic hypotension, dry mouth, constipation, urinary retention,
 Potent antagonists of serotonin photophobia and sensitivity
I  Examples are:
o Clozapine (Clozaril, risperidone (Risperdal, olanzapine (Zyprexa), 4. ENDOCRINE CHANGES
A quetiapine (Seroquel)  Lactation in females; gynecomastia and impotence in males

T 3.DOPAMINE SYSTEM STABILIZER (DSS)

 EFFECTIVE FOR WHAT TYPE OF SYMPTOM/S?_______
5. AGRANULOCYTOSIS
WOF
 Esp. for those taking clozapine
 DSS are thought to balance the dopamine systems by increasing dopamine  Decrease in white blood cell hence prone to infections
R in brain areas in which dopamine is deficient and decreasing dopamine in
brain areas in which dopamine is overactive
I  Only example is: NURSING INTERVENTION
o Aripiprazole (Abilify)  Check BP prior to administration
C  Periodic liver function test and blood counts
 Observe for warning signs of adverse effects
SIDE EFFECTS REMEMBER („pag wala sa tamang KATINUAN)  Note complaints of sore throat, nosebleed, rash, fever or other signs of
infection
N 1. EXTRAPYRAMIDAL SIDE EFFECTS (EPSE)  Warn client that drowsiness may occur until tolerance is developed
a. Acute Dystonia  Teach the client to:
U - Acute muscular rigidity and cramping, stiff thick tongue with - Avoid alcohol
difficulty swallowing; torticollis, opisthotonus or oculogyric crisis - Consult before taking other medications
R b. Pseudoparkinsonism - Precautions to avoid skin damage from photosensitivity
- Stooped, stiff posture with mask-like faces, a festinating gait, - High fiber diets, fluids, exercise and good oral hygiene
S cogwheel rigidity, drooling, bradykinesia, pill rolling tremors.
c. Akathisia
I - Feeling of internal restlessness and inability to sit down NURSING INTERVENTION
d. Tardive Dyskinesia Anticholinergic and Dopaminergic drugs
N - Syndrome of permanent involuntary movements of the tongue,  Given to control EPSEs in clients taking antipsychotic drugs
facial and neck muscles, upper and lower extremities even truncal  A balance between acetylcholine and dopamine is required for normal
G musculature movement

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NURSING INTERVENTION
 Balance is accomplished in three ways  Assess for the side effects and treat symptomatically
P 1. Drugs used to increase dopamine (Dopaminergic)  Do not give TCA‟s and SSRI‟s with or immediately with MAOI‟s
2. Drugs used to decrease the level of Ach (Anticholinergic)  Monitor blood pressure
S 3. A combination of the above drugs  Avoid TYRAMINE-containing foods (aged cheese, wine, pickled and
preserved foods and alcohol) may lead to HPN crisis (for MAOI)
 Dopaminergic drugs include:  Teach clients to:
Y - Carbidopa-levodopa (Sinemet), amantadine (Symmetrel), - Take medications with food
bromocriptine (Parlodel), pergolide (Permax), - Notify/consult before taking any other drugs
C selegilline (Eldepryl) - Not to drive or operate machineries
- Common psychiatric side effects of dopaminergics: Confusion, - Advise that these drugs may not take effect until after 2 weeks
H hallucinations, delusions, depression, anxiety, agitation
 Anticholinergics used are:
I - Benztropine (Cogentine), biperiden (Akineton), trihexyphenidyl Antimanic Drugs REMEMBER (Ang kawad ng PLDT)
(Artane), dephenhydramine (Benadryl)  Normalizes reuptake of certain neurotransmitters but exact mechanism is
A - Common side effects of anticholinergics: Mydriasis and blurred still unknown but there are theories which considers its action on the second
vision, decreased secretions, , constipation, urinary retention and messenger system of the body
T increased heart rate  Standard drug of choice is Lithium Carbonate
o Effective serum level is 0.6-1.2 meq/L
R Antidepressant Drugs REMEMBER (Kuwento nina ANA at ELA) o Effect of lithium takes 7-10 days
o SIDE EFFECT:
I 1.SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRI) o Type of RELATIONSHIP of Na and Lithium:
REMEMBER

 Block reuptake of serotonin at specific serotonin receptor sites  In the absence of lithium alternative drugs are: Valporic acid (Depakote) or
C  Serotonin syndrome may appear in some clients carbamazepine (Tegretol)
 Indicated for depression, OCD, panic disorders
 Examples are: Includes Paroxetine (Seroxat, Paxil), Sertraline (Zoloft),
Fluvoxamine (Luvox), Fluoxetine (Proxac) NURSING INTERVENTION
N  Remind the client to take the medications regularly
__________ WOF  Monitor salt and fluid intake
U 2.TRICYCLIC ANTI-DEPRESSANTS (TCA)  Report decreased in urine output WOF
 Blocks reuptake of serotonin and norepinephrine  Monitor for signs and symptoms of toxicity
R  Examples are: imipramine (Tofranil), Amitriptyline (Elavil), Clomipramine o Muscle weakness or twitiching, diarrhea, vomiting, hand tremors,
(Anafranil), Amoxapine (Asendin), Doxepin (Sinequan) drowsiness (DVDMC)
S  Teach the client to:
__________ WOF - Avoid caffeine
I 3.MONOAMINE OXIDASE INHIBITOR (MAOI) - Take medications with meals
 Prevents the breakdown of dopamine, serotonin and norepinephrine  For Anticonvulsants
N  Examples are : Isocarboxacid (marplan), Phenelzine (Nardil), - Teach client not to drive until response had been determined
Tranylcypromine (Parnate) - Avoid alcohol and non-prescription drugs
G __________ WOF - Do not stop the drug abruptly

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Psychostimulants  Maybe formalized with counseling or individual psychotherapy

 Often termed indirectly acting amines because they act by causing release
P of the neurotransmitters (NE, dopamine and serotonin) from presynaptic
terminals as opposed to having a direct agonist effects on the postsynaptic
S receptors.
 They also block the reuptake of these neurotransmitters
Y  Most common example is Methylphenidate (Ritalin)
 Most common side effects are anorexia, weight loss, nausea and irritability,
C growth and weight suppression
H
NURSING INTERVENTION
I  Caffeine-free beverages are suggested
 Taken after meals
A  Keep out of reach of children, 10-day supply can be fatal
 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 nurse‟s
presence conveys integrity and reliability. Trust develops when the client
believes that the nurse will be consistent in his or her words and actions NOTE
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.

T Anticholinesterase 3. EMPATHY
 They target Ach deficiency. By attaching to and thus blocking ChE, these -Is the ability of the nurse to perceive the meanings and feelings of the
R four drugs substantially increase the amount of intrasynaptic Ach available client and to communicate that understanding to the client.It is considered
to cholinergic receptor..in short  it INCREASES what neurotransmitter? one of the essential skills a nurse must develop.
I  Tacrine (Cognex), Denazepil (Aricept)
4. ACCEPTANCE
C THERAPEUTIC NURSE-CLIENT RELATIONSHIP -The nurse who does not become upset or respond negatively to a client‟s
outbursts, anger, or acting out conveys acceptance to the client.
Therapeutic Use of Self
 Nurses use themselves as a therapeutic tool to establish a therapeutic 5. POSITIVE REGARD
N relationships with clients and to help clients grow, change and heal -The nurse who appreciates the client as a unique worthwhile human being
 Self awareness can respect the client regardless of his or her behavior, background, or
U o A process by which the nurse gains recognition of his or her own lifestyle. This unconditional nonjudgmental attitude is known as positive
NOTE feelings, beliefs and attitudes regard and implies respect.
R o JOHARI window
ROLES OF PSYCHIATRIC-MENTAL HEALTH NURSE
S Nurse Client Relationship 1. Nurse-Teacher
It is the purposeful use of the nurse‟s interpersonal skills directed towards 2. Mother Surrogate
I growth producing outcomes for clients. 3. Technical Nurse
4. Nurse-Manager
N CHARACTERISTICS 5. Socializing Agent
 Frequently informal and spontaneous and occurs in various health care and 6. Counselor/ Nurse-Therapist
G community settings.

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PHASES REMEMBER (What are the major tasks in each phase?) 2. Components of NONVERBAL COMMUNICATION
a. Kinesics
P 1. Preorientation/Preinteraction b. Proxemics
2. Orientation c. Paralanguage
S 3. Working d. Touch
4. Termination REMEMBER e. Silence
Y (The longest and the most productive phase)

C Therapeutic Communication Therapeutic Milieu REMEMBER (What is the most important principle?)
 It is the purposeful use of all interactions to assist clients in developing
H COMMUNICATION interpersonal and social skills in a conductive physical and emotional
 The reciprocal exchange of information environment
I  Components  Manipulates environmental stimuli to provide limits, protect clients and other
- Sender, message, receiver, feedback and the context members of the therapeutic community and promote optimal functioning
A  Models/ Types (Role of the nurse?)
o Verbal REMEMBER
T  Structural Model:
 Sender, Message, Receiver, Feedback, Context EVALUATING MENTAL FUNCTIONING NOTE
R o Non-verbal Mental Status Examination
 Standardized nursing assessment procedure aimed at making a diagnosis
I 1. THERAPEUTIC COMMUNICATION (VERBAL) and determine intervention
o The process in which the nurse consciously utilizes the principles of  Designed to determine present mental status
C communication in a goal-directed professional framework.  Assessed according to the ff. mental functions:
o Best responses should focus on the general guidelines
1.General Description
GENERAL GUIDELINES NOTE A.GENEREAL APPEARANCE:
N * Open-ended questioning is best used Type, condition, and appropriateness of clothing (for age, season, setting),
* Here and now rather than the past grooming, cleanliness, physical condition, and posture
U * “What” rather than “why”
* Orientation and presentation of reality B. BEHAVIORS during the interview
R * Actual client behaviors and nursing observations rather than giving Degree of cooperation. Resistance, or evasiveness
inferences
S * Maintenance of biologic integrity C. SOCIAL SKILLS
Friendliness, shyness or withdrawal
* Nursing interventions rather than roles designated to other health
I team members
* Sharing information and exploring alternatives rather than giving D. Amount and type of MOTOR ACTIVITY
Psychomotor agitation or retardation, restlessness, tics, tremors,
N actual solutions
hypervigilance, or lack of activity
REMEMBER (Ang ating CARE)
G

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2. Emotional State G. JUDGMENT

A. AFFECT Soundness of problem solving and decisions
P Labile, blunted, flat, incongruent, or inappropriate affect
Diagnostic Statistical Manual 4TH edition Text Revision (DSM-IV-TR)
S B. MOOD  Specific diagnostic criteria developed by the
Specific moods expressed or observed- euphoria, depression, anxiety, American Psychiatric Association
Y anger, guilt, or fear  Includes diagnostic criteria and description of
each category
C 3. Thinking  Important for nurses to be familiar with this
A.THOUGHT CONTENT system in order to communicate effectively and
H Helplessness, hopelessness, worthlessness, suicidal thoughts or plans, efficiently with other members of the mental
suspiciousness, obsessions, poverty of content, denial, or delusions health team
I o Axis I - Psychiatric clinical diagnosis
B. THOUGHT PROCESS reflected in speech o Axis II - Presence of mental retardation or personality disorders
A Ambivalence, circumstantiality, tangentiality, thought blocking, loose o Axis III – General medical conditions
associations, flight of ideas, perseveration, neologism or word salad o Axis IV – Psychosocial stressor
T o Axis V - Global assessment of functioning (GAF)
4.Experience
R PERCEPTION: Hallucination ANXIETY: A Central Concept

I 5.Sensorium and Cognition Stress

A.SPEECH PATTERNS  A generalized non-specific response of the body to any demands whether
C Amount, rate, volume, tone pressure, mutism, slurring or stuttering positive or negative.
 Damaging or unpleasant forms of stress is distress.
B. DEGREE OF CONCENTRATION AND ATTENTION SPAN  When stress is sufficiently great and reaches a point above the threshold of
an individual, frustration results
N C. DEGREE OF CONSCIOUSNESS Response to Stress:
To time, place, person, and level of consciousness  Fight or flight mechanism
U  Hans Selye‟s General Adaptation Syndrome
D. MEMORY Stage I - Stage or alarm reaction
R Immediate recall, recent, remote, amnesia, and confabulation Stage II - Stage of resistance
Stage III - Stage of exhaustion
S E. INTELLECTUAL FUNCTIONING
Educational level, use of language and knowledge, abstract vs concrete Anxiety
I thinking and calculation  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
N F. INSIGHT a visible object or trigger.
Degree of awareness of illness, behavior, problems, and their causes  Subjective experience detected by the objective behaviors that result from it.
G  Emotional pain.

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 Triggers autonomic relief behaviors aimed at eliminating anxiety. DEFENSE NOTE

P  Contagious; communicated from one person to another. MECHANISM DEFINITION
Denial Unconscious refusal to admit an unacceptable idea or
S LEVELS OF ANXIETY
NOTE
behavior
 Mild (+1) Repression Unconscious and involuntary forgetting of painful ideas,
Y - Greater alertness to the environment occurs events, and conflicts
- People may feel more energetic and motivated Suppression Conscious exclusion from awareness anxiety-producing
C - Behavior may be more efficient
 Moderate (+2)
feelings, ideas and situations
Rationalization Conscious or unconscious attempts to make or prove that
- Perceptual field begins to narrow
H - Shuts out periphery; focused on central concerns
one‟s feelings or behaviors are justifiable
Intellectualization Consciously or unconsciously using only logical explanations
- Selective Inattention
I  Severe (+3)
without feelings or an affective component
Dissociation The unconscious separation of painful feelings and emotions
- Perceptual fields is greatly reduced
A - People generally focus on small details but maybe unable to focus
from an unacceptable idea, situation, or object
Introjection Unconsciously incorporating values and attitudes of others as
on the whole
T - Inability to focus on events and environment
if they were your own
identification Process by which the person tries to become like someone
 Panic (+4)
R - Disruption of the perceptual field
he admires by talking on thoughts, mannerisms or tastes of
that person
- Disorganization of the personality
I - Inability to control the self or environment
Compensation Consciously covering up for a weakness by overemphasizing
or making up a desirable trait
- Behavior purposeless and communication unintelligible
C - Complete immobility maybe present
Sublimation Consciously or unconsciously channeling instinctual drives
into acceptable activities
Reaction A conscious behavior that is the exact opposite of an
DRUG THERAPY
formation unconscious feeling
 Antianxiety
N Undoing Consciously doing something to counteract or make up for a
transgression or wrongdoing
U Coping Responses Displacement Unconsciously discharging pent-up feeling to a less
threatening object, person or animal
R COPING MECHANISMS Projection Unconsciously (or consciously) blaming someone else for
- Any effort directed at stress management. one‟s difficulties or placing one‟s unethical desires on
S - It can be problem, cognitive or emotion focused someone else
Conversion Unconscious expression of intrapsychic conflict symbolically
I DEFENSE MECHANISMS through physical symptoms
- Methods of attempting to protect the self and cope with basic drives Regression Unconscious return to an earlier and more comfortable
N or emotionally painful thoughts, feelings or events developmental level
- Become counterproductive when used to the extreme Fixation Immobilization of a portion of the personality resulting from
G unsuccessful completion of tasks in a developmental stage

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CRISIS METHODS (STEPS) OF CRISIS INTERVENTION

 Results in a period of severe disorganization resulting from the failure of an 1. An assessment of the individual and the problem
P individual‟s usual coping mechanisms, lack of usual resources, or both 2. Planing of therapeutic intervention
 Individual is in a state of disequilibrium 3. Intervention
S  Self-limiting (4-6 weeks) and is precipitated by new or sudden situations 4. Resolution of the crisis
 Occurs in all ages 5. Anticipatory planning
Y  Response is relative
 Ineffective resolution leads to future crisis GRIEF
C  Refers to the subjective emotions and affect that are normal response to the
FORMS/CATEGORIES experience of the loss
H - Maturational/Developmental crisis
- Situational/Accidental crisis KUBLER-ROSS STAGES OF GRIEF
I - Adventitious/Social crisis  Denial
 Anger
A  Bargaining
NURSING INTERVENTION
 Depression
T  Short-term therapy focused on solving immediate problem  Acceptance
 Cope with an immediate problem
R - Does not go into cause or require insight
 The goal is to return the client into pre-crisis level of functioning NURSING INTERVENTION
I  Involves clarifying present situations and problems, mobilize internal and  Acceptance
external resources and teach new coping skills.  Provide opportunity for the persons to “tell their story”
C  Recognize and accept the varied emotions people express in a loss
CRISIS INTERVENTION STRATEGIES NOTE  Provide support for the expression of difficult feelings such as anger and
1. Focus on survival, safety and security sadness
a. Assess for and prevent suicide, violence, decompensation, and  Encourage maintain established relationships
N reactivation of serious medical or psychiatric problems  Acknowledge the usefulness of counseling for especially difficult problems
b. Validate reactions and feeling as normal
U 2. Reestablish equilibrium and stabilization
ANXIETY DISORDERS REMEMBER (Ang taong PAGOD)
 Anxiety usually predominates and the person is usually in a state of conflict
3. Focus on strengths and adaptive coping
R  Persistent or recurrent
a. Encourage use if adaptive coping and personal, spiritual, family and  Certain defense mechanism are used repeatedly in an attempt to control
S community resources anxiety
4. Offer suggestions for concrete, specific problem solving  Anxiety maybe present despite the absence of triggers
I a. Focus on the “here and now”  Creates a significant impairment in socio occupational functioning
5. Make provision for follow-up care o Primary gain refers to the individual‟s desire to relieve anxiety in
N a. Arrange for monitoring for 2-3 months- the risk of suicide can persist
order to feel better and more secure
o Secondary gain refers to the attention and support the individual
G derives from others because of illness

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1.Generalized Anxiety Disorder  Dissociative symptoms immediately after

 Excessive worry and anxiety  Avoidance of stimuli related to trauma
P  Difficulty in controlling the worry  Increased arousal or anxiety
 Anxiety and worry is evident in - Sleep disturbance, hypervigilance, easy startle
S - restlessness, fatigue and irritability, diminished concentration,  Re-experiencing or relieving the traumatic event
muscle tension, disturbed sleep - distressing thoughts‟ dreams‟
Y  Chronic feelings of nervousness and apprehension “for no apparent reason”  Impairment in socio-occupational functioning

C 2.Panic Disorders 6.Posttraumatic Stress Disorder

 Recurrent, unexpected panic attacks followed by a month or more of worry  Same as that of ASD
H about having additional attacks, worry about the results of the attacks, and  Numbing of responsiveness
behavioral changes related to the attacks - Inability to recall aspects of the event
I - Restricted affect
3.Obsessive-Compulsive Disorder - Sense of „foreshortened future‟
A  Obsessions are intrusive, inappropriate, recurrent, and persistent thoughts,  „Survivor guilt‟
impulses, or images that are distressful or produce anxiety  Occurs usually within 6 months after the event or even more (delayed)
T  compulsions are repetitive behaviors, such as hand washing, or mental
acts, such as counting, performed in response to an obsession
R NURSING INTERVENTION
REMEMBER (What is the most common ritual?)  To reduce anxiety
I - Provide a calm and quit environment
4.Phobic Disorder - Ask patients to identify what and how they feel
C  Phobia is a persistent and irrational fear of a specific object, activity or - Encourage the patients to discuss feelings
situation that results in a compelling desire to avoid the dreaded object or - Help patients identify possible causes of their feelings
situation - Listen carefully for patients expressions of helplessness and
 The fear is recognized as excessive and unreasonable in proportion to the hopelessness
N actual danger - Plan and involve patients in activities such as walking or playing
 Maybe primary or secondary recreational games
U  Categorized into:
- Agoraphobia  For panic
R o Fear of being in public places wherein escape may be - Remain with the client and provide safety
difficult; „fear of the fear‟ - Reduce environmental stimuli and approach always in a calm
S - Social phobia manner
- Specific phobia (e.g. Claustrophobia) - Focus client‟s attention on a simple, repetitive task
I
5.Acute Stress Disorders  For ritualistic behaviors
N  Exposure to a traumatic event involving threat of death/injury to self or - Avoid interfering with the ritual
others, or actual injury to self and others - Set rational limits on ritualistic behavior in terms of timing frequency
G  Responses of horror, helplessness and fear and location

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- Structure simple activities or task for patients

- Encourage to participate in activities where clients can attain control 5.Body Dysmorphic Disorder
P and success  Preoccupation with some imagined defect in physical appearance which is
- Recognize and reinforce non ritualistic behaviors out of proportion to any actual abnormality
S
 For ASD and PTSD
Y - Assure them that their feelings and reaction are typical reactions to
NURSING INTERVENTION
serious trauma  Avoid reinforcing the symptoms
C - Encourage safe verbalizations of feelings especially anger - do not focus on them to reduced secondary gain
- Encourage adaptive coping strategies, exercise, relaxation - Do not attempt to persuade the client that the symptoms are not real
H techniques and sleep-promoting strategies or that the client should „give it up‟
- Facilitate progressive review of the trauma and its consequences  Increase self esteem by involving clients in activities in which they can be
I - Encourage the patients to establish or re-establish relationship successful
 Encourage to identify and explore feelings
A SOMATOFORM DISORDERS
 Involves physical symptoms without any organic or physiologic cause DISSOCIATIVE DISORDERS
T  Not under voluntary control  Sudden temporary change in consciousness, identity or motor behaviors
 Symbolizes repressed and unresolved conflicts  The repression of ideas that leads to amnesia and other forms of
R dissociation is conceived as a way of protecting the individual from
1.Somatization Disorder emotional pain
I  Chronic somatic complaints of long-duration
 Complaints changes from one anatomic site to another 1.Dissociative Amnesia
C  A complicated medical history is common  Inability to recall personal information
 Loss of memory of important personal events that were traumatic or
2.Pain Disorder stressful in nature
 Prolonged and severe pain that seem unrelated to physical causes
N  Seems to correlate with psychological stress 2.Dissociative Fugue
 May present with abuse of analgesics  Sudden unexpected travel away from home or work with loss of memory
U about the past
3.Conversion Disorder  Assumption of partial/completely new identity
R  Loss of sensory or motor functioning that seems unrelated to physical cause
 The physical problem is symbolic of underlying anxiety 3.Dissociative Identity Disorder
S  Presence of „la belle‟ indifference  Existence of 2 or more identities or personalities that take control of a
person‟s behavior
I 4.Hypochondriasis
 Preoccupation with the belief that a serious illness is present despite 4.Depersonalization
N reassurance to the contrary and may interfere with daily life  Expresses feelings of detachment from or an outside observer of one‟s
 Physical signs and symptoms are consistently misinterpreted to mean that body or mental processes
G the clients is ill  Unreality or self-estranged (derealization)

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and/or grandiose)
P NURSING INTERVENTION Disorganized All the following are prominent; disorganized speech,
disorganized behavior, flat or inappropriate affect
 Reduce external stress and demands on the client
S  Present reality
Catatonic At least two of the following are present:
A. Motoric immobility, waxy flexibility, or stupor
 Reassure the client that memory will return
Y  Encourage to explore and verbalize feelings
B. Excessive motor activity (purposely)
C. Extreme negativism or mutism
 Set rational limits on behavior D. Peculiar movements, stereotype of movements,
C  Assist in the exploration or preceding event prominent mannerisms, or prominent grimacing
 Reduce the client‟s anxiety E. Echolalia or echopraxia
H Undifferentiated Characteristic symptoms (see criteria A) are present, but
SCHIZOPHRENIA criteria for paranoid, catatonic, or disorganized subtypes
I  Occurs in the late adolescence and early adulthood are not met
 More common in lower socio-economic groups Residual A. Characteristic symptoms (see box: DSM-IV-TR criteria
A  High prevalence among family members and in twins for Schizophrenia, criterion A) are no longer present;
criteria are unmet for paranoid, catatonic, or disorganized
T SCHIZOPHRENIA DSM-IV-TR subtypes
A. Characteristic symptoms (at least two of the following): CRITERIA! B. There is continuing evidence of disturbance, such as
R Delusion the presence of negative symptoms or criteria A
Hallucinations symptoms, in an attenuated form (e.g., odd beliefs,
I Disorganized speech unusual perceptual experiences).
Grossly disorganized or catatonic behavior
C Negative symptoms ETIOLOGY
B. Social-occupations dysfunction: work, interpersonal, and self-care functioning  Biological Theories
below the level - Genetic component is present
achieved before onset - “Dopamine hypothesis” – excessive dopaminergic activities in the
N C. Duration: continuous signs of the disturbance for at least 6 months cortical areas causes acute psychotic symptoms
D. Schizoaffective and mood disorders not present and not responsible for the - Neurostructural changes
U signs and symproms  Developmental Theories
E. Not caused by substance abuse or general medical disorder - Impaired interpersonal relationship with primary caregiver
R FOUR A‟S OF SCHIZOPHRENIA - Poor ego boundaries, fragile ego and ego disintegration
1. Affective disturbances  Family Theories
S 2. Autism REMEMBER ( THE 4SUM?) - Schizophrenic mother
3. Associative looseness - Double-bind
I 4. Ambivalence  Vulnerability-Stress Model
DSM-IV-TR - Recognizes both biological and psychodynamic
N DSM-IV-TR FOR SCHIZOPHRENIA SUBTYPES CRITERIA!
Paranoid Preoccupation with one or more delusions or frequent
G auditory hallucinations (content frequently persecutory

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TYPES OF DELUSION -Avoid whispering or laughing when patients are unable to hear all of
P 1. Persutory/paranoid delusion a conversation
2. Grandiose delusion - Avoid competitive activities with some patients
S 3. Religious delusion  Encourage differentiation of self from others and the environment
4. Somatic delusion  Allow and encourage verbalization of feelings
Y 5. Referential delusion  Increased the client‟s self-esteem
6. Nihilistic delusion - Provide opportunities to be successful
C - Convey an attitude of respect
TYPES OF HALLUCINATION - Do not embarrass patients
H 1. Auditory - Reinforce positive behaviors
2. Visual - Encourage participation in self-care activities
I 3. Tactile
4. Gustatory MOOD DISORDERS
A 5. Olfactory 1. Major Depression
6. Kinesthetic 2. Mania
T 7. Cenesthetic 3. Bipolar disorder

R NURSING INTERVENTION
OTHER
1. Dysthymia
I  General Principles for a therapeutic relationship 2. Hypomania
- Be calm when talking to patients 3. Cyclothymia
C - Accept patient as they are but do not accept all behavior 4. Seasonal Affective Disorder
- Keep all promises
- Be consistent MAJOR DEPRESSION
- Be honest  Abnormal extension and over elaboration of sadness and grief
 Maintain a safe and therapeutic environment
N  Meet the patient‟s physiologic needs ETIOLOGY
 Help patient maintain contact with reality  Biological theories of depression
U - Orient the patient‟s to time and place if indicated - Genetics play a role in its occurrence
 Reduce hallucinations and delusions - Levels of norepinephrine and serotonin altered, decreased
R - Present reality without arguing availability in the CNS
- Engage in conversations that are simple, direct, specific and - Endocrine changes
S concrete  Psychological theories
- Do not dwell on the content of delusions - Object loss theory - Debilitating early life
I  Decrease withdrawal experiences
- Engage in one relationships as tolerated by clients - “Aggression towards the self” - Intrapsychic conflict
N - Engage in social activities - Cognitive theory - Antipsychiatric model
- Allow interpersonal distance if necessary - “Learned helplessness”
G - Do not touch the patients without warning them

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ESCAPES FROM DEPRESSION  Allow and encourage verbalization of feelings

 Complete hopelessness and inactivity  Bolster self-esteem
P  Soliciting or winning sympathy - Accept patients where they are and focus on their strengths
 Use of alcohol/substances - Point out even small accomplishments
S  Frenzied activity - Reinforce decision making by patients
 Excessive motor activity - Redirect client‟s conversation away from self-reproach and
Y  Suicide derogation
DSM-IV-TR
- Involve patients in activities in which they can experience success
C KEY FEATURES OF MAJOR DEPRESSIVE DISORDERS CRITERIA! - Respond to anger therapeutically
At least a 2-week period of maladaptive functioning is present that is a clear  Recognize dependence
H change from previous levels of functioning. Al least five of the following symptoms - Make decisions for patients that they are not ready to make for
must be present during that 2-week period, out of which must be (1) or (2): themselves
I  Spend time with withdrawn patients
1. Depressed mood  Encourage increasing participation in social, recreational and occupational
A 2. Inability to experience pleasure or markedly diminished interest in pleasurable activities
activities (Anhedonia)  Never reinforce delusions or hallucinations
T 3. Appetite disturbance with weight change (loss or gain of more than 5% of body
weight within 1 month) DRUG THERAPY
R 4. Sleep disturbance  Antidepressants
5. Psychomotor disturbance
I 6. Fatigue or loss of energy Electroconvulsive Therapy (ECT)
7. Feelings of worthlessness or excessive or inappropriate guilt  Induction of grand mal seizures through the application of electrical current
C 8. Diminished ability to concentrate or indecisiveness to the brain to effect behavioral changes
9. Recurrent thoughts of death or suicidal ideations  Indicated for clients with major depression, acute manic states,
schizophrenics (catatonic), OCD and some personality disorders (anti-
The mood disturbance causes marked distress or significant impairment in social social)
or occupational functioning, or both.
N No evidence of a physical or substance-induced cause exists for the patient‟s
 Exact mechanism of actions is still unknown
 There are no absolute contraindications however relative contraindications
symptoms or for the presence of another major mental disorder that accounts for
U the patient‟s depressive symptoms.
include:
- Cardiac problems
R - Increased intracranial pressure
- Severe osteoporosis
NURSING INTERVENTION
S  Maintain client‟s safety
- Acute and chronic pulmonary disorders
- Pregnancy (if with complication)
 Provide for adequate nutrition, hydration elimination, exercise and physical  The side effects are headache, confusion and temporary memory loss
I hygiene
 Help client have adequate rest and sleep
N  Provide a simple and structured schedule and environment
>>>Konti nalang…. U’r 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
 Develop trust
G  Offer sincere concern and empathy
will not always get you to the top, but it will get you pretty near. ~M. Thatcher

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NURSING INTERVENTION NOTE
Pre-ECT Post-ECT SAD PERSONS SCALE
P Secure the informed consent Client is oxygenated S ex
A ge (<19 or >45)
Keep client on NPO at least 4 hrs prior Turn head to the sides
Remove dentures, eyeglasses, Monitor vital signs D epression
S contact lenses etc. Stay with the patient until he is fully P revious Suicide Attempt
Client must be asked to void prior awake E thanol (Alcohol) Abuse
Y Remain with the client; safety precautions Reorientation R ational Thinking Impaired (judgment)
Encourage client to verbalize feelings Provide a highly structured S ocial Support Lacking ( including recent loss of loved
C Pre-medications maybe given as schedule of routine activities to one)
ordered (Atropine sulfate, minimize confusion O rganized Plan
H succinylcholine [Anectine] ) N o Spouse (single, divorced, widowed, separated)
S ickness especially Chronic
I REMEMBER (Ang AMA ng PUSA) *This scale should be used as a guideline only:
use your judgment and don‟t neglect unspecified factors
A SUICIDE
 Direct self-destructive behavior; self-inflicted death ETIOLOGY
T  Influenced by a person‟s cultural beliefs, values and norms  Psychodynamic Theories
 Never a random act, whether done impulsively or with painstaking - Instinct for life vs. instinct for death
R consideration, the act has both a message and a purpose - Aggression towards the self
 More common in white persons and least common in black persons - 3 Ps Pain, perturbation and pressure
I  Common among schizophrenics, depressed and alcoholic patients  Sociological Theories
 More common in spring - Social and cultural contexts influence ideations of suicide
C  More likely to occur in the early morning hours  Biological Theories
- There is decreased serotonin and its metabolites in patients who are
LEVELS OF SUICIDAL BEHAVIOR suicidal
 Suicidal gestures - non-lethal, self-injurious acts done to get attention  Predisposing Factors Include:
N  Suicidal ideations - thoughts of suicide - Psychiatric disorders (mood, substance, psychotic disorders)
 Suicidal threats - verbal statements - Personality traits (hostility, impulsivity, chronic depression)
U  Suicidal attempt - actual implementation
 Completed suicide - warning signs have been missed/ignored
R NURSING INTERVENTION
COMMON EXPRESSIONS OF SUICIDAL PATIENTS  Evaluate patients for suicidal risk (suicidal cues)
S  Cry for help - redemption Note behaviors like making a will, saying goodbyes and giving away
 Escape - relief of pain prized possessions
I  Heroism - retaliatory  Suspect suicidal ideation in the depressed
 Loss of self-esteem - reunion  Inquire directly about frequency and content of suicidal ideation
N  Manipulation  Ask patients about the advantages and disadvantages of suicide
 Martyrdom  Evaluate the patient‟s access to means of suicide
G  Rebirth  Develop a formal “no suicide” contract with patients

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 Monitor closely and continuously - Genetics is influential in bipolar disorders

 Encourage verbalization of feelings - Excessive levels of neurotransmitters
P  Support patient‟s reason to live -

S BIPOLAR DISORDERS NURSING INTERVENTION

 Individuals experience extremes in mood polarity  Provide for patient‟s physical safety and safety of those around him
Y  Manic-depressive DSM-IV-TR  Remind the client to respect distances between self and others
BIPOLAR DISORDERS CRITERIA!  Use short simple sentences to communicate
C I. Manic Episode:  Ask the clients to clear their messages and to decode metaphors, themes
A. A distinct period of abnormal and persistent elevated, expansive, or and symbols used in speech
H irritable mood that lasts at least 1 week or less if hospitalization is required.  Provide the clients with a list of daily activities
B. At least three of the following symptoms must occur during the episode  Ensure that food and fluid needs are met
I (or four if the patient is only irritable).  For patients „too busy to eat‟
1. Inflates self-esteem or grandiosity - Provide patients with foods that can be eaten “on the run” (finger
A 2. Decreased need for sleep foods) because patients cannot sit ling enough to eat
3. Very talkative - Provide high-protein, high calorie snacks
T 4. Flight of ideas or subjective feeling that thoughts are racing - Weight patients regularly
5. Distractability  Reduce stimulation from the environment and others
R 6. Increase in goad-directed activity (social, occupational, educational, - A quiet room maybe indicated to decreased environmental stimuli
or sexual) or psychomotor agitation - Remain quietly with the client rather than encouraging activities and
I 7. Excessive involvement in pleasurable activities that have a high conversations
potential for personal problems (e.g. sexual promiscuity, spending  Channel client‟s need for movement into socially acceptable motor activities
C sprees, bad business investments) - Goal-oriented activities are encourage
C. Mood disturbance severe enough to cause problems socially, - Competitive sports activities are not allowed initially
interpersonally, or at work, or the person has to be hospitalized, to - Mental activities will not be done by patients
prevent harm to self or others.
N D. Not due to a substance AGGRESSIVE BEHAVIORS NOTE
PHASES OF THE AGGRESSIVE CYCLE
U II. Bipolar disorders: PHASE DESCRIPTION NURSING
A. Bipolar episodes are divided into bipolar I and bipolar II. There are six INTERVENTIONS
R categories of bipolar I. In bipolar I, the patient must have a history of a Triggering Patient‟s response are nonviolent Convey emphatic support
manic episode. phase and present no danger to others Encourage ventilation
S B. Bipolar II: The patient has experienced major depression and a Escalation When verbalization and tension Provide directions for the
hypomanic episode (but not a manic episode) phase reduction strategies fail and patients client in calm firm voice
I ETIOLOGY become irrational (they begin to Tell the client to take time-
 Psychodynamic theories swear,scream,threaten), the nurse out for cooling
N - Mania as a defense or a mask of depression must take control of the situation. „Show of force‟
- Developmental: Mistrust and dependence Crisis Reached when the patient is Use involuntary seclusion,
G  Biological theories phase approaching an attack on the restraints, or IM

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environment, self, other patients, or medications (prn), if

staff. Verbal limits are ineffective, ordered 3. PSYCHOLOGICAL
P and external control by the staff is -instilling or attempting to instill fear
essential. -Isolating or attempting to isolate victim from friends, family, school or work
S Recovery Accusation, recriminations, lowering Assess patient and staff
phase of voice, decreased body tension, injuries 4. SEXUAL
Y change in conversational content, Evaluate patient‟s progress -Coercing or attempting to coerce any sexual contact without consent
more normal responses, relaxation. toward self-control -Attempting to undermine the victim‟s sexuality
C Postcrisis Crying, apologies, reconciliatory Process incident with
depression interactions, repression of patient. 5. ECONOMIC
H assaultive feelings (which might Discuss alternative -making or attempting to make the victim financially dependent
later appear as hostility, passive solutions to the situation
I aggression) and feelings. RAPE AND TRAUMA SYNDROME
Facilitate reentry to unit  Sleep disturbance, nightmares
A VICTIMS OF ABUSE AND VIOLENCE  Loss of appetite
 Fear, anxieties, phobias and suspicions
T CYCLE OF ABUSE AND VIOLENCE  Decreased activities and motivation
 Disturbance in relationships
R  Self-blame, guilt and shame
Period of Honeymoon phase
 Lowered self-esteem, worthlessness
I Violence
 Somatic symptoms

C Tension-building
phase
NURSING INTERVENTION
 Reaffirm that they are worthwhile persons with dignity and rights, who is not
cause and deserve the rape
N  Abuse is not constant nor it is random  Convey to them that their anger is natural
 There is an imbalance of power in a relationship  Move at the victim‟s pace and be supportive
U  The honeymoon phase is what convinces the partner to stay in the  Always give rationales and descriptions for any procedures
relationship  Protect the patient‟s rights
R
FORMS OF ABUSE WITHIN FAMILIES TYPES OF ABUSE AMONG SPECIAL POPULATION
S 1. PHYSICAL 1. Domestic
-Inflicting or attempting to inflict physical injury or illness 2. Partner
I -Withholding access to resources necessary to maintain health
3. Child
4. Elder
N 2. NEGLECT
-failing or refusing to provide food, shelter, healthcare or protection for a
G vulnerable elder

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SUBSTANCE RELATED DISORDERS ALCOHOLISM

 Alcohol
P Substance Abuse  Genetic predisposition
-Pattern of pathologic use  Usually appears between the ages 20-40 however becoming common in
S o Inability to cut or stop use despite physical disorder known to be increased adolescents
by its use and despite the presence of complications  BAL should be@ least _____ % considered intoxicated
Y o Usually intoxicated throughout the day  More common in men than in women
REMEMBER
- Impairment in functioning  Chronic use leads to Wernicke‟s-Korsakoff syndrome
C o Legal difficulties and failure in obligations
o Behavioral changes CAGE QUESTIONNAIRE
H Substance dependence Have you ever felt you ought to Cut down on your drinking?
NOTE
- TOLERANCE Have people Annoyed you by criticizing your drinking?
I - WITHDRAWAL SYNDROME Have you ever felt bad or Guilty about your drinking?
Have you used alcohol as an Eye-opener?
A ETIOLOGY
 Psychoanalytic/Psychodynamic SIGNS OF DRUG ABUSE
T - fixation or regression to the oral stage of development  Sudden loss of interest or deterioration in school work fand other activities
 Sociological  Dropping old friends and associating with a new peer group
R - Learned behavior encouraged by a subculture in which drugs are  Secretive behaviors; spends a lot of time alone
easily available and its use is encouraged  Sudden and unexplained changes in mood, emotion and behavior
I  Biochemical  Physical signs such as pupil changes, slurred speech, needle marks,
- Physiologic dependence; readdiction or craving photophobia etc.
C TYPES EXAMPLES - One must determine drugs use pattern of the client from information
CNS Depressants Alcohol provided by the client, family and friends:
Baribiturates 1. Drugs being used
Anxiolytics (Valium)) 2. Quantity
N Inhalants 3. Frequency
Opioids (Heroin, Morphine) 4. Length of use
U CNS Stimulants Amphetamine - Analysis of blood and urine for substances
Nicotine
R Caffeine
NURSING INTERVENTION
Hallucinogens Psylocibin (in Psilocybe mushrooms)
S Lysergic acid (LSD)  DETOXICATION PHASE
Phencyclidine (PCP) - Encourage participation in a treatment program and refer to
I Marijuana (Cannabis sativa) appropriate treatment resources
- Support the client through the detoxification or withdrawal
N Dual Diagnosis - Detoxification may take 2-3 weeks and should take place in an in-
 The co-occurrence of psychiatric and substance use disorders patient setting
G - Attend to client‟s physical problems

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 REHABILITATIVE PHASE 2.Paraphilias (sexual perversions)

- Assist clients to identify the stresses and conflicts and encourage  Sexual instinct is expressed in ways that are socially unacceptable and is
P exploration of alternative coping strategies prohibited
- Assist the client to identify social support network  Peaks between the age of 15 and 25 and decrease in incidence by age
S - Provide support to significant others  Always enters the „cycle of sexual perversion‟
- Provide health teachings to clients DSM-IV-TR
Y PARAPHILIA CRITERIA!
SEXUAL DISORDERS The following paraphilic activities last over a period of 6 months and cause
C distress or impairment in social, occupational, or other important areas of
1.Sexual Dysfunctions function:
H  Inhibition of the sexual
appetite or psycho- EXHIBITIONISM
I physiological changes that Recurrent, intense sexually arousing fantasies, sexual urges, or behaviors
compromise the sexual involving exposing one‟s genitals to unsuspecting strangers.
A response cycle
FETISHISM
T  The sexual response cycle: Recurrent, intense, sexually arousing fantasies, sexual urges, or behaviors
- Phase 1: Appetitive using nonliving objects.
R - Phase 2: Excitement
- Phase 3: Plateau FROTTEURISM
I - Phase 4: Orgasm Recurrent, intense sexually arousing fantasies, sexual urges, or behaviors
- Phase 5: Resolution involving touching and rubbing against a nonconsenting person.
C
PEDOPHILIA
TYPES OF SEXUAL DYSFUNCTION Recurrent, intense sexually arousing fantasies, sexual urges, or behaviors that
 Sexual desire disorder involves sexual activity with a child or children generally 13 years of age or
N - Hypoactive
- Sexual aversion disorder
younger.
The person is a least 16 years of age and at least 5 years older than the child
 Sexual arousal disorder
U  Orgasmic disorder
or children involved.

- Premature ejaculation
R - Anorgasmia
SEXUAL MASOCHISM
Recurrent, intense sexually arousing fantasies, sexual fantasies, urges, or
 Sexual pain disorders behaviors involving the act of being humiliated, beaten, restrained, or
S - Dyspareunia otherwise made to suffer.
- Vaginismus
I  Predisposing factors SEXUAL SADISM
- Biological Recurrent, intense sexually arousing fantasies, urges, or behaviors involving
N - Psychosocial acts in which the psychological or physical suffering of the victim is sexually
- Relationship factors exciting to the person.
G

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VOYEURISM - Presence of endogenous opiates for denial of hunger

Act of observing an unsuspecting person who is naked, in the process of  Socio-cultural
P disrobing, or engaging in sexual activity. - Society is focused on thinness and exercise
3.Gender Identity Disorder - More common in females
S  Homosexuality - Most frequent in developed countries
 Bisexuality  Common in professions such as modeling and ballet
Y  Transexualism (gender dysphoric disorder)  Psychological
- Reaction to the demands for more independence in increased social
C EATING DISORDERS and sexual functioning
- There is lack of autonomy and selfhood
H 1.Anorexia Nervosa - Acts of extraordinary self-discipline
 Profound disturbance in body image and a relentless pursuit of thinness - „Intrusive and unempathetic mother‟ model
I often to the point of starvation
 Weight phobia PHYSIOLOGIC SYMPTOMS
A  Common in females; early adolescence  Hypothermia
 Refusal to maintain body weight at a normal BMI or it is less than 85% of  Edema
T the DBW  Bradycardia
 Disturbance in the way in which one‟s body weight or shape is experienced  Hypersensitivity
R - self evaluation is based on body weight but is always in denial  Hypotension
- Amenorrhea (at least 3 consecutive cycles) NOTE  Lanugo
I  Other clinical features
- Most aberrant behaviors directed towards losing weight are in secret TREATMENT
C - Refusal to eat with families or in public places  Hospitalizations
- Drastic reduction in total food intake with disproportionate decrease  Individual (Weight-oriented)
in high carbohydrate and fatty foods  Family therapy
- There is actual preoccupation with food
N - There are peculiar behaviors regarding food
NURSING INTERVENTION
- Associated with obsessive-compulsive behaviors, depression and
U anxiety  Monitor caloric intake
- Markedly decreased interest in sex  Watch out signs of purging
R - Overall prognosis is not good though some will spontaneous  Weigh client
recovery  Monitor activities
S TYPES  Plan for a realistic and healthy diet
 Restricting type  Monitor nutritional and electrolyte status
 Binge eating/purging type  For anorexia nervosa
I - Increasing self-esteem is a primary objective
- Listen empathetically
N ETIOLOGY
 Biological - Engage clients in the food planning process
- Help identity and express bodily sensations
G - Decreased serotonin in CNS

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- Identify non-weight related interest  Characterized by an acute onset and may last from hours to a number of
- Improve social skills days and with a tendency to fluctuate during the course of the day
P  It is potentially reversible but can be life-threatening if not treated
2.Bulimia Nervosa  Secondary either to a general medical condition or to effects of substances
S  Consist of recurrent episodes of eating large amounts of food accompanied
by a feeling of out of control
Y  There are feelings of guilt, depression and self-disgust after NURSING INTERVENTION
 There are recurrent compensatory behaviors: purging, fasting or excessive  Promote client‟s safety and structured environment
C exercise  Manage the client‟s confusion(i.g., reorientation, approaching clients calmly
 They maintain normal body weight and speaking in a client low voice)
H  Common in female; adolescence or early adulthood  Promote sleep and proper nutrition
 Keep the room lit to allay fears and prevent visual hallucinations
I ETIOLOGY  Monitor effects of medications
 Biological
A - Endorphin levels are increased DEMENTIA
 Psychological  Altered mental state secondary to a cerebral disease
T - Parents maybe rejecting and neglectful  Usually irreversible, gradual in onset, progressive, degenerative
- Difficulties with adolescent demands  Characterized by a decreased intellectual function, personality change,
R - Anorexics lacks ego strength while bulimic lacks superego control impaired judgment and often change in affect
TYPES  Impairment in functioning is present
I  Purging DSM-IV-TR
 Non-purging DEMENTIA CRITERIA!
C A. The development of multiple cognitive deficits manifested by both
TREATMENT 1. Memory impairment (impaired ability to learn new information or to recall
 Individual psychotherapy previously learned
Information).
N 2. One (or more) of the following cognitive disturbances (A‟s of Dementia):
NURSING INTERVENTION a. Aphasia (language disturbance)
 For binge eating
U - Create an atmosphere of trust
b. Apraxia (impaired ability to carry out motor functions despite intact
motor function)
- Identify feeling associated with binging/purging behavior
R - Improve self-esteem
c. Agnosia (failure to recognize or identify objects despite intact sensory
functioning
- Teach about eating disorders
S - Explore interpersonal relationships
d. Disturbance or executive functioning (e.g., planning, organizing,
sequencing, abstracting)
DELIRUIM B. The cognitive deficits in criteria A1 and A2 each cause significant impairment in
I  Disturbance in consciousness accompanied by a change in cognition( e.g., social or occupational functioning and represent a significant decline from a
memory deficit, disorientation, language disturbance, perceptual previous level of functioning.
N disturbance) C. The course is characterized by a gradual onset and continuing cognitive
decline.
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REMEMBER (Ano ang alagang hayop ng taong may dementia?) DRUG THERAPY
P  Anti cholinesterase agents
Alzheimer ’s Disease  Antipsychotic agents
S  Major cause of dementia in the elderly - in low doses like haloperidol or risperidone
 Unknown etiology but some theories include
Y - Alterations in acetylcholine REMEMBER (Sino naman ang boyfriend ni LOLA?)
 Very strong genetic predisposition
C  Organic changes occur
- Brain atrophy, widening of sulcus and ventricles NURSING INTERVENTION
H - Neurofibrillary tangles and amyloid bodies  Remove any hazardous items or potential obstacles from the patient‟s
Stage 1 environment to provide and maintain safety
I  Agitated or apathetic mood  Monitor food and fluid intake
 Attempts to cover up symptoms  Provide verbal and non-verbal communication that is consistent and
A  Decline in personal appearance structured
 Decline in recent memory  State expectations simply and completely
T  Decreased concentration  Increase social interaction to provide stimulus for the patients
 Depression  Encourage the use of community resources
R  Disorientation regarding time  Promote physical activity and sensory stimulations
 Disturbed sleep  Orient the patient to his surroundings
I  Monitor the environment
Stage II  Encourage the patient to express feelings
C  May last from 2-12 years
 Confabulation (unconscious filling of memory gaps with fabricated facts and Personality Disorder
experiences)  formerly known as Character Disorder
 Continuous repetitive behaviors  an enduring pattern of inner experience and behavior that deviates markedly
N  Diminishing ability to understand or use language from the expectations of the culture of the individual who exhibits it
 Disorientation to person, place and time CLUSTER A : odd or eccentric
 Inability to recognize family members 1. Paranoid
U  Inability to retain new information 2. Schizoid
 Incontinence of bowel and bladder 3. Schizotypal
R  Socially unacceptable behavior CLUSTER B: dramatic, emotional or erratic
1. Histrionic
S Stage III 2. Antisocial
 Terminal stage (months to 5 years) 3. Narcissistic
I  Compulsive touching and examination of objects 4. Borderline
 Deterioration in motor abilities CLUSTER C: anxious or fearful disorders
N  Non responsiveness 1. Avoidant
 Severe decline in cognitive functions 2. OC
G

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3. Dependent Pervasive Developmental Disorders

ONS  Autistic disorder
P 1. Passive-aggressive  Rett‟s disorder
 Childhood disintegrative disorder
S MENTAL DISEASES IN CHILDREN  Asperger‟s disorder
Mental illness in the children and adolescents
Y  Children are less able to verbalize feelings AUTISTIC DISORDER
 Irritability maybe a predominant feature  Disturbance in social relatedness
C  Risk factors for childhood psychiatric disorders are  Common features
- Genetic and biological factors - Stereotypical behaviors -Peculiar preoccupations
H - Adverse environmental influences - Delayed socialization and communication
- Family and socio-cultural factors  Substantial percentage are mentally related
I - Stress experience (Diagnosed before ___) REMEMBER
- Children can be motivated by their peers
A - Negative effects of risk factors depend upon the severity of the risk Attention Deficit And Disruptive Behavior Disorder
and the „resiliency‟ of the child  Attention deficit hyperactivity disorder
T - Resilience is the ability to withstand problems of an undesirable
childhood
 Conduct disorder
 Oppositional defiant disorder
R Mental Retardation ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD or ADD)
 Below average intellectual functioning and impairment in adaptive skills that
I is present before 18 years old
 Most common pediatric psychiatric disorder
 Cardinal feature:
 Arrested or incomplete development of the mind
C  Classified according to severity:
o Inattention
o Hyperactivity-impulsivity
1. Mild o Impulsivity
IQ level 50-55 to 69 REMEMBER
(Diagnosed before___)
2. Moderate
N IQ level 35-40 to 50-55
DRUG THERAPY
- Psychostimulants
3. Severe
U IQ level 20-25 to 35-40
- The Feingold diet – elimination of artificial flavoring and colorings
and natural salicylates in food
4. Profound
R IQ below 20 or 25 NURSING INTERVENTION IN CHILDHOOD MENTAL DISORDERS
S REMEMBER  Help the parents accept a diagnosis and plan a realistic approach to the
(Diagnosed before___) situation
ETIOLOGY  Help shape family members and other people‟s attitudes towards them and
I >Chromosomal abnormalities > Genetic factors accept them
>Complications of pregnancy >Perinatal factors 
N >Acquired childhood disorders
Help in activities of daily living
 Standards of acceptable behavior within the ability of the child should be
G provided

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 He should b taught to seek help when in difficulty to resist frustration and REFERENCE:
P achieve emotional control
 Create a therapeutic environment Fortinash, K.M. & Holoday, P.A. (2008). Psychiatric Mental Health Nurisng
th
NOTE (4 ed.). St. Louis: Mosby/Elsevier.
S STIGMA
 An attribute or trait deemed by the person‟s social environment as negative, Keltner, N.L.,Schwecke, L.H., & Bostrom, C. E. (2007). Psychiatric Nursing,
Y different and diminishing (5th ed.). St. Louis: Mosby/Elsevier.

C ETHICAL DILEMMA NOTE
 Exists when moral claims conflict with one another. It can be defined as:
H o A difficult problem that seems to have no satisfactory solution
o A choice between equally unsatisfactory alternatives
I Shives, L.R. (2008). Basic Concepts of Psychiatric-Mental Health Nursing (7th Ed.).
PSYCHIATRIC REHABABILITATION NOTE
A  The process of helping the person return to the highest possible level of
functioning
T  The range of social, educational, occupational, behavioral, and cognitive
interventions used to increase the role performance of persons with serious
R and persistent mental illness and to enhance their recovery
Kozier, B., Berman, A., Snyder, S., & Erb, G., (2007). Kozier & Erb‟s
th
Fundamentals of Nursing: Concepts, Process & Practice (8 ed., Vol. 1).
Upper Saddle River: Prentice Hall.
Philadelphia: /Walters Kluwer Health/Lippincott Williams & Wilkins.
Stuart, G.W. & Laraia M.T. (2005). Principles and Practice of Psychiatric
Nursing (8th ed.). St. Louis: Mosby/Elsevier.
Videbeck, S.L. (2008). Psychitric-Mental Health Nursing (4th ed. ).
Philadelphia: Lippincott Williams & Wilkins.

I CARE OF THE CAREGIVER ***Edited August 2011/MERGE_Psychiatric Nursing Team

ROLE STRAIN
C  When the demands of providing care threaten to overwhelm the caregiver
 Characterized by:
- Constant fatigue unrelieved by rest
- Use of alcohol/other substances
N - Social isolation
- Inattention to personal needs
U - Inability/unwillingness to be helped by others
 It may become a factor in the neglect or abuse of patients
R  If you are depressed, it doesn‟t matter which number you press. No one will
S NURSING INTERVENTION
 Refer caregivers to knowledgeable health professional who can provide
I information, support and assistance
 Provide outlets for dealing with caregiver‟s feelings
N  Help them seek and accept assistance from other people or agency and not
wait until they are exhausted
G  Provide support for a personal life
>u’ve finished this extra CHAKRA… GREAT JOB!
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
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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