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Tips in Answering Psychosocial Integrity Questions

SAFETY – psychiatric, danger or Therapeutic Communication
emergency  Exploring, Using silence
Avoid touching autistic pt  Restating or reflecting, Making observations
Present reality, Acknowledge, Allow Is a priority but only after a client is out of
verbalization of feelings (delusional pt) immediate physical danger
Encourage verbalization of feelings – if pt is  Always ask open-ended questions and seek for more
out of danger, during admission information (not yes-no)
Promote/remind self-care and adaptation  Always stay in here and now! Keep focused
skills- assist pt with ADL’s/ physiological (depressed pt, manic pt, crisis) on issues at hand,
needs (circulation- in catatonic state) refocusing
 Always consider developmental, cultural, and
Non- Therapeutic Communication physical variables when responding
 Ignoring the pt, Flattery  Never assert personal opinion about anything or
 Giving opinion/telling the pt what to do “In my anyone
opinion, you should”
 False reassurance “Don’t worry everything will be
alright” Conceptual Frameworks
Structures of personality
 Advising. “You should do this” – No to battered
Super ego – the conscience, morality principle
wife syndrome
 Changing the subject, Challenging
 Defending “All the nurses here are great” Anorexia
Giving approval or disapproval Antisocial
 Belittling “Everyone else feels the same. Don’t be Id- the pleasure principle, avoid pain
concerned too much,” – always validate the concern Manic pt- very restless Antisocial –
or feelings they violate rules Narcissistic – too
 Judging “If you had only listened to the doctor. It’s loving
your mistake.” Addictions
 WHY? – not good for asking feelings, never put pt Anhedonia- too little preference with ID –
inability to experience pleasure
into a defensive state, depending on the situation-
OK for simple facts Ego – the reality principle, balance Id and super
For schizophrenia and schizophreniforms

Psychosis marked X reality

Ambivalence X balance


Schizoid personality disorder “loners”,

naturally detached
Schizotypal personality disorder “eccentric”,
magical thinking, very superior
Human behavior
Psychosexual (Freud)  Meaningful, attempts to communicate the
Oral- Infancy meaning 90 % - non-verbal
Anal – toddlerhood o 10 %- verbal
Phallic(oedipal) – Pre-school  Purposeful attempt to meet needs (biologic and
Latency (quiet stage)- School age  psychological)
Genital – adolescent and young adulthood  Response to stimulus
 Learned – permanent change
Psychosocial Theory (Erickson)  We learn to inc reinforcement (Positive-reward,
Negative-temper tantrums) vs punishment
Age +Value -Value Factor
group (dec/stop induce pain and fear)
0-18mons – Trust and Mistrust, Satisfaction of  Lying – loud (speak) anxious (slow voice), look
infancy safety, oral paranoid needs thru for pattern of behavior, Anxious
fixation personality feedings
(suspicion) Defense Mechanism (DM)
-gullibility  Unwanted or painful stimuli = inc anxiety/tension =
18 mons-3 Autonomy Shame vs doubt- Toilet training triggers use of defense mechanism = Normal =
yrs Independenc dec self-esteem- Adequate- good purpose-dec. anxiety until no more actions necessary or
Toddlerhoo e depression impulse control
d Dependence Too lax- to maintain equilibrium; Adequate use= acceptance -
impulsive(manic problem resolution or maintain equilibrium; Overuse
Too Strict- no acceptance, no resolution
OCPD =psychopathology, results to inc anxiety,
3-6 yrs Initiative Guilt Sexual curiosity, depression, trauma
Pre-school conscience
develop @ 5 so
best time to Primitive DM
teach the child
the appropriate Do little to try and resolve underlying issues
social behavior or problems
Antisocial- if not Less effective over long term
6-12 yrs Industry and Inferiority Learning  Very effective for short term, hence
School Age competence complex are favored by many
12-20yrs Identity Role confusion, Vocation, Body
 Conversion – expression of intrapsychic conflict
Adolescence Emotional emotional image symbolically through physical symptoms
stability & immaturity, disturbance-
long-term short term Anorexia/
Ex. A student develop diarrhea on the
thinking thinking Bulimia day of NCLEX-exam
Equate love with  Denial – conscious refusal to accept reality or fact
20-35 yrs Intimacy, Isolation Relationship acting as if painful event, thought or feeling
Early The pt able Withdrawn did not exist, common for alcoholic
adulthood to give and
receive love, Ex. A person who is functioning
interpersonal alcoholic will simply deny they have
35-65 ys Generativity Stagnation- Support a drinking problem, pointing to how
Middle Give support depression
adulthood to self and Self-centered will they handle their job and
others relationship
65 yr up Ego integrity Despair Satisfying past
Older adult Fulfillment Regrets  Dissociation – Separation and detachment of
emotional significance & affect from an idea or a
situation, common- PTSD
Ex. A client grins & chuckles when
telling about his automobile accident
and its tragic consequences
 Projection- attributing intolerable wishes, Ex. A woman rushes into marriage
feelings and motivations to other persons following a breakup with her bf
Ex. A reviewee blames the review center for
his failure in the board exam  Undoing- an attempt to actually or symbolically
take away a previously consciously intolerable
 Regression - returning to an earlier and more action or experience
comfortable level of adjustment Ex. A mother who has just punished her
Ex. A 4 years old begins to wet his pants child gives him a cookie.
following the birth of his baby brother
Mature DM
 Reaction formation- developing conscious attitude  Most constructive and helpful
and behaviors that are the opposite of what one  May require practice and effort to put into
really feels or desires to do daily use
Ex. A woman who is very angry with her boss  Compensation- an attempt to make up for real or
and would like to quit her job may instead fancied deficiencies
overly kind and generous toward her boss and Ex. A high school student does poorly in
express a desire to keep working there forever academics but becomes a talented artist
 Suppression – the conscious, deliberate forgetting  Sublimation – Diversion of consciously
of unacceptable or painful thoughts, ideas and unacceptable instinctual drives into personally &
feelings socially accepted areas
Ex. A young woman says she is not ready to Ex. Strong sexual urges are diverted into
talk about abuse as a child creative arts like painting and sculpture

Less Primitive, More Mature DM

-Step up from the primitive DM ---
Employed mostly by adults
 Displacement- redirection of emotional feelings 1. Pre-interaction Phase- Self-exploration
from original idea, person or object to a less  Major Task: Develop Self-awareness
threatening one  Initial NI: show of acceptance/neutral
Ex. A superior berates a head nurse, and  Countertransference- nurse reminded of someone
when she goes back to the unit, speaks she knows
harshly to the staff 2. Orientation Phase
 Identification – the unconscious attempt to change  Establish rapport and develop trust (first few
oneself to resemble an admired person days)
Ex. An adolescent dress like a rock star &  Establish a contract, define goals – set a sched of
mimics his behavior meetings
 Rationalization – An attempt to make unacceptable
 Prepare to mention termination of a relationship
feelings and behavior acceptable by – prevent separation anxiety
justifying the behavior; making logical excuses
 Major task: develop a mutually acceptable
Ex. A student fails the examination and says the contract
lectures were poorly organized
“I will meet you from 10 am-12 nn for 2 weeks”
 Repression – involuntary & unconscious 3. Working Phase
forgetting of unbearable ideas and impulses
 Promotes acceptance, expression of
Ex. An accident victim does not remember
feelings Promotes coping mechanisms Inc.
the details of an accident
 Substitution – Replacement of an unacceptable
 Major Task: identification and resolution of the pt
need, attitude or emotion with one that is more
 Anything related to pt problems;
Identify; resolve/interventions
4. Termination Phase  Word Salad – mixture of incomprehensible
 Summarize, evaluate outcome thoughts; an incoherent, incomprehensible
 Gradual weaning process mixture of words, phrases, consisting of both
 Encourage client to discuss feelings about real and imaginary terms
termination (final and clear) *Nrsg Dx: Alteration in thought process
 Major task: Assist the client to review what he/she
has learned and transfer his learning to his
relationship with other

Mental Status Examination Thought Content

 Delusions of grandeur – fix false belief;
 General Description – general physical
appearance of pt -DO NOT encourage verbalization of
 Mood and Affect- emotional expression/state feelings, far from reality, resistant to
logic/reason; inflated sense of self appraisal
 Blunted- severe reduction of emotional
o expression  Delusions of persecution – common among
o Flat – no reaction paranoid schizophrenic
*Nrsg Dx: Alteration in thought content
 Labile – mood swing/ extreme emotional
change  If no senses are involved- disturbance in
o Inappropriate – opposite emotional state thought and thinking
 Speech – rate and tone
Abnormal Motor Behaviors
 Perception – senses are involved “sees, perceives,
a. Echolalia- inner compulsion to repeat other
hears, feels, taste, smells” people’s words
o Hallucinations (auditory, visual,
olfactory, gustatory, tactile), without
stimulus b. Echopraxia – repeat another people’s action
o Illusions – with stimulus c. Waxy flexibility – the pt possibly allows
 *Nrsg Dx: Alteration in
sensory perception MODES OF CARE

Thought- disturbance to how pt think  Milieu Therapy – envi. Modification/most

effective:drug/subs abusers, rape; remove pt
Thought Process
in the same envi.; anxious, suicidal
 Clang associations – rhyming of similar  Psychotherapy – focus on exploring past
sounding words; repetitions of words or childhood experience & how this affect
phrases that are similar in sound but in no present behavior
other way  Behavior modification – focus changing
 Flight of ideas- rapid shifting from one topic current behavior without exploring the past
to another, with train of thought; a constant thru reinforcement and punishment
 Cognitive Therapy- focus on the pts
flow of speech in which the individual jumps
thoughts and how it affect feelings =
from one topic to another in rapid succession; actions/behavior =
Manic consequence/consciousness; Anxious- teach
 Looseness of associations – Without pt relaxation tech thru guided imagery or deep
thought; Schizophrenic; free-flowing breathing exercise; Depressed pt;
thoughts that seem to have little or no Alzheimer’s- reminiscence therapy
connection to one another  Group development/ Group therapy - 8-10
members with same condition; #1 goal provide
 Neologisms- coining of new words; newly acceptance & support (al-anonymous-for the
invented words, having no public, consensual
 Thought blocking – suddenly stopping in the
stream of thought for no apparent reason, with
no recall of the topic
Psychiatric Disorders Anxiety Disorders
 Classified in Diagnostic & Statistical manual for -recapturing of anxiety – provoking
mental disorders (DSM-V) that are most likely to stimulus= re-awakening of unwanted
appear on the NCLEX-RX thoughts, feelings, experiences from the past
 Admission to mental health institution could be memory
voluntary or involuntary
1. Phobia – irrational fear – specific;
 Voluntary- want to discharge = YES but there’s a Cibophobia – fear with food
grace period 48-72 hours reassessment with MD; Agoraphobia – open spaces
Good-OK; Bad- No involuntary commitment status
 Involuntary- Client poses a threat to himself and Provide acceptance
others, with informed consent and refusal to Teach relaxation tech
treatment, if disruptive we can give a medication Therapy – Systemic desensitization- gradual
within 24 hours
Gen. Anxiety Panic
Disorder Disorder
All pts rights are retained except for the right to
Onset Chronic Acute
leave the Institution. Duration >3 mons 10 min/episode
Gen. description Excessive Fear of going
Phone call privileges are removed if the client worrying about crazy
exhibits harm to self and others – needs Dr’s order daily concerns
or court order

ANXIETY Paresthesia
-subjective feeling of apprehension, dread or A feeling of choking for no reason
impending doom N/V
Chest pain
1. Endogenous – within, biological, or
neurochemical, brain structure is the
problem/imbalances of the brain; Gamma Mgt is same with anxiety
Amino Butyric Acid (GABA) - inhibitory
2. Exogenous – cause is environmental OCPD – no rituals, rigid personality; they lack insight of
3. Psychodynamic – ineffective coping what their problems is
mechanism OCD
Obsessive – thoughts
Levels of Anxiety Compulsion- Actions
1. Mild- increased focus; NI: encourage
verbalization of feelings; relaxation tech With rituals
2. Moderate- decrease focus; NI: encourage Insight/awareness
verbalization of feelings; relaxation tech Prob: Control of urges
3. Severe – no focus; therapeutic silence; Prob: Activity itself
PRIO: safety Time consuming
4. Panic – no focus; PRIO: safety; stay silent; Physiological need is affected
simple instructions; stay with pt, stay calm;
element of fear to a specific stimulus
Mgt: Initially provide time for rituals
1. Provide safety Ensure physiological needs met
2. Assist in minimizing the pts anxiety = deep Working phase- explain changes in routine (set
breathing limits) dec freq. and time
3. Encourage verbalization of feelings Reinforce the non-ritualistic behavior
4. Pharmacotherapy – anxiolytics Assist the client in connecting thoughts, feelings
5. Psychotherapy
associated with behavior
6. Milieu therapy
7. Behavior modification Other mgt same with anxiety
Nrsg Considerations:
Trauma and stressor-related disorders types Restless/hyperactive
PTSD - > 1 mon Flight of ideas – refocusing
ASD (Acute stress disorders) - < 1 mon Irritable/manipulative/demanding: set limits – a
matter of fact manner, just restate the fact/rules
Risk factor: immediately after it has been violated
War Delusion of grandeur
Accident Unable to sleep – envi- non- stimulating, provide
Rape rest periods, assist with warm bath, soothing music
Violence Offer: Diet: Inc Ca+ and Inc CHON – finger
Natural disaster foods, cheese burger, drink: milkshake
Emotional numbness exaggerated startled response
Anxiety & anger outburst
Sleep disturbances (insomnia, nightmares, flashbacks-
Mild depression
whenever we get bad experiences it gets frozen in the brain)
Major depression
Be non-judgmental
Encouraged verbalization of feelings Depression
Assist pt in developing adaptive coping mech and in Affects feeling, thoughts and behaviors
understanding association between feelings & Cause:
traumatic event Biological: Norepinephrine
Therapy: Serotonin
CBT (cognitive behavioral therapy), MAO – inhibitory neurotrans.
Psychoanalytic DOC- MAOI
Support group with help Psychodynamic- general feeling and sense of
Mood disorders
Specifics of Depression:
Bipolar Disorder – characterized by episodes of mania and
WOF: Suicidal ideation
depression with periods of normal mood and activity in
between Major Depression (2 wks) Vs Dysthymia (chronic
last 2 yrs, Chronic feeling of dec. self-esteem, Poor
concentration, Depressed mood)
Involutional Melancholia
Biologic –
Norepinephrine – excitatory neurotrans S/Sx:
Serotonin Guilt – excessive, inappropriate
Intracellular Na+ - DOC – lithium Psychomotor retardation
-Psychodynamic – massive denial; faulty family Older adults
dynamics (chaotic) Early morning awakening
Activity: gardening, lawnmowing, finger Significant wt loss/anorexia
painting, delivery linens, NO sewing Anhedonia
Non- competitive activity Depression worse in the morning
requiring low concentration Peripartum Depression
- During preg or within 30 days postpartum depression-
prone to psychosis
RITA- Inc. Risk postpartum dep, irritable, tearful,
Seasonal Affective Disorder (SAD)- lifetime Dementia of Alzheimer’s type
Aka: winter/fall depression Degeneration and atrophy of brain cortex
Occurs: during winter/rainy days Dec. Acetylcholine – inhibitory
Cause: absence of natural light Neurofibrillary tangles, neurotic plaques
Mgt: Phototherapy, spotlight, well lighted room Assessment: A4’s
Assessment: at least 5 of the ff: Aphasia/Speech impairment(expressive/receptive)
Sadness Agnosia- inability to recognize object/person
Loss of interest Apraxia – inability to execute learn purposeful
Worthlessness/hopelessness/low self-esteem movements
Psychomotor retardation/agitation Stages:
Somatic manifestation a. Mild- forgetfulness is the hallmark
Recurrent thought of death b. Moderate – confusion, disorientation
3As Apraxia, Agnosia, Aphasia
Points to remember: c. Severe – Personality and emotional changes
 A client with depression is preoccupied, has dec. Deterioration in all areas of function
energy, and often even simple decisions – mgt.
make simple decisions for the pt “It’s time for you Sundowning Phenomenon – inc. disorientation
to eat” during sundown, OK= lighting, close the curtain,
 A person’s feeling of self-worth is generally soothing music/radio // NO- TV
determined by accomplishments- ensure Nrsg. Intervention:
physiological needs met; assist ADL’s; Activity: Pt wander – take hand & lead the pt back home
Simple; Acknowledge simple accomplishments to Lock the facility
inc self-worth “I’ve notice you take a bath today” Pt wanders from facility – follow the pt & redirect @
 As a client with major depression begins to feel safe distance, assess if pt can follow order if pt cannot
better, the client may have enough energy to carry then reinforcement is needed
out suicide attempt – WOF: sudden inc. in energy Wandering bracelet
upon taking meds/antidepressants Check medical order
*add note_ Alzheimer- neurotic plaques

Neurocognitive Disorders Personality Disorders

-affects consciousness, memory, orientation, attention, Rigid maladaptive, causing significant personal
perception distress and impaired social functioning
-TYPES: Causes:
a. Delirium – ICU psychosis – manifestation of a. Genetic factors – hereditary predisposition
hallucination; usually elderly in ICU b. Temperament factors – innate/inborn
c. Biologic factors – ass. with depression
b. Dementia – not reversible, generally intellectual
d. Psychoanalytic factors – rejecting, hostile,
neglectful type of environment

Criteria Delirium Dementia Personality- integration of the systems and habits that
Onset Acute Insidious, gradual represent an individual
Cause: infection and
trauma Expressed through behavior
Course Fluctuating during Stable overtime Everyone is unique
the day
Duration Short term, <1 Long term
month Cluster A -odd/eccentric behavior
Consciousness Dec. Clear a. Paranoid – extreme mistrust & suspiciousness
Alertness Impaired, Abnormal Normal b. Schizoid – withdrawn, cold, introvert
Attention Dec Normal
Orientation Impaired Impaired c. Schizotypal – similar to schizoid + delusions,
Memory Recent- impaired Impaired-recent then perceptual distortions
Mgt Treat the cause Maintain optimum
level of functioning
Other Mx:
Restricting calorie intake
Cluster B – emotional/dramatic Intense fear of gaining wt
a) Narcissistic- self-loving, loves to be admired and Decreased VS
praise; lack remorse (same antisocial); Fluid & electrolyte imbalance
grandiosity Criteria for hospitalization:
b) Histrionic – attention seeker; extrovert; Failure to gain weight in an OPD setting
manipulative Loss of 30% of body weight within 6 months
c) Borderline – “psychotic-neurotic” “all good and Fluid and electrolyte imbalance
all bad”; splitting behavior, fears separation, WOF: Hypokalemia- cardiac dysrhythmias
impulsive, unstable relationship (hallmark)- shift Dec V/S: temp < 36°C, BP systolic <70 mmHg,
one job to another or labile mood; suicidal PR dec 40 bpm
d) Antisocial – violate rules and laws, lack the sense of
guilt, PRIO- SAFETY – set limits Mgt:
Re-establish appropriate eating behavior- set limits with
Cluster C- anxious/fearful eating time: within 30 mins, sit with pt 1-2 hours after meal,
a) Dependent – clingy; lack of self-confidence; looking pt wt- 2-3x/wk, wt goal: 3-5 lbs/wk
for dominant partner
b) Obsessive-Compulsive – perfectionist, rigid; order in Bulimia Nervosa
expense of efficiency & flexibility - Binge eating followed by vomiting
c) Avoidant – pre-occupied with being criticized
Principles of Nrsg Care: Biologic Dec Serotonin
- Consistency – specially with anti-social disorder Psychodynamic- ambivalence with low self-esteem;
- Limit setting – help develop trust, firm & chaotic & broken family
consistent, emotional support S/Sx:
- Treatment Plan – role Playing/Group therapy Binge eating
Assertiveness training – for avoidant & aggressive Uses purging
Medications- Anti-depressants Laxative and diuretic abuse
Induces vomiting
Eating disorders Metabolic alkalosis
Anorexia Nervosa – self-employed I (extensive caries)
starvation/perfection Chipmunk face and callus formation (swollen
Etiology- parotid)
Biologic – Inc. Serotonin Slightly below or above normal weight
Developmental factors Other manifestations
Social factor- adolescence, over demanding Under strict dieting or vigorous exercise
parents Loss of tooth enamel/tooth decay
Personality Type: Achiever, perfectionist, female, Esophageal Varices- bleeding/aspiration
S/Sx: Mgt:
Amenorrhea- within 3 consecutive months Set limits
No appetite Improve self-esteem
Obvious wt loss
Reducing ideation of perfection
Emaciated- extreme muscle loss-cachexia
Xerostomia- dry mouth
Image disturbance – Initial Dx
Abnormal har growth
Schizophrenia Underlying cause: Trauma, overuse of denial
-Split mind (Bleuler) They do not seek immediate treatment – labile
-Disharmony between the pts thinking, feeling and indifference
actions Not faking Sx; Do not ignore the client just the
Theories of Causation Curable
Biologic – Inc Dopamine in most part of the brain
Sx Goals of Treatment:
Dec. Dopamine- (pre-frontal cortex) – CEO Make client functional as his condition will
(-) Sx secondary to meds allow to improve the quality of life
Psychologic theory- general vulnerability to To relieve Sx: initially- assess the complaint;
stressors of life once admitted: ignore the condition but not
Family theory – rejecting hostile neglectful family the pt.
environment If the pt talks about the condition, listen shortly but
General Mx: (DSM V) – deterioration of personality learn to redirect the topic
Hallucination Factitious DO
Disorganized speech – ass. looseness Munchausen Syndrome
Catatonic behavior- disorganized mov’t/action Impose on self
Negative Sx Gain attention & emotional support
Fake Sx (medical/psychological)
Positive Sx Negative Sx Alter medical Hx, specimen, result
-bizarre, additional feature Withdrawn, missing Claim that they are sick
Delusions Alogia-poverty of speech They inflict pain or injury
Hallucinations Anhedonia – No pleasure
Disorganized speech Avolition – NO motivation
Insomnia Anergia- No energy Cause: unknown
Grandiosity Asocial – same autism
Illusion – inappropriate affect Inattention- No attention
Treatment: CBT, psychoanalysis; Be non-
Catatonia Flat affect judgmental; Acceptance; Trust
General Intervention:
Acceptance Munchausen Syndrome by proxy
Trust – firm & consistent Impose on others
Present reality Malingering
Acknowledge feelings external reward/incentive ex. Freedom fr
Withdrawn pts- 1:1 liability
Assist ADL’s needs legal intervention
Suspicious pts – develop trust, maintain eye Caregiver is overly attentive/concern
contact Hx of many hospitalization of the child
Disruptive – safety & set limits Improvement of child’s condition in the
*restraints – hospital but Sx recur when the child returns
Renewal hours/order: every 4 hours home
Expiry of order – every 24 hours Labs & other Dx results do not match to Sx
Check V/S: every 15 mins Drugs/chemicals (child’s urine & blood
Remove: every 2 hours for 10-15 mins sample)
Common victim- <6 yo
Somatic symptoms and other related disorders Perpetrator: mother or primary health care
Persistent worry or complaints about physical illness giver “mother imposturing”
without supporting physical findings.
Conversion DO – physical Sx or deficit suggesting
loss or altered body function
Usually voluntary movement (ex. Conversion
blindness, possible limb paralysis, selective
Substance related, and Addictive DO b. CAGE Questionnaire
Substance Use DO – a cluster of cognitive, behavioral, and C- have you ever felt the need to CUT down drinking/drug
physiological Sx indicating that the individual continues use?
using the substance despite significant substance related A- Annoyed at criticism?
problems G-Guilty about something done?
Criteria: E-Eye opener
Impaired control over substance – takes substance
in a larger amount Goals for Detox
Reports multiple unsuccessful efforts to Remove inc. toxins in blood
discontinue use Dec. craving
Social Impairment- problems with family, S/Sx: antabuse –how long? – as long as alcohol detected
occupational and social relationships Inc. HR
Risky use of substance – hazard; continuous use of Severe headache
substance despite physical or psychological Flushes/hot flushes
problems Tremors
Pharmacological Criteria – withdrawal- Mgt.: do not drink alcohol 24°before the 1st dose, 2
physiological response due to abrupt discontinuation wks post last dose
of substance use that leads to physical or Avoid: flagyl/metronidazole- because it contains
psychological readjustment; tolerance benzyl alcohol (preservative)
– need to increase the dose in order to get the same
effect Mgt.:
Stimulant vs Depressant Mark the abrupt discontinuation of the subs;
Intoxication Substance Withdrawal liver- natural detox
Inc/ upper Stimulant Decrease Approximately 7-10 days
Dec/Downer Depressant Upper PRIO- when was your last drink?
Stage Timing Withdrawal S/Sx
1 6-8 hrs after last Tremors, sweating, agitation, GI
drink Mx, (excitability)
Alcoholism – chronic disease or disorder, excessive 2 8-12 hrs Stage 1 + hallucination
alcohol intake & interference in the individual’s health, 3 2-3 days Stage 2 + seizure
interpersonal relationship and economic functioning 4 2-5 days (worst) Delirium tremens extreme CNS
irritability associated with alcohol
(WHO); depressants withdrawal
- Etiology Mgt: seizure prec; anxiolytics-
during detox; BP important – lead
Psychodynamic – oral fixation to stroke
Biologic – Dec Serotonin/hereditary
Behavioral- exhibit dependence, mistrust, feelings of Long term: REHABILITATION -45 days
inferiority, more phobic Give up alcohol-abstinence; Disulfiram
Detecting Alcoholism therapy or Aversion therapy
a. Blood alcohol level (BAL) Goal: to make drinking painful; milieu therapy
BAL S/Sx Live a positive lifestyle
Up to 0.05% Loss of inhibition
Up to 0.1% Anxiety relief, euphoria, loud speech Rehab goal: change of behavior thru Group
*0.1-0.15% Legal intoxication, slurred speech, motor therapy (alcoholic anonymous)
intoxication, moodiness Al-anon- wife Al-a-
0.2-0.3% Irritability, tremor, ataxia, may have memory lapse
(blackout) teen-for children
0.3% and up Unconsciousness
Commonly Abuse Substance
Substance Physical Signs Withdrawal Neurodevelopmental DO
effects ADHD:
A.Stimulants Attention deficit- PRIO
Amphetamine Hyperactivity Depression
(shabu) Euphoria Irritability
Inc. vs Wt loss Psychosis Main problems
Loss of appetite Inattention
Cocaine-route Perforated nasal Psychomotor
inhale septum Seizure
MI or respi arrest- Impulsive
hyperstimulation of More common in boys- onset until 12 yo
heart and lung
muscles Cause: Biochemical factors- dysregulation of
B.Narcotics/opiates norepinephrine & serotonin
-downers Biological factors – frontal lobe disfunction
-Heroin PinpOint pupils Runny nose (CEO- executive function of the brain)
-Morphine Incoordination Impotence Mx:
Dec. V/S Piloerection
-Codeine Drowsiness
Poor decision making & impulsive control
Fidgets with hands and feet or squirms in the seat
Easily distracted with external or internal stimuli
Other downers
Alcohol Difficulty in following instructions
Barbiturates Poor attention span
“Hero Mo Co but I
Shifting from one uncompleted activity to another
let you down” Talking excessively
Interrupting or intruding on others
Engaging in physically dangerous activities
Oxycodone without considering the possible consequences
Methadone Mgt:
LSD (lysergic acid Dilated pupils-all Visual disturbances Limit setting
diethylamide) stim. or flashbacks Re-channeling off energy
PCP-phencyclidine Hallucinations Hallucinations
Mescaline(peyote) Inc. V/S
Psylocibin- Set limits
mushroom Schedule
Marijuana (stim.) Weight gain Lack of appetite Structure the envi.
Blood shot eyes Depressed mood Prio Nrsg Dx.: RFI – impaired social instruction
Headache DOC:
Methylphenidate (Ritalin) – prolongs the
attention span, Inc hyperactivity; CNS
stimulant; Side effects: dec. appetite &
sleep; headache, N/V, *growth retardation;
rapid, repetitive ticks,

Do not give during hours of sleep/night

Before meals for better absorption
If once a day before breakfast; 2x a day
before breakfast & lunch; 6 hours before
bedtime or around 4 pm
Next DOC: Dexedrine & Strattera
Autism Spectrum DO ABUSE
Domestic Abuse- report automatically if suspected
Developmental disorder characterized by impairment in
Child Abuse- maltreatment of child
communication skills, or the presence of stereo-typed
behavior, interest and activities, with associated
impairment in social isolation Physical Sexual Emotional Neglect
Lack of crying Difficulty Suicide Poor hygiene
More common in boys and occurs before 18 usually Unexplained walking or attempt Inadequate wt
diagnosed at 2 injury @ sitting Learning gain
different Pain or difficulty Constant
Cause: biological factor healing stages swelling of Speech fatigue
Main problem: Impaired interpersonal functioning Bald spots genitals disorders- Inconsistent
Mx: Extreme Unwillingness selective school
aggressiveness to change mutism attendance
Impaired social interaction – prefer to be alone or withdrawal clothes Mood changes Consistent
Impaired verbal communication – echolalia Apprehensive Torn, stained Anxiety hunger
child- or bloody Depression Untreated
(acceptance) reluctance in underclothing illness
May avoid eye contact but maintain eye contact to changing WOF: any
establish communication clothes for allegations
sports made by the
Disturbance in personal identity- call by name to Fear of parents child with
establish identity Frozen sexual
watchfulness concerns
Repetitive actions – learn about their routine
Resist change
Poor nutrition – be extra sensitive to their body Priority: all types of abuse
language/needs Safety – remove the child
Temper tantrums – head banging (provide helmet) Report- to the appropriate agency
NO real fear of danger _ PRIO-safety, structure, Child/adult – child/adult protective service
support, consistency Spouse- local enforcement agency
Apparent insensibility to pain Physiological needs met
Offer presence
NO touching (may not want cuddling) Elderly Abuse- maltreatment to elders
Activity: less demanding Mx.:
Inappropriate attachment to object – allow Physical- inconsistent explanation to injuries
Be consistent possible contractures, presence ulcers
Intellectual disability (Mental retardation) Neglect – poor hygiene
Sub-average intellectual capacity Emotional abuse – fear, agitation, confusion
Develops before 18 Economic Exploitation- child’s handles the pt
IQ: below 70 account; sign unable to pay bills; no knowledge
Cause: Biological factors: inherited about own expenses/finances
Main problem: Inadequate mental functioning
Spousal Abuse (Battered wife syndrome)
Levels of Intellectual Disability - Cycle of domestic violence characterized by wife-
beating by the husband, humiliation and other forms
Level IQ Feature Mental age
Mild/moron 50/55- Educable 8-12 (school
of aggression
70 age)
Moderate/Imbecile 35/40- Trainable 3-8 (pre- BWS cycle
50-55 school)
Tension building- verbal argumentation vices,
Severe/idiot 20/25- Needs close 0-3 (toddler) jealousy
35/40 supervision Severe battery – physical contact
Profound Below Needs(complete) 0 (infant) Trigger – NONE
20-25 custodial care
DM: displacement; projection
Honeymoon – DM: undoing
Mx/Common Cues of Partner Abuse crisis- affect whole community; less severe –
Repeated vague Sx- freq. hospitalization uncontrolled crying, feelings of panic, crying-yelling;
Unexplained injuries severe – threatens to harm self of other & become out
Flinching in the presence of spouse of touch with reality – psychosis
Suicidal thoughts Characteristics of crisis state
Continual efforts to keep partner from getting Highly individualized
angry Self-limiting- 4-6 wks, true crisis state
Lack of relationship Also affects significant others
Nrsg Interventions Person is amenable to suggestions
Be non-judgmental
Ask directly if abuse is occurring Role of the nurse – more direct & active approach
Acknowledge serious abuse- help gain insight Primary objective – give guidance & support
Assist victim to assess internal strength Thera. Com: Focusing on the problem they can resolve
Give victim list of resources *local crisis hotline
Don’t push the victim to leave abuser if not ready Steps in Crisis Intervention:
Help victim come up with safety plan/escape Assess the situation (resources)
Sample: in one bag put all important documents Assess pt to develop cognitive awareness
including child’s favorite toy “where were you” “who are you with”
Prio: Assist the pt. in managing feelings- deep breathing
Remove from immediate physical danger Explore with the client the resources available “who
Report to local engagement agency are your relative that we can call”
Provide local crisis hotline Assist the client with the action plan

Rape Loss and grief- Normal reaction to real or anticipated

Sexual act with penile penetration loss
Without consent Duration: 12-24 months
Truths about rape: Types:
Is an act of violence Anticipatory- occurs before loss
Act of domination and power Disenfranchised – loss is experienced but it cannot
There are more females raped than male be acknowledged
There is more acquaintance rape done Dysfunctional – prolonged emotional instability
Rape trauma syndrome
Acute phase – immediately post rape- last 4 wks; Interventions:
denial, silent, withdrawn; Sit with pt, secure Allow adaptive denial (DABDA)
consent to assess injury, Thera: silence Explore the clients perception & meaning of loss
Outward adjustment- pt begins to verbalize Encourage the client to examine the coping patterns
Mgt: encourage further verbalization in the past & present situations of loss
Resolution – pt begins to accept – unacceptance= Encourage pt to care for self
sexual dysfunction = frigidity = sexual promiscuity
Mgt: refer to psychotherapy End of life
Ethical & legal concerns
Crisis Living will/advanced directives- pt decides for his
Critical incident – experienced, witnessed, learned further treatment plan, Last will- properties
about = stress (coping OK; if unmanaged trauma) = Durable Power of attorney – pt assigns a health
care proxy to decide for his treatment is case pt
is incapable
Hospice Care – terminally ill; 6 months to live
RN- pain mgt and supportive care- expertise
*GOAL: to make the pt more comfortable
Post mortem care Acknowledge: how difficult & painful the loses must be
Maintain dignity Assess: method
Organ donor: Driver’s license- if wife won’t Ask: give immediate solution; ideas; if anyone is with the
permit, honor wife’s request cause everything caller; ask the significant other to help the caller Refer:
expires if pt dies not unless there is a Living will walk in crisis
Respect rituals Refuse: give the tell # of the crisis center
Thera com: silence and touch
Establish privacy Electroconvulsive Therapy
Maintain respect If the pt does not respond to medications
Suicide Indications:
Anger turned inwards Severely depressed not responding to meds
Ultimate for of self-destruction Acutely suicidal
Cry for help Catatonic, manic
Who are these? Contraindications
Depressed CVA
Hallucinating Brain tumor
Borderline personality Inc ICP
Client in crisis Spinal cord injury
Psychotic clients Glaucoma
Widowers/divorced HTN, ischemia
Terminally ill; recent job loss CHF, angina
Nrsg. Interventions MI
Assess for clues of suicide Renal & Liver dse
Valuables are given away Pregnant
Living will change Notes Fracture
Verbalization Active bleeding tendencies
Conduct a lethality assessment Fever/infection
Plan- ask directly – are you planning on Pre Post
killing yourself> Convulsive O2 100%
Oxygenate 100% Monitor- V/S esp RR
Method- high-lethal= gunshot, jumping, NPO- 6-8 hrs Effects: confusion, transient,
poisoning; low lethal= med overdose, wrist V/S every & post 15 mins ECT- mem loss, disorientation (Prio-
ONLY RN reorient)
slashing Urinate first to prevent seizure Headache
Keep the client safe induce incontinence
Remove sharp or harmful objects Labs- ECG, EEG, x-ray,CBC
Secure complete PE
Nurse pt ratio 1:1 Institute cardiopulmonary
Suicidal- no harm or no suicide contract – not Clearance
IV route/heplock for meds NO
legal to write notes IVF
Check pt in varying time to avoid Pre-meds
predictability or every 5-10 mins = low Atropine SO4 – dec
Stay with the pt 24 hours round the clock = Anesthetic short acting
high barbiturates
Brebital (methohexital)
Succinylcholine (Anectine)
Telephone triage: Suicide – decseizure ep- NO paralysis
Express: genuine concern & a desire to work with the Psychopharmacology
caller SNS PNS
Identify: name, address, and tell # -adrenergic -antiadrenergic
-anticholinergic -cholinergic (think of H2O)
NO water/dry -Inc secretion
Heart contractility Heart contractility
Cardiac output, blood sugar
Cardiac output, blood Diarrhea
sugar Urinary Orthostatic hypotension Instruct ct to rise slowly form a lying to
incontinence a sitting position
Constipation (polyuria) Dermatologic Effects
Urinary retention Pupillary Photosensitivity Instruct the ct to wear protective
Constriction sunscreens, clothing and sunglasses,
(oliguria) Bronchoconstrictio and to limit exposure time in the sun
Hormonal effects
Pupillary dilation Teary, lacrimation
Dec. libido Explain that this may be transient
Bronchodilation Salivation
Amenorrhea Explain that this is reversible
NO tears/dry
Instruct ct not to discontinue the use of
Dry mouth Inhibitory
✓ birth control as ovulation is continuing
Brain MAO
✓ and pregnancy is possible
Excitatory acetylcholine
✓ ✓ Weight gain Encourage proper diet and exercise
Norepinephrine GABA
Serotonin General S/E
EPSE- Extrapyramidal S/E
Drugs for Schizophrenia Types:
-anti-psychotics Dyskinesia- difficulty controlling mov’t
Typical – dec. Positive Sx Pseudoparkinsonism- cogwheel rigidity, bradykinesia
Haloperidol (Haldol) – Inc EPSe – S/E Dsytonia – involuntary muscle spasm -
Chlorpromazine (Thorazine) – WOF hypotension Laryngeal pharyngeal constriction -
Thioridazine (Mellaril) – orthostatic hypotension Oculogyric crisis
Atypical – dec negative Sx - Writer’s cramp
Clozapine (Clozaril) – dec WBC- WOF - Torticollis (wry neck)
Agranulocytosis (fever, sore throat) Akathesia- restless
Olanzapine (Zyprexa) A/E
Risperidone (Risperdal) NMS- Neurolyptic Malignant Syndrome
Seroquel (Quetiapine) Inc temp *** indication
Aripiprazole (Ability) Dec LOC
Muscle rigidity
Risperidone (Risperdal) Tremors
1-2-3 regimen (1 OD / 2 BID/ 3 TID) Antidote- Dantrolene- muscle relaxant, dec fever
Therapeutic range – 4-8 mg/day
Autism DOC Anti-depression
Insomnia “TCA” -tricyclic anti-depressants
Suppress tardive dyskinesia “3 cute girls mahilig sa Tofu”
Irreversible Pamelor (nortriptyline) Elavil
Tongue protrusion (amitriptyline)
Lip smacking (teeth grinding) Anafranil (Clomipramine)
Tofranil (Imipramine)
Side-effect Nrsg Intervention WOF- cardiac dysrhythmias
Anticholinergic Sx SSRI
Dry mouth Encourage frequent sips of H2O, good
oral hygiene, chew sugarless gum
“Pro taxil nagZOZOlo”
Blurred vision Reassure pt of transient nature of Prozac (Fluoxetine)
blurred vision Zoloft (Sertraline)
Retinitis pigmentosa Notify the dr; slow loss of vision lead
to blindness Paxil (Paroxetine)
Urinary retention or I&O, notify dr WOF: sexual dysfunction
hesitancy- kidney dys
Constipation High fiber, Inc OFI and exercise
Paralytic ileus- Notify dr.- surgery MAOI – drug interact with SSRI AVOID
obstruction/paralysis Parnate (tranylcypromine)
small intestine
Nardil (Phenelzine)
Sedation Client teaching regarding need to
restrict driving or operation of Marplan (Isocaboxacil)
KEEP OUR FRIENDLY LITTLE SECRET Do not modify psychotic behavior
Tyramine rich precursors so AVOID tyramine S/E: drowsiness, mental confusion
rich foods: processed aged, pickled, smoked, Next DOC: Carbamazepine
overripe fruits NO banana and avocado// OK cottage
cheese or cream cheese Benzodiazepine- > S/E
WOF: hypertensive crisis - Alprazolam (xanax)
- Diazepam (valium)
Anti-depressants health teaching - Lorazepam
NO smoking, alcohol, drug to drug interactions (Ativan)
1 at a time - Temazepam (Restoril)
- Chlordiazepoxide
SSRI (librium) - Flurazepam
2nd TCA - Midazolam (Versed)
3rd MAOI
Buproprion or novel (well butrin) – anti- Nonbenzodiazepine < S/E
depressants without category new; instead of - Buspirone (BuSpar)
SSRI Zolpidem (Ambien)
Wait 2-4 wks before you introduce Medications to treat Alzheimer’s
another antidepressant Dse -inhibits acetylcholinesterase
Drugs for Mania -Ex. Donepezil (Aricept)
Level- 0.6-1.2 meq; weekly checking of blood level Tacrine (Cognex) – toxic -liver
Increase urinary output-polyuria -S/E
Toxic-coarse hand tremors (mild) “Do not pisil”
Hands -fine hand tremors (N S/E) -active bleeding tendency
Inc OFI-2-3 L/day -expected polydipsia Toxic liver
Uu- Normal mild diarrhea – toxic-diarrhea Comfort
Maintain-regular Na intake – 3g/day Room visits (polyuria, incontinence)
Impaired Sphincter control
Lithium- NO antidote N/V
Therapeutic Mild Moderate Severe Anorexia
serum level Toxicity Toxicity (>3meq/L) Alcoholism - dec serotonin
(1.5-2) (2-3 Alzheimer – dec. acetylcholine
meq/L) Anxiety – dec GABA
Fine hand Diarrhea Ataxia Seizure
tremors Vomiting Tinnitus Organ failure Depression – dec Norep/ser and Inc
Mild diarrhea Drowsiness Blurred vision Renal failure MAO Manic – Inc. Norep/ ser/
Goiter Dizziness Delirium Coma
Anorexia Coarse hard Nystagmus Death intracellular Na+ Anorexia – Inc.
Edema tremor serotonin Bulimia nervosa – dec.
Wt gain Muscular serotonin
Polydipsia weakness
Polyuria Dry mouth
Lack of
Cause: SNS Tx Goal to Gen. S/E
Norepinephrine PNS
Intracellular Na+
Major use to reduce anxiety, also induce
sedation, inhibit convulsion