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NOTES:  muscle tension, dry mouth, frequent

Anxiety – neurosis but doesn’t mean it urination

will lead to hallucinations  Diaphoresis, headache
Psychosis – has hallucinations  Inc. BP, pulse and respiration

ANXIETY Emotional
- feeling of apprehension and dread,  Increased irritability
impending doom
 motivated to decrease anxiety
- caused by a subjective threat
 Use of palliative coping mechanism
- both a stressor and for adaptation
- communicable
- has degrees
decrease anxiety
- decrease GABA
refocus attention
oral medication if needed
4 Levels
Slight perspiration
has difficulty concentrating
e.g. during exam
Mgmt: mild and moderate
I. Mild Anxiety
help client identify anxiety
encourage client to talk about feelings
assist CL problem solving
 éalertness, é to learn
refocus attention
 Logical reasoning oral meds.
 Problem solving skills
III. Severe
 restlessness, fidgeting, G.I. butterflies, Cognitive
difficulty sleeping, hypersensitive to  ê perception
noise  Perception focused to one detail or
 Slight Muscle tension scattered details
Distorted perceptions
 Irritability Physical
 Can be motivating  fight or flight response
 Use of adaptive coping mechanism  é V/S
 extreme Muscle tension
Mgmt.  severe headache, nausea & vomiting,
discuss source of anxiety diarrhea
problem solve
 vertigo, tachycardia, chest pain
accept as natural
benefit from it
 Extreme discomfort
II. Moderate
 Feeling of dread
Cogntive  Use of maladaptive mechanisms
 narrowed perception
e.g. witnessing a car accident
 focused to immediate task
 selective attention
-reduce anxiety quickly
-don’t engage client in problem solving
 é use of automatism and speech, -use calm manner
pacing -remain with the client
-minimize environmental stimuli
-use clear and simple statements OCD
-use low pitch voice  Obsessions – persistent, intrusive
-attend to physical needs of client thoughts that one is unable to omit.
-provide gross motor activity o Religion
Anti-anxiety (oral as ordered) o Sexuality
o Violence
 Compulsion – repetitious,
IV. Panic uncontrollable acts to decrease
Cognitive o ritual
 Disorganized perception Ego def – mech used: repression, undoing,
 Disorganized problem solving isolation, reaction formation
 Out of contact with reality Rxn formation – Obsession
 Neologism, clang association Undoing – Compulsion

Physical Management
 actual fight & flight
 Suicidal, hysterical > Short-term:
 Mute, incoherent 1. allow compulsion
2. limit setting
Emotional 3. diversional activity – art therapy
 Feeling overwhelmed
 Rage desperation > Long term goal:
1. psychotherapy
 Totally drained
2. Anti-anxiety medications
 Use of dysfunctional coping Take note! accdg. To ma’am,
mechanisms anti-depressants talaga dapat kasi anti-
anxiety meds, nakakaadik …
e.g. during earthquake
Phobic Disorder
 Irrational fear from stimulus (obj.,
provide client safety
emotional support
structured environment  Avoidance of the feared obj.= free
Restraints if needed from anxiety
smaller room – don’t place client in the
middle, but in the corner Ego def. Mech:
anti-anxiety (parental as ordered)  Symbolization
 Projection
Phobic NOTES!
Gen. Anxiety Disorder Types of Phobia:
Panic Disorder Social Phobia – fear of speaking
Post Traumatic Stress Disorder infront, etc .. because you don’t want
Acute Stress Disorder humiliation
Agoraphobia – fear of open
 Central cause – anxiety Specific Phobia – fear of blood,
 conflict , unacceptable to person heights, etc …
 CL unaware of cause (repression)
 Obtain gains
1. MILIEU Therapy
o Primary
2. Systematic Desensitization - gradual
o secondary
exposure to the feared object
 traumatic event persistently
NOTES! experienced, marked anxiety,
Nurse will also be a model, you will impaired functioning
teach patient how to relax
Systematic Desensitization is under Mgmt: to reduce anxiety
Behavioral Model / Therapy, it says that 1. provide a calm and quiet environment
“behavior can be learned so it can also be 2. ask patient to identify what and how they
unlearned.” feel
3. encourage to discuss feelings
3. Psychotherapy 4. listen to patient’s feeling of worthlessness
4. Behavior modification – reward & and hopelessness
recognition 5. assess for suicidal thoughts
5. Pharmacotherapy 6. provide recreational activity ie
General Anxiety Disorder
 unrealistic or excessive worry Mgmt: ASD and PTSD
occurring more days than not in a 6- 1.Verbalization – esp. anger,gradually done,
month period and only what client wants to talk about
 at least 3 of the following symptoms -acknowledge any unfairness or injustice
occur: restlessness, irritability, related to trauma
fatigue, 2. assure them that their feelings are typical
 muscle tension, sleep disturbance, reactions to trauma
impaired concentration 3. encourage adaptive coping
Panic Disorder – with or without strategies,relaxation techniques,and sleep
agoraphobia promoting strategies
 real illness accompanied by physical 4. facilitate progressive review of the trauma
and psychological component and it’s consequences
 Sudden frightening and uncomfortable 5. encourage to establish and re-establish
symptoms: relationships
o Terror, sense of unreality, fear 6.Psychotherapy
of loosing control, Chest pain,
Palpitations, Tachycardia, Management
Diaphoresis, Shortness of Pharmacotherapy:
Breath, Choking sensation, Fear  Anti-anxiety Drugs
of going crazy  Anti- depressant – Clomipramine
 After the panic attack, client (Anafranil)
exhibits concern of future attacks *GABA- an inhibitory NT - ê in anxiety

Post Traumatic Stress Disorder ANTI-ANXIETY, ANXIOLYTICS, MINOR

- re-experiencing trauma / flashback TRANQUILIZER
- emotional numbness  Tx for anxiety disorders, insomnia,
- hypervigilance, hyperalertness, OCD, depression, alcohol withdrawal
> should occur 1 month after the event TYPES:
to be able to diagnose as PTSD 1. Propanediol compounds:
2. Benzodiazepine group (BDZ)
Acute Stress Disorder 3. Non-Phenothiazine group
 differentiated from PTSD in that 4. Non-Benzodiazepine group
symptoms occur
 immediately after the trauma Propanediol compounds
 last for at least 2 days - 4 weeks 1.Meprobamate (equanil)
2. Phenaglycodol ( Ultran)
 dissociative symptoms - derealization,
3.Tybamate (solacen)
depersonalization, or dissociative
Adverse effect: hypotension, headache,
insomnia, hypersensitivity service.
3. Which of the ff. would be the most
Benzodiazepine group (BDZ) appropriate goal for a client who has been
1.Chlordiazepoxide (Librium) diagnosed as having GAD:
2.Clorazepate (tranxene) The client will describe dissociative
3.Diazepam (valium) symptoms
4.Oxazepam(serax) The client will display the ability to cope with
5.Alprazolam (xanax) mild anxiety
The client will verbalize a sense of control
Non-Phenothiazine group over ritualistic behavior
1.Hydrozyzine HCL (atarax) The client will relive the traumatic event
2.hydroxyzine pamoate (visiril) 4. A client states, “I am always late for
everything because I can’t leave my house
Non-Benzodiazepine group without checking every door and window to
1. Buspirone (Buspar) make sure it’s locked. If I don’t make sure
General Adverse effect: drowsiness, everything is locked I get so worried and I
hypotension , relaxation , inability to have to go back home. I can’t seem to stop
concentrate, muscle relaxation, my behavior. The nurse should encourage
hypersensitivity reaction this client to:
Explore childhood experience that may have
Client teaching led to the behavior
- Teach client about the tendency for Remain at home until the symptoms subside
physical dependence Stop worrying about the locks
- Clients should not drink alcohol when Adjust the personal schedule to allow time
taking anxiolytics for the ritual
- Slower reflexes-clients should not be 5. Which of the ff. statements made by a
operating heavy machineries and client with obsessive-compulsive disorder
cautioned against driving. would be the best indicator of improvement:
- Orthostatic hypotension – dangle 1st “I know that my behaviors and thoughts are
before standing not normal”
- Anti-Cholinergic effects: “I only do my ritual to reward myself when I
Dry mouth – oral hygiene have been good”
Constipation – hydration “My friends don’t know about my disorder”
Urine retention-positioning “I have more control over my thoughts and
It’s Quiz Time! 6. Which of the ff. statements by a client
1. Before an anxious client begins treatment taking triazolam (Halcion) for anxiety
it is most important to assess the client’s: indicates that teaching has not been
a. Level of motivation for treatment effective:
b. Situational and emotional support “The doctor wants me to take this drug at
c. Stressors and coping mechanisms bedtime to help me sleep better”
d. Use of alcohol or other central nervous “I should not abruptly stop taking this
system depressant agents medication”
“I might not be able to drive while I am
2. The nursing assessment indicates a client taking this medication”
is experiencing a panic attack. The client is “I will probably have to take this medication
unable to understand directions and for the rest of my life”
preoccupied with thoughts of danger. Which
of the ff. would be the most appropriate II. SOMATOFORM DISORDERS
nursing diagnosis: > Characterized by physiologic complaints or
Altered health maintenance symptoms that are not under voluntary
Altered thought process control, and do not demonstrate organic
Ineffective individual coping findings
Impaired communication > symbolizes repressed and unresolved

Somatoform Pain Disorder  alteration/loss of sensory or motor
Hypochondriasis function
Conversion Disorder  Young age, female
 common conversion - blindness,
II. Somatoform III. Psycho- paralysis, mutism, paresthesias
disorders physiolo  Symptom has a symbolic relation to
VERSUS gic the unconscious conflict
Disorder  “La belle indifference” – e.g. okay
> No medical > Medical condition lang sakin na mabulag atleast
condition with physiologic hindi ko nararamdaman ang
> (-) diagnosis, no lab. basis anxiety..
Findings > (+) diagnosis, lab
> NO MEDICAL findings Body Dysmorphic Disorder
REGIMEN > CNS – migraine,
 preoccupation with a imagined defect
tension, headache
in his or her appearance
 Imagined subjective feeling of ugliness
> Respi – Asthma
> NM – arthritis  Young adolescent – young adult,
> GIT – Peptic Ulcer female
> Endocrine –  common complains are facial flaws
Diabetes Mellitus  noselifts, facelifts
REGIMEN & Goals of Care
CONTINUED 1. Functional as his condition will allow to do
TREATMENT not focus on body
2. No specific medical regimen
3. Anti-anxiety meds.
Somatization Disorder 4. Analgesic
 Polysymptomatic – the client has 5. Stress mgmt. Theory
multi-organ complaints - relaxation
 Young age, female - deep breathing
- imagery – music
 Familial
- meditations
 Recurrent and chronic 6. Psychotherapy
 anxiety and depression often seen
 frequent attempts at suicide Its Quiz Time!
 frequently submits self to surgery A client who developed a glove anesthesia of
 antisocial behavior the right (dominant) hand was unable to play
in a piano competition yesterday. The
Somatoform Pain Disorder consequence of this symptom, not having to
 pain is the predominant focus perform, is best described as:
 Older 4th or 5th decade, female Phobia
 Familial Primary gain
 intense pain unrelieved by analgesics Carpal tunnel dysmorphia
 involves different parts of the body Secondary gain

Hypochondriasis 2. A female client with a 15-year history of

somatization disorder is to be discharged
 morbid preoccupation of a serious
from her first psychiatric hospitalization.
Which statement would indicate that nursing
 Middle or old age, male-female equal care has been effective:
 doctor shopping “I need to make sure all my medications are
 anxiety, depression and compulsive sent home with me”
personality traits “My family is so good to me when I’m sick
like this”
Conversion Disorder
“There are so many illnesses that you nurses
don’t know about” 2.Sexual Arousal Disorder
“I see that when I get stressed, my body a.female sexual desire disorder-dyspareunia
speaks for me” caused by lack of desire,hormonal
b.male erectile disorder-erectile dysfunction
3. A client convinced that her pelvic pain is or impotence,maybe organic or psychological
from an advance malignancy, and that she is
likely to die. Extensive testing has revealed 3.Orgasm Disorders
no abnormalities, “You think this is in my a.anorgasmia - absence or delayed orgasm
head, don’t you?” she asks. The nurse’s best b.premature ejaculation
response is:
“Sometimes doctors miss a diagnosis” 4.Sexual Pain Disorders
“Yes I think you have pain” a.dyspareunia - genital pain before,during or
“It must be hard for you to hear the testing after intercourse
results” b.vaginismus - involuntary muscle
“How about resting now and asking your constriction of the outer third of the
doctor later” vagina(rape trauma)

4. A client with somatization disorder has Paraphilias (sexual perversions)

been attending group therapy. Which -sexual instinct is expressed in ways that are
statement indicates that the care has been socially unacceptable and is prohibited
effective: -peaks between the age 15 and 25 and
“I think I’d better get some pills. My back decreases in incidence by age
hurts from sitting in group” -always enters the cycle of sexual perversion
“The other women in the group have mental -exhibitionism
problems! -incest
“I haven’t said much, but I get a lot out -fetishism
of listening” -necrophilia
d. “I feel better physically just from getting -frotteurism
a chance to talk” -sexual masochism
 Inhibition of the sexual appetite or -pedophilia
psycho-physiological changes that -sexual sadism
compromise the sexual response cycle -bestiality
The sexual response cycle -nymphomania
Phase 1: Desire-fantasies and sexual desire -satyriasis
Phase 2: Excitement-Psychological and -telephone scatologia
physiological stimulation (30 sec-3 minutes)
Phase 3: Orgasm-peak of sexual pleasure (3- Not otherwise classified
15 sec, dec LOC),inc VS Cunnilingus
Phase 4: Resolution-detumescence, resting anilingus
stage,refractory period(males) Fellatio
Predisposing Factors Homosexuality
2. psychosocial Txt: Psychotherapy,group therapy,sex
3. relationship therapy, behavior therapy,
1.Sexual Desire Disorders
a. Hypoactive disorder-deficiency or EATING DISORDERS
absence of fantasy and desire for sexual  Anorexia-profound disturbance in body
activity image and a relentless pursuit of
b. Sexual aversion disorder-avoidance of thinness to the point of starvation
genital contact with a partner  common in females 10-30 y/o
Diagnostic criteria include Isolation
1. refusal to maintain body weight at a Intellectualization
normal BMI or is less than 85% of DBW
2. intense fear of gaining weight Management
3. disturbed body image 1. Refeeding Therapy
4. self evaluation is based on body weight or 1-2 lbs. Initially / week
shape is experienced NGT at night
5. amenorrhea at least 3 consecutive cycles Oral
ANOREXIA NERVOSA 2. Behavior Modification Program – token
Self imposed starvation > Stress > NOTES na galing kay Hazel!
Anxiety > eating behavior > decreased 3. MILIEU
anxiety - observation during and after
Etiology - monitoring bathroom use precise
 Disturbed body image mealtimes
 Conflict in growing up - coherence to selected menu
 dominating / authoritative parents
 this is in belief -regular weighing
-weekly, biweekly
 dysfunction in hypothalamus
-same time of day
-before morning meal
-after voiding
 starving - wt. loss by 15-85%
-gown, bra, and pants only
 amenorrhea – starvation effect on LH
 dehydration -monitor VS, fluid and electrolytes
 serum Na and electrolyte imbalance, -monitor exercise
hypoglycemia -monitor elimination pattern
 V/Sx – hypotension, bradycardia -client privileges correlated with
hypothermia weight gain

As the disorder progresses: 3. Provide contract

 dry flaky skin 4. Go with client when eating
 brittle hair and nails 5. Set limits-remind contract
 constipation 6. No laxative
 skeletal appearance, BMR 16 below 7. Family therapy
 lanugo 8. CBT – Cognitive Behavioral Therapy
9. Psychotherapy
Warning signs that should alert 10. Medications
parents: -anti-depressants
-anti-histamine - Cyproheptadine
 drastic wt. loss, unusual eating habits
Weight gain, depression
 obsession with neatness, frequent
mirror gazing
Nursing Dx.
 hostility Altered Nutrition less than Body
 calorie counting, excessive exercise Requirements
 frequent weighing Disturbed Body Image
 amenorrhea Anxiety
 wearing loose fitting to hide physical Chronic Low Esteem
Ego Defense Mechanism > consist of recurring episodes of binge
Denial, Displacement eating in a discrete period of time and a
Projection sense of lack of control over eating large
amounts of food accompanied by a feeling of Promote safety
out of control Stabilize medical condition
>feelings of guilt, depression, and self Behavior modification-limit setting
disgust after bingeing Cognitive behavioral therapy
>presence of recurrent compensatory Psychotherapy
behaviors: purging, fasting or excessive
exercise It’s Quiz Time!
>they maintain normal body weight A teenager is being evaluated for anorexia
>self evaluation is unduly influenced by body nervosa. Which of the ff. symptoms would
weight and shape suggest anorexia nervosa:
>diagnostic criteria include: recurrent, The client has episodes of overeating and
at least twice a week for the past 3 progressive weight gain
months The client expresses a positive self-image
The client has had severe weight loss caused
Etiology by self-imposed dietary restrictions
 Thin is in belief The client refuses to discuss the topic of food
 Poor impulse control
2. In bulimia nervosa, the client typically
Medical Consequence Due to Bingeing responds to increased levels of anxiety by:
and Purging: Rigidly controlling what he or she eats
 inflammation of esophageal lining Bingeing and purging
 esophageal rupture Overeating
Consuming alcohol
 electrolyte imbalance-metabolic
alkalosis, arrhythmias
3. In teaching a group of young girls about
 heart problems
eating disorders, the nurse would evaluate
 dental caries-erosion of the enamel the sessions as effective if the participants
state that anorexia nervosa is best defined
Manifestations: as an eating disorder that occurs:
-bingeing Only in young girls who are depressed
-purging Primarily in young girls who perceive
-Underweight or slightly overweight themselves to be grossly overweight
-sign of guilt, remorse, relief of anxiety and In young girls and does not have serious
depression consequences
-compulsive eater In young boys and girls alike
-person is aware that behavior is abnormal
-self-critical 4. In formulating a plan of care for the
-depression anorexic client,it is most important for the
nurse to:
Nursing Dx: Allow 2 hours of exercise per day to prevent
Risk for Injury exhaustion
Binge: Altered Nutrition less than Body Remind the contract that tokens will not be
Requirements given if she does not gain weight rapidly
Purge : Altered Nutrition less than Body Set firm limits on eating behaviors and the
Requirements use of laxatives
Ineffective coping Walking with the client during stressful times
 Diary – for recording eating habits > a most extreme form of withdrawal from
 Remove anxiety –before eating to reality. Characterized by deteriorating
relieve > Personality with loss of reality testing and
 Anti-anxiety drug the 4 A’s of Schizophrenia
 Anti-depressant Fluoxetine (Prozac)
Criteria for Diagnosis
Nursing Interventions for Eating 1. at least 2 characteristic symptoms:
Disorders -Delusions
-grossly disorganized or catatonic
behavior Negative Sign
-hallucinations  anergia – lack of energy
-negative symptoms  avolition – lack of motivation
-disorganized speech  inattention – lack of attention
2. social and occupational dysfunction and  anhedonia – inability to gain pleasure
 asocial behavior – inability to form
3. disturbance for at least 6 months
close relationships to feel intimacy
4. not caused by substance abuse or a
 alogia – lacko of speech
medical condition
 apathy – lack of emotion
1. Biologic theories TYPES OF SCHIZOPHRENIA
-genetic component present Paranoid –paranoia, hallucination, delusion
-Dopamine synthesis Disorganized – disorganized speech &
2. Developmental theories behavior,flat affect – most regressed type
-poor ego boundaries,fragile ego,ego Catatonic – waxy flexibility, inc. motor
disintegration activity, mutism
3. Family theories Undifferentiated - Mixed positive and
-schizophrenogenic mother negative symptoms
-dysfunctional family theory Residual – (-) symptoms only
-double - bind
4. Vulnerability stress model Nursing Dx
Alteration in thought process
Manifestations Alteration in sensory perception
4 A’S of Schizophrenia Alteration in self – concept
affect – flat, inappropriate Alteration in social interaction
ambivalence – 2 opposing feelings at Impaired verbal communication
the same time *if client is mute – explain procedure
autism – self absorption to client but don’t expect him to answer
associative looseness * If client is talking – use open- ended
Types of Delusions *If client has concrete thinking –
direct , concise statement
 Grandeur
Self Care Deficit
 Persecution
Altered Nutrition less than Body Requirement
 reference Ineffective coping
 religiosity Potential for Injury
 somatic Potential for violence

2 TYPES Nursing Interventions

Positive Sign 1. general principles for a therapeutic
 delusions – Nihilistic – CL believes he relationship
is dead or a part of his body is -be calm when talking to patients
removed. -accept patient not the behavior
 disorganized speech -keep all promises
 neologisms -be consistent
 word salad -be honest
 clang association 2. Do not reinforce delusions nor
 verbigeration hallucinations
3. Orient clients to time and place if
 Disorganized behavior.
 Regressed
4. Do not touch patient without warning
 catatonic behavior - WAXY FLEXIBILITY 5. Avoid whispering or laughing without the
- retention of a same position for a patient hearing it
long period of time 6. Reinforce positive behavior
7. Avoid competitive activities profuse sweating
8. Do not embarrass patients Muscle spasm – convulsion
9. Start with one to one interactions Stupor, coma, death
10. Allow verbalization of feelings
Nursing Interventions:
Drugs anti psychotics
Anti Psychotic Drugs / 1. Check BP before administration
Neuroleptics/Major Tranquilizer 2. Monitor periodic liver function test
MOA: to block dopamine receptors at 3. Observe for warning signs of adverse
Post synaptic area effects
4. Note complaints of sore
I. Conventional Antipsychotic: throat,nosebleed,rash,fever,other signs of
a. Phenothiazine Group infection
Chlorpromazine(Thorazine) –
minor antipsychotic 5. Warn client drowsiness may occur until
Thioridazine(Mellaril) tolerance develops
Trifluoperazine(Stelazine) 6. Teach client to:
Perphenazine(Trilafon) - avoid alcohol
Mesoridazine(Serentil) - Consult before taking other
b. Butyrophenone Group: medications
Haloperidol(Haldol)- major anti - Precautions to avoid skin
psychotic damage
Droperidol(Inapsine) ie
II. Atypical Antipsychotic - take high fiber
Clozapine (Clozaril) diets,fluids,exercise
Risperidone(Risperdal) and good oral hygiene
Quetiapine(Seroquel) It’s Quiz Time!
Clozapine weekly-CBC 1.While talking with a client diagnosed with
schizophrenia, you notice the client loses
Adverse Effect eye contact with you and starts staring at
Sedation / drowsiness the wall. The client is making facial grimaces.
anti-cholinergic effect The most appropriate nursing intervention
orthostatic hypotension would be to:
endocrine changes a.End the conversation because the client is
Amenorrhea-Women/Gynecomastia- not listening to you
men b.administer trihexyphenidyl as prescribed
G.I. upset c. ask the client directly, “what are you
Photosensitivity seeing on the wall?”
d. redirect the client’s attention to continue
E.P.S. (Extra Pyramidal Symtoms) your conversation
akathisia – Jitteriness, anxiety, 2. A client taking antipsychotic complains to
fidgeting, restlessness the nurse of feeling nervous. The nurse
medication-Propranolol (Inderal) notices that the client has jitters and pacing
akinisia – weakness & fatigue unable to remain still. The client is most
dystonia – cramping, protrusion of likely experiencing:
tongue at sides, drooling a.Dystonia
eyes rolled up backwards (oculogyric b. tardive dyskinesia
crisis) c. akinesia
neck torsion or rigidity d.akathisia
opisthotonus, torticollis, wry neck) 3. A client is exhibiting symptoms that are
Pseudoparkinsonism – tremors, rigidity, mask characteristic of schizophrenia, but is also
– like facies exhibiting manic behaviors. This client’s
Neuroleptic Malignant Syndrome most likely diagnosis:
hyperthermia – 1st to occur a. Schizophreniform disorder
b. brief psychotic disorder
c. shared psychotic disorder
d. schizoaffective disorder
4. A male client on the unit has a diagnosis
of paranoid schizophrenia. The new mental
health care worker on this unit approaches
the nurse and asks about the best way to
work with this client, the nurse replies:
a.“avoid touching this client and invading
personal space”
b. “offer back rubs at bedtime to
decrease the client’s anxiety”
c. “greet this client with a firm
d. “ Place your hand on the client very
softly when you speak to him”
5. What nursing diagnosis is most likely to be
associated with a client as having
schizophrenia, residual type:
a.Impaired verbal communication
b. self care deficits
c. social isolation
d. anxiety