Professional Documents
Culture Documents
I. Psychiatric Nursing, 3
II. Basic Principles of Psychiatric Nursing, 3
III.3 Levels of Psychiatric Nursing (Levels of Health), 3
a. Primary, 3
b. Secondary, 4
c. Tertiary, 6
IV. Criteria of Mental Health, 6
V. Components of Assessment of Mental Status, 6
VI. DSM V (Diagnostic and Statistical Manual for Mental Health, 7
VII. Conceptual Models of Psychiatric Treatment, 7
VIII. Psychosocial Theory of Eric Erikson, 7
IX. Psychosexual (Psychoanalytical) Theory of Sigmund Freud, 7
a. Freudian Theory Component, 8
X. Essential Elements of Nurse-Client Contact, 9
XI. Four Phases of Nurse-Client Contact, 10
a. Pre-interaction/Pre-orientation, 10
b. Orientation, 10
c. Working Phase,11
d. Termination, 11
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A. Assessment Finding: General Signs, 25
B. Prioritized Nursing Diagnoses for all types of Schizophrenia, 27
C. Five Types of Schizophrenia, 27
D. Principle of Care in Schizophrenia, 28
XIX. Antipsychotics, 28
A. Phenothiazine, 28
B. Butyrophenones, 29
C. Thioxanthenes, 29
D. Atypical Anxiolytics, 29
E. Six Common Anticholinergic Side Effects of Antipsychotics, 29
F. Acute/Common side Effect for Prolonged use of Antipsychotics,30
G. Anti-Extrapyramidal Medications, 31
H. Adverse Effects of Antipsychotic Drugs, 31
XX. Affective/ Mood Disorder, 31
A. Types
I. Depressive Disorder, 31
a Antidepressants/ Thymoleptics, 34
i. Selective Serotonin Reuptake Inhibitors (SSRI), 34
ii. 2nd Generation Tricyclic Antidepressants (TCA), 35
iii. MAOI-Monoamine Oxidase Inhibitor, 36
iv. Electro Convulsive Therapy (ECT), 36
II. Bipolar Disorder, 38
a. Mood Stabilizers, 40
XXI. Psychosomatic/ Somatoform Disorder, 42
A. Psychosomatic Disorders, 42
B. Types of Somatoform Disorder/Psychosomatic Disorders, 43
XXII. Dissociative Disorder, 44
XXIII. Personality Disorders, 44
A. Cluster A: ODD/Eccentric, 45
a. Paranoid Personality Disorder, 45
b. Schizoid Personality Disorder, 45
c. Schizotypal Personality Disorder, 46
B. Cluster B: Dramatic/Erratic, 46
a. Antisocial Personality Disorder, 46
b. Borderline Personality Disorder, 47
c. Histrionic Personality Disorder, 47
d. Narcissistic personality Disorder, 47
C. Cluster C: Anxious/ Fearful, 48
a. Obsessive-Compulsive Disorder, 48
b. Dependent Personality Disorder, 49
c. Avoidant Personality Disorder, 49
d. Passive-Aggressive Personality Disorder, 49
XXIV: Cognitive/ Organic Mental Disorder, 49
A. Delirium vs. Dementia, 50
B. Types of Dementia
C. Alzheimer’s Disease, 50
XXV. Eating Disorders, 55
A. Anorexia vs. Bulimia, 55
XXVI. Drug Addiction/Non-Alcoholic Substance Abuse, 57
A. Non-Alcoholic Abused Substances, 57
XXVII. Sexual Disorder/ Dysfunction, 59
XXVIII. Pervasive Developmental Disorder, 60
A. Autistic Disorder, 60
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B. Attention Deficit Hyperactive Disorder, 61
C. Child Abuse, 61
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PSYCHIATRIC NURSING
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degree (certified occupational therapy assistant) or a baccalaureate degree
(certified occupational therapist). Occupational therapy focuses on the
functional abilities of the client and ways to improve client functioning such as
working with arts and crafts and focusing on psychomotor skills.
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Barrier - CONDOM
Oral - Artificial
Natural - not for M A M (Malnourished, Anemics
& Menses irregular)
4. Conducting rape prevention classes is an example of primary level of
prevention.
B. Herbal Medicines
D. Giving Vaccines
B. Suicide Prevention/Intervention
Suicide Interventions:
1. One-on-one supervision and monitoring
2. No suicide contract – 24 hrs monitoring
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- Patient is required to verbalize suicidal ideas
3. Non metallic/plastic/sharp objects: ex. belts, curtains
4. Avoid dark places
D. Crisis Intervention
Objective: Tto return the client to its normal functioning or pre crisis
level.
Duration: (4-6 wks)
Disorganization is a phase in the crisis state which is characterized by the
feelings of great anxiety
and inability to perform activities of daily living.
Types of Crisis:
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antipsychotic
Hypertensive crisis (MAOI Antidepressant intoxication Ca channel blocker
intoxication) Suffix:(-dipine)
Anxiolytics, Sedatives – Sedative hypnotic/ Minor Flumazenil (Romazicon)
Suffix: zepam, -zolam tranquilizer
Tensilon (Endrophonium): Anticholinesterase & Miotic Atropine Sulfate (ATSO4)
Anticholinesterase
intoxication, Pilorcarpine
(Pilocar) intoxication :
Miotic
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Concentration? Comprehension?
Example: Disorientation & Confusion ( Dementia)
APPEARANCE: Appropriateness? Grooming? Rigidity?
Mannerisms?
Example: Poor Grooming (Suicidal Patients,
Schizophrenia and Manic Depression)
AFFECT / MOOD: Appropriateness? Swing? Duration? Intensity?
Example: Flat Affect: Schizophrenia & Major
Depression. Seen also in Parkinson’s Disease &
Myasthenia Gravis.
Labile Affect: Manic Depression or Bipolar Disorder
THOUGHT CONTENT: Self-concept? Areas of concern? Themes? Obsessions?
Delusions? Hallucinations?
Example: Ddelusion of grandeur (manic), delusion of
omnipotence ( schizophrenia), delusion of persecution
& delusion of reference (paranoid delusions)
THOUGHT PROCESS: Ability to understanding abstract/symbols?
Example: Mmagical thinking and animism of
Schizotypal personality
SPEECH: Coherency? Relevance? Meaning? Quality/Quantity?
Example : Slurring of Speech ( alcoholism) and
pressured speech (manic depression or bipolar
disorder)
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BIOMEDICAL MODEL (Meyer, Kraeplin, Frances); Focus – Disease approach,
syndromes, diagnoses, etiologies.
Conscious
Subconscious
Watchman of the
Personality
Unconscious
The one who molds the personality
Storage bin of traumatic & meaningful
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memories. True desires & motives are
here.
ID: Psychoanalytic term for that part of the psyche that is UNCONSCIOUS, the
reservoir of INSTINCTS, primitive drives governed by the PLEASURE PRINCIPLE
and is SELF- CENTERED. The Ids says, “I want, what I want, when I want it”.
EGO: Psychoanalytic term for that part of the psyche that is CONSCIOUS, The “I”
that is shown to the environment and most in touch with REALITY and the
MEDIATOR between the primitive, pleasure- seeking, instinctive drives of the ID
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and the self- critical, prohibitive forces of the SUPEREGO and is directed by
REALITY PRINCIPLE. This is the thinking- feeling part of personality. The Ego
says, “I would want to have it if only I can afford it;” “Not now, I am not yet
ready; perhaps next week.”
SUPEREGO: Psychoanalytic term for that part of the psyche that RESTRAINS,
controls, inhibits and prohibits impulses and instincts, is self- critical, and is called
the CONSCIENCE or EGO IDEAL. The Superego says, “I should not want that; It is
not good to even wish for it.”
B. ORIENTATION (INITIATION)
- The start of termination phase: “Good morning, full name, RN, shift, session,
date start & end.”
C. WORKING PHASE
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Accept client as having value and worth as a unique individual.
- Stage of resistance
- Counter transference phase
- Most difficult phase
-- NCP is on going
- Identification of the problem/exploration
- The #1 Psychiatric Core Value is Consistency Ffor manipulative patients
Be consistent to patient with: BAAAM COPS
B orderline C onduct d/o
A ntisocial O oral/eating disorder
A lzheimer’s P aranoid
A utistic S uicidal
M anic
Use therapeutic and problem- solving techniques
Maintain PROFESSIONAL, therapeutic relationship
Keep interaction reality- oriented- here and now
Provide ACTIVE LISTENING and REFLECTION of feelings
Use non- verbal communication to support client
Recognize blocks to communication and work to remove them
FOCUS on client’s:
Confronting and working through identified problems
Problems- solving skills
Increasing independence
Help client develop alternative, adaptive coping mechanisms
D. TERMINATION
Plan for termination of relationship early the relationship
- Stage of Separation Anxiety
Signs & symptoms: Rregression: Ttemper tantrums, thumb sucking, apathy,
fetal position when crying.
- Phase of prognosis Eevaluation
Maintain boundaries
Anticipate problems of termination:
Increased dependency on the nurse
Recall of previous negative experience- rejection, depression, abandonment, etc.
Regressive behaviors
Discuss client’s feelings and objectives achieved
THERAPEUTIC COMMUNICATION
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DEFINITION: Continuous, dynamic process of SENDING and RECEIVING
MESSAGES by various verbal or non- verbal means (words, signals, signs,
symbols) utilized in a goal- directed professional framework.
b. Reflection: (mirror of feelings) “It must be difficult for you.” “You seem angry.
You seem concerned.”
When patient with symptoms of severe depression says to the nurse “I can’t
talk; I have nothing to say.” And continues being silent. The most appropriate
response of the nurse is to say, “It may difficult for you to speak at this time;
perhaps you can do so at another time”. This response will convey that the
nurse is willing to wait for the patient’s readiness to engage in conversation.
c. Elaboration/Exploration
“Tell me more about your feelings”
“Everyone is on my back. My husband says, ‘I don’t do anything
right,’ & my boss wants
me to do things differently.” RN’s response to elaborate feelings
includes statement like,
“Have you discussed this with your husband about how to cope with
these problems?
Tell me.”
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“What do you mean by…?” (Used in Neologism and word salad)
Brilliant & charming patient says, “I’ll be better off dead.” Best
response of the RN
includes asking questions like, “Do you have plans of suicide”?
Pt says, “I’d like to take you out & give you a good show.” best
response by the RN is
asking pt, “What do you mean by a good show?”
f. Giving Leads
“Aha..then…mmmh… go on… yes…”
g. Therapeutic Silence
h. Paraphrasing/restating – repeating
Repeats the MAIN IDEA; restate what the client says. (Patient: “I can’t believe I
cannot go home today.” Nurse: “You can’t believe that you can’t go home
today?”)’
i. Summarizing – recap
Nurse: “Today you have described your understanding of how you feel when you are
upset with your son.”
j. Validation – interpret
Client: “I see a shadow.”
Nurse: “You’re frightened.”
A patient admitted to be listening to voices should be assessed by asking,
“What does the voice
tells you?”
“I know that Prof. Draper tried to rape me, rape my mind...& he’s still
trying to rape me”, correct of
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RN includes questions like “Are you frightened being unable to control
your thoughts?”
Post-menopausal woman says, “I’m pregnant by God in heaven.”
Appropriate response by the
nurse includes statement like, “You believe something special happened
to you?’
RN’s correct response of pt w/. OCD who checks door 10-15 times
includes statement
like, “It sounds as if you have much anxiety.”
“How are you?” “How’s your day?” “What are your favorite things?”
c. False Assurance
“Ddo not worry” Tto patient who are dying & w/ incurable illness
“You have the best doctor; everything will be all right.”
“Relax that is nothing to worry about.”
h. Stereotyping
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BEHAVIORAL THERAPY
A. TERMINOLOGIES
STIMULUS: Aany event affecting an individual
PROBLEM BEHAVIOR: Ddeficient, excessive, condemned, unwanted behavior
OPERANT BEHAVIOR: Aactivities that are strongly influenced by events that
follow them.
TARGET BEHAVIOR: Aactivities that the nurse wants to develop or accelerate
in the client.
REINFORCER: Aa reward positively or negatively influences and
strengthens desirable behaviors.
POSITIVE REINFORCER: Aa desirable reward produced by specific behavior
(TV time after doing homework)
NEGATIVE REINFORCER: Aa negative consequence of a behavior (Spanking
child for wetting the floor)
Behavioral Treatments
GROUP THERAPY
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Knowledge of therapeutic modalities enhances the performance of
nursing interventions during therapy.
8-10 patients are the optimal number of patients in a group.
B. TYPES OF GROUPS
1. Structured
Goals: Ppre- determined
Format: Cclear and specific
Factual material: Ppresented
Leader: Rretains control
2. Unstructured
1. Goals: Nnot pre- determined. Responsibility for goal is shared by group and
leader
2. Format: Discussion flows according to group members’ concern
3. Materials and topics are not pre- elected.
4. Leader: Nnondirective
5. Emphasis: Mmore on FEELINGS rather than facts
1. Initial Phase
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Formation of group
Setting and clarification of goals and expectations
Initial meeting, acquaintance and interaction
2. Working Phase
Confrontation between members→ Ccohesiveness
Identification of problems→ Pproblem- solving processes
In a group therapy when one client says to another, “Maybe you’re
taking on
someone else’s problems.” this shows that they are in the working
phase
3. Termination Phase
Evaluation of goals attainment
Support for leave- taking
In group therapy if a client says, “Leave me alone & get away from
me.”, best action
of the RN is to maintain distance from the pt.
Behavior indicating that goal is met after socialization in a group
therapy includes
participation of each group member telling the leader about specific
problems
DEFENSE MECHANISMS
REPRESSSION SUPPRESSION
CONVERSION DISSOCIATION/SYMBOLIZATION
IDENTIFICATION INTROJECTION
SUBLIMATION COMPENSATION
RATIONALIZATION PROJECTION
DISPLACEMENT UNDOING
SPLITTING REACTION FORMATION
REGRESSION FIXATION
INTELLECTUALIZATION ACTING-OUT
DENIAL FANTASY
DEFENSE MECHANISMS
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Cconfabulation = making story to fill in memory gaps
also used by Wernicke’s Korsakoff’s = ↓ Vit. B1-
thiamine, peripheral neuritis (tingling
sensation) ↓ B6 Pyridoxine, B9 folic acid, B12 P.
anemia. Ex. Sexually abused as a child blocks the
experience from her consciousness and is confused
about inability to respond sexually.
SUPPRESSION – used selective Willingly or voluntarily putting unacceptable
inattention (moderate anxiety) thoughts or feelings out of one’s mind with the ability
to recall the thoughts or feelings at will.
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Ex. It wasn’t worth it; anyway, it is all for the best.
Student fails an exam, blames it on the poor lectures.
Temporarily alleviates anxiety.
PROJECTION – person Person rejects unwanted characteristics of self and
#1 DM: Pparanoid assigns them to others.Projection is attributing to
others one’s unconscious wishes/fear. Usually it
is observed in paranoid patients.
Ex. Blaming others for own faults. “scapegoat”
6. DISPLACEMENT – higher to Mechanism that serves to transfer feelings such as
lower frustration, hostility or anxiety from one idea, person or
object to another.
Ex. Yelling at a subordinate after being yelled at by the
boss.
UNDOING OR RESTITUTION – Negation of previous consciously intolerable action or
lower to higher experience to reduce or alleviate feelings of guilt.
DM: Obsessive Compulsive Ex. Sending flowers after embarrassing her in public.
7. SPLITTING Viewing people as all good, and others as all bad
Impulsive = poor self-control
Ex. Hx of drug addicts & alcoholics
DM: Borderline (female)
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look good & thin.” This shows that the teen is
denying her chronic illness
Cancer patient saying, “You might have mixed my
result with other patients,” is showing denial
ANXIETY
□ Mild: The perceptual field is wide allowing the client to focus realistically on what is
happening to him. Alert senses, increased attentiveness, and increased motivation.
□ Moderate: Another word is selective inattention. The perceptual field narrows and
the client is able to partially focus on what is happening if directed to do so and can
verbalize feelings of anxiety.
□ Severe: The perceptual field is significantly reduced and the client may not be able to
focus on what is happening to him and may not be able to recognize or
verbalize anxiety. All senses affected; decreased perceptual field; drained
energy; Learning and problem-solving not possible. Start of sympathetic
symptoms: tachycardia, palpitations, hyperventilation (brown paper
bag to prevent Respiratory Alkalosis) and cold clammy skin.
□ Panic: The perceptual field is severely reduced and the client experiences feelings of
panic and dread. Client overwhelmed and helpless; personality may
disintegrate → hallucinations and delusions. Pathological conditions
requiring immediate intervention. Client may harm self or others.
A patient stating, “Sometimes I feel like I’m going crazy & losing
control over myself,” is showing symptoms of panic attack
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□ STAY. Do not leave client alone. Recognize if additional help is needed. Provide physical
care if necessary.
□ Establish PERSON-TO-PERSON relationship and maintain an accepting attitude:
ACCEPT client. Show willingness to LISTEN.
Encourage, allow EXPRESION OF FEELINGS at clients OWN PACE avoid
forcing verbalization.
□ Administer medication as directed and needed. The pharmacology therapy of choice is
the ANXIOLYTICS-reduces anxiety so client can participate in psychotherapy.
□Assist to cope with anxiety more effectively. Assist to recognize individual strengths
realistically
Encourage measures to reduce anxiety: activities: relaxation techniques, exercises
(DANCING, WALKING, JOGGING), hobbies, talking with support groups,
desensitization treatment program
Provide individual or group therapy to identify anxiety and new ways of dealing with it
and develop more effective coping interpersonal skills.
If patient can be redirected back to the topic after he gets anxious while the
RN gives discharge teaching, it is an indication that discharge teaching can
be resumed.
1. Phobia
2. Obsessive Compulsive
3. Post Traumatic Stress Disorder (PTSD)
4. Generalized Anxiety Disorder (GAD)
5. Panic Disorder
D. NURSING IMPLEMENTATION
Recognize the client’s feelings about phobic object/ situation
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Specific precipitants are present with phobia
Avoid confrontation and humiliation; Provide constant support (Stay with
client during an attack) if exposure to phobic object or situation cannot be
avoided
Do not focus on getting patient to stop being afraid
Provide relaxation techniques
Implement behavioral therapy: SYSTEMIC DESENSITIZATION (the #1 treatment
for PHOBIA) . Administer antidepressants as ordered
OBSESSIVE-COMPULSIVE DISORDER
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Altered Skin Integrity
Ineffective Individual Coping
D. NURSING INTERVENTATION
Encourage VERBALIZATION about painful experience. Show empathy; be non-
judgmental; Help feel safe.
Rational emotive-therapy; Allow to grieve
Help client identify, label and express feelings safely
Enhance support systems: Sself-help groups, family psychoeducation, and
socialization.
In a rape victim, a statement like, “If I should not have worn that red panty, it wont
happen to me”, shows denial
Statement of a rape patient who is beginning to resolve trauma includes, “I’m able
to tell my friends about being raped.”
An RN needs further teaching about caring for a post-traumatic client when she
keeps on asking the client to describe the trauma that caused patient’s distress
after recovering from a PTSD.
PANIC DISORDER
1. Description
a. The cause usually can not be identified.
b. Panic disorder produces a sudden onset with feeling of intense apprehension
and dread.
c. Severe, recurrent, intermittent anxiety attacks lasting 5 to 30 minutes
occur.
2. Assessment
a. Choking sensation
b. Labored breathing
c. Pounding heart
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d. Chest pain
e. Dizziness
f. Nausea
g. Blurred vision
h. Numbness or tingling of the extremities
i. A sense of unreality and helplessness
j. A fear of being trapped
k. A fear of dying
L. Ffeelings of impending doom
3. Interventions
a. Attend to physical symptoms
b. Assist the client to identify the thoughts that aroused the anxiety and
identify the basis for these thoughts.
c. Assist the client to change unrealistic thoughts to more realistic thoughts.
d. Uuse cognitive restructuring.
e. Administer anti-anxiety medications as prescribed
A client in panic disorder showing dilated eyes, trembling & says, “I can no
longer go further.” Should
be accompanied in her room & RN should stay w/ her for a while
The goal of intervention in the care of the anxious patient is to enable him to
develop his capacity to tolerate mild
anxiety. A combination of behavioral and somatic approaches is effective in
the management of anxiety.
Therapeutic communication appropriate to patient showing signs of panic
disorder
includes providing a concrete direction
ANXIOLYTICS/ANTI-ANXIETY
Another word: Sedatives/Hypnotics/Minor Tranquilizer
Diazepam (Valium)* best for: Sstatus epilepticus , the best for delirium
tremens (alcohol & cocaine withdrawal)
Estazolam (Prosom)
Alprazolam (Xanax)
Chlorazepate (Tranxene)
Oxazepam (Serax)* the best in sundown syndrome (seen in Alzheimers)
Advantage: Nnot hepatotoxic
Lorazepam (Ativan)* 2nd drug for sundown syndrome
Triazolam (Halcion)* Anti-insomnia
Temazepam (Restoril)* Anti-insomnia
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Flurazepam (Dalmane)* Anti-insomnia; do not stop abruptly because
of rebound grand mal seizure
Midazolam (Dormicum)
Prazepam (Centrax)
Chlordiazepoxide (Librium)* 2nd drug of choice for delirium tremens
Clonazepam (Klonopin)
Halazepam (Paxipam)
II. Barbiturates
Action: Uused as an anticonvulsant besides being a sedative
Code: TAL / AL
Secobarbital (seconal)
Phenobarbital (luminal)* commonly used anticonvulsant barbiturate
Methohexital (Brevital)
Amobarbital (Amital)
1. SIDE EFFECTS
DROWSINESS (Do not drive; assistance w/ walking; NO alcohol)
Mental confusion (Evaluate mood, sensorium, affect)
Habituation and increased tolerance
Withdrawal symptoms: high doses & prolonged use (>6mo)
Definition: Ssevere impairment of mental & social functioning with grossly impaired reality
testing, sensory perception and with deterioration & regression of psychosocial functioning.
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A. ASSESSMENT FINDINGS (GENERAL SIGNS)
THEORIES:
1. Iincreased dopamine –coming from the substancia nigra
2. Trauma PTSD
3. Ddouble-bind theory 2 kinds of information/communication
4. Genetics 65% chances- if two parents are diagnose with schizophrenia
32.5% chances- if 1 parent is diagnosed with schizophrenia
5. Drug addicts and alcoholics: Hhigh probability for schizophrenia due to increase
Delusions & hallucination
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1. Alteration in Thought Process; 2. Alteration in Content of Thought
All this signs & symptoms can also be seen in SAM (Schizophrenia, Alzheimer’s &
Manic)
1. Neologism (creating NEW WORDS) vs. Word Salad (incoherent mixture of words)
2. Flight of Ideas (jumping from one RELATED topic to another): Ccommonly seen in
MANIC patients, also in Schizophrenia.
3. Verbigeration (meaningless repetition of action words (Verb)) vs.
Perseveration
e.g. 1st stimulus correct response
2nd & following stimulus still responding to the 1st stimuli
4. Circumstantiality (beating around the bush; answers but delayed) vs.
Tangentiality (did not answer the stimulus/ question)
5. Clang association (use of rhymes in sentences) vs. Echolalia/Parroting &
Echopraxia
(Commonly seen in AUTISM)
NURSING CONSIDERATION:
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1. Consistency to build trust
2. Food: PACKED OR SEALED foods except canned goods: Nno metal
3. Social Isolation – no group session when schizophrenic
Paranoid who is suspicious saying, “This place is meant for bugs & prison,”
In order to
encourage trust, the patient should be involved in the plan of care.
CATATONIC CHARACTERISTICS:
- Catatonic stupor – markedly slowed movement.
- Catatonic posturing- bizarre or weird positions
- Catatonic rigidity – cementation/stone-like position
- Catatonic negativism – resistance towards flexion & extension
- Catatonic hyperactivity or excitability:
5. RESIDUAL: No longer exhibits overt symptoms, no more delusions but still has
negative symptoms or odd beliefs or unusual perceptions.
Undifferentiated type chronic schizophrenia must be referred to a program
promoting
social skills due to functional loss deficit.
D. PRINCIPLES OF CARE
1. Maintenance of safety: Protect from altered thought processes. Respond to feelings,
and not to delusions; Do not argue; Validate reality; remove from areas of tension
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Suspiciousness & paranoid patient is threatening to the staff, the action of
an RN that
shows a need for further teaching is when shegoes to the room of a pt. who
yells,
“Everyone, out of here,”
Appropriate action of RN to a Schizophrenic who yells loudly, talks to wall
and saying
“Don’t talk to me, bastard.” includes walking towards the pt & ask him who
he is talking to.
2. Meeting of physical needs: May have to be fed / bathe initially
3. Establishment and maintenance of therapeutic relationship: Engage in individual
therapy; Promote trust; Encourage expression by verbalizing the observed; Offer
presence-Tolerate long silences
4. Implementation of appropriate family, group, social or diversional therapies
Patients with schizophrenia need activities that do not require interaction, so
solitary activities are preferred over team activities.
ANTIPSYCHOTICS
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In liquid form is usually put in a chaser Chaser: 60- 100
ml juice (prone or tomato); to prevent constipation
& contact dermatitis; taken with straw (bite straw &
sip)
Mesoridazine (Serentil)
Thioridazine (Mellaril)* ceiling dose/day: 800 mg Adverse Effect:
Rretinitis pigmentosa
Prochlorperazine (Compazine)* #1 commonly used anti emetic
Compazine causes anticholinergic side effects
Trifluoperazine (Stelazine)
Chlorprothixene (Taractan
Thiothixene (Navane)
Olanzapine (Zyprexia)
Clozapine (Clozaril) #1 that causes Agranulocytosis & Blood Dyscrascia
“I will need to monitor my blood level to continue my medication.” shows a
correct
understanding of a patient while taking Clozaril.
Loxapine (Loxitane)
Risperidone (Risperidone) #1 drug for Korsakoff’s psychosis
Molindone (Moban)
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1. Blurring of Vision - ↑ sympathetic reaction (don’t operate machinery);
Mydriatic – pupil dilate sympa ↑ IOP don’t use in glaucoma
3. Constipation
Nursing Interventions:
1. Prevent constipation ↑ fiber (residue) AG or roughage,
prune/pineapple/papaya juice/ fruits
2. ↑ OFI
3. ↑exercise
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Signs of motor restless: Foot tapping, finger fidgeting, can’t sit down for
more than 15 minutes and pacing back & forth.
Patient is unable to remain still
Drug of Choice: CODE: CBA
CODE: PACABBA
- Usually they are anticholinergic & antiparkinsonian drugs
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Benadryl (Diphenhydramine)
Amantadine (Symmetrel)
DIFFERENTIATION/CATEGORY:
Moderate Depression – crying at night
- Dysthymia – painful depression for 2 years
*Severe Depression – Crying at early morning, depression less than 2weeks
*Major Depression – Severe depression for more than 2 weeks
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* - both of them have the same characteristics
DIAGNOSTIC CRITERIA FOR MAJOR DEPRESSION: At least five of the following, most
of the day, nearly daily, for 2 weeks:
1. Early morning depression 6. Feelings of worthlessness &
2. Loss of interest or pleasure ambivalence (fear of death vs. fear
living) *
(ANHEDONIA)* 7. Self care deficit*
3. Insomnia* 8. History of suicide*
4. Psychomotor retardation (slow mov’t) 9. Weight loss or gain
5. Fatigue or loss of energy (anemia) 10. Flat affect*
11. Constipation*
PREDISPOSING FACTORS:
1. Single, Annulled & Divorced
2. Loss of loved one (situational crisis)
3. SAD – Seasonal Affective Disorder – common on winter season (Nov.-Feb.) or
intimate months
Seasonal depression occurs during winter and fall this is due to abnormal
melatonin
metabolism.
Intervention for pt with seasonal affective disorder (SAD) during a
depressed mood
includes the use of broad spectrum light in high activity area. This
produces high
intensity color like broad day light.
Also instruct the pt that the light source must be 3 ft away from the eye
4. Caucasians/Afro-Americans/Asians*
5. Alcoholics/Drug addicts*
A 66 y/o American men, no hobby, no friend, retired 6 yrs ago, no money
& has history of
alcohol abuse is at risk for suicide
6. Protestants
7. Incurable Illness*
8. Post partum depression
9. Schizophrenia*
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Prone: Mmale Age bracket prone for suicide
#1. Adolescent (identity crisis)
2. Elderly (ego-despair)
3. Middle age men (45 y.o. above)
4. Post partum depression (7 days/2-4 weeks)
1. Ambivalence. They have 2 conflicting desires at the same time: T to live and to die.
Ambivalence accounts for the fact that a suicidal person often takes lethal or near-
lethal action but leaves open the possibility for rescue.
2. Communication. Some, people cannot express their needs or feelings to others, or
when they do, they do not obtain the results they hope for. For them, suicide
becomes a clear and direct, if violent, form of communication.
1. Single people
2. Divorced, separated or widowed
3. People who are confused about their sexual orientation
4. People who have experienced a recent loss: divorce, loss of job, loss of prestige, loss
of social status or who are facing the threat of criminal exposure
5. Caucasians, Eskimos and Native Americans
6. Protestants or those who profess no religious affiliation
36
Clinical variables:
Management – people bent on suicide almost always give either verbal or nonverbal clues of
their intent. They actually make a powerful attempt to communicate to others their hurt ad
desperation. They are crying out for help.
3 Moderate risk of
immediate suicide Has considered suicide
with high lethal method
but no specific plan or
threats; or has plan with
low lethal method ,
history of low lethal
attempts, with
dysfunctional family
37
history and reliance on
Valium or other drugs
for stress relief; is
weighing the odds
between life and death
4 High risk of
immediate suicide Has current high lethal
plan, obtainable means,
history of previous
attempts, has a close
friend but is unable to
communicate with him
or her a drinking
problem; is depressed
and wants to die
5 Very high risk of
immediate suicide Has current high lethal
plan with available
means, history of high
lethal suicide attempts,
is cut off from
resources; is depressed
and uses alcohol to
excess, and is
threatened with a
serious loss, such as
unemployment or
divorce or failure in
school age more in
elderly and adolescents
General guidelines – the general task of the nurse is to work with the client to stop the
constricted processing of suicidal thinking long enough to allow the client and the family to
consider alternatives to suicide.
38
Search the client’s belongings for potentially harmful objects. Make the
search in the client’s presence and ask for the client’s assistance while
doing so
Check articles brought in by visitors
Allow the client to have regular food tray but check whether the glass
or any utensils are missing when collecting the tray
Allow visitors and telephone calls unless the client wishes otherwise
Check that visitors do not potentially dangerous objects in the room
e. Expect that the client will be experiencing shame, and work to assists the client
toward self- acceptance
f. Relieve the client’s obvious immediate distress
g. Find out what, in the client’s view, the most pressing need is
h. Assume a nonjudgmental, caring attitude that does not engender self-pity in
the client
i. Ask why the client chose to attempt suicide at this particular moment. The
answer will shed light on the meaning suicide has for this patient and may
provide information that can lead to other helpful interventions
j. Decide if a no-harm, no suicide contract will be used
k. Be careful not to encourage staff behaviors that give clients or staff members a
false sense of security
l. Do not make unrealistic promises
m. Encouraged the client to continue daily activities and self-care as much as
possible
n. Decide with the client which family members and friends are to be contact and
by whom
o. Be prepared to deal with family members who may be confused, angry or
uninterested
p. Evaluate the client’s need for medication
q. Evaluate the plan developed in collaboration with the client and arrange for
appropriate follow-up
r. Monitor your personal feelings about the client and decide how they may be
influencing your clinical work
s. Work with other team members to evaluate the issues fully
t. Do a body examination
u. Recognize that people can and have hanged or strangled themselves with
shoelaces, brassiere straps, pantyhose, robe belts, etc.
39
SUICIDAL BEHAVIORS:
SUICIDAL GESTURE: Ddirected toward the goal of receiving attention rather than
actual self-destruction; b) SUICIDAL THREAT: Ooccurs before the overt suicidal
activity takes place: “Will you remember me when I am gone,” “Take care of my
children”; c) SUICIDAL ATTEMPTS: Aany self-directed actions taken by the
individual that will lead to death if not interrupted. A most suicidal person has
made a specific plan, and has the means readily available.
Best question to be asked after a patient who recovers from an overdose of
pills includes
asking “Do you still want to end your life?”
Suicidal attempts are common when client is strong enough to carry out a
suicidal plan, usually 10-14 days after start of medication, and after ECT
40
10. Join group therapy
Depressed patients usually turn their hostile feelings towards themselves.
Providing an activity that serves as an outlet for these aggressive feelings
will make the patient feel less guilty.
During family therapy, a mother asks, “How long will my daughters have
suicidal thoughts?”
appropriate response of the RN- ‘’ Your daughter will go on to view suicide
as a way of
coping.”
11. Monitor in giving medication – do not leave patient after giving medication for 30
minutes. Check under the tongue & pillow
12. Monitor patient in CR, between shift & during endorsement
13. #1 Attitude Therapy: Kind Firmness
14. Step by step Tx: ANTIDEPRESSANT another word is THYMOLEPTICS
1st SSRI (Selective Serotonin Reuptake Inhibitor) A
2nd Second Gen. TCA
3rd MAOI
4th ECT (last resort)
15. Meet physical needs:
Promote eating, rest, elimination
Promote self-care whenever appropriate / possible
16. Support self-esteem:
Warm and consistent care
Being patient with client’s slowness
Simple tasks that increase success and self-esteem and imply
confidence in capabilities
Example: Self care activities that will not easily tire the patient.
Rationale: Depressed patients have fatigue.
17. Decrease social withdrawal: Ssit with client during quiet times; introduce to others
when ready
The priority focus for a suicidal patient in the ER with a slash in her wrist is
her physiologic homeostasis.
Assess attempt for suicide in a 16 y/o girl who is eating & sleeping poorly
since break-up
and saying,” My life is ruined now.”
ANTIDEPRESSANTS or THYMOLEPTICS
41
Venlafaxine (Effexor)
Citalopram (Celexia)
Nursing Considerations:
1. Ffor insomnia:
a. Induce sleep thru: 1. Wwarm bath (systemic effect)
2. Warm milk/banana (active substance: tryptophan)
3. Massage
b. Give meds in single AM dose
Antidepressants are best taken after meals
42
ACTION: Psychomotor stimulator or psychic energizers; block oxidative deamination
of naturally occurring monoamines (epinephrine, NOREPINEPHRINE, serotonin) → CNS
stimulation
Effect: 2 weeks
CODE: PAMMANA
Parnate (tranylcypromine)
Marplan (Isocarboxacid)
Mannerix (Moclobemide) *the newest MAOI
Nardil (Phenelzine SO4)
ECT is passing of an electric current through electrodes applied to one or both temples to
artificially induce a grand mal seizure for the safe and effective treatment of depression.
ECT’s mechanism of action is unclear at present
Advantages: Quicker effects than antidepressants; Safer for elderly; 80 % improvement rate
of major depressive episode with vegetative aspects
43
- Invasive
- Induction of 70-150 volts of electricity in).5-2secs. Then, it is followed by a
grand-mal seizure lasting 30-60 secs.
- 6-12 treatments, “every other day”
Side Effects:
1. Temporary RECENT Memory Loss –
ANTEROGRADE amnesia
Intervention: Rre-orient client to 3 spheres
2. confusion/disorientation – (usually 24 hours)
3. Headache ↑ 02 demand, ↑ cerebral hypoxia
4. Muscle spasm
5. Wt. gain (stimulate thalamic/limbic appetite)
Contraindicated:
1. Informed Consent – if client is coherent, if not a guardian may sign the consent
forms.
2. No metallic objects
3. No nail polish to check peripheral circulation
4. No contact lenses it may adhere to the cornea
5. Wash & dry hair
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9. Have patient VOID before giving ECT
Nursing Diagnosis:
1. Risk for Airway Obstruction/aspiration
2. Risk for Injury
3. Impaired/Altered Cognition/LOC
Nursing Intervention
FIRST & TOP priority: Ensure a patent airway. Side-lying after removal of
airway. Observe for respiratory problems
Remain with client until alert. VS q 5 min until stable.
REORIENT: Ttime, place (unit), person (nurse); Reassure regarding confusion and
memory loss. Same RN before & after.
B. BIPOLAR DISORDERS: With one or more manic episodes, with or without a major
depressive episode
MANIC EPISODE:
Neurotransmitter imbalance: * 1. Norepinephrine 2. Serotonin
45
DIAGNOSTIC CRITERIA FOR A MANIC EPISODE: At least 3 of the following for
at least 1 week:
NURSING DIAGNOSIS:
NURSING INTERVENTIONS:
46
7. Avoid ACTIVITIES that increases attention span such as chess, bingo,
scrabble...
8. Avoid CONTACT SPORTS: Bbasketball, gym, strenuous activities & Increase
perspiration!!
ACCEPTABLE ACTIVITIES: Bbrisk walking, punching bag, raking leaves, tearing
newspaper.
9 Productive activities: Ggardening, finger painting, household chores,
Activity for Manic Bipolar includes raking leaves (quiet physical,
constructive, productive) to increase self-esteem;
competitive is not safe.
10. Less environmental stimulus: Nno bright lights, do not touch
11. Encourage OFI: Bbecause of Lithium and increased metabolism
12. Check Lithium intoxication
SELECTED SITUATIONS AND INTERVENTIONS:
B. Aggressive Reaction
1. Decrease environmental stimulation
A pt who is pt watching TV suddenly throws the pillows & chair,
immediate action
is to place pt in seclusion.
“Staff 1st used a lesser means of control for less success.” Shows a
documentation
that indicates a pt’s right is being safeguarded during aggressive
reactions.
C. Violent Patients
1. Move to the door fast and call the crisis management team
D. Swearing
1. Setting of Limits
2. Give avenues for verbalization/expression vs. Physical violence
47
Effect: 1 wk.
CODE: LITH
Nursing Considerations:
1. Before extracting Lithium serum level Lithium fasting 12 hrs check vital signs
2. Avoid diuretics to prevent hyponatremia
3. Avoid strenuous exercise/activities gym works
4. Avoid sauna baths
5. Avoid caffeine because it is a diuretic
6. For hypernatremia AVOID Na CO3
7. Avoid taking soda and/or soda drinks
8. ↑ OFI – 3 L /day; ↑ Na – 3mg/day
A patient who is talking lithium must be placed in a normal sodium (3 gms.) ,
high fluid diet (3 L of water). This is done to facilitate excretion of lithium
from the body.
48
Avoid caffeine because it is a diuretic
49
NURSING CARE: Holistic or TOTAL – physical and emotional
Understand that PHYSICAL SYMPTOMS ARE REAL and that the client is not faking and
the TREATMENT OF PHYSICAL PROBLEMS DOES NOT RELIEVE EMOTIONAL PROBLEMS
Develop nurse-client relationship:
Respect the client and his problems.
Help to express feelings, Allow client to feel in control
Let client meet dependency needs.
2. Help to work through problems and learn new coping mechanism.
NURSING INTERVENTION:
Do’s: Divert attention from symptom; Provide social and recreational
activities; Reduce pressure on client; Control environment
Don’ts: Confront client with his illness; Feed into secondary gains through
anticipating client needs.
ASSESS FOR
Preoccupation with body functions or fear of serious disease misinterpretation
and exaggeration of physical symptoms
Adoption of sick role and invalid life-style; signs of severe regression
Lack of interest in environment history of repeated absences from work
If the client is MALINGERING: Ddeliberately making up illness to prolong
hospitalization; ‘faking illness’
Nursing Intervention:
Show acceptance of the client.
Prepare for, assist in complete medical workup to reassure client and rule and
medical problems
Psychotherapy, family therapy and group therapy:
A combination of somatic and behavioral treatment modalities facilities
treatment of the disorder.
50
o Meet physical needs giving accurate information and correcting
misconception.
o Demonstrate friendly, supportive approach but NOT focusing on the
illness.
o Provide diversionary activities that build self-esteem.
o Help client refocus on topics other than the illness.
o Assist client understand how he uses illness to avoid dealing with his
problems.
DEFENSE MECHANISMS IN SOMOTOFORM DISORDERS: Denial, Projection,
Conversion, and Introjection
DISSOCIATIVE DISORDERS
PERSONALITY DISORDERS
51
A. DEFINITION: Borderline state of personality characterized by defects in its
development or by pathologic trends in its structure; premorbid personality of
individuals resembling the compensatory mechanisms associated with the pathologic
counterpart.
GENERAL CHARACTERISTICS:
1. Denial
2. Maladaptive behavior inflexible
3. Minor stress poor tolerance mood disturbance
4. in reality
5. Not caused by physiological pattern
- Attitude can be changed
- Immature
- do not adjust to environment
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- Functional when works alone; more interested on objects
Shy, introverted since childhood but with fair contact with reality
Autistic thinking, dreaming, emotional detachment, avoidance of meaningful
interpersonal relationships, cold and detached
#1 NURSING DIAGNOSIS: Social Isolation\
THEORIES: Ggenetic/hereditary
Physical/Sexual abuse
Low socioeconomic status maladaptive behaviors
CHARACTERISTICS:
- Impulsive, aggressive, manipulative
- Low self-esteem
- lack remorse
- hates rule/regulations, authority figures
- coprolalia (bad words)
- Kills, cheats, steals, rapes, destroys
- #1 Defense Mechanism: Rrationalization
- Underdeveloped superego; lack of guilt, conscience and remorse; unable to
learn from experience or punishment
- Life-long disturbances that conflict with laws and customs
- Unable to postpone gratification, immature, irresponsible
- Randomly acting out aggressive egocentric impulses on society; reckless, unlawful,
disregard for right of others.
- Steals, cheats, lies
- Appears charming, intellectual, smooth talker
- Antisocial patients have low tolerance to frustration.
53
NURSING INTERVENTION/CONSIDERATION:
1. SETTING OF LIMITS – “matter of fact,” voice not high nor low, does not say
please.
Setting of limits prevent the patient from manipulating the nurse.
2. Consistency is a must regarding rules & regulation.
Efficacy of treatment is achieved for an antisocial if the patient is able to
respect
nurse’s & other patients boundaries.
Positive outcome for antisocial personality disorder includes adherence to
rule of hospital unit
Interventions that can be appreciated by antisocial include
exchanging tokens for any privilege
- Mostly in females
CHARACTERISTICS:
- Impulsive, self-destructive, unstable
- Self-mutilation & suicidal
Therapeutic measure to prevent self-mutilation in borderline includes
behavioral contract.
The purpose of behavioral contract in borderline is to limit use of
unhealthy defense
mechanisms
- Unpredictable behavior (gambling, shopping, sex, substance abuse)
- Disturbance in self-concept: Iidentity
- #1 DEFENSE MECHANISM: Ssplitting
“You’re the only nurse who understands me.” This statement is shown in a
patient with
borderline behavior.
- Identity disturbance with chronic feelings of emptiness (Anhedonia)
- Marked mood swings and impulsive unpredictable behavior with potential
for self-destruction.
- Intense, brief, unstable interpersonal relationships with impulsiveness,
manipulation, physical fights and temper tantrums
A borderline patient indicates an improvement when she state, “I ran
around the block
rather than cutting myself”.
Borderline personality with a history of cutting her wrist shows an intense
& a changeable
affect during the middle phase of nurse-pt relationship. The patient says,
"You’re a smart
nurse. I want to be just like you.” This statement shows Transference
A patient borderline state, “You’re a phony. You don’t know what
happened to me.”
54
Best response of the nurse will be, “I’ll ensure what is necessary will be
done to you
Intervention for borderline d/o includes setting of limits through saying,
“The policy of the unit is that, ‘You can’t
leave in the unit in 1st 24 hrs.’”
CHARACTERISTICS:
CHARACTERISTICS:
- Vanity in personal appearance
- Exaggerated or grandiose sense of self-importance
- Boastful, egotistical, superiority complex
- preoccupied with fantasies: Ppower, success, beauty
- Excessive admirations; envies other, arrogant, lack of empathy
-Overblown sense of importance, grandiosity; with strong need for attention
and admiration from others
CHARACTERISTICS:
- Cardinal Signs: RITUALISTIC
- #1 DEFENSE MECHANISM: Undoing, Repression, Symbolization
# 1 Ritual: handwashing
55
Other Ritualistic behaviors: 4 C’s:
Controlling perfectionism
Collects or hoarding
Cleaning
Checking
56
CHARACTERISTICS:
- Submissive, clinging
- lacks self-confidence, low self-esteem, helpless, good follower
- Lacks self-confidence, helpless when alone, preoccupied with fear of being alone
- Fails to make decisions and accept responsibility→ induces others to
take responsibility
A pt with Dependent personality who shows ineffective decision making
should have
setting of limits & make behavioral contract on its daily activities.
CHARACTERISTICS:
- Shy, timid, inferiority complex
- avoid open forum
- Over sensitive to rejection/criticism
- Social withdrawal = inept
- Depression, anxiety, anger are common
- Withdrawn, loner, lacks self-confidence; with feelings of discomfort/timidity
when with others
-Unwilling to get involved with others and in situations where negative evaluation,
rejection and failure are a possibility
CHARACTERISTICS:
- insecure backbiter plastic
- loves to procrastinate, cant finish a task
- Patients with passive-aggressive personality expresses anger through
passivity.
#1 Defense Mechanism: Rreaction formation
.
Goal of nurse in Passive Aggressive Personality includes verbalization of
anger when
needed
Goal of Care for Passive Aggressive includes verbalization of feelings of
anger when the
need arises.
I. COGNITIVE/PSYCHIATRIC DISORDERS
With organic etiology
With deficits in COGNITION and MEMORY
Effects: Cchanges in levels of functioning and disturbed behavior
MOST COMMON AREAS OF DIFFICULTY (JOCAM)
J – Judgment (impaired)
O – Orientation (confused/disoriented; illusion/hallucination)
C – Confabulation (filling in memory gaps)
A – Affect (mood changes, depression, tearful, withdrawn)
57
M- Memory (Impaired especially for names and recent events – compensated
by confabulation and circumstantiality)
Delirium Dementia
SYMPTOMS OF DELIRIUM
TYPES OF DEMENTIA
58
Pick’s Disease: Similar picture to DAT, but with frontal lobe symptoms (personality changes)
and reactive gliosis.
Parkinson’s Disease:
Dopamine in the basal ganglia & extra-pyramidal system causes tremors (pill-rolling
& resting), bradykinesia, cogwheel rigidity, shuffling gait, mask-like fascies.
Progresses to depression & dementia, treated with L-dopa
Nursing care for the patient with dementia is geared towards maintaining
existing functions by minimizing regression.
Place an alarm signal to know that the pt is attempting to exit in a dementia
client who used to wander away from acute facility.
ALZHEIMER’S DISEASE
NATURE: Gradual, progressive; Onset: Usually after 65 (2-4%); may begin at 40-
65; may die within 2 yrs or 8-10 yrs if with total care. The main pathology is the of
presence of senile plaques that destroys neurons leading to decreased
acetylcholine.
59
Predisposing/Contributing Factors: Psychiatric Mental Health Nursing 3rd edition by
Mary C. Townsend
Exact cause unknown but several hypothesis were introduced; (pg 342-343)
1) Acetylcholine Alteration: Ddecrease in acetylcholine reduces the amount of
neurotransmitter which results in disruption of cognitive process.
2) Accumulation of Aluminum: Sstudies show that aluminum accumulates in damaged
areas of the brain.
3) Alterations in the Immune System: Aantibodies are being produced in the brain which
causes a reaction against self it is called autoimmune.
4) Head Trauma: Head injuries
5) Genetic Factor: Pattern of inheritance
60
and calming. Note that the nurse’s response in a way that is congruent is the main concern.
The individual may not recognize family members. There may be problems of immobility.
61
Reminiscing helps lessen the patient’s loneliness.
13. Wear the Medical Alert Bracelet – (name, Address, Tel #,
Diagnosis, Medication)
14. Avoid afternoon naps, avoid caffeine, TV & radio remote
15. REMEMBER THE 3 C’s for Alzheimer’s to DECREASE
DISORIENTATION: Color, Calendar, Clock
62
7. Give foods high in carbohydrates to an Alzheimer’s who
refuses to eat his meal
In an Alzheimer’s caregiver class, the nurse tells the student that the reason
why pt’s do not take a bath is that they cant remember anymore if they have
taken the bath already.
DRUG STUDY:
No cure or definitive treatment exists for Alzheimer’s disease. However, three drugs,
tacrine (Cognex), rivastigmine (Exelon), and donepizel (Aricept), have been approved
by the Food and Drug Administration to improve cognitive function in patients with mild to
moderate Alzheimer’s disease.
63
Test stools periodically for
GI bleeding.
Ginkgo biloba, a plant extract, contains several ingredients that many believe can slow
memory loss in people with Alzheimer’s disease, Research has shown that ginkgo
produces arterial, venous, and capillary dilation, leading to improved tissue
perfusion and blood flow. Adverse effects are uncommon but may include GI
upset or using anticoagulants.
EATING DISORDERS
#1 CAUSE: Unknown
#1 Personality Disorder of Eating Disorders: Obsessive Compulsive Personality
THEORIES OF CAUSATION:
1. Behavioral: Aattention-seeking by rejecting foods; manipulation to gratify needs
2. Family interaction: Aambivalent feelings towards mother; overprotection, rigidity,
lack of personal boundaries and independence; use of anorexia to avoid interpersonal
conflicts. The issue of CONTROL is a central one for the client with anorexia nervosa. It
is believed that symptoms are caused by stressor that the adolescent perceives as a
loss of control in some aspect of her life. Controlling intake and weight gain is a way
the client establishes a sense of control over her life.
3. Psychoanalytic: Rregression to oral and anal developmental stage to avoid
adolescent sexuality and independence
4. Medical: Ggenetic predisposition, increased catecholamines, hypothalamus dysfunction
ANOREXIA BULIMIA
- Amenorrhea lanugo - Binge/purge syndrome
Binge eating: Eating increased amounts of
high calorie food in a short period of time.
-2 binge-eating episodes or more per week
for 3 months
64
Defective defense mechanism: Denial There is ACCEPTANCE
Poor to fair prognosis - good prognosis acceptance
- Bulimic patients are usually aware of
their abnormal behavior.
CHARACTERISTICS CHARACTERISTICS
- vegetarian - carbohydrate, ↑ caloric fast foods
- All are females - 4 % are Boys
- Adolescent 11-17 yo - young adults
- hoards/collects food - loves to cook
- strenuous exercise -abuses laxatives/enema
- introvert - extrovert
- Patient’s with eating disorders are
usually high achievers, perfectionist and
preoccupied with food.
OTHERS:
Refusal to take meals → dramatic weight loss
Anorexic patients usually suppress their
appetite, which makes it difficult for the
nurse to convince them to eat.
Resistance to treatment; difficulty accepting
nurturance & caring
Feelings of loneliness and isolation
Hypotension, bradycardia, hypothermia
Secondary sexual organ atrophy;
amenorrhea
Reduced metabolism, reduced hormonal
functioning; hypoglycemia; electrolyte
imbalance Complications:
Hyperactivity; Constipation; Leukopenia - esophageal varices
Skin problem: Hyperkeratosis - dental carries
(overgrowth of horny layer of epidermis) - callous finger
- chipmunk face
Complications:
#1 Cause of death: cardiac dysrrhythmia STEP BY STEP NURSING DIAGNOSIS:
--. Hypokalemia ECG ST segment 1. F/E imbalance
depression & Prominent U wave 2. Fluid volume deficit – hypovolemic
shock
3.Altered Nutrition less than body
requirement
STEP BY STEP NURSING DIAGNOSIS:
1. F/E imbalance
2. Fluid volume deficit – hypovolemic
shock
3. Altered Nutrition less than body
requirement
4. Altered Body Image
Change of body image causes
65
difficulty in self-esteem. Long term
treatment for anorexia/bulimia
includes outpatient family therapy
sense of control over herself is a
positive outcome in eating disorder.
66
DRUG ADDICTION/NONALCOHOLIC SUBSTANCE ABUSE
TERMS
DEFINITIONS
67
Polysubstance abuse Concurrent use of multiple drugs
68
memory loss for actions as a direct
result of using drugs or alcohol
Sobriety
Complete abstinence from drugs while
developing a satisfactory lifestyle
Abstinence
Voluntarily refraining from
activities or the use of substances
that cause problems in the
physiologic, psychological, social,
intellectual, and spiritual arenas of
a person’s life
A. ASSESSMENT FINDINGS
● History. Academic or job failures, marital failures, stealing to support habit,
personality change, violent acting out
● Physical Examination: Mmalnutrition; abdominal cramps; diaphoresis,
yawning, lacrimation, rhinorrhea 10 hours after the last opiate injection;
needle marks on arms along path of a vein (wearing of long- sleeves);
nasal discharge with nasal septum perforation (cocaine)
● Social: Inability to maintain ADL and fulfill role responsibilities and obligations
69
B. NURSING DIAGNOSES, POTENTIAL:
Lacrimation
(Watery eyes)
RUNNY NOSE
YAWNING
↑ BP
Dilated pupils
Cramps
Muscle SPASM
Nausea, VOMITING
Panic, diaphoresis,
and weight
loss/anorexia
70
ANXIOLYTICS: Slurred speech Fatigue Sodium
Minor tranquilizers Respiratory Anxiety bicarbonate → excretion
Valium depression ↓ BP and Depression Activated charcoal,
Librium PR ↑ BP and PR gastric lavage
Barbiturates- Ataxia/ impaired Tachycardia
(Downes, rainbows, coordination Tremors
pink ladies) Drowsiness Convulsions
Phenobarbital Seizures, Coma Delirium
Nembutal ↓ Memory Hallucinations
Anxiety
Insomnia
STIMULANTS Euphoria Depression Activated charcoal, use
(Upper, meth, speed, Agitation Fatigue gastric lavage
pep, pills, crystal, ↑ BP, PR, RP, Temp Apathy
Ice, Hyperactivity, dilated Disorientation
Uppers, Crank pupils, Grandiosity Irritability
Amphetamines Hypervigilance, Altered sleep
Dexedrine Euphoria, Appetite
Methamphetamine suppression,
Personality changes,
Antisocial behavior
71
Euphoria
Relaxed inhibition
Dilated pupils
Psychosis
72
period.
73
II. Hallucination – #1 hallucination of Alcohol withdrawal is TACTILE
Nursing diagnosis for patient with delirium tremens who says, “There are bugs in
my bed crawling over me” is Altered Thought Process
2. Visual hallucination
Intervention: > Use lampshade to ↓ shadow (illusions)
Leaving a light on the patient’s room will decrease visual
hallucinations, which frequently occur in
alcohol withdrawal syndromes.
Shadow stimulates hallucination
don’t leave the patient (Offering of self)
Assigning a staff to the patient promotes safety especially during
withdrawal episodes.
Anticonvulsants
Anticholinergics
Antidepressants
Antihistamines
Antipsychotics
Aspirin
Barbiturates
Benzodiazepines
Cardiac glycosides
Cimetidine (Tagamet)
Hypoglycemic agents
Insulin
Narcotics
Propranolol (Inderal)
Reserpine
Thiazide diuretics
74
MOST COMMON CAUSES OF DELERIUM
Infection
Systemic: Ssepsis, urinary tract infection,
pneumonia
Cerebral: Mmeningitis, encephalitis, HIV,
syphilis
Drug-related
Intoxication: Aanticholinergics, lithium,
alcohol, sedatives, and hypnotics
Withdrawal: Aalcohol, sedatives, and
hypnotics
Reactions to anesthesia, prescription
medication or illicit (street) drugs
75
6. Valproic Acid (Depakene/Depakote) therapeutic serum level: 40-100 mcg.
Adverse Reaction: Hepatotoxic (assess SGPT or ALT)
7. Ethosuccimide (zarontin)
A. SEXUAL DISORDER: Ddeviations in sexual behavior; sexual behaviors that are directed
toward anything other than consenting adults or are performed under unusual
circumstances and are considered abnormal
B. PARAPHILIA: Sexual fantasies or urges that are directed toward nonhuman objects, the
pain to self or partner, or children and other nonconsenting individuals.
1. EXHIBITIONISM: Sexual gratification from exposing genitalia
2. FETISHISM: Sexual gratification from an inanimate object (usually clothing material)
substituted for the genitals
3. FROTTEURISM: Sexual gratification from toughing or rubbing against a
nonconsenting person (usually in crowds, public transportation)
4. MASOCHISM: Sexual gratification from self-suffering used as an accompaniment of
the sexual act or substitute for it
5. PEDOPHILIA: Sexual gratification from children
6. SADISM: Sexual gratification from inflicting pain or cruelty to others used as an
accompaniment of the sexual act or a substitute for it
7. TRANSVESTISM: Sexual gratification from wearing clothes of the opposite sex
8. VOYEURISM: Sexual gratification from watching the sexual play / act of others
9. ZOOPHILIA: Sexual gratification from animals
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C. SEXUAL DYSFUNCTION: Generalized or situational, acquired or lifelong inhibition or
interference with any of the phases of the sexual responses which may be due to
psychogenic factors alone or psychogenic and biologic combined.
D. NURSING DIAGNOSES
1. Anxiety related to threat to security and fear of discovery
2. Anxiety related to conflict between sexual desires social norms
3. Sexual dysfunction related to actual or perceived sexual limitations
4. Sexual dysfunction related to inability to achieve sexual satisfaction without the use of
paraphilic behaviors
5. Potential for infection related to frequent changes in sexual partners or sadistic or
masochistic acts
6. Potential for injury / violence related to sexual behavior and retaliation for sexual
behaviors
AUSTITIC DISORDER
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5. SEVERE AUTISM – Severe apathy, Association looseness, Autistic thinking, Poor grasp
of reality, Ambivalence, Poor communication skills, Poor interpersonal relations, Poor
intellectual functioning
C. NURSING DIAGNOSIS: Potential for Injury
D. NURSING IMPLEMENTATION:
CHARACTERISTICS:
1. Hyperactive could not sit and stay in 15 minutes
2. ↑metabolism fatigue
3. handwriting not legible
4. Easily agitated by noise & color (orange/yellow)
B. ASSESSMENT
1. Severe inattentiveness with or without hyperactivity
2. Short attention span
3. Excessive impulsiveness
4. Squirming and fidgeting
5. Hyperactive could not sit and stay in 15 minutes
2. ↑metabolism fatigue
3. handwriting not legible
4. Easily agitated by noise & color (orange/yellow)
C. NURISNG IMPLEMENTATION:
1. Set realistic, attainable goals
2. Provide firm, consistent discipline with opportunities to experience satisfaction and
success
3. Provide a structured environment-
● With a balance of energy expenditure and quiet time
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● With learning experience utilizing child’s ability
● With exercise in perceptual-motor coordination
● With LESS STIMULATION
The priority needs of the child with ADHD are safety and provision of
inadequate nutrition.
Catching attention of a child with ADD includes getting him to look at his
mom & give him simple
directions.
4. Administer drugs as ordered: RITALIN (methylphenidate) or dextroamphetamine
sulfate
CHILD ABUSE
A. DEFINITION: Physical abuse and emotional neglect; may include sexual abuse
B. CAUSE: Exact-unknown; Present in all socioeconomic levels
C. ASSESSMENT:
● Obvious physical injuries, disturbance on parent-child interaction (Absence of PROTEST
on admission of a toddler is a sign of abuse.)
● Inconsistency of declaration of the type, location, cause of injury, discovery of
undeclared / unreported fractures
● Malnutrition / failure to thrive / emotional neglect
● Sexual abuse signs: Ggenital bruises, lacerations; STDs
History: Parents who were abused as kids
○ Other characteristics of abusive parents: 1) Tend to be young, immature, dependent;
20 Low in self- esteem 3) Lacks identity 4) Expect child to provide them with love and
care (PERSONAL ROLE THEORY of causation) 5) With incorrect concept of what the
child is, and can do 6) With inadequate resources and support system
Abusive parents usually have low-self-esteem and has little social
involvement.
Child abuse is common in the lower socio-economic class.
The interaction between the abuse child and a mother provides a clue to the
kind of relationship that this child has with his mother.
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In working with the mother of abused child, therapeutic use of self requires
self awareness initially, therefore the nurse has to deal with her feelings first.
Attendance to a parenting class is a step towards learning parenting skills,
which are lacking in abusive parents.
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Helplessness
Hesitance to talk openly
Anger or agitation
Withdrawal or depression
Neglect indicators
Dirt, fecal or urine smell, or other health hazards in the elder’s living environment
Rashes, sores, or lice on the elder
Elder has an untreated medical condition is malnourished or dehydrated not related to
a known illness
Inadequate clothing
Indicators of self-neglect
Elder is not given opportunity to speak for self, to have visitors, or to see anyone
without the presence of the caregiver
Attitudes of indifference or anger toward the elder
Blaming the elder for his or her illness or limitations
Defensiveness
Conflicting accounts of elder’s abilities, problems, and so forth
Previous history of abuse or problems with alcohol or drugs.
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