Psychiatric Nursing (Notes)

Alcohol Abuse
Alcoholic Beverage

An alcoholic drink contains ethanol, commonly termed as alcohol. Alcohol is a psychoactive drug
that is central nervous system depressant and rapidly absorbed in the bloodstream. It can be
addictive and the state of alcohol addiction is known as alcoholism.

Physiologic Effects of Alcohol Use

When a person drinks alcohol, he or she may experience relaxation and loss of inhibitions initially.
However, when large amount of alcohol is ingested intoxication may occur. The person who is
intoxicated may experience the following manifestations.

 Slurred speech
 Unsteady gait
 Lack of coordination
 Decreased attention span
 Reduced concentration
 Impaired memory
 Impaired judgment
An overdose of alcohol in a short period of time can result to the following manifestations:

 Vomiting
 Loss of consciousness
 Respiratory depression
Physiologic Effects of Long-term Alcohol Use

 Cardiac myopathy
 Wernicke’s encepalopathy
 Korsakoff’s psychosis
 Pacreatitis
 Esophagitis
 Hepatitis
 Cirrhosis
 Leucopenia
 Thrombocytopenia
 Ascites

Treatment of Alcohol Overdose

1. Gastric lavage or dialysis. The procedure is performed to remove the drug from the
systemic circulation.
2. Support of respiratory and cardiovascular functioning.

Alcohol Withdrawal

When an alcoholic withdraws from alcohol use, withdrawal symptoms usually starts at about 4 to
12 hours after a marked reduction or cessation of alcohol intake. The withdrawal may take 1 to 2
weeks. It can be life-threatening thus, prompt treatment and management is required or
necessary. If you feel that you need help with the withdrawal process as this can often be a
stressful time, you are not alone. Many people choose to visit Avante Institute and Retreat in order
to help with their addiction. Keep reading to find out more about the symptoms you might need
help with.
Symptoms of alcohol withdrawal are:

 Coarse hand tremors

 Sweating
 Elevated pulse
 Increase blood pressure
 Insomnia
 Anxiety
 Nausea and vomiting

Delirium Tremens (DT’s)

In cases where the withdrawal signs and symptoms are not treated or becomes severe, the
condition may progress to a condition called delirium tremens. Delirium tremens is an acute
episode of delirium that is mainly caused after a long period of drinking and being stop abruptly
and the person experiences withdrawal. It may also be triggered by head injury, infection, or
illness in people with a history of heavy use of alcohol. A list of the  Signs and Symptoms of
Delirium Temens is below.
Signs and Symptoms of Delirium Temens:

 Transient hallucinations
 Seizures
 Delirium

Management for Alcohol Withdrawal

1. Detoxification under medical supervision

2. For mild alcohol withdrawal symptoms and the client can abstain from alcohol, home
treatment is possible.
3. For severe cases where the client cannot abstain from alcohol during detoxification, a short
admission (about 3-5 days) is done.
4. Safe withdrawal is accomplished through the administration of benzodiazepines such as
Chlordiaxepoxide (Librium), Lorazepam (Ativan) or Diazepam (Valium) to suppress the
withdrawal symptoms.
Alcohol Detoxification
Alcohol detoxification from the los angeles detox center is the removal of alcohol from the body of
an individual who is alcohol dependent or alcoholic. It is the abrupt cessation of alcohol intake
coupled with the substitution of alcohol with drugs used to prevent alcohol withdrawal. Alcohol
detoxification is not possible without support from friends and family. Most of all it needs a
commitment on the part of the individual who will undergo detoxification to abstain from alcohol
use.

Alcohol Detoxification Process

The process of alcohol detoxification requires that alcohol be eliminated from the human body and
that any withdrawal or other symptoms that are bound to occur are treated medically or
psychologically or both. As mentioned earlier, the detoxification process is largely determined by
the alcoholic himself. The detoxification process is determined by the person’s condition and by
his approach.

In some cases, patients who undergo the alcohol detoxification process may suffer from
hallucinations, delirium tremens and convulsions, which require immediate attention and
treatment. To minimize these symptoms, medical drugs are given. However, the administration of
these medications has to be monitored and accurately controlled. Usually such medications have
are given at high dosages initially, but is gradually tampered down over a week.

Withdrawal symptoms can be quite distressing and can even become fatal if the addiction to
alcohol is very severe. Safe withdrawal is accomplished with the administration of
benzodiazepines to suppress the withdrawal symptoms. Drugs under this category are:

 Chlordiaxepoxide (Librium) – is the benzodiazepine of choice in uncomplicated alcohol

withdrawal due to its long half-life.
 Diazepam (Valium) – is available as an injection for patients who cannot safely take
medications by mouth.
 Lorazepam (Ativan) – is available as an injection for patients who cannot safely take
medications by mouth. This is also indicated in patients with impaired liver function because
they are metabolized outside of the liver.
The most common drugs used for alcohol detoxification are benzodiazepines, with
Chlordiazepoxide being the most preferred benzodiazepine used. Diazepam is also widely used,
but fatal effects may occur if it is mixed with huge doses of alcohol. Hence, supervision is
necessary for use of diazepam as a detoxifier.

Where is alcohol detoxification done?

In most cases, alcohol detoxification can be done at home. This is applicable when the alcohol
consumption is just moderate. However, in cases where hallucinations, severe withdrawal
symptoms and multi-substance misuse are noted, an inpatient detoxification is required.

Anorexia Nervosa
Definition

 Anorexia Nervosa is a disorder with an insidious onset that often affects adolescent girls.
 Sufferers are typically high achievers, with good grades and described by parents as
perfect children. Disorder occurs commonly in upper middle class families. Usually the
youngest child is affected.
 Unlike bulimics, anorexics uses denial and do not accept that they have a problem, thus,
they are more difficult to treat.
 10-20 % of anorexics die and half of these deaths are due to suicide.
 They are often not recognized  because they eat normally in social situations but after
eating they retreat to the nearest bathroom and purge themselves.
 In order to prevent themselves from eating and to help maintain their very restrictive dietary
program, they avoid socializations such as parties, even family meals, thus becoming
increasingly socially isolated.
 They often start as chubby children or overweight adolescents. The disorder begins with
somebody took notice of their being overweight. Because the self-esteem of this person is
based on the acceptance of others, they go on dieting to lose weight and feel accepted again.
 The personality is perfectionist, introverted, with low self-esteem and often has problems
with peer relationships. They are good children who are conscientious, hard working, and
ideal students. Typically they are people pleasers who seek approval and avoid conflict.
 The person may have low tolerance to change and do not adjust well to new situations.
Often they are overly engaged with or dependent on parents or family. Dieting may represent
avoidance or, or ineffective attempts to cope with, the demands of a new life stage such as
adolescence.
 They may fear growing up and assuming adult responsibilities including an adult lifestyle.
The symptoms of anorexia are thought to be a kind of symbolic language that expresses: ” I’m
not ready to grow up yet,” or ” I’m starving for attention”.
 Another factor is that this individual may have felt worthless and helpless. They try to
combat these feelings by taking over those parts of their life that they can control, that is, their
weight and the food that they eat.

Types:

1. Restricting – weight loss by dieting, fasting and excessive exercise.

2. Binge eating or purging – uses self induced vomiting, abuses laxatives, diuretics or enema.

Assessment

 Behaviors directed toward weight loss like dieting, exercise and purging.
 Withdrawn and socially isolated, refuses to eat with family on the table.
 Distorted body image, they see themselves as fat despite being emaciated.
 Intense fear of becoming fat.
 Due to misconception that food can make them obese and look ugly, their life is dominated
by behavior directed at avoiding food intake and weight loss. They then become preoccupied
with food and engage in bizarre behaviors such as peculiar way on handling food, hoarding
food, collecting recipes, rearranging food on plate repeatedly, dawdling, reading multiple
materials about food to the point of thinking that they have superior knowledge
 Depressed, sleep disturbances, suicidal tendencies and crying spells.
 Compulsive rituals.
 In women, amenorrhea for at least four months and lack of interest in sexual activity due to
lack of nourishment, menstruation can occur only if a woman is able to maintain at least 17%
of body fat.
 In men, level of sex hormones drop. Males develop eating disorders too. About 10% of
patient with eating disorders are male.
 Physical symptoms include bradycardia, hypothermia, dehydration, dependent edema,
hypotension due to decreased metabolic rate as a compensatory mechanism of the body to
low food intake.
 Induce vomiting, uses enema, diet pills, excessive exercise, diuretics and laxatives.
 As disease progresses, becomes deceitful, stubborn, hostile, and manipulative.

Nursing Interventions

1. Cognitive and Behavioral therapy to positive and negative reinforcement: focus is on client’s
responsibility to gain weight.
 Privileges are gained with weight gain.
 Privileges are lost with weight loss.
2. Increase self-esteem by acceptance and non-judgmental approach so the patient will
realize that they do not need to artificial perfection they believe thinness provides. Assist to
find other positive qualities about self.
3. Teach about the disorder. The more information they receive that validates their problem,
the less likely they will deny it.
4. Monitor weight three times a week but weigh with the patient facing away from the weighing
scale to help them reduce their focus on weight. Make sure the patient is not hiding heavy
objects under her clothing.
5. As soon as the ideal weight is gained, allow patient to regulate his or her own progression
and program.
6. High protein and high carbohydrate diet, serve foods the patient prefer in small frequent
feedings. NGT if the patient refuses to eat.
7. Setting limits to avoid manipulative behavior:
 Restrict use of bathroom for 2 hour after eating.
 Accompany to the bathroom to ensure that they will not self induce vomiting.
 Stay with client during meals.
 Do not accept excuses to leave eating area.
8. Help the patient identify and express feelings. Avoid being judgmental. People with eating
disorders are thought to be afraid of expressing strong emotions; they express their feelings
unconsciously by vomiting, starvation, and purging.
9. Help the patient to identify and express other bodily concerns such as hairstyle, clothing.
Typically anorectic patients have little bodily awareness other than a distorted perception of
their size.
10. Identify the patients non-weight related interests. This could help reduce anxiety, become
creative outlet for energy, raise self-esteem and divert attention from eating and weight.
11. Avoid being confrontational and engaging in long discussions or explanations about food or
body.
12. Ignore manipulative behaviors.
13. Refer to self-help groups.

Anxiety
Definition:

 Is a subjective, individual experience characterized by a feeling of apprehension,

uneasiness, uncertainty, or dread.
 It occurs as a result of threats that may be actual or imagined, misperceived or
misinterpreted, or from a threat to identity or self-esteem.
 It often precedes new experiences.
 May be treated by therapy, counselling. Some trials say CBD seems to have a positive
effect on anxiety.

Types of Anxiety:

1. Normal
 A healthy type of anxiety that mobilizes a person to action.
2. Acute
 Precipitated by imminent loss or change that threatens the sense of security.
3. Chronic
 Anxiety that the individual has lived with for a long time.

Levels of Anxiety:

1.Mild/ Alertness Level (+1)

 This is the type of anxiety associated with the normal tension of everyday life.
 The individual is alert
 Perceptual field is increased
 Produce growth and creativity, as it increases learning
 The person uses adaptive coping mechanisms to solve problems and alleviate anxiety.
Nursing Interventions:
1. Recognize the anxiety by statements such as “I notice you being restless today”.
2. Explore causes of anxiety and ways to solve problems that cause anxiety by statements
such as “Let’s discuss ways to…”
2. Moderate/ Apprehension Level (+2)
 The response of the body to immediate danger and focus is directed to immediate
concerns.
 Narrows the perceptual field to pay attention to particular details.
 Selective inattentiveness occurs
 The increased tension makes this the optimal time for learning
 The person uses palliative coping mechanisms.
Nursing Interventions:
1. Provide outlets for anxiety such as crying or talking.
2. Tell client “It’s all right to cry”.
3. Encourage in motor activity to reduce tension.
4. Make client be aware of his behavior and feelings by statements such as “ I know you feel
scare…”
5. Encourage client to move from affecting (feeling) to cognitive mode (thinking).
6. Refocus attention
7. Encourage the client to talk about felings and concerns.
 8. Help the client identify thoughts and feelings that occurred prior to the onset of anxiety.
9. Provide anti-anxiety oral medications.
3. Severe/ Free-floating Level (+3)
 Creates a feeling that something bad is about to happen, or feeling of an impending doom.
 Fight and flight response sets in
 Narrow perceptual field occurs and focus is on specific details or scaterred details so that
learning and problem-solving is not possible.
 All behaviors are directed at alternative the anxiety
 The individual needs direction to focus
 Dilated pupils, fixed vision
 The person uses maladaptive coping mechanisms.
Nursing Interventions:
1. Do not focus on coping mechanisms
2. Stay calm and stay with the client
3. Give short and explicit direction
4. Modify the environment by setting limits or seclusion, limit interaction with others, and
reduce environmental stimuli to calm client.
5. Provide IM antianxiety medications.
4. Panic Level (+4)
 Feelings of helplessness and terror
 The personality and behavior is disorganized
 The individual lessens perception of the environment to protect the ego from awareness
and anxiety causing distorted perceptions and loss of rational thoughts.
 Is unable to communicate or function effectively
 Inability to concentrate
 If prolonged, panic can lead to exhaustion and death
 The person uses dysfunctional coping mechanisms.
Nursing Interventions:
1. Guide patient step by step to action
2. Restrain if necessary.
 

Behavior Modification
Definition

Behavior modification is a method of strengthening desired behavior or response through a

positive or negative reinforcement of adaptive behavior or the reduction of a maladaptive behavior
through extinction, punishment or therapy.
For example you are an employee. You worked extra hours just to finish your tasks, arrives at
work on time and sometimes you skip lunch just to complete the assigned job. A hard worker –
that’s what you are! Now after a month of hard work your paycheck is delayed. Weeks and months
passed and still the salary is not released. Would you perform the same effort towards your job
now that you are still unpaid? You might still go to work with a change behavior or stop working.

For working people, receiving a regular and on-time paycheck is a positive reinforcer that
motivates the employees to do their job well. If this motivating factor is lacking, expect a less
efficient job performance from the employees. Behaviorists believed that a behavior can be
change through a system of rewards and punishments.
Positive and Negative Reinforcement

A positive reinforcement is provided by giving a person attention and positive feedback. For
example, a child has successfully made it through the night without wetting the bed. The mother
acknowledges the child’s behavior in front of the family during breakfast period.
A negative reinforcement on the other hand is done by removing a stimulus after a behavior
occurred to prevent it from occurring again. For example, a student becomes anxious when he is
seated at the back during classes. He or she may ask the professor to be seated in front to
prevent such anxiety.

Indication

 Obsessive-compulsive behavior (OCD)

 Attention deficit hyperactivity disorder (ADHD)
 Phobias
 Enuresis (bed-wetting)
 Generalized anxiety disorder
 Separation anxiety disorder

Behavior Modification Techniques

ABC approach

A – Antecedents
Antecedents are the events that occur before a particular behavior is demonstrated. “What comes
directly before the behavior?”

B – Behaviors
The behavior developed as a result of the presence of antecedent. “What does the behavior look
like?”

C – Consequences
These are the events that occur after the behavior. “What comes directly after the behavior?”

After the ABC’s are assessed, the data gathered is analyzed and identified as inappropriate and
appropriate behavior. Inappropriate behaviors are observed, targeted and stopped while the
appropriate ones are identified, developed, strengthened and maintained.

Some Behavioral Theories and Theorists

Theorists such as Ivan Pavlov and Burrhus Frederick Skinner focused on observable behaviors
and factors that bring about behavioral changes.

Classical Conditioning by Ivan Petrovich Pavlov

Ivan Pavlov is a Russian psychologist, physiologist and physician widely known for providing the
best example of classical conditioning through experimentation on dogs. Classical conditioning
principle states that a behavior can be modified or changed through conditioning of the external
stimuli or conditions.

Operant conditioning by Burrhus Frederick Skinner

B.F. Skinner is an American psychologist who developed the operant conditioning. Operant
conditioning states that people learn their behaviors from their past experiences particularly those
which as constantly reinforced.
Bipolar and Unipolar Comparison
Bipolar

 Results from disturbances in the areas of the brain that regulate mood
 It involves periods of excitability (mania) alternating with periods of depression
 This may affects men and women equally
 Usually appears between ages 15 – 25
Cause

 Unknown
 It occurs more often in relatives of people with bipolar disorder, if you believe you have
bipolar you might want to visit somewhere like https://www.therecoveryvillage.com/mental-
health/bipolar-disorder/ for more information.
Symptoms

Manic Phase

1. Agitation or irritation
2. Elevated mood (hyperactivity, increased energy, lack of self-control, racing thoughts)
3. Inflated self-esteem (delusions of grandeur, false beliefs in special abilities)
4. Little need for sleep
5. Over-involvement in activities
6. Poor temper control
7. Reckless behavior (binge eating, drinking, and/or drug use, impaired judgment, sexual
promiscuity, spending sprees)
8. Tendency to be easily distracted

Depressed Phase

1. Difficulty concentrating, remembering, or making decisions

2. Eating disturbances
3. Fatigue or listlessness
4. Feelings of worthlessness, hopelessness and/or guilt
5. Loss of self-esteem
6. Persistent sadness and thoughts of death
7. Sleep disturbances
8. Suicidal thoughts
9. Withdrawal from activities that were once enjoyed

Medical Intervention

 Proper History Taking and Observation

 Antipsychotic medications (such as lithium and mood stabilizers or antidepressant for
depressive phase)
 Electroconvulsive therapy (ECT)

Nursing Interventions

1. Provide a calm environment

2. Giving health teachings about regular exercise, and proper diet
3. Explain to patient that getting enough sleep helps keep a stable mood
Unipolar

 Another name for major depressive disorder

 Occurs when a person experiences the symptoms for longer than a two-week period

Causes

 The biopsychosocial model proposes that biological, psychological, and social factors all
play a role in causing depression
 The diathesis–stress model specifies that depression results when a preexisting
vulnerability, or diathesis, is activated by stressful life events
Symptoms

1. Depressed mood
2. A lack of interest in activities normally enjoyed
3. Changes in weight and sleep
4. Fatigue
5. Feelings of worthlessness and guilt
6. Difficulty concentrating
7. Has thoughts of death and suicide

Medical Interventions

 Antidepressants
 Tricyclic antidepressants
 Monoamine oxidase inhibitors
 Selective serotonin re-uptake inhibitors
 Electroconvulsive therapy

Nursing Interventions

1. Interpersonal Therapy
2. Psychotherapy
3. Encourage client to have a regular exercise
4. Cognitive behavioral therapy
5. Behavioral modification therapy
Difference between Bipolar and Unipolar Disorder

UNIPOLAR BIPOLAR

Gender Affects women more often

and Age than men, appears later in Affects men and woman equally, average age of
of Onset life onset suspected to be 18 years

Generally insomnia,
difficulty falling asleep or
waking repeatedly during Generally hypersomnia, excessive tiredness and
Sleep the night difficulty waking in the morning

Appetite Often has a loss of Often binge-eating and cravings for

appetite and diminished
 interest in eating carbohydrates, may alternate with loss of appetite

Agitated, pacing and Inactivity, somnolence, a slowing down of

Activity restlessness are more movements (psychomotor retardation) more
Level common common

Sadness, hopelessness, Same as for unipolar, although guilt is often much

Mood feelings of worthlessness more prominent

Episodes often last

longer, sometimes more Risk of drug abuse and suicide higher than in
Other responsive to treatment unipolar depression

Bipolar Disorder
Description

A mood disorder, formerly known as manic depression is characterized by recurrent episodes of

depression and mania. Either phase may be predominant at any given time or elements of both
phases may be present simultaneously.

Risk Factors

1. Biochemical imbalances
2. Family genetics – one parent, child has 25% risk; two parents, 50-75% risk.
3. Environmental factors such as stress, losses, poverty, social isolation.
4. Psychological influences – inadequate coping, denial of disordered behavior.
Specific Biological Factors

1. Possible excess of norepinephrine, serotonin, and dopamine.

2. Increased intracellular sodium and calcium
3. Neurotransmitters supersensitive to transmission of impulses
4. Defective feedback mechanism in limbic system.
Signs and Symptoms

1. Risk for self or others

2. Impaired social interactions
3. Mania

 Persistent elevated or irritable mood
 Poor judgment
 Increase in talking and activities, grandiose view of self and abilities.
 Impulsivity such as spending money, giving away money or possessions.
 Impairment in social and occupational functioning
 Decreased sleep
 Distractibility
 Delusions, paranoia, and hallucinations
 Dislike of interference or intolerance of criticism
 Denial of illness
 Agitation
 Attention seeking behavior
 Depression

Nursing Diagnoses

1. High risk for violence, directed at self or others

2. Impaired verbal communication
3. Anxiety
4. Individual coping, ineffective
5. Disturbance of self-esteem
6. Alteration in though processes
7. Alteration in sensory perceptions
8. Self-care deficits
9. Sleep pattern disturbances
10. Alteration in nutrition
Therapeutic Nursing Management

1. Environment
2. Psychological treatment
 Individual Psychotherapy – may be used to identify stressors and pattern of
behavior.
 Group therapy – establishes a supportive environment and redirect inappropriate
behavior.
 Family therapy – verbalizes family frustration and establishes a treatment plan for
outpatient use.
3. Somatic and Psychopharmacologic treatments
 electroconvulsive therapy
 Psychopharmacology

Nursing Interventions

1. Assess client’s suicidal feelings and intentions and escalating behavior regularly.
2. Set consistent limits on inappropriate behavior to help the client de-escalate.
3. Establish a calm environment for the client.
4. Reinforce and focus on reality.
5. Provide outlets for physical activity but prevent client for escalating.
6. Client may be very likable during “high periods”. Staff members need to avoid participating
in this behavior, at other times, client may be very irritable and staff members should
approach client quietly and with limits, if necessary.
7. If the client cannot control self and other methods are not successful, staff may need to
provide client protection if a threat of a self-harm or injury to other exist.
8. Monitor client’s nutrition, fluid intake and sleep.
9. Discuss with the client and family the possible environment or situational causes,
contributing factors and triggers for a mood disorder with recurrent episodes of depression
and mania.

Bulimia Nervosa
Definition

 “The Diet-Binge-Purge Disorder”.

 Is a disorder characterized by alternating dieting, binging and purging through vomiting,
enema, and laxatives.
 The person engages in episodes of starvation and other methods of controlling weight (diet
pills, excessive exercise, enemas, diuretics, laxatives), then engages in uncontrolled and rapid
eating for about two hours (over 8000 calories in 2 hours and 50,000 in 1 day) then terminates
binging by inducing self to vomit, going to sleep or going to social activities.
 Weight fluctuations are due to alternating fasting and binging.
1.
1. Bulimia means insatiable appetite.
2. Binging means eating an unusually large amount of food over a short period of time.
3. Purging is an attempt to compensate for calories consumed via self-induced vomiting
or abuse of laxatives, diuretics, or enemas.
 A chronic disorder that usually manifest first during late adolescence and early adulthood,
around the ages 15-24 years. It almost always occurs after a period ofdieting.
 The bulimic often belong to a family and society that place great value on external
appearance. The person strives to be thin to be accepted because they believe self-worth
requires being thin.
 Usually of normal weight or obese, extrovert, reports self loathing, low self-esteem, has
symptoms of depression, of fear of losing control, with self-destructive tendencies such as
suicide.
 These individuals are known to be perfectionist, achievers scholastically and professionally
and highly dependent on the approval of others to maintain self-esteem. They hide their
disorder because of fear of rejection.
 Like anorexia, bulimia can kill. Even though bulimics put up a brave front, they are often
depressed, lonely, ashamed, and empty inside. Friends may describe them as competent and
fun to be with, but underneath, when they hide their guilty secrets, they are hurting. Feeling
unworthy, they suffered from great difficulty talking about their feelings, which almost always
include anxiety, depression, self-doubt, and deeply buried anger. Impulse control may be a
problem like shoplifting, sexual adventurousness, alcohol and drug abuse, and other kinds of
risk taking behavior in which the person acts with little consideration of consequences.
 The person is aware that the behavior is abnormal, but is unable to stop because she is
immobilized by her fear that she cannot stop her behavior voluntarily. The binge episode
usually ends when the person becomes exhausted eating, develops GIT discomfort, runs out
of food or is noticed by others.
 After the episode she becomes guilty and depressed that she was unable to control herself,
and engages in self-critism. Then she purges her self as a form of cleansing and punishment.

Common Complications Related to the Manner of Purging

 Chronic inflammation of the lining of the esophagus due to induced vomiting, acidic gastric
secretions irritates esophageal mucosa.
 Rupture of esophagus and stomach.
 Electrolyte imbalance causing cardiac arrythmias, hypokalemia due to
diarrhea,hypochloremia due to vomiting, hyponatremia due to vomiting and diarrhea.
 Dehydration.
 Enlargement of the parotid gland.
 Irritable bowel syndrome.
 Rectal prolapse or abscess.
 Dental erosion.
 Chronic edema.
 Fungal infection of vagina and rectum.

Nursing Diagnosis

 Alterations in health maintenance.

 Altered nutrition: Less than body requirements.
 Altered nutrition: More than body requirements
 Anxiety
 Body image disturbance
 Ineffective family coping; compromised
 Ineffective individual coping
 Self-esteem disturbance

Nursing Interventions

1. Patient with bulimia are aware of their problems and they want to be helped because they
feel helpless and unable to control themselves during episodes of binging. But because of
their intense desire to please and need to conform they may resort to manipulative behavior
and tell half-truths during interview to gain trust and acceptance of nurses. Create an
atmosphere of trust. Accept person as worthwhile individual. If they know that no rejection or
punishment is forthcoming they disclose their problem, they will be more open and honest.
2. Develop strength to cope with problems. Encourage patient to discuss positive qualities
about themselves to increase self-esteem.
3. Help patient identify feelings and situations associated with or that triggers binge eating.
 Assist to explore alternative and positive ways of coping.
 Encourage making a journal of incident and feelings before-during and after a binge
episode.
 Make a contract with the patient to approach the nurse when they feel the urge to
binge so that feelings and alternative ways of coping can be explored.
4. Encourage adhering to meal and snack schedule of hospital. This decreases the incidence
of binging, which is often precipitated by starvation and fasting.
5. Encourage participating in group activities with other persons having the same eating
disorder to gain additional support.
6. For young adolescent living at home, encourage family therapy to correct dysfunctional
family patterns.
7. Cognitive behavioral therapy is the ideal therapy to help the bulimic understand the problem
and explore appropriate behaviors.

Cognitive Disorders
Definition

 Cognitive disorders are characterized by the disruption of thinking, memory, processing,

and problem solving.
 Types of cognitive disorders include: delirium, dementia, and memory loss disorders
(amnesia or dissociative fugue).
Risk Factors

1. Physiological changes such as neurological, metabolic, and cardiovascular disease.

2. Cognitive changes
3. Family genetics
4. Infections
5. Tumors
6. Sleep disorders
7. Substance abuse
8. Drug intoxications and withdrawals

Signs and Symptoms

1. Irritability; mood most frequently seen in organic brain disorder.

2. Change in level of consciousness.
3. Difficulty thinking with sudden onset.
4. State of awareness ranging from hyper vigilance to stupor or coma.
5. Impairment in cognition and thought process, particularly short-term memory.
6. Anxiety
7. Confabulation

Therapeutic Nursing Management

1. The nurse plays a primary role in providing a safe environment for the client and others.
2. Exogenous stimuli in the environment can intensify the client’s level of orientation.
3. Cognitive changes may often include a period of confusion or forgetfulness.
4. The nurse may encourage family members to bring photographs or familiar items as
strategy to orient the client.
5. Psychological treatment may focus more on the family to offer them support during this
stressful time.
6. Cognitive changes affect the family and care providers. Cognitive decline often means a
change in the family roles and activities of daily living.
7. Pharmacologic therapy is implemented to reduce or alleviate the associated symptoms
such as antianxiety medications, antidepressants, and antipsychotics.

Nursing Interventions

1. Determine the cause and treatment of the underlying causes.

2. Remain with the client, monitoring behavior, providing reorientation and assurance.
3. Provide a room with a low level of visual and auditory stimuli.
4. Provide palliative care with the focus on nutritional support.
5. Reinforce orientation to time, place, and person.
6. Establish a routine.
7. Client protection may be required.
8. Have client wear an identification bracelet, in case she or he gets lost.
9. The client should not be left alone at home
10. Break test into small steps, giving one instruction at a time.

Crisis Intervention
Definition
Crisis is a situation or period in an individual’s life that produces an overwhelming emotional
response. This event occurs when an individual is confronted by a certain life circumstance or
stressor that he or she cannot effectively manage by using his or her usual coping skills. Crisis is
an unexpected event that can create uncertainty to an individual and has been viewed as a threat
to a person’s important goals.

Stages of Crisis

The first stage of crisis occurs when the person is confronted by a stressor. Exposure to this
stressor would result to anxiety. The individual then tries to handle things by using his or her
customary coping skills. Second stage of crisis occurs when the person realizes that his usual
coping ability is ineffective in dealing with anxiety. As the person becomes aware of his
unsuccessful effort in dealing with the perceived stressor, he moves on to the next stage of crisis
where the individual tries to deal with the crisis using new methods of coping.  The fourth stage of
crisis takes place when the person’s coping attempts of resolving the crisis fail. The individual then
experiences disequilibrium and significant distress.

Types of crisis

1. Maturational crisis – also called developmental crisis. These are predictable events in a
person’s life which includes getting married, having a baby and leaving home for the first time.
2. Situational crises – unexpected or sudden events that imperils ones integrity. Included in
this type of crisis are: loss of a job, death of a loved one or relative and physical and emotional
illness of a family member or an individual.
3. Adventitious crisis – also called social crisis. Included in this category are: natural disasters
like floods, earthquakes or hurricanes, war, terrorist attacks, riots and violent crimes such as
rape and murder.

Crisis Intervention

Crisis intervention refers to the methods used to offer immediate, short-term help to individuals
who experience an event that produces emotional, mental, physical, and behavioral distress or
problems.

Guide for an effective crisis intervention:

1. Assist the person to view the event or issue in a different perspective.

2. Assist the individual to use the existing support systems. It is vital to help the person find
new sources of support that can help in decreasing the feelings of being alone or
overwhelmed.
3. Assist the individual in learning new methods of coping that will help resolve the current
crisis and give him or her new coping skills to be used in the future when dealing with another
overwhelming situation.
Defense Mechanisms
People use defense, or coping, mechanisms to relieve anxiety. The definitions below will help you
determine whether your patient is using one or more of these mechanisms.

1. Acting Out
 Acting out refers to repeating certain actions to ward off anxiety without weighing the
possible consequences of those action.
 Example: A husband gets angry with his wife and starts staying at work later.
2. Compensation
 Also called substitution.
 It involves trying to make up for feelings of inadequacy or frustration in one area by
excelling or overindulging in another.
 Example: An adolescent takes up jogging because he failed to make the swimming
team.
3. Denial
 A person in denial protects himself from reality – especially the unpleasant aspects
of life – by refusing to perceive, acknowledge, or face it.
 Example: A woman newly diagnosed with end-stage-cancer says, “I’ll be okay, it’s
not a big deal”.
4. Displacement
 In displacement, the person redirects his impulses (commonly anger) from the real
target (because that target is too dangerous) to a safer but innocent person.
 Example: A patient yells at a nurse after becoming angry at his mother for not calling
him.
5. Fantasy
 Fantasy refers to creation of unrealistic or improbable images as a way of escaping
from daily pressures and responsibilities or to relieve boredom.
 Example: A person may daydream excessively, watch TV for hours on end, or
imagine being highly successful when he feels unsuccessful. Engaging in such activities
makes him feel better for a brief period.
6. Identification
 In identification, the person unconsciously adopts the personality characteristics,
attitudes, values, and behavior of someone else (such as a hero he emulates and
admires) as a way to allay anxiety. He may identify with a group to be more accepted by
them.
 Example: An adolescent girl begins to dress and act like her favorite pop star.
7. Intellectualization
 Also called isolation.
 Intellectualization refers to hiding one’s emotional responses or problems under a
façade of big words and pretending there’s no problem.
 Example: After failing to obtain a job promotion, a worker explains that the position
failed to meet his expectations for climbing the corporate ladder.
8. Introjection
 A person introjects when he adopts someone else’s values and standards without
exploring whether they fit him.
 Example: An individual begins to follow a strict vegetarian diet for no apparent
reason.
9. Projection
 In projection, the person attributes to others his own unacceptable thoughts, feelings,
and impulses.
  Example: A student who fails a test blames his parents for having the television on
too loud when he was trying to study.
10. Rationalization
 Rationalization occurs when a person substitutes acceptable reasons for the real or
actual reasons that are motivating his behavior.
 The rationalizing patient makes excuses for shortcomings and avoids self-
condemnation, displacements, and criticisms.
 Example: An individual states that she didn’t win the race because she hadn’t gotten
a good night’s sleep.
11. Reaction Formation
 In reaction formation, the person behaves the opposite of the way he feels.
 Example: Love turns to hate and hate into love.
12. Regression
 Under stress, a person may regress by returning to the behaviors he used in an
earlier, more comfortable time in his life.
 Example: A previously toilet-trained preschool child begins to wet his bed every night
after his baby brother is born.
13. Repression
 Repression refers to unconsciously blocking out painful or unacceptable thoughts
and feelings, leaving them to operate in the subconscious.
 Example: A woman who was sexually abused as a young child can’t remember the
abuse but experiences uneasy feelings when she goes near the place where the abuse
occurred.
14. Sublimation
 In sublimation, a person transforms unacceptable needs in acceptable ambitions and
actions.
 Example: He may channel his sex drive into his sports or hobbies.
15. Undoing
 In undoing, the person tries to undo the harm he feels he has done to others.
 Example: A patient who says something bad about a friend may try to undo the harm
by saying nice things about her or by being nice to her and apologizing.

Developmental Theories
Theorists consider that emotional, social, cognitive and moral skills develop in stages.

1. Psychosocial – Erik Erikson’s theory of psychosocial development is most widely used. At

each stage, children confront a crisis that requires the integration of personal needs and skills
with social and cultural expectations. Each stage has two possible components, favorable and
unfavorable.
2. Psychosexual – Sigmund Freud considered sexual instincts to be significant in the
development of personality. At each stage, regions of the body assume prominent psychologic
significance as source of pleasure.
3. Cognitive – Jean Piaget proposed four major stages of development for logical thinking.
Each stage arises from and builds on the previous stage in an orderly fashion.
4. Moral – Lawrence Kohlberg’s theory of moral development is based on cognitive
development and consists of three major levels, each containing two stages.
Stage Erikson Freud Piaget Kohlberg

Infancy
(birth to 1 year) Trust vs. Sensorimotor
mistrust Oral (birth to 2 years)

Toddlerhood Autonomy vs. Anal Sensorimotor (1- Preconventional

 2 years);
preoperational
(1-3 years old) same and (preconceptual)
doubt (2-4 years)

Preoperational
(preconceptual)
(2-4 years);
Preschool preoperational
(3-6 years old) Initiative vs. (intuitive) (4-7
guilt Phallic years) Preconventional

Concrete
School Age operations
(6-12 years) Industry vs. (7-11 years)
inferiority Latency Conventional

Formal
Adolescence Identity vs. role operations
(12-18 years) diffusion (11-15 years)
(confusion) Genital Postconventional

Eating Disorders
Overview

Eating is very important in every human being. Not only that it is necessary for survival but it is
also a social activity and has been part of many occasions all around the world. For some
individuals, eating is one source of their worries, anxiety and problems.

Many people are worried and apprehensive about how they look. Most of the time, they can feel
self-conscious about their bodies. Amongst the population, the teens are the ones most concerned
about their body figure. This can be true, especially that they are going through puberty and they
undergo dramatic physical changes and face social pressures.

Definition

Eating disorders refer to a group of conditions that are described and typified by the abnormal
eating habits that are involved. The food intake in this case are either insufficient or excessive that
results to detriment of an individual’s physical and emotional health.
List of Common Eating Disorders

 Anorexia Nervosa (AN). AN is a life-threatening eating disorder. It is characterized by the

client’s refusal or inability to maintain a minimally normal weight and an intense fear of gaining
weight. Clients with anorexia nervosa have a disturbed perception of the size and shape of
their body. These people have body weight that is 85% or less of that expected for their age
and height. Anorexia can cause menstruation to stop, and often leads to bone loss, loss of
skin integrity, etc. It greatly stresses the heart, increasing the risk of heart attacks and related
heart problems. The risk of death is greatly increased in individuals with this disease.
 Bulimia Nervosa. Bulimia is characterized by recurrent binge eating followed by
compensatory behaviors such as purging (self-induced vomiting, excessive use of
laxatives/diuretics, or excessive exercise). The amount of food consumed during a binge
episode is quite larger than a person would normally eat. Bulimics may also fast for a certain
amount of time following a binge. Clients with bulimia binge because of strong emotions which
are then followed by guilt and shame.
 Binge Eating Disorder. This type of eating disorder is characterized by a compulsive
overeating. However, unlike bulimia nervosa no compensatory behavior is noted after the
binge episode.
 Purging Disorder. Individuals who are eating normally but are recurrently purging to
promote weight loss are under this category.
 Pica. Individuals who cannot distinguish between food and non-food items have PICA. In
this type of eating disorder, a person is craving to eat, chew or lick non-food items or foods
containing no nutrition. These things include chalk, paper, plaster, paint chips, baking soda,
starch, glue, rust, ice, coffee grounds and cigarette ashes.

Erik Erikson’s Theory of Psychosocial Development

AKA Erik Homburger Erikson

Born: June 15, 1902 Birthplace: Frankfurt am Main, Germany

Died: May 12, 1994
Location of death: Harwich, MA
Cause of death: unspecified
Religion: Jewish
Race or Ethnicity: White
Occupation: Psychologist
Nationality: United States
Executive summary: Eight Stages of Childhood
Psychosocial development as articulated by Erik Erikson describes eight developmental stages
through which a healthily developing human should pass from infancy to late adulthood. In each
stage the person confronts, and hopefully masters, new challenges. Each stage builds on the
successful completion of earlier stages. The challenges of stages not successfully completed may
be expected to reappear as problems in the future.

Psychosocial Development Stages Summary

 Basic  Important
 Stage Conflict Events  Outcome

Children develop a sense of trust when

 Infancy (birth  Trust vs. caregivers provide reliabilty, care, and
to 18 months) Mistrust  Feeding affection. A lack of this will lead to mistrust.

Children need to develop a sense of

personal control over physical skills and a
 Early  Autonomy sense of independence. Success leads to
Childhood (2 to vs. Shame feelings of autonomy, failure results in
3 years) and Doubt  Toilet Training feelings of shame and doubt.

Children need to begin asserting control

and power over the environment. Success
in this stage leads to a sense of purpose.
Children who try to exert too much power
 Preschool (3  Initiative vs. experience disapproval, resulting in a
to 5 years) Guilt  Exploration sense of guilt.

Children need to cope with new social and

academic demands. Success leads to a
 School Age (6  Industry vs. sense of competence, while failure results
to 11 years) Inferiority  School in feelings of inferiority.

Teens needs to develop a sense of self

and personal identity. Success leads to an
 Adolescence  Identity vs. ability to stay true to yourself, while failure
(12 to 18 Role  Social leads to role confusion and a weak sense
years) Confusion Relationships of self.

Young adults need to form intimate, loving

 Young relationships with other people. Success
Adulthood (19  Intimacy vs. leads to strong relationships, while failure
to 40 years) Isolation  Relationships results in loneliness and isolation.

 Middle  Generativit  Work and Adults need to create or nurture things that
 will outlast them, often by having children
or creating a positive change that benefits
other people. Success leads to feelings of
usefulness and accomplishment, while
Adulthood (40 y vs. failure results in shallow involvement in the
to 65 years) Stagnation Parenthood world.

Older adults need to look back on life and

feel a sense of fulfillment. Success at this
 Ego stage leads to feelings of wisdom, while
 Maturity(65 to Integrity vs.  Reflection on failure results in regret, bitterness, and
death) Despair Life despair.

Psychosocial Development Stages

Infancy (Birth -18 months)

 Psychosocial Crisis: Trust vs. Mistrust
Developing trust is the first task of the ego, and it is never complete. The child will let its mother
out of sight without anxiety and rage because she has become an inner certainty as well as an
outer predictability. The balance of trust with mistrust depends largely on the quality of the
maternal relationship.

 Main question asked: Is my environment trustworthy or not?

 Central Task: Receiving care
 Positive Outcome: Trust in people and the environment
 Ego Quality: Hope
 Definition: Enduring belief that one can attain one’s deep and essential wishes
 Developmental Task: Social attachment; Maturation of sensory, perceptual, and motor
functions; Primitive causality.
 Significant Relations: Maternal parent
Erikson proposed that the concept of trust versus mistrust is present throughout an individual’s
entire life. Therefore if the concept is not addressed, taught and handled properly during infancy
(when it is first introduced), an individual may be negatively affected and never fully immerse
themselves in the world. For example, a person may hide themselves from the outside world and
be unable to form healthy and long-lasting relationships with others, or even themselves. If an
individual does not learn to trust themselves, others and the world they may lose the virtue of
hope, which is directly linked to this concept. If a person loses their belief in hope they will struggle
with overcoming hard times and failures in their lives, and may never fully recover from them. This
would prevent them from learning and maturing into a fully-developed person if the concept of trust
versus mistrust was improperly learned, understood and used in all aspects of their lives.

Younger Years (1 1/2 – 3 Years)

 Psychosocial Crisis: Autonomy vs. Shame & doubt
If denied independence, the child will turn against his/her urges to manipulate and discriminate.
Shame develops with the child’s self-consciousness. Doubt has to do with having a front and back
— a “behind” subject to its own rules. Left over doubt may become paranoia. The sense of
autonomy fostered in the child and modified as life progresses serves the preservation in
economic and political life of a sense of justice.

 Main question asked: Do I need help from others or not?

Early Childhood (3-6 Years)
 Psychosocial Crisis: Initiative vs. Guilt
Initiative adds to autonomy the quality of undertaking, planning, and attacking a task for the sake
of being active and on the move. The child is learning to master the world around them, learning
basic skills and principles of physics; things fall to the ground, not up; round things roll, how to zip
and tie, count and speak with ease. At this stage the child wants to begin and complete their own
actions for a purpose. Guilt is a new emotion and is confusing to the child; she may feel guilty over
things which are not logically guilt producing, and she will feel guilt when her initiative does not
produce the desired results.

 Main question asked: How moral am I?

Middle Childhood (7-12 Years)

 Psychosocial Crisis: Industry vs. Inferiority

To bring a productive situation to completion is an aim which gradually supersedes the whims and
wishes of play. The fundamentals of technology are developed. To lose the hope of such
“industrious” association may pull the child back to the more isolated, less conscious familial
rivalry of the oedipal time.

 Main question asked: Am I good at what I do?

Adolescence (12-18 Years)

 Psychosocial Crisis: Identity vs. Role Confusion
The adolescent is newly concerned with how they appear to others. Ego identity is the accrued
confidence that the inner sameness and continuity prepared in the past are matched by the
sameness and continuity of one’s meaning for others, as evidenced in the promise of a career.
The inability to settle on a school or occupational identity is disturbing.

 Main question asked: “Who am I, and what is my goal in life?”

Early Adulthood (19-34 years)

 Psychosocial Crisis: Intimacy vs. Isolation
Body and ego must be masters of organ modes and of the other nuclear conflicts in order to face
the fear of ego loss in situations which call for self-abandon. The avoidance of these experiences
leads to openness and self-absorption.

Middle Adulthood (35-60 Years)

 Psychosocial Crisis: Generativity vs. Stagnation
Generativity is the concern of establishing and guiding the next generation. Simply having or
wanting children doesn’t achieve generativity. Socially-valued work and disciplines are also
expressions of generativity.

 Main question asked: Will I ever accomplish anything useful?…

Later Adulthood (60 years – Death)

 Psychosocial Crisis: Ego integrity vs. despair
Ego integrity is the ego’s accumulated assurance of its capacity for order and meaning. Despair is
signified by a fear of one’s own death, as well as the loss of self-sufficiency, and of loved partners
and friends.

Electroconvulsive Therapy (ECT)

Definition

Electroconvulsive therapy or the shock treatment is used to treat depression in clients who do not
respond to antidepressants or those patients who have intolerable adverse reactions at
administered therapeutic doses. Despite the controversy about the therapy, it is proven to be
effective for certain patients. Many depressed (major) clients, particularly those with psychotic
symptoms, don’t respond to medications but do respond to ECT.

Indications
Nowadays, ECT is not only used for major depression, but also for the treatment of:

 mania (in bipolar disorder)

 catatonia
 quick relief for self-destructive behavior (suicide attempts)
ECT may only be indicated for the treatment of severely depressed clients that needs fast relief.
Suicidal clients may be given ECT. Giving antidepressant medication may take weeks before the
full effects to occur. That is an enough time for a self-destructive client to harm himself.

Can pregnant women undergo ECT?

Pregnant clients can also undergo an electroconvulsive therapy. The treatment poses no harm or
injury to the fetus. Thus, pregnant self-destructive women may undergo ECT to provide quick relief
of depression and self-directed violence. This prevents a fetus from suffering if an untreated the
mother tries to hurt herself while waiting for the medication to take full effect.

Contraindications and precautions

ECT stimulates a seizure episode to occur, however it does not cause a seizure disorder and
patient with a seizure disorder may undergo the therapy. No absolute contraindications are noted
with ECT but a few conditions have been associated with morbidity and mortality rate which
includes the following:

 recent myocardial infraction

 stroke
 sever hypertension
 presence of intracerebral mass
Mechanism of action

The therapy induces a therapeutic tonic seizure (a seizure where the person loses consciousness
and has convulsions) which lasts for about 15 seconds. To do this, electrodes are applied to the
head of the client which will deliver an electrical impulse in the brain that causes a seizure. It is
believed that the shock intensifies brain chemistry to correct the chemical imbalance in depression
(decrease serotonin and norepinephrine).

Frequency of treatment

A series of about 6-15 treatments are scheduled three times a week. Six treatments are needed to
observe a sustained improvement of depressive symptoms. Maximum effect or benefit is achieved
in 12 to 15 treatments.

Side Effects

 Confusion or Disorientation
 Fatigue
 Headache
 Short-term memory impairment (temporary)
Nursing Interventions

Before ECT
1. Informed consent should be signed.
2. NPO post midnight.
3. Remove fingernail polish.
4. IV line initiation.
5. Administration of short-acting anesthetic.
6. Administration of a sedative or muscle relaxant (succinylcholine).  Atropine is also given to
decrease bronchial secretions which could block the airways during seizures.
7. Let the client void before the procedure.
During ECT
1. Place electrodes on the client’s head on one side (unilateral) or both (bilateral).
2. Brain monitoring through electroencephalogram (EEG).
3. Oxygen administration with an Ambu-bag.
After ECT
1. When the client is awake, reorient the client.
2. Obtain vital signs.
3. Assess client for the return of gag reflex.
4. Allow the client to eat (with a positive gag reflex).

Feeding and Eating Disorders of Infancy and Early Childhood

Definition

Feeding disorder of infancy or early childhood is characterized by the failure of an infant or child
under six years of age to eat enough food to gain weight and grow normally over a period of one
month or more. The disorder can also be characterized by the loss of a significant amount of
weight over one month. The disorders of feeding and eating included in this category are
persistent in nature and are not explained by underlying medical conditions. They include the
following:

1. Pica
2. Rumination disorder
 3. Feeding disorder
PICA

Pica is an eating disorder typically defined as the persistent ingestion of nonnutritive substances
for a period of at least 1 month at an age at which this behavior is developmentally inappropriate
(eg, >18-24 mos). It is seen more in young children than adults. Between 10 and 32% of children
ages 1 – 6 have these behaviors.

Children with Pica may eat:

1. Animal feces
2. Clay
3. Dirt
4. Hairballs
5. Ice
6. Paint
7. Sand
This pattern of eating should last at least 1 month to fit the diagnosis of pica. It is not yet known
what causes pica, but research indicates that it may be related to mineral deficiencies such as an
iron deficiency. However, often the non-food items that an individual chooses to consume will not
contain the mineral of which they are deficient, so pica is not an alternative means of obtaining
nutrients.

RUMINATION DISORDER

The term rumination is derived from the Latin word ruminare, which means to chew the cud.
Rumination disorder is the repeated regurgitation and re-chewing of food. With this disorder, the
child brings the partially digested food up into the mouth and usually re-chews and re-swallows the
food. This regurgitation appears effortless, may be preceded by a belching sensation, and typically
does not involve retching or nausea.
In rumination, the regurgitant does not taste sour or bitter. To be considered a disorder, this
behavior must occur in children who had previously been eating normally, and it must occur on a
regular basis, usually daily, for at least one month. The child may exhibit the behavior during
feeding or right after eating.

Symptoms of rumination disorder in babies and young kids include:

1. Repeated regurgitation of food

2. Repeated re-chewing of food
3. Weight loss
4. Bad breath and tooth decay
5. Repeated stomach aches and indigestion
6. Raw and chapped lips
This disorder is relatively uncommon and occurs more often in boys than in girls. It results in
malnutrition, weight loss, and even death in about 25% of affected infants.

FEEDING DISORDER

Feeding disorder of infancy or early childhood is characterized by persistent failure to eat

adequately, which results in significant weight loss or failure to gain weight. This disorder is
equally common in boys and girls. It occurs most often during the first year of life.

General Nursing Interventions for the Mental Health Client

Forming a one-to-one relationship with the client

 It will help the client to enhance communication, problem solving, and social skills.
 Coping skills and trust in relationships may be learned or enhanced.
 The nurse who establishes this relationship needs to be clear about its purpose and provide
positive interaction with the client.
 Establishment of a specific meeting time, expectations for interaction, and the duration of
therapy are important boundaries to establish.
Constructive Feedback

 Given to the client so that the client’s self-esteem will not be compromised.
 When the confrontation technique is used, the nurse needs to discuss the discrepancies
between the client’s verbalized intensions and non-verbal behavior carefully, without
appearing to be attacking the client.

Trust

 Essential to establish a therapeutic relationship.

 Consistency is the key.
 If the nurse cannot meet with client at an appointed time, the client must be informed at the
earliest possible time.
 A new meeting time is scheduled.
 Direct communication is essential for the building of a therapeutic relationship.
 Other factors that facilitate trust within the nurse/client relationship include:
1.
1. Recognizing the client’s feelings.
2. Honesty
3. Respect for the client
4. Non-judgmental attitude

Emphasize Positive Results

 Do not argue with the client.

 Recognize that the client is experiencing pain but do not dwell on that pain.

Assessment

 Critical of their behavior at the time of admission or initial treatment. Reassessment is

indicated at appropriate intervals.
 The client must also learn how to self-monitor his or her symptoms.
 This communicates to the client that he or she is respected and can control his or her
symptoms.

Safety

 The primary concern.

 The client may require protection interventions; these must be provided in a safe manner
with respect for the client.
 The milieu may need to be evaluated for safety

Environment

 Provide privacy and time with decreased stimuli.

 It should be a calm environment in which the client feels safe from psychological and
physical threats.

Physical needs

 Intricately related to psychological function.

 Ensure that the client’s nutritional, fluid, sleep, hygiene, activities of daily leaving, and
exercise needs are met.

Treatment planning

 The client should encourage to participate in every planning.

Medications

 Approach the confused or combative client in a calm, firm manner when administering
client.
 Restrains or the assistance of another care provider may be necessary for injections.
 Ensure that the client takes medications and is not hoarding pills.
 Client will need to learn about his or her medications and hot to maintain this treatment
without direct staff supervision.

Education

 Very important throughout treatment.

Discharge planning

 Begins with the client is admitted, whether it is in the hospital, home care, or any other
treatment program.
 The family must be involved in the process to become successful.

Gestalt Therapy
Definition

Gestalt therapy is a form of psychotherapy, based on the experiential ideal of “here and now,” and
relationships with others and the world. It is an existential or experiential form of psychotherapy
that emphasizes personal responsibility. Gestalt therapy is used often to increase a client’s self-
awareness by putting the past to rest and focus on the present.

History

Gestalt therapy was originally developed by Frederick “Fritz” Perls, Laura Perls, and Paul
Goodman in the 1940s. Perls believed that self-awareness leads to self-acceptance and
responsibility for one’s thoughts and feelings. Gestalt therapy rose from its beginnings in the
middle of the 20th century to rapid and widespread popularity during the decade of the 1960s and
early 1970s. During the 70s and 80s Gestalt therapy training centers spread globally, but they
were, for the most part, not aligned with formal academic settings.
Focus of the therapy

The therapy focuses upon the individual’s experience in the present moment, the therapist-client
relationship, the environmental and social contexts of a person’s life, and the self-regulating
adjustments people make as a result of their overall situation.

Goals that are encouraged to achieved by the patient during Gestalt Therapy

1. Identifying the person’s action or becoming aware of what they are doing.
2. Becoming aware of how they are doing a certain behavior.
3. Learning how to change the behaviors that keeps him or her from achieving life goals.
4. Accepting and valuing him or herself as a person.
5. Emphasizes of what is being done, thought and felt at the present time rather than what
might have been, should have been, was or might be. It FOCUSES on what is happening
instead of on the subject being discussed.

Gestalt Techniques

1. Increasing the awareness of body language and of negative internal messages.

2. Making a client speak continually in the present tense and in the first person to emphasize
self-awareness.
3. Creation of episodes by the therapist and diversions that clearly demonstrate a point rather
that explaining in words.
4. Asking the client to concentrate on a part of his or her personality or one emotion. The
therapist would then ask the client to address it as if it were sitting by itself in the client’s chair.
5. To increase self-awareness the therapist often use this therapy by having then write and
read letters, keep journals and perform other activities designed to put the past tp rest and
focus on the present.

Group Therapy
Definition

Group therapy is a form of psychotherapy which as small, carefully selected group of individuals
meets regularly with a therapist. The client participates in sessions with a group of people. These
individuals share a common purpose and are expected to contribute to the group to benefit from
others in return.

In group therapy approximately 6-10 individuals meet face-to-face with a trained group therapist.
During the group meeting time, members decide what they want to talk about. Members are
encouraged to give feedback to others. Feedback includes expressing your own feelings about
what someone says or does. Group rules are established that all members must observe. These
set of rules vary according to the type of group.

Purpose of a Group Therapy

1. It helps an individual gain new information or learning

2. It helps an individual gain inspiration or hope.
3. The group also allows a person to develop new ways of relating to people.
4. During group therapy, people begin to see that they are not alone and that there is hope
and help. It is comforting to hear that other people have a similar difficulty, or have already
worked through a problem that deeply disturbs another group member.
5. In a group, a person feels accepted.
6. Group therapy sessions allow an individual to interact freely with other members that
shares the same past or present difficulties and problems. The individual then, becomes
aware that he is not alone and that others share the same problem.
7. A person gains insight into one’s problem and behaviors and how they affect to others.
8. Altruistic behavior is practiced. Altruism is the giving of oneself for the benefit of others.
As the group members begin to feel more comfortable, they will be able to speak freely. The
psychological safety of the group will allow the expression of those feelings which are often difficult
to express outside of group. The client will begin to ask for the support he or she needs.

Types of Group Therapy

1. Psychotherapy Groups
2. Family therapy
3. Education groups
4. Support groups
5. Self-help groups

Human Growth and Development

Definition

The term growth and development both refers to dynamic process. Often used interchangeably,
these terms have different meanings. Growth and development are interdependent, interrelated
process. Growth generally takes place during the first 20 years of life.; development continues
after that.

Growth:

1. Is physical change and increase in size.

2. It can be measured quantitatively.
3. Indicators of growth includes height, weight, bone size, and dentition.
4. Growth rates vary during different stages of growth and development.
5. The growth rate is rapid during the prenatal, neonatal, infancy and adolescent stages and
slows during childhood.
6. Physical growth is minimal during adulthood.

Development:

1. Is an increase in the complexity of function and skill progression.

2. It is the capacity and skill of a person to adapt to the environment.
 3. Development is the behavioral aspect of growth
 

Freud’s Psychosexual Development Theory

STAGE AGE CHARACTERISTICS

Center of pleasure: mouth (major source of gratification &

exploration)

Primary need: Security

Birth to 1½
1. Oral y/o Major conflict: weaning

Source of pleasure: anus & bladder (sensual satisfaction & self-

control)

2. Anal 1½ to 3 y/o Major conflict: toilet training

Center of pleasure: child’s genital (masturbation)

3. Phallic 4 to 6 y/o Major conflict: Oedipus & Electra Complex

Energy directed to physical & intellectual activities

Sexual impulses repressed

4. 6 y/o to
Latency puberty Relationship between peers of same sex

5. Puberty Energy directed towards full sexual maturity & function &
Genital onwards development of skills to cope with the environment

Erikson’s Stages of Psychosocial Development Theory

CENTRAL
STAGE AGE TASK (+) RESOLUTION (-) RESOLUTION

Mistrust,
Birth-18 withdrawal,
1. Infancy mos Trust vs Mistrust Learn to trust others estrangement

2. Early 1½ to 3 Autonomy vs Self control w/o loss Compulsive, self-

childhood y/o Shame & doubt of self esteem restraint or
compliance.
Ability of cooperate
& express oneself Willfulness &
 defiance.

Lack of self-
confidence.

Learns to become Pessimism, fear of

assertive wrongdoing.

3. Late Ability to evaluate Over-control & over-

childhood 3 to 5 y/o Initiative vs guilt one’s own behavior restriction.

Learns to create,
develop &
manipulate. Loss of hope, sense
of being mediocre.
Develop sense of
4. School 6 to 12 Industry vs competence & Withdrawal from
Age y/o Inferiority perseverance. school & peers.

Coherent sense of Feelings of

self. confusion,
indecisiveness, &
5. Identity vs role Plans to actualize possible anti-social
Adolescence 12–20 y/o confusion one’s abilities behavior.

Intimate relationship Impersonal

with another relationships.
person.
Avoidance of
Commitment to relationship, career
6. Young Intimacy vs work and or lifestyle
Adulthood 18-25 y/o isolation relationships. commitments.

Self-indulgence,
Creativity, self-concern, lack of
Generativity vs productivity, interests &
7. Adulthood 25-65 y/o stagnation concern for others. commitments.

Acceptance of
worth & uniqueness
of one’s own life.

65 y/o to Integrity vs Acceptance of Sense of loss,

8. Maturity death despair death. contempt for others.
Havighurst’s Developmental Stage and Tasks
DEVELOPMENTAL
STAGE DEVELOPMENTAL TASK

 eat solid foods

 walk
 talk
 control elimination of wastes
 relate emotionally to others
 distinguish right from wrong through development of a
conscience
1. Infancy & early  learn sex differences and sexual modesty
childhood  achieve personal independence
 form simple concepts of social & physical reality

 learn physical skills, required for games

2. Middle childhood
 build healthy attitudes towards oneself
 learn to socialize with peers
 learn appropriate masculine or feminine role
 gain basic reading, writing & mathematical skills
 develop concepts necessary for everyday living
 formulate a conscience based on a value system
 achieve personal independence
 develop attitudes toward social groups & institutions

 establish more mature relationships with same-age

individuals of both sexes
 achieve a masculine or feminine social role
 accept own body
 establish emotional independence from parents
 achieve assurance of economic independence
 prepare for an occupation
 prepare for marriage & establishment of a family
3. Adolescence  acquire skills necessary to fulfill civic responsibilities
 develop a set of values that guides behavior

4. Early Adulthood
 select a partner
 learn to live with a partner
 start a family
 manage a home
 establish self in a career/occupation
 assume civic responsibilities
 become part of a social group

 fulfill civic & social responsibilities

5. Middle Adulthood
 maintain an economic standard of living
 assist adolescent children to become responsible, happy
adults
 relate one’s partner
 adjust to physiological changes
 adjust to aging parents

6. Later Maturity  – adjust to physiological changes & alterations in health

 status
 – adjust to retirement & altered income
 – adjust to death of spouse
 – develop affiliation with one’s age group
 – meet civic & social responsibilities
 – establish satisfactory living arrangements

Levinson’s Seasons of Adulthood

AGE SEASON CHARACTERISTICS

Seeks independence by separating from

18-20 yrs Early adult transition family

Experiments with different careers &

21-27 yrs Entrance into the adult world lifestyles

28-32 yrs Transition Makes lifestyle adjustments

33-39 yrs Settling down Experiences greater stability

45-65 yrs Pay-off years Is self-directed & engages in self-evaluation

Sullivan’s Interpersonal Model of Personality Development

STAGE AGE DESCRIPTION

Birth to 1½ Infant learns to rely on caregivers to meet needs &

1. Infancy yrs desires

1½ to 6 Child begins learning to delay immediate gratification of

2. Childhood yrs needs & desires

3. Juvenile 6 to 9 yrs Child forms fulfilling peer relationships

4. Preadolescence 9 to 12 yrs Child relates successfully to same-sex peers

5. Early 12 to 14 Adolescent learns to be independent & forms

Adolescence yrs relationships with members of opposite sex
 6. Late 14 to 21 Person establishes an intimate, long-lasting relationship
Adolescence yrs with someone of the opposite sex

Piaget’s Phases of Cognitive Development

PHASE AGE DESCRIPTION

Sensory organs & muscles become

a. Sensorimotor Birth to 2 yrs more functional

Birth to 1
Stage 1: Use of reflexes month Movements are primarily reflexive

Perceptions center around one’s body.

Objects are perceived as extensions of

Stage 2: Primary circular reaction 1-4 months the self.

Becomes aware of external environment.

Stage 3: Secondary circular reaction 4-8 months Initiates acts to change the movement.

Stage 4: Coordination of secondary Differentiates goals and goal-directed

schemata 8-12 months activities.

Experiments with methods to reach

goals.
12-18
Stage 5: Tertiary circular reaction months Develops rituals that become significant.

Uses mental imagery to understand the

environment.
18-24
Stage 6: Invention of new means months Uses fantasy.

b. Pre-operational 2-7 years Emerging ability to think

Thinking tends to be egocentric.

Pre-conceptual stage 2-4 year Exhibits use of symbolism.

Unable to break down a whole into

separate parts.

Able to classify objects according to one

Intuitive stage 4-7 years trait.
 Learns to reason about events in the
c. Concrete Operations 7-11 years here-and-now.

Able to see relationships and to reason

d. Formal Operations 11+ years in the abstract.

Kohlberg’s Stages of Moral Development

LEVEL AND STAGE DESCRIPTION

LEVEL I: Pre-conventional Authority figures are obeyed.

(Birth to 9 years) Misbehavior is viewed in terms of damage done.

Stage 1: Punishment & A deed is perceived as “wrong” if one is punished; the

obedience orientation activity is “right” if one is not punished.

“Right” is defined as that which is acceptable to &

approved by the self.
Stage 2: Instrumental-relativist
orientation When actions satisfy one’s needs, they are “right.”

LEVEL II: Conventional Cordial interpersonal relationships are maintained.

(9-13 years) Approval of others is sought through one’s actions.

Stage 3: Interpersonal
concordance Authority is respected.

Individual feels “duty bound” to maintain social order.

Stage 4: Law and order
orientation Behavior is “right” when it conforms to the rules.

Individual understands the morality of having

LEVEL III: Post-conventional democratically established laws.

(13+ years)

Stage 5: Social contract

orientation It is “wrong” to violate others’ rights.

Stage 6: Universal ethics The person understands the principles of human rights &
orientation personal conscience.
 Person believes that trust is basis for relationships.

Gilligan’s Theory of Moral Development

LEVEL CHARACTERISTICS

Concentrates on what is best for self.

Selfish.
I. Orientation of Individual
Survival Transition Dependent on others.

Recognizes connections to others.

Transition 1: From Selfishness
to Responsibility Makes responsible choices in terms of self and others.

Puts needs of others ahead of own.

Feels responsible for others.

Is dependent.

May use guilt to manipulate others when attempting to

II. Goodness as Self-sacrifice “help.”

Decisions based on intentions & consequences, not on

others’ responses.

Considers needs of self and others.

Wants to help others while being responsible to self.

Transition 2: From Goodness
to Truth Increased social participation.

Sees self and others as morally equal

Assumes responsibilities for own decisions.

Basic tenet to hurt no one including self.

Conflict between selfishness and selflessness.

Self-judgment is not dependent on others’ perceptions but

III. Morality of Nonviolence rather on consequences & intentions of actions.

Fowler’s Stages of Faith

STAGE AGE CHARACTERISTICS
 Trust, hope and love compete with
Pre-stage: environmental inconsistencies or threats if
Undifferentiated faith Infant abandonment.

Imitates parental behaviors and attitudes

about religion and spirituality.

Stage 1: Intuitive- Toddler- Has no real understanding of spiritual

projective faith preschooler concepts.

Accepts existence of a deity.

Religious & moral beliefs are symbolized by

stories.

Appreciates others’ viewpoints.

Stage 2: Mythical-literal
faith School-aged child Accepts concept of reciprocal fairness.

Stage 3: Synthetic- Questions values & religious beliefs in an

conventional faith Adolescent attempt to form own identity.

Stage 4: Individuative- Late adolescent & Assumes responsibility for own attitudes &
reflective faith young adult beliefs.

Stage 5: Conjunctive Integrates other perspectives about faith

faith Adult into own definition of truth.

Stage 6: Universalizing
faith Adult Makes concepts of love & justice tangible.

Jean Piaget’s Theory of Cognitive Development

Born: Aug 9, 1896
Birthplace: Neuchâtel, Switzerland
Died: September 17, 1980
Location of death: Geneva, Switzerland
Cause of death: unspecified
Gender: Male
Race or Ethnicity: White
Occupation: Psychologist
Nationality: Switzerland
Executive summary: Elaborated the stages of childhood
Cognitive development refers to how a person perceives, thinks, and gains understanding of his or
her world through the interaction of genetic and learned factors. Among the areas of cognitive
development are information processing, intelligence, reasoning, language development, and
memory.

Cognitive Stages of Development

Sensorimotor (0-2 Development proceeds from reflex activity to representation and
years) sensorimotor solutions to problems

Problems solved through representation; language development; (2-4

Pre-operational (2-7 years); thoughts and language both egocentric; cannot solve
years) conservation problems.

Reversibility attained; can solve conservation problems; Logical

Concrete Operation (7- operation developed and applied to concrete problems; cannot solve
11 years) complex verbal problems.

Formal Operation (11 Logically solves all types of problems; thinks scientifically; solves
years-adulthood) complex problems; cognitive structures mature.

 Sensorimotor stage (infancy): In this period, which has six sub-stages, intelligence is
demonstrated through motor activity without the use of symbols. Knowledge of the world is
limited, but developing, because it is based on physical interactions and experiences. Children
acquire object permanence at about seven months of age (memory). Physical development
 (mobility) allows the child to begin developing new intellectual abilities. Some symbolic
(language) abilities are developed at the end of this stage.
 Pre-operational stage (toddlerhood and early childhood): In this period, which has two sub
stages, intelligence is demonstrated through the use of symbols, language use matures, and
memory and imagination are developed, but thinking is done in a non-logical, non-reversible
manner. Egocentric thinking predominates.
 Concrete operational stage (elementary and early adolescence): In this stage,
characterized by seven types of conservation (number, length, liquid, mass, weight, area, and
volume), intelligence is demonstrated through logical and systematic manipulation of symbols
related to concrete objects. Operational thinking develops (mental actions that are reversible).
Egocentric thought diminishes.
 Formal operational stage (adolescence and adulthood): In this stage, intelligence is
demonstrated through the logical use of symbols related to abstract concepts. Early in the
period there is a return to egocentric thought. Only 35 percent of high school graduates in
industrialized countries obtain formal operations; many people do not think formally during
adulthood.

Johari Window
Description

As a nurse, dealing with physically and/or mentally ill patients requires a great deal of patience
and understanding. However, before a person can understand and empathize with others, he or
she must first know himself or herself. The process of knowing ones own principle, beliefs,
feelings, personality, strengths, weaknesses, preconceptions, attitudes and responses in different
situations is called self awareness. Discerning ones own capabilities and limitations allow a nurse
to consider, observe and pay attention to the bizarre or subtle reactions of clients.
Self-awareness gives the nurse a skill in establishing relationships with clients of different values,
beliefs, attitudes and principles. This is achieved by the nurse’s utilization of aspects in his or her
personality, values, feelings and coping skills commonly known as the therapeutic use of self.

Johari window is a psychological tool used to develop self-awareness and promote better
relationshipsamong people. It was created by two American Psychologists Joseph Luft and Harry
Ingham in 1955. The word “JOHARI” comes from the first names of its developers Joseph
and Harry (Joharry).  It is also known as “disclosure or feedback model of self awareness.”
Utilizing this tool creates a portrait of someone; this is done by giving the person a psychosocial
exercise. A list of 56 adjectives is given to the subject and he or she is instructed to choose five or
six words that best describe him or her. The same list is given to the subject’s peers, friends and
colleagues. These people will also choose 5 or 6 adjectives that best describe the subject. After
the test, the answers are mapped, compared and categorized in four areas. The four areas are as
follows:

Quadrant 1: Open Arena or Public self

 These pertain to the qualities known to others and the subject himself.
 If quadrant 1 is the longest, it means that the subject is open to others and has gained self-
awareness.
 If this area is the shortest, the subject shares little about him or her.
Area or Quadrant 2: Blind spot or Blind Area

 These refer to the subject’s attributes that are unknown to him but are known by his or her
peers.
Area or Quadrant 3: Hidden or Private self

 The things that the subject knows about himself.

Area or Quadrant 4: Unknown

 An empty quadrant which symbolizes the qualities undiscovered by the neither the subject
nor others.
The success of the test depends on the honesty of the opinions given. A person is represented
with little insight if quadrants 1 and 3 have the smallest adjective listed. The main goal the subject
is to work towards moving the qualities from quadrants 2, 3, and 4 to the first area.

Kohlberg’s Theory of Moral Development

Born: October 25, 1927

Birthplace: Bronxville, New York, United States

Died: January 19, 1987
Location of death: Cape Cod, Massachusetts, United States
Nationality: American
Occupation: Psychologist, College Teacher
Moral development is the process thought which children develop proper attitudes and behaviours
toward other people in society, based on social and cultural norms, rules, and laws.
Moral Development by Lawrence Kohlberg

 Level of Moral  Approximate

development  Stage of Reasoning Age

Stage 1: (Punishment and Obedience Orientation).

 Right is obedience to power and avoidance of

punishment.
 (“I must follow the rules otherwise I will be
punished”).
Stage 2: Instrumental Relativist Orientation.
 Right is taking responsibility and leaving
 Preconventional others to be responsible for themselves.
“do’s and don’ts”  (”I must follow the rules for the reward and  <11
favor it gives”).

Stage 3: Good-Boy-Nice Girl Orientation.

 Right is being considerate: “uphold the values

of other adolescents and adults” rules of society”.
 (”I must follow the rules so I will be accepted”)
Stage 4: Society-Maintaining Orientation.
 Right is being good, with the values and adolescence
norms of family and society at large. and
 Conventional  (”I must follow rules so there is order in the adulthood
society”).

Stage 5: Social Contract Reorientation.

 Right is finding inner “universal rights” balance

between self-rights and societal rules – a social
contract.
 (”I must follow rules as there are reasonable
laws for it”).
Stage 6: Universal Ethical Principle orientation.
 Right is based on a higher order of applying
principles to all human-kind; being non-
judgmental and respecting all human life.
 Postconventional  (”I must follow rules because my conscience  after 20
tells me”).
Three Levels of Moral Development

PRECONVENTIONAL LEVEL.
The child at the first and most basic level, the preconventional level, is concerned with avoiding
punishment and getting needs met. This level has two stages and applies to children up to 10
years of age.

 Punishment-Obedience stage. Children obey rules because they are told to do so by an

authority figure (parent or teacher), and they fear punishment if they do not follow rules.
Children at this stage are not able to see someone else’s side.
 Individual, Instrumentation, and Exchange stage. Here, the behavior is governed by moral
reciprocity. The  child will follow rules if there is a known benefit to him or her. Children at this
 stage also mete out justice in an eye-for-an-eye manner or according to Golden Rule logic. In
other words, if one child hits another, the injured child will hit back. This is considered
equitable justice. Children in this stage are very concerned with what is fair.Children will also
make deals with each other and even adults. They will agree to behave in a certain way for a
payoff. “I’ll do this, if you will do that.” Sometimes, the payoff is in the knowledge that behaving
correctly is in the child’s own best interest. They receive approval from authority figures or
admiration from peers, avoids blame, or behaves in accordance with their concept of self.
They are just beginning to understand that others have their own needs and drives.

CONVENTIONAL LEVEL.

This level broadens the scope of human wants and needs. Children in this level are concerned
about being accepted by others and living up to their expectations. This stage begins around age
10 but lasts well into adulthood, and is the stage most adults remain at throughout their lives.

 Interpersonal Conformity is often called the “good boy/good girl” stage. Here, children do
the right thing because it is good for the family, peer group, team, school, or church. They
understand the concepts of trust, loyalty, and gratitude. They abide by the Golden Rule as it
applies to people around them every day. Morality is acting in accordance to what the social
group says is right and moral.
 Law and Order or Social System and Conscience stage. Children and adults at this stage
abide by the rules of the society in which they live. These laws and rules become the
backbone for all right and wrong actions. Children and adults feel compelled to do their duty
and show respect for authority. This is still moral behavior based on authority, but reflects a
shift from the social group to society at large.

POST-CONVENTIONAL LEVEL.

Some teenagers and adults move beyond conventional morality and enter morality based on
reason, examining the relative values and opinions of the groups with which they interact. Few
adults reach this stage.

 Social Contract and Individual Rights stage. Individuals in this stage understand that codes
of conduct are relative to their social group. This varies from culture to culture and subgroup to
subgroup. With that in mind, the individual enters into a contract with fellow human beings to
treat them fairly and kindly and to respect authority when it is equally moral and deserved.
They also agree to obey laws and social rules of conduct that promote respect for individuals
and value the few universal moral values that they recognize. Moral behavior and moral
decisions are based on the greatest good for the greatest number.
 Principled Conscience or the Universal/Ethical Principles stage. Here, individuals examine
the validity of society’s laws and govern themselves by what they consider to be universal
moral principles, usually involving equal rights and respect. They obey laws and social rules
that fall in line with these universal principles, but not others they deem as aberrant. Adults
here are motivated by individual conscience that transcends cultural, religious, or social
convention rules. Kohlberg recognized this last stage but found so few people who lived by
this concept of moral behavior that he could not study it in detail.
Korsakoff’s Syndrome (Korsakoff’s Psychosis)
Definition

Korsakoff’s syndrome is a condition that mainly affects chronic alcoholics. It is also called
Korsakov’s syndrome, Korsakoff’s psychosis or amnesic-confabulatory syndrome. It is a brain or
neurological disorder caused by thiamine or Vitamin B1 deficiency. The syndrome is named after
Sergie Korsakoff, a neuropsychiatrist who popularized the theory.

Causes

1. Chronic Alcoholism. This syndrome is due to the direct effects of alcohol or to the severe
nutritional deficiencies that are associated with chronic alcoholism. A lack of Vitamin B1 is
common in people with alcoholism thus, Vitamin B deficiency is noted. In chronic alcoholism
the condition usually occurs following delirium tremens.
2. Malabsorption. It is also common in persons whose bodies do not absorb food properly
(malabsorption).
3. Other severe brain disturbances. The syndrome also occurs in other severe brain
disturbances such as paralysis, dementia, brain damage, infections and poisonings.
4. Dietary deficiencies
5. Prolonged vomiting
6. Eating disorders
7. Effects of chemotherapy
8. Hyperemesis gravidarum
9. Severe malnutrition. Alcoholism may be an indicator of poor nutrition, which in addition to
inflammation of the stomach lining causes thiamine deficiency.

Disease Process

A deficiency of thiamine or Vitamin B causes damage to the medial thalamus and to the
mammillary bodies of the hypothalamus. As a result, generalized cerebral atrophy may occur. In
cases where Wernicke’s encephalopathy, a neurological disorder that causes brain damage in
lower parts of the brain called the thalamus and hypothalamus, accompanies Korsakoff’s
syndrome the disorder is called Wernicke-Korsakoff syndrome.

In most cases, Korsakoff syndrome, or Korsakoff psychosis, tends to develop as Wernicke’s

symptoms go away. It results from damage to areas of the brain involved with memory, thus,
Korsakoff’s syndrome involves:

 Neuronal loss or damage to neurons

 Gliosis, which is a result of injury to the supporting cells of the central nervous system.
 Hemorrhage or bleeding of the mammilary bodies.

Signs and Symptoms

1. Anterograde amnesia or the inability to form new memories

2. Retrograde amnesia or the loss of memory (can be severe)
3. Confabulation or the reciting of imaginary experiences.
4. Lack of insight
5. Apathy or the absence of interest in or concern about emotional, social, or physical life
6. Hallucinations or seeing and hearing things are not really present
7. Delirium
8. Anxiety
9. Fear
10. Depression
11. Confusion
12. Delusions and insomnia
13. Painful extremities

Treatment

1. Thiamine by injection into a vein or a muscle or by mouth. Usually, thiamine does not
improve loss of memory and intellect that occur with Korsakoff’s psychosis. However it may
improve symptoms such as delirium or confusion.
2. Stopping alcohol use to prevent additional loss of brain function and damage to the nerves.
3. Eating a well balanced and nourishing diet with increase intake of foods containing Vitamin
B1.

Kubler-Ross Stages of Dying / Grief

Precipitating Factors of Grief

 Death in family
 Separation
 Divorce
 Physical Illness
 Work failure disappointments
1. Denial
 Initial response to protect the self from anxiety.
 “No not me”, “Its not true”, “Its not impossible”
 May continue to make impractical/unrealistic plans
 May comment that a mistake has been made about the diagnosis of terminal illness
 May appear normal and can continued ADL as if nothing is wrong
 May not conform with the advised treatment regimen
 Adaptive response – crying, verbal denial
 Maladptive response – absence or reaction such as crying.
2. Anger
 Individual feel that they are victims of incompetence or a vengeful God (they did something
wrong so they are being punished), fate (karma), circumstances (wrong place and wrong
time).
 “Why me”, “What did I do to deserve this?”
 They seek for reasons, answers and explanations
 May express anger overtly – being irritable, impatient, critical verbally abusive.
 May express anger covertly by neglecting self, not eating, nor going to check ups,
committing suicide, drinking alcohol.
 Adaptive response – verbal expression
 Maladaptive – persistent guilt or low self esteem, aggression, self destructive ideation or
behavior.
3. Bargaining
 The person try to inhibit good behavior, make up for perceived wrong doings or other
engage in behaviors that would please GOD so he will be given more time-an extension of life
or granted recovery.
 “Yes, me but”
 “If I live until Christmas or until my child’s graduation ( So many if’s), I will do this…”
 Adaptive response – bargains for treatment control, express wish to be alive for specific
events in the near future.
 Maladaptive response – bargains for unrealistic activities or events in the distant future.
4. Depression
 Occurs when the reality of loss or impending loss cannot be ignored anymore and the
person grieves for himself and those he will leave behind, for the things that he can no longer
accomplish or experience.
 “Yes, I’m dying”
 Withdrawn, has no energy and interest to interact.
 Cries
 Makes few demands
 Adaptive response – crying, withdrawing from interaction
 Maladaptive response – self destructive actions, despair.
5. Acceptance
 Occurs when the person has come to peace with himself and others
 “Yes, I am ready”
 Stage of affective void – not happy nor sad
 Only persons who are highly significant to him stimulates a reaction. Others are merely
tolerated.
 Makes realistic preparation
 Adaptive response – may wish to be alone, limit conversation, complete personal and
family business.

Nursing Interventions:

 Assess; specific loss, meaning of loss, coping skills, support persons.

 Accept the client; do not respond personally to the client.
 Support adaptive responses; allow to express feelings
 Support defense mechanism – reassure client that denial and wanting to be alone is
normal.
 Help find constructive outlets of anger. Do not take clients hostility personally. Do no
retaliate.
 Monitor for self destructive behaviors
 Help express feelings: Ask how they feel
 Meet needs
 Allow as much decision making as possible to maintain dignity by giving choices and
alternatives.

Major Depressive Disorder

Description

 A mood disorder may include symptoms of depressed mood, feelings or hopelessness and
helplessness, decreased interest in usual activities, disinterest in relationship with others or
cycles of depression and mania.
 Depression is often concurrent with other psychiatric diagnoses. Almost have of clients with
major depressive disorders have histories of non-mood psychiatric disorders.
 A high incidence exists for persons with chronic illness or prolonges hospitalization or
institutional care.

Risk Factors

1. Biological factors – brainchemicals

2. Family genetics – parent with depression, child 10-13% risk of depression.
3. Gender – higher rate for women
4. Age – often less than 40 when begins
5. Marital status – more frequently single, widowed
6. Season of year – Seasonal Affective Disorder (SAD) occurs when client experiences
recurrent depression that occurs annually at the same time.
7. Psychological influences – low self-esteem, unresolved grief.
8. Environmental factors – lack of social support, stressful life events.
9. Medical co-morbidity – clients with chronic or terminal illness, postpartum, and current
substance abuse are especially prone to becoming depresses.

Signs and Symptoms

1. Sexual disinterest
2. Suicidal and homicidal ideations
3. Decrease in personal hygiene
4. Tearfulness, crying, and melancholy
5. Altered thought process; difficulty concentrating, self-destructive behavior.
6. Loss of energy or restlessness
7. Anhedonia or loss of pleasure
8. Gain or loss of weight
9. Anger, self-directed
10. Psychomotor retardation or agitation
11. Insomnia or hypersomnia
12. Feelings of hopelessness, worthlessness, and helplessness.

Medical Diagnosis
A number of tests should be conducted to diagnose major depression:

 Beck Depression Inventory is a psychological test used to determine symptom onset,

severity, duration, and progression.
 Dexamethasone suppression test showing failure to suppress cortisol secretion in
depressed patients (although test has high false-negative rate).
 Toxicology screening suggesting drug-induced depression.
 Diagnosis is confirmed if DSM-V-TR criteria is met.

Nursing Diagnoses

 Risk for violence, self-directed or directed at others

 Impaired verbal communication
 Decisional conflict
 Altered role performance
 Hopelessness
 Deficit in diversional activity
 Fatigue
 Sel-care deficit
 Altered thought processes
 Self-esteem
 Anxiety

Medical Management
Medications are the primary treatment for major depression. Ideally, medications should be
combined with various therapies. Drugs generally work by modifying the activity of relevant
neurotransmitter pathways.

 Antidepressants are classified according to class:

 The first-line treatment for patients with depression because these drugs lack the most of
disturbing effects of TCAs and MAOIs. Examples include citalopram (Celexa), paroxetine
(Paxil), and sertraline (Zoloft).
 Generally used as second-line agents for patients with major depressive disorder. Example
include venlafaxine (Effexor)
 Atypical antidepressants. Their mechanism of action is not clearly understood. Some
examples include bupropion (Wellbutrin) and mirtazapine (Remeron). They are used as
second-line agents too.
 An older class of antidepressants. Some examples include amitriptyline (Elavil) and
amoxapine (Asendin).
 May be prescribed for patients with atypical depression (e.g. depression marked by
increased appetite and sleep). Rarely used today because of high risk for adverse effects like
hypertensive crisis and dangerous interactions with foods and medications.
 Improve treatment outcome by helping patient cope with low self-esteem and self-
demoralization.
 Electroconvulsive therapy. To treat severe depression.

Therapeutic Nursing Management

1. Safe environment
2. Psychological treatment
 Individual psychotherapy – long –term therapeutic approach or short term solution-
oriented, may focus on in-depth exploration, specific stress situations, or problem solving.
 Behavioral therapy – modifying behavior to assist in reducing depressive symptoms
and increasing coping skills.
 Behavioral contacts – focus on specific client problems and need to help the client
resolve them.
3. Social treatment
 Milieu therapy – incorporates day to day living experiences in a therapeutic
environment to expect changes in perception and behavior.
 Family therapy – aimed at assisting the family cope with the client’s illness and
supporting the client in therapeutic ways.
 Group therapy – focuses on assisting clients with interpersonal communication,
coping, and problem-solving skills.
4. Psychopharmacologic and Somatic treatments
 Administer antidepressant medications
 Continued assessment by monitoring client’s mental health status is critical,
particularly interms of agitation and suicidal ideation.
 Electroconvulsive therapy

Nursing Interventions

1. Priority for care is always the client’s safety.

2. Use of behavioral contacts. Use this technique to meet outcomes relating to “no self-harm”
or no suicidal ideation or plan.
3. Assess regularly for suicidal ideation or plan.
4. Observe client for distorted, negative thinking.
5. Assist client to learn and use problem solving and stress management skills.
6. Avoid doing too much for the client, as this will only increase client’s dependence and
decrease self-esteem.
7. The nurse’s role in the physical care of the client experiencing major depressive disorder is
to provide assessment and interventions related to appropriate nutrition, fluids, sleep,
exercise, and hygieme, and to provide health education.
8. Explore meaningful losses in the client’s life.
9. Help the client and family to identify the internal and external indicators of major depressive
disorder.

Obsessive Compulsive Disorder (OCD)

Description
Obsessive Compulsive Disorder (OCD) is characterized by persistent thought and urges to
perform repeated acts or rituals, usually as a means of releasing tension or anxiety. The frequency
and intensity of the ritualistic behaviors, such as handwashing, ordering, or checking, are time
consuming (taking more than one hour per day) and cause marked distress, significant
impairment, or interfere with daily living.
1. Obsession
 The person experiences recurrent and persistent thoughts, impulses, images that
are intrusive, disturbing, inappropriate, and usually triggered by anxiety.
 The thoughts, images, and impulses are not simply excessive worries about real life
problems.
 The person recognizes the thoughts, images, and impulses are from within own
mind.
2. Compulsion
 Repetitive behaviors or mental acts that a person feels driven to perform, which
usually adhere to a rigid and specifically defined routine.
 The behaviors and ideations are typically aimed at reducing anxiety or preventing
some dreaded situation from occurring.

Specific Biological Factors

 There is some evidence that indicates OCD is linked to a deficiency in serotonin.

 Clients have also been shown to have abnormalities in frontal lobes and basal ganglia; it is
unclear what the implications are for clinical care.

Signs and Symptoms

 Obsessions – recurrent, persistent ideas, thoughts or impulses, involuntarily coming to

awareness.
 Ruminations – forced preoccupation with thoughts about a particular topic, associated with
brooding and inconclusive speculation.
 Cognitive rituals – elaborate series of mental acts the client feels compelled to complete.
 Compulsive motor rituals – elaborate rituals of everyday functioning such as grooming,
dressing, eating, washing or checking doors or appliances.
 Other symptoms – chronic anxiety, low self-esteem, difficulty expressing positive feelings
and depressed mood.
Nursing Diagnoses

 Anxiety
 Powerlessness
 Ineffective verbal communication
 Self-esteem disturbance
 Impaired social interaction
 Risk for injury
 Sleep pattern disturbances
 Ineffective breathing pattern

Nursing Interventions

1. Limit, but do not interrupt, the compulsive acts.

2. Teach the client to use alternate coping methods to decrease anxiety.
3. Client’s behavior maybe frustrating to staff and family. Power struggles often result.
Consistency to the approach to care is critical.
4. Assess the client’s needs carefully.
5. Provide an environment that has structure and predictability as a strategy to decrease
anxiety.
6. Risk associated with the use of alcohol and drug abuse.

Oppositional Defiant Disorder

Definition

The American Psychiatric Association’s Diagnostic and Statistical Manual, Fourth Edition (DSM

IV), defines oppositional defiant disorder (ODD) as a recurrent pattern of negativistic, defiant,
disobedient, and hostile behavior toward authority figures that persists for at least 6 months. ODD
is a condition in which a child displays an ongoing pattern of uncooperative, defiant, hostile, and
annoying behavior toward people in authority. The child’s behavior often disrupts the child’s
normal daily activities, including activities within the family and at school.

Causes and Risk Factors

The causative factors can be divided into categories, namely:

 Biological Factor. Aggressive behavior may be caused by alterations in the neurotransmitter

activity of the brain. Neurotransmitters help nerve cells in the brain communicate with each
other. If these chemicals are out of balance or not working properly, messages may not make
it through the brain correctly, leading to symptoms of ODD, and other mental illnesses. Also,
some studies suggest that defects in or injuries to certain areas of the brain can lead to
serious behavioral problems in children.
 Familial Factor. Familial influences on child development may be genetically linked,
attributed to conflict in the family home or based on parent-child interactions. Additionally, a
parent’s prior aggressive behavior (in childhood) has been shown to manifest itself in their
child at the same age.
 Genetics. Many children and teens with ODD have close family members with mental
illnesses, including mood disorders, anxiety disorders, and personality disorders. This
suggests that a vulnerability to develop ODD may be inherited.
 Environmental. Factors such as a dysfunctional family life, a family history of mental
illnesses and/or substance abuse and inconsistent discipline by parents may contribute to the
development of behavior disorders.

Clinical Manifestations

 Actively does not follow adults’ requests

 Angry and resentful of others
 Argues with adults
 Blames others for own mistakes
 Has few or no friends or has lost friends
 Is in constant trouble in school
 Loses temper
 Spiteful or seeks revenge
 Touchy or easily annoyed

Diagnosis

To fit this diagnosis, the pattern must last for at least 6 months and must be characterized by the
frequent occurrence of at least four of the following behaviors: losing temper, arguing with adults,
actively defying or refusing to comply with the requests or rules of adults, deliberately doing things
that will annoy other people, blaming others for his or her own mistakes or misbehavior, being
touchy or easily annoyed by others, being angry and resentful, or being spiteful or vindictive.

Management of Children with ODD

 Behavior management techniques. Use behavior contracts.

 Be fair but be firm, give respect to get respect.
 Using a consistent approach to discipline and following through with positive reinforcement
of appropriate behaviors. Apply effective contingencies that are consistent responses to the
child’s behavior, following through with appropriate rewards and consequences when these
are needed.

Paraphilias
Definition

Paraphilias are complex psychiatric disorders that are manifested as unusual sexual behavior.
Diagnostic and Statistical Manual of Mental Disorders, Text Revision (DSM-IV-TR) defined it as a
“recurrent, intensely sexually arousing fantasies, sexual urges, or behaviors generally involving:

 Inanimate objects (non-human objects)

 Suffering or humiliation of oneself or partner
 Children
 Nonconsenting person

Diagnosis

The criteria for diagnosing this disorder are:

Criterion A: the unusual sexual behavior should occur over a period of 6 months
Criterion B: the sexual behavior caused a clinically significant distress or impairment in social,
occupational or other important areas of functioning. Criterion B differs in for some disorders.

 For pedophilia, voyeurism, exhibitionism and frotteurism, the diagnosis is formulated if

acting out on these urges or if the urge itself caused a significant distress or interpersonal
difficulty.
 For sadism, a diagnosis is made if these urges are done to a nonconsenting person.
 For the other paraphilias, a diagnosis created when the sexual behavior, urges or fantasies
caused a clinically significant distress or impairment in social, occupational or other important
areas of functioning.

Eight specific disorders of paraphilia

1. Exhibitionism – the repeated urge or behavior of exposing one’s genitals to strangers or

masturbating in public areas.
2. Exhibitionism – this is characterized by the use of inanimate objects (fetish) to achieve
orgasm or gain sexual excitement. Common fetishes are women’s undergarments (brassiere,
lingerie, and panty), shoes and other apparels. An individual with this disorder masturbates
while holding or rubbing the object to them.
3. Frotteurism – persistent urges of touching or rubbing against a nonconsenting person in a
place where a person with this disorder can make a quick escape (e.g. crowded places, public
transportation, shopping mall or a crowded sidewalk). The person rubs his hands against a
victim’s breasts or genitalia or he can rub his genitals against the victim’s thigh or buttocks.
4. Pedophilia – a sexual activity done with a child 13 years younger is a characteristic of this
disorder. The pedophile should be at least 16 years old or at least 5 years older than the
victim.
5. Sexual masochism – the intense and persistent sexual urge involving acts of suffering
(beaten or bound) and being humiliated.
6. Sexual sadism – sexual urge involving acts in which the pain, suffering or humiliation of a
partner is arousing a person.
7. Transvestic fetishism – sexual fantasies, urge and behaviors involving cross-dressing by a
heterosexual male.
8. Voyeurism – sexual arousal by observing an unsuspecting person who is naked, in the
process of undressing or engaging in sexual activity.

Personality Disorders
Definition

Personality disorder is defined as the totality of a person’s unique biopsychosocial and spiritual
traits that consistently influence behavior.
The following traits are likely in individuals with a personality disorder:

1. Interpersonal relations that ranges from distant to overprotective.

2. Suspiciousness
3. Social anxiety
4. Failure to conform to social norms.
5. Self-destructive behaviors
6. Manipulation and splitting.
Prognosis is poor, and clients experience long term disability and may have other psychiatric
disorders.

Diagnosis

A personality disorder is diagnosed when a person exhibits deviation on the following areas:
1. Cognition – ways a person interprets and perceives him or herself, other people and
events.
2. Affect – ranges, lability and appropriateness of emotional response
3. Impulse control – ability to control impulses or express behavior at the appropriate time and
place.

Cluster A: Personality Disorders ( The Eccentric and Mad group)

1. Paranoid Personality disorder– People with a paranoid personality disorder are characterized by
an overly suspicious and mistrustful behavior.

Clinical Manifestation
a. Aloof and withdrawn
b. Appear guarded and hypervigilant
c. Have a restricted affect
d. Unable to demonstrate a warm and empathetic emotional responses
e. Shows constant mistrust and suspicion
f. Frequently see malevolence in the actions when none exists
g. Spends disproportionate time examining and analyzing the behavior and motive of others to
discover hidden and threatening meanings
h. Often feel attacked by others
i. Devises plans or fantasies for protection
j. Uses the defense mechanism of projection (blaming other people, institution or events for
their own difficulties)
2. Schizoid Personality Disorder- People who are showing a pervasive pattern of social
relationship detachment and a limited range of emotional expression in the interpersonal settings
falls under this type of personality disorder.
Clinical Manifestations:
a. Displays restricted affect
b. Shows little emotion
c. Aloof, emotionally cold and uncaring
d. Have rich and extensive fantasy life
e. Accomplished intellectually and often involved with computers or electronics in hobbies or
job
f. Spends long hours solving puzzles and mathematical problems
g. Indecisive
h. Lacks future goals or direction
i. Impaired insight
j. Self-absorbed and loners
k. Lacks desire for involvement with others
l. No disordered or delusional thought processes present
3. Schizotypal Personality Disorder– Schizoid and schizotypal personality disorder are both
characterized by pervasive pattern of social and interpersonal deficits, however, the latter is noted
with cognitive and perceptual distortions and behavioral eccentricities.
Clinical Manifestations:
a. Odd appearance (stained or dirty clothes, unkempt and disheveled)
b. Wander aimlessly
c. Loose, bizarre or vague speech
d. Restricted range of emotions
e. Ideas or reference and magical thinking is noted
f. Expresses ideas of suspicions regarding the motives of others
g. Experiences anxiety with people

Cluster B: Personality Disorders ( The Erratic and Bad group)

1. Antisocial Personality Disorder– Antisocial Personality disorder is characterized by a persistent
pattern of violation and disregard for the rights of others, deceit and manipulation
Clinical Manifestations:
a. Violation of the rights of others
b. Lack of remorse for behaviors
c. Shallow emotions
d. Lying
e. Rationalization of own behavior
f. Poor judgment
g. Impulsivity
h. Irritability and aggressiveness
i. Lack of insight
j. Thrill seeking behaviors
k. Exploitation of people in relationships
l. Poor work history
m. Consistent irresponsibility
2. Borderline Personality Disorder– Borderline personality disorder is the most common
personality disorder found in clinical settings. This disorder is characterized by a persistent pattern
of unstable relationships, self image, affect and has marked impulsivity. It is more common in
females than in males. Self-mutilation injuries such ascutting or burning are noted in this type of
personality disorder.
Clinical manifestations:
a. Fear of abandonment (real or perceived)
b. Unstable and intense relationship
c. Unstable self-image
d. Impulsivity or recklessness
e. Recurrent self-mutilating behavior or suicidal threats or gestures
f. Chronic feelings of emptiness and boredom
g. Labile mood
h. Irritability
i. Splitting
j. Impaired judgment
k. Lack of insight
l. Transient psychotic symptoms such as hallucinations demanding self-harm
3. Narcissistic Personality Disorder– A person with a narcissistic personality disorder shows a
persistent pattern of grandiosity either in fantasy or behavior, a need for admiration and a lack of
empathy.
Clinical Manifestations:
a. Arrogant and haughty attitude
b. Lack the ability to recognize or to empathize with the feelings of others
c. Express envy and begrudge others of any recognition of material success (they believe it
rightfully should be theirs)
d. Belittle or disparage other’s feelings
e. Expresses grandiosity overtly
f. Expect to be recognized for their perceived greatness
g. Preoccupied with fantasies of unlimited success, power, brilliance, beauty or ideal love
h. Compares themselves with famous or privileged people
i. Poor or limited insight
j. Fragile and vulnerable self-esteem
k. Ambitious and confident
l. Exploit relationships to elevate their own status
4. Histrionic Personality disorder– Excessive emotionality and attention-seeking behaviors are
pervasive patterns noted in people with a histrionic personality disorder.
Clinical manifestations:
a. Exaggerate closeness of relationships or intimacy
b. Uses colorful speech
c. Tends to overdress
d. Concerned with impressing others
e. Emotionally expressive
f. Experiences rapid mood and emotion shifts
g. Self-absorbed
h. Highly suggestible and will agree with almost anyone to gain attention
i. Always want to be the center of attraction

Cluster C: Personality Disorders ( The anxious and Sad group)

1. Avoidant Personality Disorder
Avoidant personality disorder is characterized by a persistent pattern of:
a. Social uneasiness and reticence
b. Low self-esteem
c. Hypersensitivity to negative reaction
Clinical Manifestations
a. Shy
b. Unusually fearful of rejection, criticism, shame or disapproval
c. Socially awkward
d. Easily devastated by real or perceived criticism
e. Have a very low self-esteem
f. Believes that they are inferior
2. Dependent Personality Disorder– People who are noted to excessively need someone to take
care of them that lead to their persistent clingy and submissive behavior have a dependent
personality disorder. These individuals have fear of being separated from the person whom they
cling on to. The behavior elicits caretaking from others.
Clinical Manifestations
a. Pessimistic
b. Self-critical
c. Can be easily be hurt by other people
d. Frequently reports feeling unhappy or depressed ( due to actual or perceived loss of
support from a person)
e. Preoccupied with unrealistic fears of being alone and left alone to take care for themselves
f. Has difficulty deciding on their own even how simple the problem is
g. Constantly seeks advice from others and repeated assurances about all types of decisions
h. Lacks confidence
i. Uncomfortable and helpless when alone
j. Has difficulty initiating  or completing simple daily tasks on their own
3. Obsessive Compulsive Personality Disorder– Individuals who are preoccupied with
perfectionism, mental and interpersonal control and orderliness have an obsessive compulsive
personality disorder. Persons with an obsessive compulsive personality are serious and formal
and answer questions with precision and much detail. These people often seek treatment because
of their recognition that life has no pleasure or because they are experiencing problems at work
and in their relationships.
Clinical Manifestations
a. Formal and serious
b. Precise and detail-oriented
c. Perfectionist
d. Constricted emotional range (has difficulty expressing emotions)
e. Stubborn and reluctant to relinquish control
f. Restricted affect
g. Preoccupation to orderliness
h. Have low self-esteem
i. Harsh
j. Have difficulty in relationships
Signs and Symptoms
1. Inappropriate response to stress and inflexible approach to problem solving.
2. Long term difficulties in relating to others, in school and in work situations.
3. Demanding and manipulative.
4. Ability to cause others to react with extreme annoyance or irritability.
5. Poor interpersonal skills.
6. Anxiety
7. Depression
8. Anger and aggression
9. Difficulty with adherence to treatment.
10. Harm to self or others.

Nursing Diagnoses
 Ineffective individual coping
 Social isolation
 Impaired social interaction
 High risk for violence to self or others
 Anxiety

Nursing Interventions
1. Work with the client to increase coping skills and identify need for improvement coping.
2. Respond to the client’s specific symptoms and needs.
3. Keep communication clear and consistent.
4. Client may require physical restraints, seclusion/observation room, one to one supervision.
5. Keep the client involved in treatment planning.
6. Avoid becoming victim to the client’s involvement in appropriate self-help groups.
7. Require the client take responsibility for his/her own behavior and the consequences for
actions.
8. Discuss with the client and family the possible environment and situational causes,
contributing factors, and triggers.

Phobias
Definition

 A phobia is an anxiety disorder characterized by obsessive, irrational, and intense fear of a

specific object an activity, or a physical situation.
 The fear, which is out of proportion to reality, usually results from early painful or
unpleasant experiences involving a particular object or situation.
 A phobia may arise from displacing an unconscious conflict on an object that is symbolically
related.
Types of Phobias

1. Agoraphobia
 Fear of being in places or situations from which escape may be difficult or help may
not be readily available.
2. Social Phobia
 Also called Social Anxiety Disorder
 Characterized by persistent fear of appearing shameful, stupid or inept in the
presence of others.
3. Specific Phobia
 Also called Simple Phobia
 A persistent fear of a specific object or situation, other than of two phobias
mentioned above.
 Sub-categories:
1. Injury-blood-injection
2. Situational
3. Natural environment
4. Animals
5. Other (fear of costumed character, space, etc)
Risk Factors

1. Learning theory
 The belief that phobias are learned and become conditioned responses when the
client needs to escape an uncomfortable situation.
2. Cognitive theory
 Phobias are produced by anxiety-inducing self-instructions of faulty cognitions.
3. Life experiences
 Certain life experiences, such as traumatic events, may set the sage for phobias
later in life.

Signs and Symptoms

1. Withdrawal
2. High levels of anxiety
3. Inability to function and meet self-care needs
4. Inappropriate behavior used to avoid the feared situation, object or activity
5. Dysfunctional social interactions and relationships

Nursing Diagnoses

1. Anxiety
2. Powerless
3. Ineffective individual coping
4. Impaired verbal communication
5. Altered thought processes
6. Self-esteem disturbance
7. Impaired social interaction
8. Risk for injury

Therapeutic Nursing Management

1. Systematic desensitization
 This process of gradual exposure to phobic object or situation aimed at decreasing
the fear and increasing the ability to function in the presence of phobic stimulus.

Psychiatric Mental Health Assessment

Definition

 Accuracy in assessment determines whether the following steps of the nursing process will
produce accurate nursing diagnoses, palnning, and intervention.
 Psychiatric-mental health assessment is the gathering, organizing, and documenting of
data about the psychiatric and mental health needs of the client and family.

Assessment

 The first step of the nursing process.

Interview

 The degree to which the interview is therapeutic, or helpful, to the client may determine the
extent and honesty of the information shared by the client.
 Clients expect the interviewer to be an expert who is confident in the professional role,
maintains confidentiality, demonstrates warmth and genuineness, is nonjudgmental toward
them and their past or current behavior, and recognizes that clients are experts on themselves
and their behavior.

Assessment Data

1. Subjective
 Client’s current problem and reason for seeking help.
 Past mental illness and treatment
 Family history and mental illness
 Medical history
 Allergies to medications, foods, and other substances
 Past and present medications and their effects
 Past and present abuse
 Substance abuse history
 Educational and/or vocational history
 Health habits
 Safety issues
 Cultural beliefs and practices
2. Objective
 Behavior
 Communication
 Physical assessment
 Laboratory or testing data
 Mental status
Appearance
 Hygiene, grooming, appropriateness of clothing, posture, and gestures.
Behavior
 Eye contact, motor behavior, body language, behavioral responses to others and
environment, volume and speed of speech, tone of voice, flow of words.
Affect and Mood
 Happy, sad, anxious, sullen, hostile, inappropriate for situation, silly, and range of emotions.
Orientation
 To person, place, time, situation, relationship with others.
Memory
 Immediate recall, recent and remote memory.
Sensorium or Attention
 Ability to concentrate on a task or conversation, perception of stimuli.
Intellectual functioning
 General fund of knowledge about the world, cognitive abilities such as a simple arithmetic.
 Ability to think abstractly or symbolically.
Judgement
 Decision making ability, especially regarding delay of gratification.
Insight
 Awareness of one’s responsibility for and analysis of current problem, understanding of how
client arrived in current situation.
Thought Content
 Recurrent topics of conversation, themes.
Thought process
 Processing of events in the situation, awareness of one’s thoughts, logic of thought.
Perception
 Awareness of reality vs. fantasy, hallucinations, delusions, illusions, suicidal or homicidal
ideation or plans.

Reality Therapy
Definition

Reality therapy is devised by William Glaser in 1965 which focuses on the person’s behavior and
how that behavior keeps him or her from achieving life goals. The approach was developed while
Glaser is working with persons with delinquent behavior, unsuccessful school performance and
emotional problems. This therapy is considered a cognitive-behavioral approach to treatment.

Approach of Reality Therapy

William Glaser believed that people who are unsuccessful often blame their problems on other
people, the system or the society. It is Glaser’s belief that these types of people can only find their
own identities through a responsible behavior. The focus of approach of counseling and problem
solving in reality therapy focuses on the here-and-now of the client and how to create a better
future.

In this therapy, the individual is challenged to examine himself for ways in which his own behavior
obstructs his attempts of achieving his life goal. The focus of Reality Therapy is to help counselees
take ownership of their behavior and responsibility for the direction their lives take.

With reality therapy, whatever happened in our lives or what has been done in the past, the person
can still choose behavior that will help him meet his needs more effectively in the future. It is
believed that these needs that a person has to effectively meet are the following:

1. Power – this includes a person’s achievement and feeling worthwhile. Winning is also
included here.
2. Love and belonging – this includes families, loved ones, relatives and groups.
3. Freedom – independence, autonomy, personal “space”
4. Fun – pleasure and enjoyment
5. Survival – nourishment, shelter

Process Involved in Reality Therapy

In practicing reality therapy, two major components should be considered:

 A trusting environment should be created.

 Therapeutic techniques should be utilized to help a person discover what they really WANT,
reflect on their current activities and behavior and devise a new plan to fulfill that WANT
effectively in the future.
The processes taking place in reality therapy are:

1. Developing a good RAPPORT with the client. To make the entire process effective, trust
and rapport should be built at the beginning.
2. The current behavior (not the previous one) should be examined and evaluated by the
client with the help of a psychotherapist. The therapist will ask the client to make a value
judgment about his current behavior.
3. Help the client plan a new behavior that can be possibly done that works better than the
current one.
4. The participant must make a commitment to carry out the plan.
5. There should be no punishment to be implemented. The therapist however, should stress to
the client that there are no excuses and to never give up.

Summary of Facts about Reality Therapy

Focus of Reality Therapy: Help counselees take ownership of their behavior and responsibility for
the direction their lives take.
Basic Premise of Reality Therapy: Regardless of what has happened to us in our lives, or what we
have done in the past, we are living and making choices here and now.

Restraint Application
Definition

Restraint application is a technique of physically restricting a person’s freedom of movement,

physical activity or normal access to his body. A physical restraint is a piece of equipment or
device that restricts a patient’s ability to move. It is any manual method or physical or mechanical
device, material, or equipment attached or adjacent to the resident’s body that the individual
cannot remove easily which restricts freedom of movement or normal access to one’s body.
The definition of restraint is based not on the equipment or device but rather on the functional
status of the client. If the client cannot release himself from the device physically, then the said
device is considered a restraint.

Purpose of Restraint Application

Restraints are used to control a patient who is at risk of harming him or her self and/or others. In
some cases, restraints are also used for children who are not capable of remaining still when they
are frightened or in pain during administration of medication or performing other procedures.
However, using restraints in any health care facility should be used as the last option in dealing
with patients.

When to use restraints?

Physical restraint should be used only when other, less restrictive, measures prove ineffective in
protecting the patient and others from harm.
Types of Restraints

1. Soft restraints. This type of physical restraint device is used to limit movement of patients
who are confused, disoriented or combative. The main goal of using this restraint is to prevent
the patient from injuring him or her self and/or others.
2. Vest and Belt Restraints. In using this device full movement of arms and legs are permitted.
This is used to prevent the patient from falling from bed or a chair.
3. Limb Restraints. Patients who are removing supportive equipments such as I.V. lines,
indwelling catheters, NGTs and etc. are placed on limb restraints. This device allows only
slight limb motion.
4. Mitts. This device prevents the patient from removing supportive equipment, scratching
rashes or sores and injuring him or herself and/or others.
5. Body restraints. When patients become combative and hysterical they can be controlled by
applying body restraints. This immobilizes almost all of the body.
6. Leather Restraints. This restraint is only used when soft restraints are not sufficient to
control the patient and when sedation is either dangerous to the patient or ineffective.

Precautions of Restraint Application

1. Before applying restraints it is important to try other methods of promoting patient safety.
Alternative methods that might be effective are reorientation of the patient to the physical
surroundings, moving the patient’s room near to the staff members, teaching relaxation
techniques in order to decrease anxiety and fear and decrease overstimulation.
2. Documentation of any alternative method used is extremely important. Restraint application
should be documented thoroughly.\

Situations that Requires Restraint Application

1. Confused client tries to endanger him or herself

2. Confused client attempts to remove supportive equipments such as necessary tubes, IV
lines or protective dressings.
3. The client is at risk for falls.
4. The client is suicidal.
5. The client poses harm or threat of inflicting harm to health care staff, other clients and/or
visitors.
6. A child is unable to remain still during a minor surgical procedure.

Equipments

Soft restraints
 Vest restraint
 Limb restraint
 Mitt restraint
 Belt restraint
 Body restraint as needed
 Padding if needed (large gauze pads can be used)
 Restrain flow sheet (washcloth can be used)
Leather restraints
 Two wrist and two ankle leather restraints
 Four straps
 Key
 Large gauze pads – this is used to cushion each extremity
 Restraint flow sheet (washcloth can be used)
Restraint Application Key Steps
1. Make sure that the restraints are correct size for the patient’s build and weight.
2. Explain the need for restraint to the patient. Assure him or her that they are used to protect
him from injury rather than to punish him. It is necessary to inform the patient of the conditions
necessary to release him or her from restraints.
3. Restraints are ONLY used when all other methods have failed to keep the patient from
harming himself or others. Restraints used should be least restrictive to the patient.
4. Obtain adequate assistance to manually restrain the patient.
5. After an hour of placing a restraint, the patient should be evaluated by a licensed
independent practitioner and an order must be written for restraints.
6. The order must ne time limited: 4 hours for adults; 2 hours for patients ages 9 to 17 years
old; 1 hour for patients younger than 9 years old.
7. The original order expires in 24 hours. Thus, the same order cannot be used the following
day.
8. To promote safety and ensure the patient is not harmed with restraint application, the
patient should be assessed every 2 hours or according to the facility policy.
9. In cases where the client consented to have his family informed of his care, the family
should be notified of the use of restraints.

Schizophrenia Nursing Care Plan & Management

DEFINITION

Schizophrenia is an extremely complex mental disorder: in fact it is probably many illnesses

masquerading as one. A biochemical imbalance in the brain is believed to cause symptoms.
Recent research reveals that schizophrenia may be a result of faulty neuronal development in the
fetal brain, which develops into full-blown illness in late adolescence or early adulthood.

Schizophrenia causes distorted and bizarre thoughts, perceptions, emotions, movement, and
behavior. It cannot be defined as a single illness;

rather thought as a syndrome or disease process with many different varieties and symptoms. It is
usually diagnosed in late adolescence or early adulthood. Rarely does it manifest in childhood.
The peak incidence of onset is 15 to 25 years of age for men and 25 to 35 years of age for
women.

The symptoms of schizophrenia are categorized into two major categories, the positive or hard

symptoms which include delusion, hallucinations, and grossly disorganized thinking, speech, and
behavior, and negative or soft symptoms as flat affect, lack of volition, and social withdrawal or
discomfort. Medication treatment can control the positive symptoms but frequently the negative
symptoms persist after positive symptoms have abated. The persistence of these negative
symptoms over time presents a major barrier to recovery and improved the functioning of client’s
daily life.
PATHOPHYSIOLOGY

TYPES OF SCHIZOPHRENIA:
The diagnosis is made according to the client’s predominant symptoms:

 Schizophrenia, paranoid type is characterized by persecutory (feeling victimized or spied

on) or grandiose delusions, hallucinations, and occasionally, excessively religiosity (delusional
focus) or hostile and aggressive behavior.
 Schizophrenia, disorganized type is characterized by grossly inappropriate or flat affect,
incoherence, loose associations, and extremely disorganized behavior.
 Schizophrenia, catatonic type is characterized by marked psychomotor disturbance, either
motionless or excessive motor activity. Motor immobility may be manifested by catalepsy
(waxy flexibility) or stupor.
 Schizophrenia, undifferentiated type is characterized by mixed schizophrenic symptoms (of
other types) along with disturbances of thought, affect, and behavior.
 Schizophrenia, residual type is characterized by at least one previous, though not a current,
episode, social withdrawal, flat affect and looseness of associations.

Paranoid Schizophrenia
 Is characterized by persecutory or grandiose delusional thought content and, possibly,
delusional jealousy.
 Some patients also have gender identity problems, such as fears of being thought of as
homosexual or of being approached by homosexuals.
 Stress may worsen the patient’s symptoms.
 Paranoid schizophrenia may cause only minimal impairment in the patient’s level of
functioning – as long as he doesn’t act on delusional thoughts.
 Although patients with paranoid schizophrenia may experience frequent auditory
hallucinations (usually related to a single theme), they typically lack some of the symptoms of
other schizophrenia subtypes – notably, incoherent, loose associations, flat or grossly
inappropriate affect, and catatonic or grossly disorganized behavior.
 Tend to be less severely disabled than other schizophrenia.
 Those with late onset of disease and good pre-illness functioning (ironically, the very
patients who have the best prognosis) are at the greatest risk for suicide.

Signs and Symptoms

 Persecutory or grandiose delusional thoughts

 Auditory hallucinations
 Unfocused anxiety
 Anger
 Tendency to argue
 Stilted formality or intensity when interacting with others
 Violent behavior

Diagnosis

 Ruling out other causes of the patient’s symptoms.

 Meeting the DSM-IV-TR criteria.
Treatment

 Antipsychotic drug therapy.

 Psychosocial therapies and rehabilitation, including group and individual psychotherapy.
Nursing Interventions

1. Build trust, and be honest and dependable, don’t threaten or make promises you can’t fulfill.
2. Be aware that brief patient contacts may be most useful initially.
3. When the patient is newly admitted, minimize his contact with the staff.
4. Don’t touch the patient without telling him first exactly what you’re going to be doing and
before obtaining his permission to touch him.
5. Approach him in a calm, unhurried manner.
6. Avoid crowding him physically or psychologically; he may strike out to protect himself.
7. Respond neutrally to his condescending remarks; don’t let him put you on the defensive,
and don’t take his remarks personally.
8. If he tells you to leave him alone, do leave- but make sure you return soon.
9. Set limits firmly but without anger, avoid a punitive attitude.
10. Be flexible, giving the patient as much control as possible.
11. Consider postponing procedures that require physical contact with hospital personnel if the
patient becomes suspicious or agitated.
12. If the patient has auditory hallucinations, explore the content of the hallucinations (what
voices are saying to him, whether he thinks he must do what they command) tell him you don’t
hear voices, but you know they’re real to him.

Disorganized Schizophrenia
 Is marked by incoherent, disorganized speech and behaviors and by blunted or
inappropriate affect.
 May have fragmented hallucinations and delusions with no coherent theme.
 Usually includes extreme social impairment.
 This type of schizophrenia may start early and insidiously, with no significant remissions.

Signs and Symptoms

 Incoherent, disorganized speech, with markedly loose associations.

 Grossly disorganized behavior.
 Blunted, silly, superficial, or inappropriate affect.
 Grimacing
 Hypochondriacal complaints.
 Extreme social withdrawal.

Diagnosis

 Ruling out other causes of the patients symptoms.

 Meeting the DSM-IV-TR criteria.

Treatment

 Treatments described for other types of schizophrenia.

 Antipsychotic drugs and psychotherapy.
Nursing Interventions

1. Spend time with the patient even if he’s mute and unresponsive, to promote reassurance
and support.
2. Remember that, despite appearances, the patient is acutely aware of his environment,
assume the patient can hear – speak to him directly and don’t talk about him in his presence.
3. Emphasize reality during all patient contacts, to reduce distorted perceptions (for example,
say, “The leaves on the trees are turning colors and the air is cooler, It’s fall”)
4. Verbalize for the patient the message that his behavior seems to convey, encourage him to
do the same.
5. Tell the patient directly, specifically, and concisely what needs to be done; don’t give him
choice (for example, say, “It’s time to go for a walk, lets go.”)
6. Assess for signs and symptoms of physical illness; keep in mind that if he’s mute he won’t
complain of pain or physical symptoms.
7. Remember that if he’s in bizarre posture, he may be at risk for pressure ulcers or
decreased circulation.
8. Provide range-of-motion exercises.
9. Encourage to ambulate every 2 hours.
10. During periods of hyperactivity, try to prevent him from experiencing physical exhaustion
and injury.
11. As appropriate, meet his needs for adequate food, fluid, exercise, and elimination; follow
orders with respect to nutrition, urinary catheterization, and enema use.
12. Stay alert for violent outbursts; if these occur, get help promptly to intervene safely for
yourself, the patient, and others.

Catatonic Schizophrenia
 Is a rare disease form in which the patient tends to remain in a fixed stupor or position for
long periods, periodically yielding to brief spurts of extreme excitement.
 Many catatonic schizophrenia have an increased potential for destructive, violent behavior
when agitated.

Signs and Symptoms

 Remaining mute; refusal to move about or tend to personal needs.

 Exhibiting bizarre mannerisms, such as facial grimacing and sucking mouth movements.
 Rapid swing between stupor and excitement (extreme psychomotor agitation with
excessive, senseless, or incoherent shouting or talking).
 Bizarre posture such as holding the body (especially the arms and legs) rigidly in one
position for a long time.
 Diminished sensitivity to painful stimuli.
 Echolalia (repeating words or phrases spoken by others).
 Echopraxia (imitating other’s movements).

Diagnosis

 Ruling out other possible causes of the patient’s symptoms.

 Meeting the DSM-IV-TR criteria.

Treatment

 ECT and benzodiazepines (such as diazepam or lorazepam) for catatonic schizophrenia.

 Avoiding conventional antipsychotic drugs (they may worsen catatonic symptoms).
 Investigating atypical antipsychotic drugs to treat catatonic schizophrenia (requires further
evaluation).

Nursing Interventions

1. Spend time with the patient even if he’s mute and unresponsive, to promote reassurance
and support.
2. Remember that, despite appearances, the patient is acutely aware of his environment,
assume the patient can hear – speak to him directly and don’t talk about him in his presence.
3. Emphasize reality during all patient contacts, to reduce distorted perceptions (for example,
say, “The leaves on the trees are turning colors and the air is cooler, It’s fall”)
4. Verbalize for the patient the message that his behavior seems to convey, encourage him to
do the same.
5. Tell the patient directly, specifically, and concisely what needs to be done; don’t give him
choice (for example, say, “It’s time to go for a walk, lets go.”)
6. Assess for signs and symptoms of physical illness; keep in mind that if he’s mute he won’t
complain of pain or physical symptoms.
7. Remember that if he’s in bizarre posture, he may be at risk for pressure ulcers or
decreased circulation.
8. Provide range-of-motion exercises.
9. Encourage to ambulate every 2 hours.
10. During periods of hyperactivity, try to prevent him from experiencing physical exhaustion
and injury.
11. As appropriate, meet his needs for adequate food, fluid, exercise, and elimination; follow
orders with respect to nutrition, urinary catheterization, and enema use.
12. Stay alert for violent outbursts; if these occur, get help promptly to intervene safely for
yourself, the patient, and others.

DIAGNOSTIC TEST:
1. Clinical diagnosis is developed on historical information and thorough mental status
examination.
2. No laboratory findings have been identified that are diagnostic of schizophrenia.
3. Routine battery of laboratory test may be useful in ruling out possible organic etiologies,
including CBC, urinalysis, liver function tests, thyroid function test, RPR, HIV test, serum
ceruloplasmin ( rules out an inherited disease, wilson’s disease, in which the body retains
excessive amounts of copper), PET scan, CT scan, and MRI.
4. Rating scale assessment:

 Scale for the assessment of negative symptoms.
 Scale for the assessment of positive symptoms.
 Brief psychiatric rating scale

TREATMENTS AND MEDICATIONS:

Currently, there is no method for preventing schizophrenia and there is no cure. Minimizing the
impact of disease depends mainly on early diagnosis and, appropriate pharmacological and
psycho-social treatments. Hospitalization may be required to stabilize ill persons during an acute
episode. The need for hospitalization will depend on the severity of the episode. Mild or moderate
episodes may be appropriately addressed by intense outpatient treatment. A person with
schizophrenia should leave the hospital or outpatient facility with a treatment plan that will
minimize symptoms and maximize quality of life.

A comprehensive treatment program can include:

 Antipsychotic medication
 Education & support, for both ill individuals and families
  Social skills training
 Rehabilitation to improve activities of daily living
 Vocational and recreational support
 Cognitive therapy
Medication is one of the cornerstones of treatment. Once the acute stage of a psychotic episode
has passed, most people with schizophrenia will need to take medicine indefinitely. This is
because vulnerability to psychosis doesn’t go away, even though some or all of the symptoms do.
In North America, atypical or second generation antipsychotic medications are the most widely
used. However, there are many first-generation antipsychotic medications available that may still
be prescribed. A doctor will prescribe the medication that is the most effective for the ill individual
Another important part of treatment is psychosocial programs and initiatives. Combined with
medication, they can help ill individuals effectively manage their disorder. Talking with your
treatment team will ensure you are aware of all available programs and medications.

In addition, persons living with schizophrenia may have access to or qualify for income support
programs/initiatives, supportive housing, and/or skills development programs, designed to promote
integration and recovery.

Sigmund Freud’s Psychosexual Theory of Human Development

AKA Sigismund Schlomo Freud

Born:May 6, 1856
Birthplace: Freiberg, Moravia
Died: September 23,1939
Location of death: London, England
Cause of death: Euthanasia [1]
Remains: Cremated, Golders Green Crematorium, London, England
Gender: Male
Religion: Atheist
Race or Ethnicity: White
Occupation: Psychiatrist
Nationality: Austria
Executive summary: Die Traumdeutung
The concept of psychosexual development, as envisioned by Sigmund Freud at the end of the
nineteenth and the beginning of the twentieth century, is a central element in the theory of
psychology. It consists of five separate phases: oral, anal, phallic, latency, and genital. In the
development of his theories, Freud’s main concern was with sexual desire, defined in terms of
formative drives, instincts and appetites that result in the formation of an adult personality.
Freud’s model of psychosexual development

 AGE  EROGENOUS
 STAGE RANGE ZONE(S)  CONSEQUENCES OF FIXATION

Orally Aggressive:
Involves chewing gum or ends of pen.Orally
Passive:
 0 – 18 Involves
 Oral months  Mouth smoking/eating/kissing/fellatio/cunnilingus

Anal-retentive:
Obsession with organization or excessive
 Bowel and neatnessAnal-expulsive:
 18 – 36 Bladder Reckless, careless, defiant, disorganized,
 Anal months Elimination Coprophiliac

Oedipus Complex (in boys according to

 3 – 6 Freud)Electra Complex (in girls according to
 Phallic years  Genitals Jung not Freud)

 6 years (People do not tend to fixate at this stage, but if

 Latenc –  Dormant Sexual they do, they tend to be extremely sexually
y Puberty Feeling unfulfilled.)

 Puberty
and  Sexual interest
 Genital beyond mature Frigidity, impotence, unsatisfactory relationships

Oral phase

The oral stage in psychology is the term used by Sigmund Freud to describe the child’s
development during the first eighteen months of life, in which an infant’s pleasure centers are in
the mouth. This is the first of Freud’s psychosexual stages.

This is the infant’s first relationship with its mother; it is a nutritive one. The length of this stage
depends on the society. In some societies it is common for a child to be nursed by its mother for
several years, whereas in others the stage is much shorter. Suckling and eating, however,
compose the earliest memories for infants in every society. This stage holds special importance
because some, especially those in tribal societies commonly found in the Southwest Pacific and
Africa, consider the stomach to be the seat of emotions.

Anal phase

The next stage of psychosexual development is centered around the rectum, but can also include
bladder functions. This phase usually occurs from eighteen months to thirty-six months of age. In
this stage children learn to control the expulsion of feces causing their libidinal energy to become
focused in this area. The added awareness of this erogenous zone arises in children from
concentrating on controlling their defecation. They come to see it as just another way to
experience pleasure, and begin to take pride in either defecating in a fashion that may be
considered socially unacceptable, or, in the case of very strict parents, they may begin to resist the
urge to defecate to the extent where it becomes pathological. Two types of characters can develop
out of this: the expulsive and the retentive. The expulsive character would have been prone to
malicious excretion either just before they were placed on the toilet or just after they were removed
from the toilet. The retentive character takes pleasure in holding in the feces in spite of his or her
parents’ training. The child comes to view the feces as a possession which he does not want to
relinquish. Freud postulated that such children develop into adults who are usually neat,
organized, careful, meticulous, and obstinate.

Phallic phase

At thirty-six months to about seventy-two months of age the libidinal energy shifts from the anal
region to the genital region. At this point, according to Freud’s model, the Oedipus or Electra
complex can develop. The Oedipus complex is central to the psychodynamic fixations in this time
period for men; the Electra complex for women.

Around this time in males, according to Freud, the young boy falls in love with his mother and
wishes that his father was not in the way of his love. At this point he notices that women have no
penis and fears that the punishment of his father for being in love with his wife is castration. This
fear is enhanced if he is castigated for masturbation at this stage. Once the fear of retaliation has
subsided the boy will learn to earn his mother’s love by becoming as much like his father as
possible. Thus, the superego is born. He will adopt his father’s beliefs and ideals as his own and
move on to the latency stage.

Freud’s theory regarding the psychosexual dynamic present in female children in this point of their
psychosexual development is termed, though not by Freud himself, the Electra complex.
According to Freud, young girls, after they come to the realization that they have no penis, begin
to blame the mother for having taken it, and look to the father as a substitute for the loss that they
perceive. This is termed “penis envy.” Freud’s theory of feminine sexuality, particularly penis envy,
has been sharply criticized in both gender and feminist theory.

Latency phase

The latency period begins sometime around the age of six and ends when puberty starts to begin.
Freud believed that in this phase the Oedipus complex was dissolved and set free, resulting in a
relatively conflict-free period of development. In this phase, the child begins to make connections
to siblings, other children, and adults. This phase is typified by a solidifying of the habits that the
child developed in the earlier stages.

Genital phase

The genital stage starts at puberty, allowing the child to develop opposite sex relationships with
the libidinal energy again focused on the genital area. According to Freud, if any of the stages are
fixated on, there is not enough libidinal energy for this stage to develop untroubled. To have a fully
functional adulthood, the previous stages need to be fully resolved and there needs to be a
balance between love and work.

Somatoform Disorders
Definition

 Somatoform disorders are characterized by physical symptoms, which suggest medical

diseases, but without organic pathology to support the illness.
 It refers to all mechanisms by which anxiety is translated into physical illness.
 Somatoform disorders include somatization disorder.

Types of Disorder

1. Somatization disorder
 This chronic syndrome is characterized by multiple somatic symptoms that cannot be
explained medically.
 The physical symptoms are associated with psychological stress.
2. Conversion disorder
 A loss or change in bodily function is the result of psychological conflict, allowing the
client to resolve the conflict through loss of a physical function.
 The client often exhibits a lack of concern about the severity of the disease (la belle
indifferences).
3. Sleep disorder
 This is characterized by difficulty initiating or maintaining sleep.
 Sleep disorders include hypersomnia or excessive sleepiness, narcolepsy,
parasomnias, undesirable behaviors that occur during sleep.
 In sleep disorders, the sleep-wake schedule and circadian rhythm are disturbed.
4. Hypochondriasis
 This is a person’s unwanted fear or belief that he or she has a serious disease
without significant pathology.
 Hypochondrias interferes with client’s work and social relationships.
5. Body dysmorphic disorders
 The client is preoccupied with an image defect in appearance when there is no
abnormality.
 Client obsesses about imaged bodily defects (facial flaws, heavy buttocks or thighs)
and becomes embarrassed about them.
6. Pain disorder
 The pain is unrelated to a medical disease.
 The individual experiences severe pain that is in disproportion to the originating
source.

Risk Factors

1. Gender: Female
2. Age: Children and older adults

Signs and Symptoms

1. Pain in the absence of organic pathology.

2. Preoccupation with physical symptoms, disease, physical flaws, and oneself.
3. Dependence on addictive substances for relief of pain that is unsubstantiated by physical
findings.
4. Frequent visits to health care providers.
5. Symptoms of anxiety and/or depression.
6. Hydrochondriasis is not a conscious decision on the part of the client; they believe that they
are ill.

Nursing Diagnoses

 Impaired adjustment
 Chronic pain
 Sleep pattern disturbance
Nursing Interventions

1. Alternative therapeutic interventions may be used, such as therapeutic touch, imaging, and
acupuncture.
2. Assist the client in identifying and describing in stress he/she experiences.
3. Assist the client in monitoring stress and knowing when to intervene.
4. Teach the client about medications and to avoid alcohol and other such drugs used to
alleviate stress approximately.
5. Recognize medical problem.

Complications

1. Risk to self and others.

2. Dependency on addictive medications.
3. Withdrawal symptoms related to discontinuation of sedatives, hypnotics, and narcotics.

Suicide Ideation
Definition

 Self imposed death stemming from depression.

Risk Factors

1. Theories of Suicide
 Anger turned inward: anger that was previously directed at someone else is turned
inward.
 Hopelessness, depression, and guilt: desperate feelings of the client.
 A history of aggression and violence: rage and violent behavior is correlated with
suicides.
 Shame and humiliation: suicide viewed as a “saying face” or saving the family name
following a suicidal defeat.
 Developmental stressors: certain stressors at developmental stages have been
identified as precipitating factors to suicide.
2. Biological theories
 Generic tendency: Twin studies have indicated a predisposition toward suicidal
behavior.
 Neurochemical factors: Postmortem studies have revealed a decreased serotonin
level in the brainstem and spinal fluid.

Signs and Symptoms

1. Self mutilation
2. Unexplained decrease in daily functioning
3. Isolation and withdrawal, decreased social interaction
4. Channeling of anger and hostility towards self
5. Inability to discuss the future
6. Destructive coping mechanisms
7. Express anger toward self
8. Previous suicide attempts
9. Low self-esteem
10. Anxious and apprehensive
11. Non-verbal cues such as giving away possessions
Assessment

1. Suicidal Assessment: Question to ask the client to assess how realistic the client’s plan is.
 Do you have thoughts of harming or killing yourself?
 Do you have a plan to harm or kill yourself?
 What is the plan?
 Is it possible to implement the plan?
 When do you plan to do it?
2. A person is considered at a high-risk for suicide if the plan could be carried out within 24-48
hours. Other issues in determining risk include the lethality of the method and the plan of
discovery after death.

Nursing Diagnoses

 High risk for violence, self-directed or directed at others

 Risk for self mutilation
 Ineffective individual coping
 Ineffective family coping
 Spiritual distress

Therapeutic Nursing Management

1. Establish a therapeutic relationship

2. Talk directly with the client about suicide and plans
3. Communicate the potential for suicide to team members and family
4. Stay with the client
5. Accept the person. Listen to the person.
6. Secure a “no suicide/harm” contract
7. Give the person a message of hope based on reality
8. When client is able, encourage gradual increase in activities
9. Maintain suicide precautions, be particularly concerned with personal items the client may
used to harm self, remove all dangerous and potentially dangerous items (belts, glass,
sharps).

Therapeutic and Non-Therapeutic Communication

Effective Communication:

1. Open ended questions

2. Focus on feelings
3. State behaviors observed
4. Reflect, restate, rephrase verbalization of patient
5. Neutral responses
6. Appropriate
7. Simple
8. Adaptive
9. Concise
10. Credible
Therapeutic relationship – is a relationship that is established between a health care professional
and a client for the purpose of assisting the client to solve his problems.
Components of a Therapeutic Relationship

One of the most important skills of a nurse is developing the ability to establish a therapeutic
relationship with clients. For interventions to be successful with clients in a psychiatric facility and
in all nursing specialties it is crucial to build a therapeutic relationship. Crucial components are
involved in establishing a therapeutic nurse-patient relationship and the communication within it
which serves as the underpinning for treatment and success. It is essential for a nurse to know
and understand these components as it explores the task that should be accomplish in a nurse-
client relationship and the techniques that a nurse can utilize to do so.

TRUST

Without trust a nurse-client relationship would not be established and interventions won’t be
successful. For a client to develop trust, the nurse should exhibit the following behaviors:

 Friendliness
 Caring
 Interest
 Understanding
 Consistency
 Treating the client as human being
 Suggesting without telling
 Approachability
 Listening
 Keeping promises
 Providing schedules of activities
 Honesty

GENUINE INTEREST

Another essential factor to build a therapeutic nurse-client relationship is showing a genuine

interest to the client. For the nurse to do this, he or she should be open, honest and display a
congruent behavior. Congruence only occurs when the nurse’s words matches with her actions.

EMPATHY

For a nurse to be successful in dealing with clients it is very essential that she empathize with the
client. Empathy is the nurse’s ability to perceive the meanings and feelings of the client and
communicate that understanding to the client. It is simply being able to put oneself in the client’s
shoes. However, it does not require that the nurse should have the same or exact experiences as
of the patient. Empathy has been shown to positively influence client outcomes. When the nurse
develops and utilizes this ability, clients tend to feel much better about themselves and more
understood.

Some people confuse empathizing with sympathizing. To establish a good nurse-patient

relationship, the nurse should use empathy not sympathy. Sympathy is defined as the feelings of
concern or compassion one shows for another. By sympathizing, the nurse projects his or her own
concerns to the client, thus, inhibiting the client’s expression of feelings. To better understand the
difference between the two, let’s take a look at the given example.

Client’s statement:
“I am so sad today. I just got the news that my father died yesterday. I should have been there, I
feel so helpless.”

Nurse’s Sympathetic Response:

“I know how depressing that situation is. My father also died a month ago and until now I feel so
sad every time I remember that incident. I know how bad that makes you feel.”

Nurse’s Empathetic Response:

“I see you are sad. How can I help you?”

When the nurse expresses sympathy for the client, the nurse’s feelings of sadness or even pity
could influence the relationship and hinders the nurse’s abilities to focus on the client’s needs. The
emphasis is shifted from the client’s to the nurse’s feelings thereby hindering the nurse’s ability to
approach the client’s needs in an objective manner.

In dealing with clients their interest should be the nurse’s greatest concern. Thus, empathizing with
them is the best technique as it acknowledges the feelings of the client and at the same time it
allows a client to talk and express his or her emotions. Here a bond can be established that serves
as a foundation for the nurse-client relationship.

ACCEPTANCE

Clients are unpredictable. There are times that they outburst with anger or act out their
inappropriate desires. A nurse, who does not judge the client or person no matter what his or her
behavior, is showing acceptance. Acceptance does not mean accepting all the inappropriate
behavior but rather acceptance of the person as worthy. When the client displays an improper
behavior, the nurse can communicate with the client by being firm and clear without anger or
judgment. In this way, the nurse allows the client to feel intact but at the same time aware that his
certain behavior is unacceptable. Let’s take a look at the given example.
Situation: A client tries to kiss the nurse.
Inappropriate response: What the hell are you doing?! I’m leaving maybe I’ll see you tomorrow.
Appropriate response: Adam, do not kiss me. We are working on your relationship with your
girlfriend and that does not require you to kiss me. Now let us continue.

POSITIVE REGARD

Positive regard is an unconditional and nonjudgmental attitude where the nurse appreciates the
client as a unique worthwhile human being that shows respect for the client regardless of his or
her behavior background and lifestyle. The following ways are example of how to promote respect
and positive regard to a client:

 Calling the client by name

 Spending time with the client
 Listening to the client
 Responding to the client openly
 Considering the client’s ideas and preferences when planning care

SELF-AWARENESS

Self-awareness is the process of understanding one’s own values, beliefs, thoughts, feelings,
attitudes, motivations, prejudices, strengths and limitations. Before a nurse can understand clients
he or she should be able to understand him or herself. The first step in preparing oneself to build a
therapeutic nurse-patient relationship is to understand oneself.

THERAPEUTIC USE OF SELF

A nurse can only use his or her personality, experiences, values, feelings, intelligence, needs,
coping skills and perceptions to build a relationship with clients (therapeutic use of self) when he
or she has developed self-awareness and self-understanding.
Therapeutic Technique

1. Offering Self
 making self-available and showing interest and concern.
 “I will walk with you”
2. Active listening
 paying close attention to what the patient is saying by observing both verbal and non-verbal
cues.
 Maintaining eye contact and making verbal remarks to clarify and encourage further
communication.
3. Exploring
 “Tell me more about your son”
4. Giving broad openings
 What do you want to talk about today?
5. Silence
 Planned absence of verbal remarks to allow patient and nurse to think over what is being
discussed and to say more.
6. Stating the observed
 verbalizing what is observed in the patient to, for validation and to encourage discussion
 “You sound angry”
7. Encouraging comparisons
 · asking to describe similarities and differences among feelings, behaviors, and events.
 · “Can you tell me what makes you more comfortable, working by yourself or working as a
member of a team?”
8. Identifying themes
 asking to identify recurring thoughts, feelings, and behaviors.
 “When do you always feel the need to check the locks and doors?”
9. Summarizing
 reviewing the main points of discussions and making appropriate conclusions.
 “During this meeting, we discussed about what you will do when you feel the urge to hurt
your self again and this include…”
10. Placing the event in time or sequence
 asking for relationship among events.
 “When do you begin to experience this ticks? Before or after you entered grade school?”
11. Voicing doubt
 voicing uncertainty about the reality of patient’s statements, perceptions and conclusions.
 “I find it hard to believe…”
12. Encouraging descriptions of perceptions
 asking the patients to describe feelings, perceptions and views of their situations.
 “What are these voices telling you to do?”
13. Presenting reality or confronting
 stating what is real and what is not without arguing with the patient.
 “I know you hear these voices but I do not hear them”.
 “I am Lhynnelli, your nurse, and this is a hospital and not a beach resort.
14. Seeking clarification
 asking patient to restate, elaborate, or give examples of ideas or feelings to seek
clarification of what is unclear.
 “I am not familiar with your work, can you describe it further for me”.
 “I don’t think I understand what you are saying”.
15. Verbalizing the implied
 rephrasing patient’s words to highlight an underlying message to clarify statements.
 Patient: I wont be bothering you anymore soon.
 Nurse: Are you thinking of killing yourself?
16. Reflecting
 throwing back the patient’s statement in a form of question helps the patient identify
feelings.
 Patient: I think I should leave now.
 Nurse: Do you think you should leave now?
17. Restating
 repeating the exact words of patients to remind them of what they said and to let them know
they are heard.
 Patient: I can’t sleep. I stay awake all night.
 Nurse: You can’t sleep at night?
18. General leads
 using neutral expressions to encourage patients to continue talking.
 “Go on…”
 “You were saying…”
19. Asking question
 using open-ended questions to achieve relevance and depth in discussion.
 “How did you feel when the doctor told you that you are ready for discharge soon?”
20. Empathy
 recognizing and acknowledging patient’s feelings.
 “It’s hard to begin to live alone when you have been married for more than thirty years”.
21. Focusing
 pursuing a topic until its meaning or importance is clear.
 “Let us talk more about your best friend in college”
 “You were saying…”
22. Interpreting
 providing a view of the meaning or importance of something.
 Patient: I always take this towel wherever I go.
 Nurse: That towel must always be with you.
23. Encouraging evaluation
 asking for patients views of the meaning or importance of something.
 “What do you think led the court to commit you here?”
 “Can you tell me the reasons you don’t want to be discharged?
24. Suggesting collaboration
 offering to help patients solve problems.
 “Perhaps you can discuss this with your children so they will know how you feel and what
you want”.
25. Encouraging goal setting
 asking patient to decide on the type of change needed.
 “What do you think about the things you have to change in your self?”
26. Encouraging formulation of a plan of action
 probing for step by step actions that will be needed.
 “If you decide to leave home when your husband beat you again what will you do next?”
27. Encouraging decisions
 asking patients to make a choice among options.
 “Given all these choices, what would you prefer to do.
28. Encouraging consideration of options
 asking patients to consider the pros and cons of possible options.
 “Have you thought of the possible effects of your decision to you and your family?”
29. Giving information
 providing information that will help patients make better choices.
 “Nobody deserves to be beaten and there are people who can help and places to go when
you do not feel safe at home anymore”.
30. Limit setting
 discouraging nonproductive feelings and behaviors, and encouraging productive ones.
 “Please stop now. If you don’t, I will ask you to leave the group and go to your room.
31. Supportive confrontation
 acknowledging the difficulty in changing, but pushing for action.
 “I understand. You feel rejected when your children sent you here but if you look at this
way…”
32. Role playing
 practicing behaviors for specific situations, both the nurse and patient play particular role.
 “I’ll play your mother, tell me exactly what would you say when we meet on Sunday”.
33. Rehearsing
 asking the patient for a verbal description of what will be said or done in a particular
situation.
 “Supposing you meet these people again, how would you respond to them when they ask
you to join them for a drink?”.
34. Feedback
 pointing out specific behaviors and giving impressions of reactions.
 “I see you combed your hair today”.
35. Encouraging evaluation
 asking patients to evaluate their actions and their outcomes.
 “What did you feel after participating in the group therapy?”.
36. Reinforcement
 giving feedback on positive behaviors.
 “Everyone was able to give their options when we talked one by one and each of waited
patiently for our turn to speak”.

Avoid pitfalls:

1. Giving advise
2. Talking about your self
3. Telling client is wrong
4. Entering into hallucinations and delusions of client
5. False reassurance
6. Cliché
7. Giving approval
8. Asking WHY?
9. Changing subject
10. Defending doctors and other health team members.

Non-therapeutic Technique

1. Overloading
 talking rapidly, changing subjects too often, and asking for more information than can be
absorbed at one time.
 “What’s your name? I see you like sports. Where do you live?”
2. Value Judgments
 giving one’s own opinion, evaluating, moralizing or implying one’s values by using words
such as “nice”, “bad”, “right”, “wrong”, “should” and “ought”.
 “You shouldn’t do that, its wrong”.
3. Incongruence
 sending verbal and non-verbal messages that contradict one another.
 The nurse tells the patient “I’d like to spend time with you” and then walks away.
4. Underloading
 remaining silent and unresponsive, not picking up cues, and failing to give feedback.
 The patient ask the nurse, simply walks away.
5. False reassurance/ agreement
 Using cliché to reassure client.
 “It’s going to be alright”.
6. Invalidation
 Ignoring or denying another’s presence, thought’s or feelings.
 Client: How are you?
 Nurse responds: I can’t talk now. I’m too busy.
7. Focusing on self
 responding in a way that focuses attention to the nurse instead of the client.
 “This sunshine is good for my roses. I have beautiful rose garden”.
8. Changing the subject
 introducing new topic
 inappropriately, a pattern that may indicate anxiety.
 The client is crying, when the nurse asks “How many children do you have?”
9. Giving advice
 telling the client what to do, giving opinions or making decisions for the client, implies client
cannot handle his or her own life decisions and that the nurse is accepting responsibility.
 “If I were you… Or it would be better if you do it this way…”
10. Internal validation
 making an assumption about the meaning of someone else’s behavior that is not validated
by the other person (jumping into conclusion).
 The nurse sees a suicidal clients smiling and tells another nurse the patient is in good
mood.

Other ineffective behaviors and responses:

1. Defending – Your doctor is very good.

2. Requesting an explanation – Why did you do that?
3. Reflecting – You are not suppose to talk like that!
4. Literal responses – If you feel empty then you should eat more.
5. Looking too busy.
6. Appearing uncomfortable in silence.
7. Being opinionated.
8. Avoiding sensitive topics
9. Arguing and telling the client is wrong
10. Having a closed posture-crossing arms on chest
11. Making false promises – I’ll make sure to call you when you get home.
12. Ignoring the patient – I can’t talk to you right now
13. Making sarcastic remarks
14. Laughing nervously
15. Showing disapproval – You should not do those things.

Therapeutic Community ( Milieu Therapy)

Sullivan envisioned the goal of treatment as the establishment of satisfying interpersonal
relationships. The therapist provides a corrective interpersonal relationship for the client. Sullivan
coined the term participant observer for the therapist’s role, meaning that the therapist both
participates in and observes the progress of the relationship.
Credit is also given to Sullivan for the developing the first therapeutic community or milieu
therapy with young men with schizophrenia in 1929 (although that term was not used extensively
until Maxwell Jones published The Therapeutic Community in 1953). In the concept of therapeutic
or milieu therapy, the interaction among clients is seen as beneficial, and treatment emphasizes
the role of this client-to-client interaction. Until this time, it was believed that the interaction
between the client and psychiatrist was the one essential component to the client’s treatment.
Sullivan and later Jones observed that interactions among clients in safe, therapeutic setting
provided great benefits to clients. The concept of milieu therapy, originally developed by Sullivan,
involved clients’ interactions with one another; i.e., practicing interpersonal relationship skills,
giving one another feedback about behavior, and working cooperatively as a group to solve day-
to-day problems.
Milieu therapy was one of the primary modes of treatment in the acute hospital setting. In today’s
health care environment, however, inpatient hospital stays are often too short for clients to develop
meaningful relationships with one another. Therefore the concept of milieu therapy receives little
attention. Management of the milieu or environment is still a primary role for the nurse in terms of
providing safety and protection for all the clients and promoting social interaction.

Therapeutic Therapy
Definition

A simple type of milieu therapy by which the total social structure of the treatment unit is involved
in the helping process.

Goal and Objectives

1. To help the patient develop a sense of self-esteem and self- respect.

2. To help him learn to trust others.
3. To improve his ability to relate to others and with authority.
4. To return him to the community, better prepared to resume his role in living and working.

Elements

1. People
2. Organized activities
3. Environment

Characteristics of therapeutic community

1. Emphasis on social and group interaction

2. Focusing communication
3. Sharing responsibilities with patient
4. Living and learning abilities

Therapeutic Activities

1. Music appreciation thru arts

2. Craft and occupation therapy
3. Newspaper discussion
4. Bibliotherapy
5. Activities of daily living
6. Calisthenics
7. Indoor/ outdoor games
8. Play therapy

Therapeutic Meetings

1. Circle meeting – highlights of 24 hours

2. Small group – personal problems of patient
3. Community meeting – problems of patient encountered in the ward of general interest
4. Treatment planning – treatment regimen of a patient
5. Discharge planning conference – discharge plan for patient
 6. Patient government meeting – officers of the patients discuss issue related to their welfare
7. Staff’s shift-to-shift meeting – discussion of the demotion and promotion of patient status
Attitude therapy

 Prescribed ways on how to handle mentally ill patients according to the behavior symptoms
they manifest.

Types of attitude therapy

1. Active friendliness – withdrawn patient

2. Passive friendliness – paranoid patient
3. Kind-firmness – depressed client
4. Matter-of-fact – manipulative/ demanding client related
5. No demand – furious in rage
Characteristics of attitude therapy

1. Consistency must be used in order for the client to reach the maximum therapeutic value.
2. All persons who come in contact with the patient should have a uniform attitude.
3. Should be prescribed by the physician and should be individualized depending on the
individual needs.

Three Phases of Nurse-Client Relationship

Nurse-Client Relationship

 The nurse and the client work together to assist client to grow and solve his problems. This
relationship exists for the benefit of the client so that it is important that at every interaction,
the nurse uses self therapeutically. This is achieved by maintaining the nurses’ self-
awareness to prevent her unrecognized needs from influencing her perception of and
behavior towards the client.

Three Phases of Nurse-Client Relationship:

1. Orientation Stage
 Establishing therapeutic environment.
 The roles, goals, rules and limitations of the relationship are defined, nurse gains trust of
the client, and the mode of communication are acceptable for both nurse and patient is set.
 Acceptance is the foundation of all therapeutic relationship
 Acceptance of others requires acceptance of self first.
 Rapport is built by demonstrating acceptance and non-judgmental attitude.
 Acceptance of patient means encouraging the patient verbally and non-verbally to express
both positive and negative feelings even if these are divergent from accepted norms and
general viewpoint.
 The nurse can encourage the client to share his/her feelings by making the client
understand that no feeling is wrong.
 Trust of patient is gained by being consistent.
 Assessment of the client is made by obtaining data from primary and secondary sources.
 The patient set the pace of the relationship.
 During this phase, the problems are not yet been resolved but the client’s feelings
especially anxiety is reduced, by using palliative measures, to enable the client to relax
enough to talk about his distressing feelings and thoughts.
 This stage progresses well when the nurses show empathy provide support to client and
temporary structure until the client can control his own feelings and behavior.
 Reality testing – is accepting the patient’s perceptions, feelings and thoughts as
neither right nor wrong, but at the same time offering other options or points of view to the
client in a non-argumentative manner for the purpose of helping the client arrive at more
realistic conclusions.
 To provide structure is to intervene when the client loses control of his own feelings
and behaviors by medications, offering self, restrain, seclusion and by assisting client to
observe a consistent daily schedule.
2. Working/ Exploration/ Identification Stage – at this point, the client’s problems are identified and
solutions are explored, applied and evaluated.
 The focus of the assessment and of the relationship is the client’s behavior and the focus of
the interaction is the client’s feelings.
 The nurse should realize that the client’s feelings of security are developed by being
consistent at all times.
 Perception of reality, coping mechanisms and support systems are identified.
 The nurse assists the patient to develop coping skills, positive self concept and
independence in order to change the behavior of the client to one that is adaptive and
appropriate.
 The nurse uses the techniques of communication and assumes different roles to
help the client.
3. Termination/ Resolution stage
 the nurse terminates the relationship when the mutually agreed goals are met, the patient is
discharged or transferred or the rotation is finished. The focus of this stage is the growth that
has occurred in the client and the nurse helps the patient to become independent and
responsible in making his own decisions. The relationship and the growth or change that has
occurred in both the nurse and the patient is summarized.
 Client may become anxious and react with increased dependence, hostility and withdrawal,
these are normal reactions and are signs of separation anxiety, these feelings and behavior
should be discussed with the client.
 The nurse should be firm in maintaining professionalism until the end of the relationship.
She should not promise the client that the relationship will be continued.
 The time parameters should be made early in the relationship and meetings are set further
and further apart near the end to foster independence of the patient and prepare the latter
gradually for the separation.
 The nurse should not give her address or telephone numbers to the patient.
 Referral for continuing health care and support after discharge provides additional
resources for the client and the family.
 The goal of the therapeutic relationship have been met when the patient has developed
emotional stability, cope positively, recognized sources or causes of anxiety, demonstrates
ability to handle anxiety and independence, and is able to perform self-care.
 Preparation of the termination phase begins at the orientation phase, when the
duration and length of the nurse-client relationship was established.
  · It is normal for the client to experience separation anxiety such as sleeplessness,
anorexia, physical symptoms, withdrawal and hostility.

Wernicke’s Encephalopathy
Definition

Wernicke’s encephalopathy is a serious neurological condition that results primarily from a

deficiency of the nutrient thiamine which is also known as Vitamin B1. This condition is an
inflammatory, hemorrhagic, degenerative condition of the brain. It is characterized by lesions in
several parts of the brain, including the hypothalamus, mammillary bodies, and tissues
surrounding the ventricles and aqueducts, double vision, ophthalmoplegia, involuntary and rapid
movements of the eyes, lack of muscular coordination, and decreased mental function, which may
be mild or severe. The disease is comprised of three main symptoms: mental confusion, lack of
muscle coordination, and a paralysis of the muscles which control eye movements.

Frequency

 The male-to-female ratio is 1.7:1, likely owing to alcoholism being 3-4 times more frequent
in men than in women.
 Wernicke encephalopathy have placed the incidence between 0.8% and 2.8% of the
general population
 The incidence can be as high as 12.5% in a population of alcoholics

Causes

 This disease is caused by a lack of thiamin (vitamin B1), which leads to problems with the
normal functioning of the brain.
 Thiamine deficiency is characteristically associated with chronic alcoholism, because it
affects thiamine uptake and utilization. Most cases of Wernicke’s encephalopathy are rooted
in chronic alcohol abuse.  Alcohol can, over time, severely impair the body’s ability to absorb
thiamine, gradually leading to a deficiency of this nutrient. When someone who is known to
abuse alcohol has symptoms such as confusion and gait ataxia, meaning lack of coordination
in walking, Wernicke’s encephalopathy should be considered as a possible cause.
 Wernicke encephalopathy may develop in nonalcoholic conditions such as:
1. prolonged starvation
2. hyperemesis gravidarum (continuous nausea and vomiting during pregnancy)
3. bariatric surgery and other gastric bypass surgeries
4. HIV-AIDS
5. healthy infants given the wrong formulas
6. malnutrition
7. complication of GI tract disease
8. Cancers that have spread throughout the body
9. Heart failure (when treated with long-term diuretic therapy)
10. Long periods of intravenous (IV) therapy without receiving thiamine supplements
11. Long-term dialysis
12. Very high thyroid hormone levels (thyrotoxicosis)
13. Chronic renal failure
14. Carbohydrate loading in the presence of marginal thiamine stores (feeding after
starvation)
15. Absence of thiamine from the diet (in the case of infants fed formula without the
addition of thiamine)
16. Congenital transketolase function abnormalities
Signs and Symptoms

TRIAD SYMPTOMS

The 3 components of the classic triad of Wernicke encephalopathy are encephalopathy, ataxic
gait, and some variant of oculomotor dysfunction.

 Encephalopathy. Encephalopathy is characterized by a global confusional state, disinterest,

inattentiveness, or agitation. The most constant symptoms of Wernicke encephalopathy are
the mental status changes. Stupor and coma are rare.
 Loss of muscular coordination (ataxia) – Leg tremor. Gait ataxia is often a presenting
symptom. Ataxia is likely to be a combination of polyneuropathy, cerebellar damage, and
vestibular paresis. Vestibular dysfunction, usually without hearing loss, is universally impaired
in the acute stages of Wernicke encephalopathy.
 Ocular Abnormalities. Ocular abnormalities are the hallmarks of Wernicke encephalopathy.
The oculomotor signs are:
1. Abnormal eye movement (back and forth movements called nystagmus) – most
common
2. Double vision
3. Eyelid drooping
4. bilateral lateral rectus palsies
5. conjugate gaze palsies reflecting cranial nerve involvement of the oculomotor,
abducens, and vestibular nuclei
6. pupillary abnormalities such as sluggishly reactive pupils, ptosis, scotomata, and
anisocoria
OTHER SYMPTOMS

 Vestibular dysfunction
 Hypotension. Hypotension can be secondary to thiamine deficiency either through
cardiovascular beriberi or thiamine deficiency–induced autonomic dysfunction.
 Hypothermia. Thiamine deficiency often affects the temperature-regulating center in the
brainstem, which can result in hypothermia.
 Coma
 Wet beriberi
 Nutritional polyneuropathy
 Muscle atrophy,
 Cold skin.
 Loss of memory, can be profound.
 Swallowing difficulties,
 Double vision.
 Abnormal eye movements.
 Inability to form new memories.
 Dry skin,
 Staggering gait.
 Eye movement abnormalities.
 Difficulty with speech,
 Confabulation (making up stories).
 Reduced eye movement.

Diagnosis

No specific laboratory test is available for diagnosing Wernicke encephalopathy. Wernicke

encephalopathy is a clinical diagnosis, and normal electrolyte levels may only give false
reassurance and delay therapy. This is particularly the case where malnutrition is likely to be
present. The motto should be “If in doubt, treat,” as administration of thiamine does not pose
potential harm.

A Diagnosis can be made by treating the patient with thiamin and watching the symptoms
improve.  There are blood and urine tests available to check the level of thiamin, but giving the
patient thiamin and seeing the response is the best way to diagnose this condition.

 When a person appears poorly nourished (malnourish). The following should be done to
check the patient’s nutrition level:
1. Serum albumin. This test relates to the person’s general nutrition
2. Serum vitamin B1 levels
3. Transketolase activity in the red blood cells. The level of this is reduced in people
with thiamine deficiency.
 Blood pyruvate and lactate measurements. These tests are sensitive and helpful, as
thiamine is a cofactor of the pyruvate dehydrogenase enzyme, an important enzyme in
aerobic metabolism.
 Toxic drug screening is performed to exclude some causes of drug-induced altered mental
status.
 To exclude hypoglycemia and hyperglycemia, serum glucose levels should be obtained.
 Complete blood cell (CBC) count rules out severe anemias and leukemias as causes of
altered mental status.
Treatment

 Intravenous thiamine is given to the patient for a few days until it can be given by mouth.
 The most effective treatment is to eat properly.
 Start thiamine prior to or concurrently with treatment of intravenous glucose solutions, and
continue until the patient resumes a normal diet.
 Patients with Wernicke encephalopathy are likely hypomagnesemic and should be treated
empirically with parenteral magnesium sulfate, as they may be unresponsive to parenteral
thiamine in the presence of hypomagnesemia. After correction of hypomagnesemia in
conjunction with thiamine repletion, the blood transketolase activity can return to normal and
clearing of the clinical signs may occur.
 Stabilize airway, ensure oxygenation and maintain the patient’s blood pressure as patients
with Wernicke’s encephalopathy present with an altered mental status in prehospital settings.
 Promoting hydration.
 Providing proper nutrition.