CONCEPT: PSYCHIATRIC NURSING

THERAPEUTIC COMMUNICATION
 In psychiatric emergency, priority is client’s ___________
 The NCLEX-RN always employs the __________________
 Always promote ____________ and _____________ skills

THERAPEUTIC COMMUNICATION
Therapeutic
 Accepting – initial action / response
 Broad opening – “tell me more about it”
 Encouraging expression
 Silence
 Restating – same as paraphrasing
 Presenting reality
 Offer self – to make yourself available for the
patient
 Making observations – “you seem..” “you look..”
 Active listening – paying close attention
 Clarification – to clear any doubt
 Refocusing –picking up central topics
 Focusing –explore a specific topic
Non-Therapeutic
 Ignoring the client.
 Flattery – insincere praise
 Advising: “You should do this…”
 Giving of opinion/Telling the client
what to do: “In my opinion, you
should…”
 False reassurance: “Don’t worry,
everything will be alright.”
 Belittling: “Don’t be concerned too
much, everyone else feels the same.”
 Judging: “It’s your mistake. If you had
only listened to the doctor…”
 Defending: “All of the nurses here are
great…”
 WHY?

PHASES OF NURSE-PATIENT RELATIONSHIP

1. PRE ORIENTATION
____Meeting the client
Major Task: Self-awareness – psychological state in which a person is aware of his/her own feelings
behavior and trait
2. ORIENTATION
____Meeting the client
Acceptance -
Establish ________ and ________Rapport – HOW? Spend time at scheduled intervals
Establish a contract, define goals - Schedule of meeting
Prepare for termination of relationship
Major Task: develop a mutually acceptable contract

3. WORKING PHASE
Promote coping mechanisms
Increase independence
 Major Task: identification and resolution of the client’s problems

“The struggle you’re in today is developing the strength you need for tomorrow. “
 4. TERMINATION
Summarize, evaluate outcome
Gradual weaning process
Encourage client to discuss feelings about termination
 Major Task: assist the client to review what he/she has learned and transfer his learning
to his relationship with others

MENTAL STATUS EXAMINATION

GENERAL DESCRIPTION –
MOOD
AFFECT
SPEECH

PERCEPTION

HALLUCINATION
Sensory impressions without external stimuli
ILLUSION
Real stimuli misinterpreted

Nursing Diagnosis: Alteration in __________ perception

THOUGHT

Thought Process

a. Clang associations – rhyming of words

b. Flight of ideas – jumping from one idea to another
c. Looseness of associations – stringing of unrelated topics
d. Neologisms – newly coined word or expressions
e. Thought blocking – mental block
f. Word salad – mixing of real and imaginary terms

Nursing Diagnosis: Alteration in _________ process

Thought Content

a. Delusions of grandeur – superior to others

b. Delusions of persecution – harm is occurring, or is going to occur.

Nursing Diagnosis: Alteration in _________ content

“The struggle you’re in today is developing the strength you need for tomorrow. “
ABNORMAL MOTOR BEHAVIOR

a. Echolalia – repetition of words

b. Echopraxia – repetition of actions/ movements

c. Waxy flexibility – “Catatonia” Assuming a position for long hours

ANXIETY and MOOD DISORDERS

A. Anxiety – subjective feeling of apprehension, dread, or impending doom
LEVELS FOCUS MANAGEMENT

Mild ____focus Acceptance

Optimal for learning Continuously monitor the
You become interested to the topic patient

Moderate _____focus
Learning is intact Allow verbalization
_____vital signs
Physical symptoms:

Priority:
Severe and Panic Leads to :
Patient becomes violent

OBSESSIVE - COMPULSIVE DISORDER

____________– frequently occurring thoughts that increase anxiety but cannot be suppressed

____________ - repetitive acts that alleviates person’s obsession

MANAGEMENT:
DIVERSION: TO DIVERT THE ATTENTION AWAY FROM THE NEGATIVE THOUGHTS

DESENSITIZATION: GRADUALLY EXPOSING THE CLIENT TO AN ANXIETY-PROVOKING STIMULI

NOTE: Must learn relaxation technique
PURPOSE: To decrease time and frequency of the compulsion

“The struggle you’re in today is developing the strength you need for tomorrow. “
 B. BIPOLAR DISORDER

MANIA DEPRESSION
Uncoordinated colorful clothing Monochromatic clothing
APPEARANCE Disheveled – untidy, unkempt,
poor hygiene
Hyperactive Passive
BEHAVIOR
Anhedonia
Attention seeker
Anergia
Competitive
Avolition
Aggressive

Flight of ideas Slow mentation

COMMUNICATION Fast pressurized speech Poverty of speech

Quiet, non-stimulating Lively, stimulating environment

MILLIEU THERAPY environment
______ from nurses station ______ nurses station
Safe, simple Repetitive
ACTIVITIES Easy to accomplish Conserve energy
Uses up energy

ATTITUDE THERAPY Matter of Fact Firm / Kindness

RISK FOR INJURY

NUTRITION Finger foods Small feedings

High calorie and High protein diet
Offer fluid every hour

WHAT TO REMEMBER ABOUT DEPRESSION:

 Giving away valued items

 A client with depression is preoccupied, has decreased energy, and is unable to make
decisions, often even simple decisions
 A person’s feeling of self-worth is generally determined by accomplishments
 As the client with major depression begins to feel better, the client may have enough
energy to carry out a suicide attempt.

“The struggle you’re in today is developing the strength you need for tomorrow. “
 SUICIDE
I –deation – thought or thinking

P –lanning - strategy

M –eans - method

PRIORITY: ASK DIRECT QUESTIONS – TO GET TO THE CORE OF THE PROBLEM

NURSING INTERVENTION:
VISIT THE PATIENT REGULARLY IN AN IRREGULAR INTERVAL

COGNITIVE DISORDERS

DEMENTIA OF ALZHEIMER’S TYPE

 Degeneration and atrophy of brain cortex

 ____ Acetylcholine
 Neurofibrillary tangles / neurotic plaques
ALZHEIMER’S DISEASE

ASSESSMENT:

1. AMNESIA – memory loss

2. AGNOSIA – inability to recognize persons, objects, shape, smell and sound

3. APHASIA – communication disorder

4. APRAXIA – movement disorder

STAGES

MILD
2-3 YEARS Clinical Hallmark:
MODERATE Confusion
4-5 YEARS Disorientation
3 A’s: Apraxia, Agnosia, Aphasia
SEVERE Personality and emotional changes
5-10 YEARS Deterioration in all areas of function

“The struggle you’re in today is developing the strength you need for tomorrow. “
 PERSONALITY DISORDERS
Rigid, maladaptive, causing significant personal distress and impaired social functioning
CATEGORY PERSONALITY DISORDERS

1._________________ extreme mistrust and suspiciousness

CLUSTER A 2._________________withdrawn, cold, introvert

ODD/ ECCENTRIC 3._________________similar to schizoid + delusions

1._________________self-loving, loves to be admired and praised.

CLUSTER B 2._________________”over acting”, attention-seeker, extrovert

DRAMATIC/ ERRATIC / 3._________________”psychotic-neurotic”, “all good-all bad”,

EMOTIONAL (splitting), fears separation, impulsive, unstable relationship.

4._________________violates rules and regulations, lacks sense of

guilt, no concept of right or wrong

CLUSTER C 1.__________________”clingy”, lacks self confidence

ANXIOUS / FEARFUL 2.__________________perfectionist, rigid

3.__________________preoccupied with being criticized

EATING DISORDERS
CRITERIA FOR HOSPITALIZATION: ANOREXIA NERVOSA
Loss of body weight:

Potassium level: Provide 3-5 lbs weight gain

Pulse rate: Weigh the client 2-3 times a week

Systolic BP: Structured meal: Limit meal time for 30mins

Temperature: Monitor the client for 1 hour

Failure to gain weight

“The struggle you’re in today is developing the strength you need for tomorrow. “
 ANOREXIA NERVOSA BULIMIA

A MENORRHEA B INGE EATING

N O APPETITE U SES PURGING

O BVIOUS WEIGHT LOSS L AXATIVE AND DIURETIC USE

R EDUCING IDEATION I NDUCES VOMITING

E MACIATED – abnormally thin M ETABOLIC ALKALOSIS

X EROSTOMIA – dry mouth I (EXTENSIVE) CARRIES

I MAGE DISTURBANCE (BODY) A CHIPMUNK FACE AND CALLOUS FORMATION

A BNORMAL HAIR GROWTH

SCHIZOPHRENIA

MAIN DISORDER: DISTURBANCE IN THOUGHT AND PERCEPTION

POSITIVE SIGNS AND SYMPTOMS NEGATIVE SIGNS AND SYMPTOMS

(+) EXTRA BEHAVIOR THAT ARE NOT SEEN IN A (-) LACK OR ABSENCE OF NORMAL FUNCTIONS
NORMAL PERSON

DELUSION ALOGIA

HALLUCINATION ASOCIAL

DISORGANIZED SPEECH ANHEDONIA

INSOMNIA AVOLITION

GRANDIOSITY ANERGIA

ILLUSION INATTENTION

ABNORMAL MOTOR BEHAVIOR FLAT AFFECT

INAPPROPRIATE AFFECT

“The struggle you’re in today is developing the strength you need for tomorrow. “
 SOMATOFORM DISORDERS

Common Types:

A. CONVERSION DISORDER – Physical symptom or deficit suggesting loss or altered body function
due to psychological conflict

Goals of Intervention for conversion disorder:

1. Make client as functional as possible

2. To relieve the symptoms:

Initially: assess the complaint

Once admitted: ignore the condition, but not the patient

* If the patient talks about the condition, listen shortly, but learn how to _________________________

B. FACTITIOUS DISORDER

-Deliberately producing or exaggerating symptoms

Fake symptoms

Alter medical specimen

Imposed on self Claim that they are sick

(MUNCHAUSEN SYNDROME) They inflict injury or pain to self

Caregiver (Abuser)

Imposed on others Has history of many hospitalizations

(MUNCHAUSEN SYNDROME BY Improvement in the child’s condition when in the hospital

PROXY)
Laboratory and diagnostic test do not match the reported s/sx

Drugs and chemicals (blood and urine)

“The struggle you’re in today is developing the strength you need for tomorrow. “
 Chronic disease or disorder characterized by
excessive alcohol intake and interference in the
individual’s health, interpersonal relationship, and
ALCOHOLISM: economic functioning. (WHO)
MANAGEMENT:

SHORT TERM – DETOXIFICATION

STAGE TIMING WITHDRAWAL S/SX

1 6-8 HOURS AFTER DRINKING TREMORS, SWEATING,
AGITATION
2 8-12 HOURS AFTER DRINKING STAGE 1 AND HALLUCINATION

3 2-3 DAYS STAGE 2 AND SEIZURE

DELIRIUM TREMENS
4 2-5 DAYS DOC: Anxiolytics
Anticonvulsants

LONG TERM – REHABILITATION

1.Give up alcohol

2.Live a positive life

SUPPORT GROUPS:

ALCOHOLICS ANONYMOUS - patient

AL-Anon – immediate family (spouse, parents)

Alateen – teenager or child of the alcoholic patient

“The struggle you’re in today is developing the strength you need for tomorrow. “
 CONCEPT: NEUROSENSORY
CENTRAL NERVOUS SYSTEM
The Brain

APHASIA

Receptive aphasia
is the inability to distinguish between sounds, meaning and the comprehension of those words
whether written or spoken.

Expressive aphasia
is the inability to express oneself in either spoken or written words.

Neurotransmitters of the Brain:

1. Dopamine
2. Acetylcholine
3. Serotonin
4. Norepinephrine
5. Gama-amino butyric acid (GABA)
6. Glutamate

“How you SEE YOUR FUTURE is more important than what happened in your past.”
 CNS NEUROTRANSMITTER PROBLEMS

PARKINSON’S DISEASE DYSPHAGIA - difficulty swallowing

PROBLEM:

TRIAD: MANAGEMENT:
1. Resting Tremors
Comfortable position :
2. Cogwheel Rigidity High Fowler’s / Upright /Sitting

3. Bradykinesia Thickened Food and Fluid

ASSISTIVE DEVICE: Assist in flexing the neck upon swallowing –

Difficulty standing from a sitting position to have control over swallowing

DOC: LEVODOPA + CARBIDOPA (Sinemet)

MYASTHENIA GRAVIS
PROBLEM: DOPAMINERGICS

CHARACTERISTIC:
EARLY SYMPTOMS:
1.
2.

PRIORITY:
DIAGNOSTIC TEST:

1. TENSILON TEST Edrophonium Chloride (Tensilon)

DOC: PYRIDOSTIGMINE BROMIDE (MESTINON)

(CHOLINERGIC)
BEST TAKEN:

COMPLICATIONS:

CHOLINERGIC CRISIS MYASTHENIC CRISIS

(OVERMEDICATE) (UNDERMEDICATE)
DOC: DOC:

MEDICATION TO AVOID: Muscle Relaxant

“How you SEE YOUR FUTURE is more important than what happened in your past.”
 AMYOTROPHIC LATERAL SCLEROSIS
PROBLEM: 1.
2.
AFFECTS: Motor Neurons

SIGNS AND SYMPTOMS:

1. Fasciculation - spasms
2. Hyper reflexes – over reflexes
3. Atrophy – decrease in muscle mass

DOC:

HIGHER INCIDENCE OF RATE:

Upon Diagnosis: Life span
COMMON CAUSE OF DEATH:

Nursing Diagnosis: Anticipatory grieving related to inevitable death

Ineffective airway clearance

TYPES SEIZURES / EPILEPSY DISORDER

GRAND MAL TONIC- stiffness

CLONIC- contraction and relaxation of muscles rapidly

PETIT MAL ABSENCE SEIZURE

“Blank stare” – Day dreaming

JACKSONIAN LOCALIZED - DISTAL TO PROXIMAL GROUP OF MUSCLES

MYOCLONIC BRIEF SHOCK-LIKE JERKS OF GROUP OF MUSCLES

DOC:Phenobarbital (Luminal) – LONG TERM USE

Phenytoin (Dilantin)
Lamotrigine (Lamictal)

“How you SEE YOUR FUTURE is more important than what happened in your past.”
NURSING INTERVENTION:
DURING SEIZURE:
1. TURN THE CLIENT TO SIDE
2. PROTECT THE HEAD
3. REMOVE CONSTRICTIVE CLOTHING
AFTER SEIZURE:
1. BED REST
2. KEEP DIAZEPAM (VALIUM)
3. OXYGEN
4. SUCTIONING

INJURY TO THE BRAIN: CEREBROVASCULAR ACCIDENT (CVA)

ISCHEMIC HEMORRHAGIC

Position: Flat on bed Position: Semi-fowler’s

DOC: Thrombolytics – TPA’s DOC: Aminocaproic Acid (Amicar)

Antidote: Aminocaproic Acid (Amicar)

PRIORITY: Prevent pressure ulcers!

BRAIN SURGERY: CRANIOTOMY

SUPRATENTORIAL CRANIOTOMY

INFRATENTORIAL CRANIOTOMY

Flat on either side

Log Roll

Keep the neck in neutral position

“How you SEE YOUR FUTURE is more important than what happened in your past.”
 DEMYELINATION PROBLEMS

GUILLAIN BARRE SYNDROME MULTIPLE SCLEROSIS

PROBLEM: Autoimmune PROBLEM: Autoimmune disease with

(Damaged nerve cells) Unknown cause
TRIGGERED:

CHARACTERISTIC: CHARACTERISTIC:

FEATURES: FEATURES:
**DYSKINESIA VISUAL DISTURBANCES
IMMOBILITY
PARESTHESIA ATAXIA
DYSPHAGIA SPASTICITY
CLUMSINESS SCANNING SPEECH
INTENTION TREMORS

COMMON CAUSE OF DEATH: DOC: Muscle Relaxant

Decreased respiratory function
PROMOTE: INDEPENDENCE, ENSURE SAFETY

PERIPHERAL NERVOUS SYSTEM

CRANIALNERVES

Number Cranial Nerve Major Function Number Cranial Nerve Major Function
I VII
Olfactory SENSE OF SMELL Facial FACIAL EXPRESSIONS

II VIII
Optic Nerve SENSE OF SIGHT Vestibulocochlear HEARING AND BALANCE
(Acoustic)
III IX
Oculomotor PUPIL CONSTRICTION Glossopharyngeal TASTE / SWALLOWING
IV X
Trochlear SUPERIOR – OBLIQUE Vagus HEART RATE AND
EYE MOVEMENT DIGESTION
V XI
Trigeminal MASTICATION “CHEW SHRUG SHOULDER
”
STROKE THE FACR WITH
Spinal Accessory TRAPEZIUS AND
COTTON WOOL STERNOCLEIDOMASTOID
MUSCLE
VI XII
Abducens LATERAL EYE MOVEMENT Hypoglossal TONGUE MOVEMENT

“How you SEE YOUR FUTURE is more important than what happened in your past.”
CRANIAL NERVE PROBLEMS:

TRIGEMINAL NEURALGIA BELL’S PALSY

“TIC DOLOREUX” “IDIOPATHIC FACIAL PARALYSIS”

PAIN: PAIN:

TRIGGER: FEATURE:
Cold draft -Drooping of the mouth and eyelid
Pressure on the face Priority:
Too hot/ too cold foods Management:
Hard to chew foods
-Facial paralysis
DOC: -Disturbed speech
Baclofen (Lioresal)
Phenytoin (Dilantin)
Carbamazepine (Tegretol) MASSAGE:

MASSAGE: TREATMENT:
DOC: Corticosteroids
TREATMENT: Eye patch
RHIZOTOMY – shutting off the pain signal to
cauterize or burn the nerve

The higher the injury, the greater the damage!

“How you SEE YOUR FUTURE is more important than what happened in your past.”
 AUTONOMIC DYSREFLEXIA
COMPLICATION AFTER A SPINAL CORD INJURY AT THE LEVEL OF T6 OR HIGHER

SIGNS AND SYMPTOMS: WHAT TO DO:

HEADACHE
FACIALFLUSHING
STUFFY NOSE
DIAPHORESIS
INCREASE BP
DECREASE HEART RATE

Intervention: High Fowler’s

Anti-hypertensive drug (Reserpine)

THE EYES
CATARACT GLAUCOMA RETINAL DETACHMENT

DESCRIPTIONS Opacity of the lens Aqueous Humour Separation of retina to

choroids

MANIFESTATIONS

ICCE – Intracapsular Laser Coagulation

TREATMENTS cataract extraction -to cauterize ocular
(Complete surgery) blood vessels
Lens + capsule
Scleral Buckle
ECCE – Extracapsular -silicone band is attached
cataract extraction to the eye surface
(Partial surgery) forming an indent or
Lens buckle

POSITION POST-OP UNAFFECTED SIDE UNAFFECTED SIDE AFFECTED SIDE

HEALTH TEACHING Eye patch on both Eye drop care Eye patch on both eyes
eyes

“How you SEE YOUR FUTURE is more important than what happened in your past.”
 THE EARS

OTOSCLEROSIS MENIERE’S DISEASE

CAUSE Hereditary Idiopathic

AFFECTED PART
Middle Ear Inner Ear

TYPE OF HEARING LOSS Conductive Hearing loss Unilateral Sensorineural Hearing

loss

SIGNS AND SYMPTOMS Tinnitus (ringing Vertigo

in the ear)
Aural fullness
Tinnitus

MANAGEMENT Stapedectomy Chemical Labyrinthectomy

Removal of the stapes Chemical Injection to decrease

and replaced with a the fluid inside the ears
plastic tube called
prosthesis
POINTS TO REMEMBER:

RINNE’s TEST – AIR CONDUCTION AND BONE CONDUCTION

TUNING FORK ON THE MASTOID PROCESS (BONE) THEN IN FRONT OF THE EAR (AIR)
NORMAL: AIR CONDUCTION IS LONGER THAN THE BONE CONDUCTION

CONDUCTIVE – BONE CONDUCTION IS LOUDER THAN AIR CONDUCTION

SENSORINEURAL – AIR CONDUCTION IS ABOUT THE SAME AS BONE CONDUCTION

WEBER’s TEST - LATERALIZATION

TUNING FORK ON THE MIDDLE OF FOREHEAD OR HEAD

NORMAL: SOUND IS HEARD IN BOTH EARS

CONDUCTIVE - SOUND IS HEARD IN POOR EAR

SENSORINEURAL – SOUND IS HEARD IN GOOD EAR

“How you SEE YOUR FUTURE is more important than what happened in your past.”
 EAR DROP ADMINISTRATION EYE DROP ADMINISTRATION

SIDE LYING SITTING, HYPEREXTEND THE NECK

STRAIGHTEN EAR CANAL EXPOSE LOWER CONJUNCTIVAL SAC
3 Y.O. AND UP -PULL PINNA UP HOLD DROPPER & STABILIZE AT THE
AND BACK FOREHEAD
3 Y.O. AND BELOW-PULL PINNA LOOK UP – INSTILL 1-2 DROPS
DOWN AND BACK CLOSE EYES GENTLY
INSTILL THE MEDICATION – HOLD OCCLUDE NASOLACRIMAL DUCT FOR 1
DROPPER 1 INCH AWAY MINUTE
PRESS EAR FLAP – PUT COTTON BALL
ABOVE EAR FLAP
MASSAGE – REMAIN STILL FOR 10MINS

HUNTINGTON DISEASE
CAUSES:
1. Neurodegenerative disease
1. Genetic

HALLMARK: CHOREA MOVEMENT –abnormal involuntary movement (dance-like)

DOC: TETRABENAZINE (Xenazine) - antihyperkinetic movement

S/SX: Psychosis
Dementia
DOC: ANTIPSYCHOTIC MEDICATIONS
TEACHING: Genetic Counseling

“How you SEE YOUR FUTURE is more important than what happened in your past.”