QUALITY OF PSYCHIATRIC NURSING CARE Mental Health (WHO, 1999)

a. Structure - A state of well-being in which every individual (1)

 Qualifications of the nurse realizes his or her own potential (self-image), (2)
 Functions of the nurse can cope with normal stresses of life / capacity to
 Organization and administration of move on or bounce back (resiliency),(3) can work
nursing care productively and fruitfully. ex: showing
 Physical facilities and equipment innovations to benefit the community (productivity
and creativity) and is (4) able to make a
b. Process contribution to his community (sense of purpose).
 Assessment – 1. Psychiatric interview
2. Mental status exam - A diagnosable illness that significantly interferes
 Analysis of data with an individual's thinking, feeling or social
 Planning activities and even daily functioning.
 Implementation – NPR, Pharmacologic
Family dynamics
therapy, Environment (Milieu)
- are patterns of relating or interactions between
 Evaluation
family members.
*anamnesis- fam hx taking
c. Outcome
 Progress of care – there’s improvement
Behavior
every interaction with pt
Response to stimuli
 Effect of care
a. Reflexive
*Example: Restless and agitated (Mgt:
- Hindi na nagiisip, automatic response
Calm the pt ; administer med like
b. Goal directed
Benzodiazepam
- Something you want to achieve base on
your response
Legal Considerations
c. Frustration
1. Rights of clients and related issues
- If goals are not met ; they no longer want
2. Involuntary hospitalization
to continue
3. Release from the hospital
4. Conservatorship and guardianship
Factors affecting Behavior:
5. Least restrictive environment
A. Needs
*Least to most restrictive ; Example: Assaultive
- An organismic condition that exists within
behavior let pt express (verbalization) ; isolation
an individual and which demand certain
room (not applicable cause it makes pt feel like
activity
being punish)
* MASLOW'S HIERARCHY OF NEEDS
**Pharmacologic therapy – benzodiazepam as
primary med and inhibit GABA
B. Conflict
- Valium – Anxiolytic first line drug
- The result of the presence of two opposing or
***Mechanical Restraints – pt cant controll
incompatible drives that requires a person to
impulses internally need external control such as
make a choice between possible responses.
restraints.
6. Confidentiality
C. Stress
7. Duty to warn 3rd parties
- Occurs when a person has difficulty
8. Insanity defense-particular area for court cases;
dealing with life situations, problems and
pt. being evaluated
goals
9. Nursing liability-know the scope of practice
● Recurring – nangyari ng paulit-ulit
● Normal – see stress as something that will
Ethical Issues
motivate you to be better
1. Autonomy- consent ; sound mind and body
● Cannot be avoided
2. Beneficence
● Brought about by a stressor
3. Nonmaleficence- do no harm
4. Justice- benefiting everyone
5. Veracity- truth
6. Fidelity- loyalty
 NURSING
SEVERE PANIC
INTERVENTIONS
 Perceptual field  Perceptual field  Reduce the
reduced to1 or reduced to focus anxiety quickly
scattered detail on self  Approach client
 Cannot complete  Cannot process in a calm manner
task environmental  Always remain
 Cannot solve stimuli with the client
problems or learn  Distorted  Minimize
effectively perceptions environmental
 Behavior geared  Loss of rational stimuli
toward anxiety thought  Provide clear,
relief  Personality simple
 Doesn't respond disorganization statements
to redirection  Doesn't  Use a low-
 Severe headache, recognize danger pitched voice
vertigo  Possibly suicidal  Attend to
 Nausea, vomiting,  Cannot physical needs
D. Frustration diarrhea communicate  Provide gross
 Trembling  verbally motor activity
- A state that results if stress becomes  Rigid stance  Either cannot sit  Administer
sufficiently great and reaches a point above  Tachycardia, or totally mute anxiolytic as
chest pain and immobile prescribed
the threshold of an individual.  Ritualistic
behavior,
Responses: purposeless,
repetitive)
a) Fixation – inability to move on w/
developmental milestone Defense Mechanism*
b) Aggressive – person can’t handle
c) Regression - Modes of Coping
d) Resignation – feel helpless ADAPTIVE PALLIATIVE MALADAPTIVE DYSFUNCTIONAL
Solves the Temporarily Unsuccessful Is not successful
problem that decreases the attempts to in reducing
E. Anxiety is causing anxiety but decrease the anxiety or solving
the anxiety, does not solve anxiety without the problem
- A vague feeling of dread and so the the problem, so attempting to solve
apprehension in response to external or anxiety is
decreased
the anxiety
eventually
the problem Even minimal
functioning
internal stimuli that can have behavioral, returns The anxiety becomes difficult
The patient remains and new problems
emotional, cognitive and physical Is objective, Temporary begin to develop
symptoms. rational and relief allows the
productive patient to return
to problem
Levels of Anxiety solving
NURSING
MILD MODERATE
INTERVENTIONS Security Operations
 Sharpened  Selectively  Help the client SELECTIVE SOMNOLENT APATHY
senses attentive identify the PREOCCUPATION
INATTENTION DETACHMENT
 Increased  Perceptual field anxiety Turning out Sleep used to Self-absorbed or Emotional
motivation limited to  Encourage to talk details avoid anxiety engrossed in one’s detachment
 Alert immediate task about feelings associated own thought to a or numbing
 Can be redirected with anxiety- *from infancy degree that hinders even
 Enlarged and concerns
producing (crying) – effective contact with experiences
perceptual  Cannot connect  Help the client situations needs are not or relationship to are
 field thoughts and identify thoughts provided = external reality remembered
 Can solve events and feelings that SLEEP
problems independently occurred before Ex: Walk in hallway *no more
 Learning is  Muscle tension the onset of the and see professor w/ emotional
deadlines to meet – response
effective  Diaphoresis anxiety
avoid contact or take
 Restless  Pounding pulse  Encourage
other route
 Gl "butterflies"  Headache problem-solving
 Sleepless  Dry mouth  Encourage gross
 Irritable  Higher voice pitch motor exercise F. Crisis
 Hypersensitive to  OF - State of disequilibrium resulting from a stressful
noise  Increased rate of
speech
event or perceived threat where the individual's
 Gl upset usual coping mechanisms become ineffective in
 Frequent dealing with it.
urination
 Increased
automatism Types of Crisis:
 Developmental
- Maturational
 - Part of the process of life
- Anticipatory guidance-impact not much
- ex: a girl with menarche
 Situational
- Suddenly occur and not anticipated to
happen: beyond one's coping
- Ex: an employer loses her job; death in the
family
 Adventitious
- Extraordinary ; traumatic
- Man-made or natural disaster
- Ex: typhoon
Balancing Factors in Crisis
- Individual's perception of the event
- Situational support
- Coping mechanisms
Phases of Crisis
Characteristics of Crisis State
- Highly Individualized
- Self- limiting (4-6 weeks) – we learn to adapt
PRE-CRISIS
● State of equilibrium
● Denial-relieve tension (ineffective)
● Heightening of tension
CRISIS
● Feeling of falling apart (Disorganization)
● Attempt at re-organization
- Discover an effective Coping
- Ineffective coping
POST-CRISIS
- Successful resolution
- Unsuccessful resolution – persistence of problem
STEPS IN THE CRISIS INTERVENTION
1. Assess the situation
2. Assists the client to develop cognitive awareness
of the event
3. Assists the client managing feelings
4. Explore the client's resources available
5. Assists the client action planning
Techniques of Crisis Intervention
● Abreaction- encourage verbalization
● Clarification- done through communication
technique
● Suggestion
● Manipulation- using the positive points of the
clients for his/her advantage
● Reinforcement of behavior- recognition
- Attempt of the person to recover from the
crisis situation
● Support of defenses- initial reaction accept;
prolonged - must be corrected
● Raising of self-esteem
● Exploration of resolution
Theories of Personality Development
Personality
- It is the integration of interests, abilities and habits
to create a unique quality of response by an
individual to internal and external environment.
Theories of Personality Development
● Sigmund Freud's Psychosexual Theory
● Erik Erikson's Psychosocial Theory
● Harry Stack Sullivan's Interpersonal Theory
● Jean Piaget's Cognitive Theory
● Eclectic Approach
Psychosexual Theory
Sigmund Freud
- Unconscious processes or
psychodynamic factors as basis for
motivation and behavior.
Freud's model of personality structure*
 Id – immediate gratification ;  Unconscious – difficult to
pleasure seeking retrieve (unwanted)
**Ex: Kinukuha gadget ng iba
without permission  Pre-conscious – can be real
 Ego – integrator of reality  Conscious – intact with
**Ex: Ask permission to external reality ; affect our
borrow the gadget behavior
 Superego – moral imperative
; conscience
Stages of Psychosocial Development INDUSTRY VS. INFERIORITY Emerging confidence in own
(School age) abilities; taking pleasure in
1. Oral- the mouth accomplishments
IDENTITY VS. ROLE Formulating a sense of self and
● Sucking, swallowing CONFUSION belonging
- EGO DEVELOPS (Adolescence)
INTIMACY VS. ISOLATION Forming adult, loving
2. Anal- the anus (young adulthood) relationships, meaningful
● Withholding or expelling feces attachment to others
GENERATIVITY VS. Being creative and productive;
3. Phallic- the penis or clitoris STAGNATION establishing the next
(Middle adulthood) generation
● Masturbation EGO INTEGRITY VS Accepting responsibility for
- SUPEREGO DEVELOPS DESPAIR one’s self and life
(Older adulthood)
4. Latent- little or no sexual motivation presence
5. Genitals- the penis or vagina Interpersonal Theory
- sexual intercourse Harry Stack Sullivan
- Inadequate or non-satisfying relationships
FIXATION + ADULT PERSONALITY produce anxiety which is the basis for all
emotional problems.
1. ORAL Infancy Relief from anxiety thru oral
(Birth – 18 months) gratification
- Forceful feeding Childhood Delay in personal gratification
- Deprivation (18 months – 6 y/o) w/o undue anxiety
Juvenile Learning to form satisfactory
- Oral Early weaning (6-9 y/o) peer relationship
Preadolescence Relationship w/ person of same
(9-12 y/o) sex; initiation of feelings of
Adult: affection for another person
Early Adolescence Relationship w/ opposite sex ;
- Oral activities (eg smoking) (12-14 y/o) developing a sense of identity
- Dependency Late Adolescence Self identity ; develop lasting
- aggression. (14-21 y/o) intimate opposite sex
relationship

2. ANAL
Cognitive Model
- Toilet training
Jean Piaget
- Too harsh
- Intellectual development is a result of constant
- Too lax
interaction between environmental influences
and genetically determined attributes.
Adult Sensorimotor Preverbal; Learning occurs
- Obsessiveness, 0-2 y/o) through use of senses and
simple motor activities
- tidiness, meanness; Preoperational Can now use language and
Pre-conceptual symbolic representations in
- untidiness, generosity (2-4 y/o) play
EGOCENTRIC
Preoperational Asks questions, begins to
3. PHALLIC Intuitive understand relationship
- Abnormal family set up leading to (4-6 y/o) INTUITIVE REASONING
Concrete Operations Increase conceptual
unusual relationship with mother father. (7-11 y/o) development: problem solving,
cause and effect, inductive
reasoning, logical thought
Adult Formal Operations Can reason logically and
(>12y/o) abstractly; can formulate and
- Vanity, self-obsession, sexual anxiety, test hypothesis
inadequacy, inferiority, envy.

Psychosocial Theory Eclectic Theory

Erik Erikson - Concepts from more than one school of thought
- Each stage of development is an emotional crisis are used in developing a usable theory on
involving positive and negative experiences. personality development.
TRUST VS. MISTRUST Viewing the world as safe and - Use of a combination of theories.
(infancy) reliable ; relationships as
nurturing, stable and
dependence
AUTONOMY VS. SHAME Achieving a sense of control
AND DOUBT and free will.
(toddlerhood)
INITIATIVE VS. GUILT Beginning development of
(Preschool) conscience; learning to
manage conflict and anxiety
 The Therapeutic Relationship
3. WORKING:
Components of a Therapeutic Relationship: - Encourage verbalization of feelings
 Trust - Assist patient to learn more socially
 Congruence acceptable behavior
 Genuine interest - Assist patient to learn more effective
 Empathy coping patterns
 Acceptance - Assist the client to develop insight
 Positive Regard - On-going assessment of the client.
4. TERMINATION:
Self-awareness - Encourage verbalization of feelings that go
- is the process of developing an understanding of with termination
one's own values, beliefs, thoughts, feelings, - Summarize what he learned in the
attitudes, motivations, prejudices, strengths, and relationship
limitations and how these qualities affect others. ● Evaluate outcomes of the relationship
- Solidify the closure of the relationship
Joharis' Window* (Luft, 1970)
Impasses to an Effective Nurse-Patient Relationship
● Resistance
Therapeutic Use of Self - patient refuses
- Nurses use themselves as a therapeutic tool to ● Transference-
establish the therapeutic relationship with clients - Patient Significant Other (Past) - - -->
and to help them grow, change and heal. Nurse (Present)
● Counter-transference
Types of Relationships - Patient <-- - Significant Other ← Nurse
● Inappropriate boundaries- Violation of
1. Social relationship is initiated for the purpose of boundaries.
friendship, socialization, companionship or ● Feeling of sympathy and encouraging
accomplishment of a task dependency
2. Intimate relationship involves 2 people who are - Empathy only → Reflecting the feeling
committed with each other and with individual and implied
mutual goals
3. Therapeutic relationship is a professional,
planned relationship between a nurse and a client Communication
that focuses on client needs, feelings, problems Forms:
and ideas; designed to promote patient growth, - Verbal
discuss issues, and resolve problems. - Nonverbal

Phases of the Nurse-Client Relationship Aspects of Non-Verbal Communication

1. PRE-ORIENTATION:
- Develop self-awareness
- gather initial information about the patient
2. ORIENTATION:
- Establish rapport
- Set a contract with the client
(Expectations (Confidentiality
Information), Parameters)
● Give structure and boundaries of the
relationship
● Prepare the client for termination
- Do the initial assessment of the client
● History-Taking
● Mental Status Assessment
● Kinesics - body movements (*mannerism of
communication)
● Proxemics - physical spaces bet communicators
- Intimate zone (0-18 inches between 2
people)
- Personal zone (18-36 inches)
- Social zone (4-12 feet)
of - Public zone (12-25 feet)
● Touch
- Functional (professional)
- Social (polite)
- Friendship (warmth)
- Love (intimacy)
- Sexual (arousal)
● Silence - giving time to think
 ● Paralanguage
- voice quality or how the language is
delivered
Therapeutic Communication Techniques
Non- therapeutic Communication Techniques
Milieu Management
- Helps patients recover from psychiatric and
mental health problems
- The environment should function to protect the
patient from destructive influences.
- It should maximize opportunities for patients to
learn something about themselves and their
problem everyday living.
Elements of the Therapeutic Milieu
Safety
- Physical protection - safety from physical harm
through the management of risks in the
environment
- Psychological protection- involves the nurses'
active intervention to prohibit verbal abuse,
ridicule, or harassment of patients.
Structure
- Refers to the physical environment, rules and
daily schedule of the treatment.
Norms
- specific expectations of behavior that permeate
the treatment environment.
Limit setting
- reinforces the norm of making rules and
expectations clear.
Balance
- is the process of gradually allowing independent
behaviors in a dependent situation.
Framework of Care and Treatment Modalities
Biologic
- Psychological conditions are caused by
physiologic functions.
Psychoanalytic
- All human behavior is caused and can be
explained. Repressed sexual impulses and
desires motivate much human behavior.
Interpersonal
- Inadequate or non-satisfying relationships
produce anxiety, which is the basis for emotional
problems (Sullivan, 1953).
Social
- The environment can affect the individual.
Cognitive
- People are capable of thinking rationally and
irrationally which affects their thoughts and
feelings.
Cognitive restructuring
Narrow to broad frame of reference
Behavioral
- Focuses on observable behaviors and what one
can do externally to bring about behavior
changes.
Behavior can be learned or modified:
- Acquisition-learned
- Extinction - unlearned
● Positive and negative reinforcement
● Token economy- regularity of behavior is
rewarded
● Aversion therapy- behavior is associated with
unpleasant consequences.
● Time out- being quiet and regaining control.
● Systematic desensitization
- gradual exposure to identified source of
fear
● Flooding- bombardment of fearful experience.
● Behavior shaping- imitating behavior then given
reward.
Humanistic
- Focuses on a person's positive qualities, his or
her capacity to change, and the promotion of self-
esteem.
- Satisfaction of human needs
(Maslow, 1954)
(Rogers, 1961)
Existential
- Helps the person discover an authentic sense of
self, which emphasizes personal responsibility for
one's self, feelings, behaviors, and choices
Rational emotive therapy
- uses confrontation of irrational beliefs that
prevent the individual from accepting
responsibility for sell and behavior
Logotherapy
- helps individuals assume personal responsibility
in searching for meaning in life.
Schizophrenia Spectrum Disorder
Forms:
● Grandeur-belief that one is an exalted
person; but in reality, there is
inadequacy.
● Persecutory/Paranoid-belief that one
may harm him/her; prone to be violent to
protect himself/herself.
● Reference-belief that all communication
is all about him
● Control- strong belief that an external
force controls him/her
*Thought insertion - someone provides
him/her with ideas
*Thought withdrawal - someone removes
his/her ideas
*Thought broadcast- know what he is

PSYCHOTIC DISORDERS ● Religious

- Inability to distinguish what is real from what is - belief that he/she is God or any religious
not. character
- Altered thought process and ● Somatic
- content -Sensory perceptual problems - belief that his/her body is anging in some
way
ETIOLOGY ● Nihilistic
1. Biochemical - increased dopamine production - belief that his/her body and parts do not
(Dopamine – excitatory exist anymore.
neurotransmitter ; any changes ● Erotomanic
in the level = BEHAVIORAL - Belief that a person is madly in love with
CHANGES) them.
2. Physiologic- mental defects
3. Social- dysfunctional family relationships and b. Hallucinations
communication - False sensory perception
● Lack of nurturing
● Inconsistencies ● Auditory- hearing;most common
● Visual-seeing
UEGEN BLEULER'S 4A's ● Tactile-feeling
1. Affect ● Gustatory-tasting
- presence of apathy (flat affect) and ● Olfactory-smelling
inappropriate affect (ineffective response
to the situations). c. Disorganized speech-reflects disorganized
2. Ambivalence thoughts
- presence of two opposing feelings at the ● Word salad-jungle of words that are put
same time (co-existing) together, meaningless, not anxiety-provoking
3. Associative looseness ● Slang association- Rhyming words put
- altered thought process (impaired together.
connection) reflected as incoherent ● Neologism- creation of new words that are
speech. meaningless.
4. Autism ● Perseveration- same response to different
- having a make-believe and fantasy stimuli.
world. ● Verbigeration- repeating of words without
stimuli
Positive symptoms (*dapat na wala, pero meron) ● Echolalia-repeating of words from external
a. Delusions- fixed false beliefs stimuli

d. Grossly disorganized or catatonic behavior
- Regressive behavior – fetal position,
undressing
- Catatonic behavior – decrease in motor
activities/ movement
Negative symptoms (meron, pero nawawala)
a. Alogia- poverty of content
b. Anhedonia- inability to experience pleasure
c. Avolition- lack of motivation
d. Anergia- lack of energy
e. Asocial- lack of social ability
f. Inattention- inability to focus
TYPES OF SCHIZOPHRENIA
1. Paranoid type
- Persecutory delusions and auditory
hallucinations
- With tendency to be violent
- Very organized
2. Catatonic type
- with acute motor manifestations
a. Catatonic stupor - like unconscious
b. Catatonic rigidity-assumes a stiff posture -
c. Catatonic posturing-assumes bizarre
posture.
d. Catatonic waxy flexibility-assumes a
position and maintains as imposed
e. Negativistic catatonia - does the opposite
of what he/she is expected to do
f. Catatonic excitement - goes into
hyperactivity without any provocation
3. Disorganized type
- Disorganized speech and behavior
- Most regressed
4. Undifferentiated type
- All positive (+) symptoms
5. Residual type
- Negative (-) symptoms only
PSYCHOTHERAPEUTIC MANAGEMENT
1. Promote safety of the patient and others.
● Establish a trusting relationship to encourage the
patient to verbalize the content of his/her
hallucinations and delusions.
● Observe the patient further
2. Establish a therapeutic relationship.
● Withdrawn patient - active
friendliness
● Keep interactions short and
frequent.
● One-on-one interaction
● Avoid touching; maintain
distance
- Suspicious patient - passive friendliness
● Make self available while
maintaining distance until the
patient is ready to interact.
● Establish consistency and
honesty.
3. Use therapeutic communication
For concrete thinking
- Check abstract thinking through interpretation of
proverbs.
- Psychotics are concrete thinkers (interprets
literally).
- Be concrete in communicating.
For incoherence
- Use appropriate communication techniques.
For mutism
- Give them time to talk; Use open-ended
questions with spaces in between.
- Initiate neutral topics first.
4. Do not reinforce delusions and hallucinations.
- Do not argue about delusions.
- Do not reinforce hallucinations.
- If the patient is acting odd and the nurse suspects
or she is hallucinating, the patient should be ked
about it. VALIDATE.
- Help patients identify stressors that might
precipitate hallucination or delusions. (Example:
yeling: Anxiety)
- Focus on real people and real events.
5. Provide physiologic and self-care
● Catatonic type- circulation, nutrition, hygiene
● Disorganized type - Provide instructions; be with
the patient.
● Paranoid type- Prepare sealed foods; Open food
in front of the patient; Prepare food with the
patient; Serve family-style food; Do not taste the
food.
6. Deal with socially inappropriate behavior
PHARMACOLOGIC TREATMENT
Antipsychotics
- Neuroleptic Agents or Major Tranquilizing Agents
- Blocks the receptors of dopamine in the
presynaptic area
 - Drug maintenance and compliance even without REHABILITATION
active symptoms - Compliance to treatment
- Independence in activities of daily living
Typical Antipsychotics - Developing social skills
 Phenothiazines - Developing more effective coping patterns
 Chlorpromazine (Thorazine) - Dealing with future hallucinations --(ignore
 Trifluoperazine HCI (Stelazine) and/or keep them busy)
 Thioridazine HCI (Mellaril) - Family interactions
 Perphenazine (Trilafon)
 Prochlorperazine (Compazine)
 Fluphenazine (Prolixin)
Mood Disorders
 Buterophenone
 Haloperidol (Haldol) 1. Unipolar- manifesting 1 type of condition; major
 Haloperidol (Serenase) depression
2. Bipolar- 2 types of condition; depression and
Atypical Antipsychotics manic
 Risperidone (Risperdal)
 Clozapine (Clozaril) GRIEVING
 Ziprasidone (Zeldox) - Normal reaction to real or anticipated loss
 Quetiapine (Seroquel) - Phases of the Grieving Process (6 months - 1 yr;
 Aripiprazole (Abilify) older people - 1½-2 yrs)
 Olanzapine (Zyprexa)
Grieving Process: DABDA
- ELIZABETH KUBLER-ROSS
Side effects
- CNS depression
1. Denial - disbelief
- Anti-cholinergic effect
2. Anger-helpless and abandoned
- Orthostatic hypotension
3. Bargaining - exchange or trade-off; exchange
- GI upset
favor to God
- Weight gain
4. Depression - pain of the loss
- Endocrine changes (gynecomastia and
5. Acceptance - emotional void (doing some
amenorrhea)
modifications in life)
- Photosensitivity-skin discoloration to direct
sunlight
Assessment:
Three Major Areas to Assess
Extrapyramidal Symptoms (EPS)
1. Adequate perception regarding the loss
Etiology: decreased dopamine
2. Adequate support while grieving for the loss
● Akathisia - fidgety, restlessness
3. Adequate coping behavior during the process
● Akinesia - muscle weakness and fatigue
● Dystonia- tongue protruding, opisthotonus,
Interventions:
oculogyric crisis (hardening of the muscles in the
1. Allow adaptive denial.
eye)
2. Explore the client's perception and meaning of
● Pseudo parkinsonism - forward posture, shuffling
the loss.
gait, mask-like facies
3. Encourage the reach out for and accept support.
Pharmacologic treatment: Anti-EPS
4. Encourage the client to examine coping patterns
Medications: (Akineton, Artane, Benadryl Symmetrel)
in the past and present situation of loss.
5. Encourage patient to care for self.
Adverse Effects
- Decreased seizure threshold
Major Depressive Disorder
- Blood dyscrasias
- Unipolar Disorder
- Tardive dyskinesia - an irreversible form of EPS
resulting from long term use of antipsychotics
ETIOLOGY
● lip smacking
1. Cognitive
● cheek puffing
- pessimism
● vermicular movement of the tongue
- negative sense of self and environment
● masticating

2. Biologic
- decreased norepinephrine, serotonin and
dopamine (Norepi and Serotonin are amines or
PROTEINS)
- increased monoamine oxidase (MAO)
(*Broken down in synaptic area in the brain = Sx
of depression)
3. Psychodynamic
- unresolved conflict
- debilitating early life experience
- reaction to life events
MANIFESTATIONS
At least 5 of the criteria for a minimum of 2 weeks
● Depressive mood or sadness
● Anhedonia
● Worthlessness / excessive or inappropriate guilt
● Psychomotor disturbance - (slow movement,
agitation)
● Diminished ability to concentrate or
indecisiveness
● Somatic manifestations - (appetite disturbance,
sleep disturbance, fatigue or loss of energy)
● Recurrent thoughts of death
PSYCHOTHERAPEUTIC MANAGEMENT
1. provide for the client's safety- control the
environment.
● Assess for cues and clues of suicide
● Validate direct and indirect verbalization
of suicide
● Provide repetitive, monotonous, non
gratifying activity- externalizes anger.
● Kind firmness
● Establish a "NON SUICIDE" contract
Behaviors Suggestive of Suicidal Ideation
● Gives off valuable things
● Possesses potentially harmful things
● Starves oneself
● Puts into order his/her affair
● Makes farewell notes
● Sudden changes in behavior and mood
(indicates uplifting of depression- most priority
one
Assessment for Suicide
1. Plan- how determined the patient is to perform
suicide
2. Means-lethality of method for suicide
● Low risk - cutting the wrist
● High risk-strangulation, overdose from
antidepressants, ingestion of poison and
chemicals
3. Rescue - chances of being rescued from
committing suicide
a. Primary Suicide Prevention- not eminent with
dying (**Mgt: Don’t put structure such as visit
@irregular interval ---pt should not know patterns
cause they might do something during your visit)
b. Secondary Suicide Prevention- determined to
commit suicide; need to have family, staff to
supervise the patient.
Risk Factors for Suicide
a. Recent loss
b. Age- elderly
c. Sex- females usually attempt; males usually
succeed
d. Civil status- dingle and widowed
e. Previous history of suicide
2. Promote a therapeutic relationship.
● Accept the patient
● Spend time with patient.
● Respond to the patient's anger therapeutically.
- Shout-set limits
- Self-destructive - limit
3. Focus on the patient's strength.
● Be with the patient.
● Provide music and art therapies.
● Avoid activities that entail detailed works and
decision making skills.
● Assist the patient in decision making.
4. Create a scheduled and structured but non-demanding
environment
● Start on one-one-one activity then progressive
 ● Insomnia
5. Promote independence by encouraging to perform ● Headache
ADL's. ● Weight loss
● Give enough time to finish performing ADL's. ● Sexual dysfunction (anorgasmia for women and
● Consider patient's preferences ejaculatory dysfunction for men)
● Provide small but frequent feedings.
3. Monoamine Oxidase Inhibitors (MAOI's) inhibit
PHARMACOLOGIC TREATMENT the MOA, which is responsible for breaking down
1. Tricyclic Antidepressants (TCA's) block the excess serotonin and norepinephrine at the
reuptake of neurotransmitters such as serotonin, synapse.
norepinephrine, acetylcholine and dopamine at (*Given @ Morning to prevent sleep disturbance)
the presynaptic neurons. (*If given with food: watch out for
- Delayed onset of effect for 3-4 weeks HYPERTENSIVE CRISIS especially those
- (**Norepi and Serotonin in between synapses of containing with Tyramine)
2 neurons--- they are excitatory which transmit
impulse---- increase amount of these 2 protein = Types
SEROTONIN SYNDROME) ● Phenelzine (Nardil)
● Isocarboxazid (Marplan) Tranylcypromine
Examples of Tricyclic Antidepressants: (Parnate)
● Imipramine (Tofranil) ● Moclobemide (Manerix)
● Amitriptyline (Elavil)
● Desipramine (Norpramin) Common Side Effects
● Trimipramine (Surmontil) ● Anticholinergic effects
● Nortriptyline (Aventyl) ● Cardiovascular effects
● Chlomipramine (Anafranil) ● CNS stimulation (anxiety, agitation, restlessness,
insomnia)
Side Effects
● Anticholinergic effects Serious Side Effects
● Cardiovascular effects ● Agranulocytosis
● Photosensitivity ● Hepatic toxicity
● GI effects (anorexia and nausea) ● Hypertensive crisis - (severe occipital headache,
● CNS effects (sedation and fatigue) nausea, vomiting, elevated BP, photophobia,
dilated pupils, arrhythmia)
Adverse Effects
● TCA overdose
● Serotonin syndrome - hypothermia,
hyperreflexia, tachycardia, diaphoresis and
decreased LOC
● Agranulocytosis (WBC <2000)
● Seizures

2. Selective Serotonin Reuptake Inhibitors

(SSRI's) prevent the reuptake of serotonin at the
synapse.
(**this thereby decrease symptom of depression)
(*to be taken @Morning) 4. Atypical Antidepressants are thought to act
similarly with TCA's except that it has fewer
Types: anticholinergic and cardiovascular effects.
● Fluoxetine (Prozac) Drugs
● Sertraline (Zoloft) ● Bupropion (Wellbutrin)
● Paroxetine (Paxil) ● Mirtazapine (Remeron)
● Fluvoxamine (Luvox) ● Nefazodone (Serzone)
● Venlafaxine (Effexor)
Side Effects ● Trazodone (Desrel)
 ● In non- modification ECT, patients do not receive
Electroconvulsive Therapy sedatives.

Outcomes of ECT
***Electric current @temporal area = reorganization of
neurons on brain
● Produces grand-mal seizures that last for 30 to
60 seconds
- Turn patient to the sides. (R: drainage of
secretions and tongue is relaxed which
can obstruct the airway)
- Check for respiratory depression.
- Evaluate return of reflex. gag
● Brings about temporary memory impairment
- Orient the patient.
● Increased willingness of patient to socialize with
others.

Indications:
- Literally depressed patients BIPOLAR DISORDERS
- Acutely suicidal patients
- Patients who do not respond to medications and ETIOLOGY
other neurochemical and physiologic therapies 1. Biologic
- genetics
Contraindications - increased norepinephrine and serotonin
● Heart conditions (ECG) - Increased intracellular sodium
● Organic mental disorders (EEG)
● Active bleeding tendencies 2. Psychodynamics
● Pregnant women - Extremes polar experience
● Hypertension and hyperthermia
● Fractures
● Pacemakers

Nursing Considerations
● Secure informed consent from a responsible
family member.
● Place the patient on NPO for at least 6-8 hours
prior to the procedure.
● Let the patient wear loose clothing
● Application of hair shampoo is not required; hair
should be dried
● Remove the patient's dentures
● Encourage the patient to void
● Monitor VS before and after the procedure MANIFESTATIONS
● Apply mouth gag to prevent aspiration
● In Modified ECT, pre-procedure medications are - Elevated, expansive and irritable mood with labile
administered: affect (happy then angry) for at least 1 week and
- Brevital Sodium (Pentothal) - short- at least 3 of the following:
acting sedative ----prevent severe
seizure ● Engaging in pleasurable activities
- Atropine Sulfate (Atropine) - prevents ● Increased participation in goal-directed activities
bradycardia but it dries the mouth. --- or psychomotor agitation
Anticholinergic med ● Inflated self-esteem or grandiosity (indicates
- Succinyl Hydrochloride (Anectine) - feeling of inadequacy)
relaxes the muscles ● Pressured speech (fast) and loquacious speech
(productive)
 ● Flight of ideas or feeling that thoughts are rising
● Distractibility Post crisis
● Somatic manifestations (nutrition and sleep
deprivation)
● Sarcasm, manipulative behavior a d demanding Psychotherapeutic Management
behavior
Triggering Phase - had just started to become angry
● • Good time to express patient's feelings.
● Maintain safe distance
● Approach in a clam manner
● Use non-confrontational approach.
● Hands on sides, palms up
● Establish sporadic eye contact but no staring
Escalating Phase
● The patient becomes more angry.
● There is more muscle tension.
● It calls for a time-out.
● The patient has to go back to his room (not
isolation room).
● Check on the client to take note if there is regain
of control.
● Administer medications: Haldol or Thorazine and
Benadryl
Crisis
● Verbal limits -tells the patient what is expected to
do
● If the client proceeds with behavior, there is a
need for restraint application.
● Ask help if the client will be put on restraints.
● Crisis team-help in gaining control because the PHARMACOLOGIC TREATMENT
patient cannot control himself
● Safely apply restraints
- Tie on the frame of the bed.
- Monitor the client every 15 minutes.
- Assess for nail beds, cold, clammy skin,
comfortable
- Untie for 15 minutes every 2 hours with
relative or one to position accompany
him
- Documentation
- Recovery
1. Provide for client's physical safety and safety of
those around him or her.
● Hyperactivity - can result to exhaustion, heart
problem
● Limit external stimuli. Provide quiet, non-
stimulating environment.
● Place the patient farthest to the nurse's station.
2. Ensure that nutritional and fluid balance needs
are met.
● Finger foods
● High caloric, high protein - (sandwich, French
fries, chicken)
● Give fluids - Lithium Carbonate; Polyuria
● Offer in an hour or two
3. Use short,simple sentences to communicate
4. Set limits but respond to legitimate complaints
● Provide privacy
● If has extreme talkativeness, keep statements
concise.
● Sexual - matter of fact
5. Channel excessive energy into socially
acceptable motor activities (gross motor).
● Writing with supervision
● Brisk walking
● Cleaning activities
6. Reinforce reality
7. Enhance the patient's self-esteem
a. Anti-anxiety- reduces hyperactivity
- Usually given with Lithium Carbonate
b. Lithium Carbonate (Eskalith, Lithane) -
facilitates reuptake of excessive Norepinephrine
and Serotonin
- Therapeutic level is 0.6 to 1.2 mL up to
1.5
- 10 days to ⅔ weeks to reach the
Therapeutic level.
 - Monitor level through Serum Lithium h. Once stimulated, it heightens continuously like
Determination (should not have taken seizures.
lithium for at least 12 hours before
examination) c. Anticonvulsants
Side Effects - inhibit kindling activity in the brain that interrupts
the automatic sequences of neurotransmission;
● Fine tremors stimulates the GABA that produces a calming
● Nausea effect.
● Diarrhea
● Gl upset (should be taken with meals) Drugs:
● Polyuria; Oliguria; Anuria ● Carbamazepine (Tegretol)
● Polydipsia ● Valproic Acid (Depakene, Depakote)
● Headache
● Metallic taste
ANXIETY- RELATED DISORDERS
Adverse Effects
● Gross tremors catergories:
● Vomiting
● Tinnitus 1. Anxiety Disorders
● Confusion 2. Obsessive-Compulsive and Related Disorders
● Motor incoordination 3. Trauma and Stress-Related Disorders
● Ataxia 4. Somatic Symptom Illness

ETIOLOGY
Contraindication
● Pregnant Women 1. Biologic Perspective
- Affects the ANS
- Decrease in GABA
- Affects Serotonin
2. Behavioral Perspective
- Learned response

3. Psychodynamic Perspective
- Id and Superego
- Repression (main defense mechanism)
4. Interpersonal Perspective
- Unsatisfying and inadequate
relationships

NURSING CONSIDERATIONS
1. Phobic Disorder
a. No diuretics
b. Toxicity- hemodialysis - Phobia is an irrational ffear. -Illogical, intense,
c. Oral form only persistent
d. For those who cannot tolerate Lithium Carbonate, - Extreme distress that interferes with functioning.
they are given Clonazepam (Rivotril)
e. Regular sodium diet (liberal but not excessive) Defense Mechanisms:
f. Lithium and Sodium has affinity - looks for sodium - Repression
intracellularly and kicks off sodium - Displacement
g. Dangerous - Symbolization
- Low sodium results to hyponatremia
- High sodium results to excretion of Types:
lithium
Specific Phobia
 - Provoked by a specific feared object or situation
which causes an avoidant behavior
Agoraphobia
- Fear of open spaces and being alone where
escape is difficult
- Impaired ability to work and perform daily
responsibilities
Social Phobia / Social Anxiety Disorder
- Fears any situations that a person can be
embarrassed and humiliated in public
- General intense fear or anxiety triggered by social
or performance situations
Manifestations:
- Blushes, sweats, trembles, palpitates,
feels nauseous
- Looks and sounds very shy
- Struggles to be with other people
- Very self-conscious and afraid of
judgments
- Stays away from crowded places
Nursing considerations:
● Do not let avoidance to take place for too long.
● Systematic Desensitization-serial / gradual
exposure to the object feared.
● Flooding- tapis desensitization
● Patient is aware of the fear but cannot control his
reactions. Accept that the client's fear is real.
● Promotes patient's safety.
2. General Anxiety Disorder
● Excessive and persistent anxiety or worry that
lasts for at least 6 months
● Diffuse and free-floating anxiety
● Restlessness
● Fatigue
● Difficulty concentrating
● Irritability
● Muscle tension
● Uncontrollable feelings of worry
● Trouble sleeping
● Vigilant
Nursing considerations:
- All interventions for moderate and severe anxiety
levels
3. Panic Disorder
● Characterized by sudden periods of intense fear
that peak within minutes
● Occurs for a maximum of 10 hours with recurrent
generalized symptoms
- Palpitation, sweating
- Trembling or shaking
- Shortness of breath or chocking
- Feelings of impending doom
- Feelings of being out of control
Nursing Considerations:
- Ensure the client's safety.
- Remain with the client.
- Provide less stimulating environment.
- Help client focus on deep breathing.
- Talk in a calm and reassuring voice.
- Teach relaxation techniques.
- Conduct cognitive restructuring techniques.
- Assist in exploring how to decrease stressors and
anxiety-provoking situations.
OBSESSIVE-COMPULSIVE AND RELATED
DISORDERS
OBSESSION
- repetitive thoughts that cannot be controlled
COMPULSION
- repetitive actions for coping with the anxiety that
cannot be controlled and which affects ADL's
Body Dysmorphic Disorder
- Preoccupation with imagined defect
Body Identity Integrity Disorder
- Feels alienated from a part of their body and
desires amputation

Defense Mechanisms Hoarding Disorder

- Undoing - Persistent difficulty discarding or parting with
- Reaction formation possessions because of a perceived need to
- Isolation save them
- Repression
NURSING CONSIDERATIONS
Real compulsion cannot be stopped by the person.
SHORT-TERM

1. Do not stop the compulsion but lessen the number of

compulsions (limit setting).
2. Modify the schedule.
3. Use diversional activities like:
Relaxing activities
- Counting activities
- Activities that require precision
4. Recognize positive behaviors.
5. Do not confront the client. He knows that he has rituals.
6. Perform thought stopping techniques.
7. Avoid stressful situations and recognize ritualistic
behaviors as maladaptive responses.

LONG TERM
1. Demonstrate more effective methods of coping.

Persons with OCD have uncontrollable thoughts and

behaviors related to: TRAUMA AND STRESS- RELATED DISORDERS
- Fear of germs or contamination
- Having things in perfect order - Post Traumatic Stress Disorder (PTSD)
- Excessive cleaning - Dissociative Disorders (Dissociative Amnesia
- Repeatedly check on things with Fugue; Dissociative Identity Disorder; and
Depersonalization Disorder)
Persons with OCD typically spend at least 1 hour a
day on these thoughts or behaviors. Post Traumatic Stress Disorder
- Triggered by a terrifying or frightening event
SOMATIC DISORDERS either by experiencing or witnessing it
Dermatillomania - Stress after a traumatic experience such as an
- Skin picking adventitious crisis
- Survivors not victims
Trichotillomania - Symptoms may last for at least a month or longer
- Hair pulling
Manifestations
Onychophagia ● Flashback
- Nail biting - reliving of the experience very vividly as
Oniomania if the traumatic event is just happening
- Compulsive buying now
 ● Emotional numbness and avoidance
● Impaired functioning
- cannot perform activities of daily living
(eat,drink, sleep, concentrate, work, etc.)
Nursing Considerations
● Show empathy and acceptance of the client.
● Encourage the client to verbalize feelings.
● Process the event through desensitization-to talk
about the event intensely (vividly detailed) and
progressively
● Assist in minimizing client's anxiety
● Provide for the safety of the client.
● Assist in developing a more effective coping
- Continuous amnesia
- Global amnesia- anything can't be recall
Dissociative Identity Disorder
- Multiple Personality Disorder
- Existence of 2 or more personalities with
impairment of the EGO
- Changes personality when a stressful situation is
experienced Happens in a trance-like state
Depersonalization Disorder
- Derealization
- Happens in a trance-like state
- Happens like a dream

Other Treatment Modalities: Goals of Care

● Psychological First Aid - Integrate the identity, personality and memory.
● Critical Incident Stress Debriefing (CISD)- made - Establish trust and support to encourage
to talk about the event that has happened (to let verbalization.
go and to move on) - Ensure patient's safety.
● Psychotherapy - use of verbal channels that - Reduce self-harm and violence.
intend to change behavior or symptoms
● Milieu management Other Treatment Modalities:
● Behavior modification by providing rewards 1. Milieu Therapy
● Therapeutic use of self 2. Psychotherapy
3. Psychoanalysis

Dissociative Disorders
- Dissociative Amnesia with Fugue Somatic Symptom Illnesses
- Dissociative Identity Disorder ● Somatic Symptom Disorder
- Depersonalization Disorder ● Pain Disorder
● Illness Anxiety Disorder
● Conversion Disorder

ETIOLOGY
1. PSYCHOSOCIAL THEORIES
● Internalization - keeps stress, anxiety or
frustration inside rather than expressing them
outwardly
● Internalized feelings of stress through physical
symptoms
● Tremendous difficulty dealing with interpersonal
conflict
● Primary gains-direct external benefits (relief of
anxiety)
● Secondary gains - internal or personal benefits
(attention)

Dissociative Amnesia with Fugue

2. BIOLOGIC THEORIES
- Loss of memory and assumes a new identity then
● They may experience a normal body sensation
migrates.
and attach it to a pathologic rather than normal
meaning.
Types of Amnesia
- Localized amnesia
 ● Minor discomfort → amplified → attention on - Physical symptoms stop as soon as they have
discomfort gained what they want.

Factitious Disorder
- Intentionally produces or feigns physical or
psychologic symptoms solely to gain attention
- May inflict injury on themselves to receive
attention
- AKA Munchausen Syndrome

Munchausen Syndrome by Proxy

- When a person inflicts illness or injury on
someone else to gain the attention of the
emergency personnel or to be a "hero" for saving
the victim.

SOMATIC SYMPTOM ILLNESS Body Identity Integrity Disorder

- Somatoform disorders - Feels alienated from a part of their body and
- Physical manifestations vary depending upon the desires amputation
type of somatic symptom illness. - Feels anguish and distress with their intact bodies
- Anxiety is attached to the body functions. - Reports feeling "natural" after an amputation
- Resorts to packing limb in dry ice until amputation
Somatic Symptom Disorder is needed
- Somatization disorder - AKA amputee identity disorder, apotemnophilia
- Varied physical complaint or "amputation love".
- Symbolic meaning
Goals of Interventions
- To make the client as functional as his condition
Pain Disorder allows to improve his/her quality of life
- Somatic pain disorder - To relieve symptoms through medications
- Pain is the only manifestation. - Do not push awareness of or insight into conflicts
- Pain is excessive and prolonged or problems.
- Pain is not proportionate to the cause. - Initially, do not insist to change his coping
mechanisms.
- Eventually, the nurse can assist the client to see
the relationship of his symptoms and the event
Illness Anxiety Disorder - To encourage expression of emotional feeling
- Hypochondriasis - To assist in learning more effective coping
- Morbid preoccupation strategies
- Misinterpretation of symptoms as having grave - Visual imaging and relaxation
illness - Psychotherapy
- Stress management techniques
Conversion Disorder - Peer support, therapy group
- Conflicts that are not resolved - Trusting relationships helps client to receive care
- Alteration and loss in motor and sensory from one provider instead of "doctor shopping".
functions
● LA BELLE INDIFFERENCE - a beautiful Pharmacologic Treatment for Anxiety- Related
indifference (Patient is not worried and is not Disorders
affected by the symptoms.)
● Anti-anxiety medications elevate the GABA
Malingering that brings about a calming effect.
- Intentional production of false or grossly ● Manifestations of Decreased
exaggerated physical or psychologic symptoms Anxiety
- Motivated by external incentives - Relaxed - no muscle tensions
 - Normal and stable VS - Interpersonal functioning
- Impulse control
BENZODIAZEPINES
● Diazepam (Valium) a. Cognition-ways of perceiving and interpreting
● Chlordiazepoxide (Librium) self, other people and events
● Chorazepate (Tranxene)
● Lorazepam (Ativan) b. Affect-range, intensity, lability and
● Clonazepam (Rivotril, Klonopin) appropriateness of emotional responses
● Alprazolam (Xanax)
c. Interpersonal functioning-interpersonal
Side Effects relationships
● CNS Depressant -Promote safety.
● No stimulants-counter the effect of the drug d. Impulse control - ability to express behavior at
● No depressants - potentiate the effect of the drug the appropriate time and place
● Postural hypotension - Check the BP. If the BP
decreases by at least 20mmHg, hold the drug.
- lying down
- sitting
- standing
- walking

Anticholinergic Side Effects

● Drying of the mouth - Increase fluids, take sour
candies, and perform oral hygiene.
● Nausea - Take medications with food.
● Blurring of vision-Promote safety.
● Constipation - Increase fiber in the diet and fluid
intake.
● Urinary retention - Palpate the hypogastric area
to differentiate distention from suppression
Adverse Effects
● Physical and Psychological Dependence
- Take the medications for not more than 3
weeks.
- If there is a need to stop taking it, there
should be gradual withdrawal.
● Paradoxical Excitement - Refer to the attending
physician.
● Alternative Medications: Tricyclic
Antidepressants (TCA) and Selective Serotonin
Reuptake Inhibitors (SSRI)
PERSONALITY DISORDER
● When personality traits become inflexible and
maladaptive
● Interferes with the functioning of a person in the
society
● When it causes the person emotional distress
Enduring behavioral patterns that deviate from
cultural expectations in two or more of the ff:
- Cognition
- Affect
PARANOID PERSONALITY DISORDER
- Suspicious and mistrusts others
- Defense mechanism: projection
- Aloof, withdrawn, maintains a considerable
physical distance, guarded, hypervigilant
- Restricted affect and labile mood
- Distorted thought process and content; may
develop transient psychotic symptoms
Nursing Considerations:
1. Approach in a serious and straightforward
manner.
2. Observe passive friendliness approach.
3. Teach client to validate ideas before taking
action.
4. Involve client in treatment planning
SCHIZOID PERSONALITY DISORDER
- Detachment from social relationships; self-
absorbed, prefers to be alone
- Insight may be impaired but intellectually
accomplished
- Restricted range of emotional expression:
constricted affect; aloof and indifferent;
emotionally cold; uncaring or unfeeling
- Does not engage in leisure activities; rarely
experiences enjoyment
 - If under stress, may become passive and
disinterested • Lacks future goals because of
absence of aspirations
Nursing Considerations:
- Improve client's functioning in the community
SCHIZOTYPAL PERSONALITY DISORDER
- Odd appearance, unkempt, disheveled, ill-fitting
mismatched, stained or dirty clothes
- Coherent speech but loose, digressive, vague
and bizarre
- Ideas of reference, magical thinking, odd beliefs
(not firmly fixed and delusional like in
schizophrenia)
- Cognitive or perceptual distortions: may have
transient psychotic episodes when under stress
- Restricted range of emotions; flat affect
- Experiences anxiety around unfamiliar places
and persons (does not improve with time or
exposure rather it gets worse)
- Behavioral eccentricities
- Social and interpersonal deficits; acute
discomfort with and reduced capacity for close
relationships but are unhappy being alone.
Nursing Considerations:
- Develop self-care skills.
- Improve community functioning.
- Initiate social skills training.
Antisocial Personality Disorder
- Disregard for and violation of the rights of others
- Lying, deceit and manipulation
- Inability to empathize with others
- Lacks remorse or guilt for behavior and does not
think of repercussions of actions
- Shows false emotions that will work for their
advantage
- Exploits people around them
- No distorted thoughts and sensory perceptual
alterations but worldview is narrow and distorted
- Average or above average IQ •Oriented but lack
of insight and with poor judgment
- Impulsive and thrill-seeking
- Shallow, empty, and devoid of personal emotions
- Appear normal, engaging and charming
- Also known as Psychopathy, Sociopathy,
Dyssocial Personality Disorder
Nursing considerations:
- Limit setting-State behavioral limits on
unacceptable behaviors, identify consequences
and expected behaviors.
- Observe consistent, matter-of-fact and non-
judgmental attitude when dealing with the client.
- Confrontation-Point out manipulative or
deceptive behaviors.
- Focus on the client's behavior rather than on his
attempts to justify it.
- Teach client to solve problems effectively and
manage emotions of anger and frustration.
Borderline Personality Disorder
- Labile and unpredictable mood and affect
- Dysphoric (unhappiness, restlessness, and
malaise)
- Fear of abandonment
- With unstable self-image and interpersonal
relationships
- Insight is limited
- May experience dissociative episodes or may
develop transient psychotic symptoms
- Makes decisions based on emotions rather than
facts.
- With marked impulsivity
- Manipulates others for gratification
- Rarely experiences satisfaction or well- being
- Splitting-polarized and extreme thinking about
self and others
- Blames others and experiences difficulty
accepting responsibility
- Recurrent self-mutilation (anger, helplessness or
punishment, reinforce being alive).
Nursing considerations:
Promote client's safety.
- Initiate a "NO-SELF-HARM" contract.
- Encourage verbalization of feelings.
Help the client to cope and control emotions.
- Delay gratification.
- Decrease impulsivity.
- Identify feelings.
- Moderate emotional responses.
- Teach cognitive restructuring techniques such as
thought stopping, decatastrophizing, and positive
self-talk.
- Structure time.
- Observe limit setting and matter-of fact approach.
- Teach social skills.
Histrionic Personality Disorder
- Excessive emotionality, dramatizing and
attention seeking
 - Wants to impress others to draw compliments
- Exaggerated closeness of relationships (shallow
and insincere)
- Speech is expressed in colorful, theatrical,
superlatives manner (vague and lacks detail)
- Highly suggestible but opinions may usually shift
- Overall appearance is normal but may have the
tendency to overdress
- Shifts emotions and mood rapidly
Nursing Consideration
- Teach assertive communication and social skills.
- Provide factual feedback about behavior.
- Model appropriate behavior.
Narcissistic Personality Disorder
- With behavioral patterns of grandiosity: believes
that they are superior and special
- Has strong feeling of entitlement- unrealistic
expectation of special treatment
- With strong need for admiration
- Expresses envy and begrudges others for any
recognition or success
- Fragile and vulnerable self-esteem: limited ability
to accept criticism or feedback
- Lacks empathy: disparages, belittles, discounts
the feelings of others
- Attributes their own problems to be the fault of
others
- Exploits relationships just to elevate one's status
- With intact thought process but with poor to
limited insight
- Acts out when feeling angry
- May be rude and arrogant, unwilling to wait, harsh
and critical
Nursing considerations:
- Observe matter of fact approach.
- Gain cooperation of client with needed treatment
- Teach client any needed self-care skills.
Avoidant Personality Disorder
- Fearful of rejection, criticism, shame and
disapproval
- Strong desire of social acceptance and
companionship
- Need excessive reassurance and guaranteed
acceptance
- Low self-esteem, hypersensitive to negative
evaluation
- Readily believe themselves as inferior from
others
- Social discomfort and reticence
Nursing consuderations:
- Provide support and reassurance.
- Teach cognitive restructuring techniques such as
positive self-talk, reframing and
decatastrophizing.
- Promote self-esteem by doing self- affirmation
and positive self-aspects.
- Develop social skills.
Dependent Personality Disorder
- Excessive need to be taken care of
- Fear of separation: uncomfortable and feels
helpless being alone
- Difficulty making decisions no matter how small it
is
- Makes judgments and decisions but lacks
confidence to do so
- Seeks advices and repeated reassurances about
decisions made Unhappy or depressed moods
- Submissive and clinging behavior
- Pessimistic, self-critical, easily hurt by others
- Unrealistic fear of being left alone to care of
themselves
- Believe they would fail alone
- Difficulty initiating tasks independently
- Fear gaining competence with eventual loss of
support
- "Any relationship is better than none at all."
- Reluctant to express disagreements with others.
- Does almost anything even tolerate abuse just to
maintain relationships.
Nursing Considerations:
- Foster client's self-reliance and autonomy.
- Teach problem-solving and decision-making
skills.
- Teach cognitive restructuring techniques such as
positive feedback, reframing and
decatastrophizing.
Obsessive-Compulsive Personality Disorder
- Preoccupation with perfectionism, mental and
interpersonal control and orderliness at the
expense of flexibility, openness and efficiency
- Extremely high and unattainable standards to
oneself and others
- Low self-esteem, harsh and critical of themselves
- Desire for perfection prevents reaching judgment
and decisions.
 - Difficulty expressing emotions, rigid, stiff and
lacking spontaneity
- Emotional range: formal, serious and constricted.
- Insight is limited
- May have the tendency to dismiss others
because they are absorbed in their own
perspective
- Stubborn and inflexible
- No time for leisure

Nursing considerations: DELIRIUM

- Encourage negotiation with others. - Acute confusion state
- Assist client to make timely decisions and - Disturbance of consciousness accompanied by a
complete work. change in cognition
- Cognitive restructuring techniques, - Short period, fluctuates
- Practice negotiation. - Difficulty paying attention, easily distracted
- Disoriented, sensory disturbances
Treatment modalities: - Easily distractible
- FOCUS: building trust, teaching basic living skills, - Transient condition
providing support, decreasing anxiety, improving
interpersonal relationships Causes:
- Relaxation or meditation techniques for Cluster C PHYSICAL ILLNESS
Personality Disorders. 1. CHF
- Improvement of basic living skills for clients with 2. Uremia
schizotypal and schizoid behaviors. 3. Pneumonia
- Assertiveness training for dependent and 4. Metabolic disorders
passive- aggressive clients. 5. CVA
- Dialectical Behavior Therapy for Borderline 6. Dehydration
Personality Disorder 7. Infection
- Cognitive Behavior Therapy
- Cognitive Restructuring Techniques (thought PRESCRIPTION DRUGS
stopping, positive self-talk, decatastrophizing) Polypharmacy
Anti-cholinergic effects
1. Antipsychotic
Cognitive Disorders 2. Antihistamine
Affects the area of cognition which includes: 3. Antihypertensive
● Consciousness 4. CV drugs (Digoxin, Diuretics, Cimetidine,
● Memory Antiparkinson)
● Perception
● Orientation Manifestations:
● Attention - Disturbances in consciousness with reduced
● Language disturbance ability to focus, sustain and shift attention
- Changes in cognition
- Develops over a short period of time and with a
tendency to fluctuate during the course of the day
(SUN DOWNING)

DEMENTIA
Causes:

REVERSIBLE
- Encephalopathy
- Infections like syphilis
 - Toxic conditions due to substances like alcohol
and metals
NON REVERSIBLE
- Disorders like Alzheimer's Parkinson's Disease,
Picks D., Huntington's , Chorea disease

Manifestations:
- Memory impairment - Amnesia
- 1 or more of the following cognitive disturbances:
● Aphasia
● Apraxia Stages:
● Agnosia Mild Stage
- Disturbance in executive functions (planning, ● 2-3 years
organizing, sequencing, abstracting) ● Amnesia - forgetfulness is the hallmark
- Cognitive defects can cause significant No recent memory
impairment in social and occupational function Routine - consistent arrangement
● Other cognitive difficulties - decision- making,
Assessment judgment, reasoning
- History taking-family or friends (impaired recent ● Repetitive questioning
memory recall)
- Uninhibited behavior Anxiety and fear Moderate Stage
- Labile mood over time, may also shift rapidly and ● 3-4 years
drastically ● Confusion and disorientation apparent
- Emotional outbursts Withdrawal from the world - Intervention:
- Impaired to loss of ability to think abstractly a. Supply the information
- Delusions of persecution b. Orientation board - font size
- Poor judgement, limited insight c. They can easily see vivid hues -
- Chronically confused amenable
- Disoriented d. Every start of contact -
- Hallucinations orientation
- Profoundly impacts roles and relationships
- Disturbed sleep-wake cycles ● Wandering
- Ignore internal cues ● Safety - provide a place where he can do it
- Inability to do ADL's ● Sleep disturbance
● Risk for insomnia - name the causes
DEMENTIA
- Initially - recent memory is impaired, intact long- Interventions:
term - Activity towards the afternoon
- Later stages- affects remote memory and even - Warm milk and warm bath
their own name
- Echolalia (echo) Papilalia (repeat) Apraxia
- Forgets activities of daily living
ALZHEIMER'S DISEASE - Self-care deficit
- Be with the client
Etiology:
- Unknown AGNOSIA
- Genetic - Loss of ability to name things
- Toxin - Give instruction
- Infection - Supervise the client
- Cholinergic deficit
APHASIA
- Loss of language
- Expressive aphasia
- Receptive aphasia
 - Do not lose their appetite but they ignore it
Confabulation - Absorbed in quest for weight loss and thinness
- Filling in memory gaps *Factor: Serotonin = Appetite
- To prevent loss of self- esteem
- May get frustrated or angry with themselves for ETIOLOGY:
forgetting 1. BIOLOGIC FACTOR
- Genetic predispositions
- Dysfunctional hypothalamus
Severe stage - Decreased serotonin
● 5-10 years
● Personality and emotional changes 2. SOCIAL FACTOR
● Deterioration in all areas of function - Thin is in
● May be delusional, require assistance in ADL's, - Rely on physique to get the approval of others
may wander
3. DEVELOPMENTAL FACTOR
● Overprotective / domineering enmeshed
NURSING CONSIDERATIONS: family→ decreased control and helplessness
- Promote client's safety and protection from injury ● Disturbed body image → Sees oneself as fat
- Structure environment and routine - Use diuretics and laxatives
- Promote adequate sleep, proper nutrition, - Locks herself in the room and does
hygiene and activity extraneous exercise
- Initial work - simple work ● Conflicts about growing up
- Provide interaction and involvement - Does not like to be adolescent
- Provide emotional support
- Family/Caregiver support
- Provide opportunities for recall of past events
- Encourage use of written cues
- Minimize environmental changes
- Short, simple instructions
- Integrate reminders of previous events into
current interactions
- Assist w tasks but do not rush
- Reframing
- Reminiscence therapy

DRUGS USED TO TREAT DEMENTIA

- Donepezil (Aricept)
- Rivastigmine (Exelon)
- Galantamine (Reminyl)
- Memantine (Namenda) Assessment:
- Refusal to maintain body weight at or above
minimum normal weight
EATING DISORDERS - Intense fear of gaining weight 3. VS decreased
- Absence of at least 3 consecutive menstrual
Bulimia Nervosa cycles
- Binge eat- Purge behavior - Lanugo
- Hypoglycemia, fluid and electrolyte imbalance
Anorexia Nervosa
- Self-imposed starvation Management:
- Re-establish appropriate eating behaviors
A. Feed the patient
ANOREXIA - Be firm and consistent
- Characterized by self-imposed starvation
 - Be with them to assess what the client had eaten ETIOLOGY
and set limits do not force the client → make 1. BIOLOGIC
agreement - Dysfunctional hypothalamus
- Behavior Modification Contract/Therapy → "You - Decreased serotonin
agreed that whatever is served you will eat. You
have 30 minutes to consume the food 2. PSYCHODYNAMIC
- Make part of the decisions → take over internal - Ambivalent feelings toward self-knows
locus of control increased self- esteem that eating is maladaptive
- Limit setting - Low self-esteem
● Stay with the client for 1 hour after meals - Depression
● Place in a public place after meal

B. Monitor the patient's weight

- Nutritional Assessment
- Before checking weight (early morning, before
breakfast, same clothes, same time)
- Weight gain of 1-2 lbs/week; 500 calories per day
divided in meals
- Constipation - Increase fluid intake, do not give
laxative but a stool softener
- Increase Self-esteem
- Good points of clients
- Recognize if the client had eaten

Assist expression of feelings

- Do not use starvation to reduce anxiety
- Journaling or writing diary
- Exercise-Stop from doing it then give alternatives
- Activities
- Verbalization
Assessment:
- Recurrent episodes of binge- eating
Other Treatment Modalities:
- A feeling of lack of control over eating behavior
a. Behavior modifications
→ compulsive eating
b. Pharmacotherapy antidepressants (Elavil,
Inappropriate compensatory behavior to lose
Prozac)
weight (the use of ipecac syrup to induce
c. Family therapy
vomiting)
d. Psychotherapy

Nursing Interventions:
Bulimia
- Set limit to binge eating- adhere to meal
- Characterized by binge- eating over a short
schedule
period of time followed by purging behavior.
- Assist feelings in binge eating and purging
- Recurrent episodes (at least twice a week for 3
- Improve self-esteem
months) of binge eating followed by purging,
- Use of treatment
fasting or excessively exercising.
- Antidepressants
- Binging and purging episodes are often
- Cognitive Behavioral Therapy
precipitated by strong emotions and followed by
guilt, remorse, shame or self-contempt
- Binge eating-consuming a large amount of food
in two hours of less SEXUAL DISORDERS
- Purging-compensatory behaviors to eliminate
food through self-induced vomiting or misuse of Categories of Sexual Disorders:
laxatives, enemas and diuretics 1. GENDER IDENTITY DISORDER
2. SEXUAL DYSFUNCTION
3. PARAPHILIAS
 - Sexual gratification from the exposure of one's
1. Gender Identity/ Dysphoria genitalia

 GENDER IDENTITY d. TRANSVESTISM

- (psychological state) - Finds pleasure in wearing the garments of the
opposite sex
 SEXUAL IDENTITY
- (physical state: boy or girl) e. FETISHISM
***** - Experience of sexual arousal from an object
A. Non-cross transexualism – discomfort but they symbolic to the person of the opposite sex
don’t want sex surgery
B. Transexual – trap in different body; subject to f. FROTTEURISM
surgery - Attains sexual orgasm through touching and
C. Ego-diptonic homosexuality – desires in rubbing of genitals to a non-consenting person
heterosexual relationship but experiences
sexual arousal with homosexual partner g. VOYEURISM
D. Bisexualism – partner of the same sex and - Peeping Tom
opposite sex - Sexual arousal obtained from watching the
sexual foreplays of others
2. Sexual Dysfunction
- Inhibition of sexual appetite or psycho- h. MASOCHISM
physiological change that compromise the sexual - Sexual satisfaction obtained from enduring pain
response cycle inflicted by partner

i. SADISM
Human Sexual Response Cycle - Sexual satisfaction obtained from inflicting pain to
partner

j. SODOMY
- Anal intercourse as the preferred sexual act
between adults

k. PEDARASTY
- Anal intercourse of a man and a boy

l. NYMPHOMANIA
- Female excessive desire for sexual act

m. SATYRIASIS
- Male excessive desire for sexual act
3. Sexual Perversions/ Paraphilias
- Sexual instincts that are expressed in ways that n. FELLATIO
are socially prohibited or unacceptable or are - Oral sex of the male genital
biologically undesirable
Types: o. CUNNILINGUS
a. PEDOPHILIA - Oral sex of the female genital
- Experience of sexual pleasure by an adult to a
child less than 13 y/o p. PERTIALISM
- Oral sex that does not proceed to genital sex
b. INCEST
- Sexual contact with a person belonging to the q. PYROMANIA
same blood line - Sexual arousal obtained from fire

c. EXHIBITIONISM r. KLISMAPHILIA
 - Sexual gratification from using enema Conduct disorder
- Repetitive or persistent pattern of conduct in
s. UROPHILIA which either the basic rights of others or major
- Sexual satisfaction derived from urinating one's age-appropriate societal norms or rules are
partner violated

t. COPROPHILIA Etiology
- Sexual satisfaction derived from defecating one's - Genetics
partner - Environmental adversity
- Poor coping
u. NECROPHILIA - Risk factors:
- Sexual satisfaction obtained from a corpse - Poor parenting, Poor family functioning
- Low academic achievement
v. TELEPHONE SCATOLOGIA - Poor peer relationships
- Telephone sex - Low self-esteem
- Exchange of sexually provocative remarks - Lack of reactivity to ANS→ decreased normal
avoidance or social inhibitions
w. ZOOPHILIA
- Bestiality Classifications:
- Sexual arousal with animals
Mild: relatively minor harm to others Lying, staying out
late without permission
ADOLESCENT DISORDERS
Moderate: increased problems and harm to others
Separation Anxiety Disorder - Vandalism, theft
- Normal among infants (8-9 months) - notion as
separate entity to mother Severe: considerable harm
- Cries if mother would leave- thought it would be - Forced sex, cruelty to animals, use of weapon,
forever burglary, robbery
- Beyond age- excessive anxiety to separation
from mother Manifestations:
- Aggression to people and animals
Manifestations: - Destruction of property
- Follows mother around - Deceitfulness or theft
- If separated-forever, something would happen to - Serious violations of rules
mother - May be quiet or openly hostile
- School phobia-separation to mother because of - Disrespectful to authority figures
school - Irritable, temper outbursts
- Uncooperative
Management: - Capable of logical and rational thinking
- Accompany the child - Perceive world as aggressive and
- Desensitize the child-used to separate to mother threatening act similarly
(gradual experience of separations)
- Counterproductive-Home Study no Manifestations:
independence - Intellectual capacity is NOT impaired but with
poor grades
Childhood Depression - Behavioral problems
- Loss of parents through divorce, separation or - Failure to attend class and complete assignments
death - Self-esteem is low but appear tough and cool
- Death of other person close to the child; death of - Disruptive and violent
pet - Relationship with peers limited to those who
- Movement to another neighborhood display similar behaviors as them
- Academic problems or failure. - Perceive those who follow rules as dumb afraid
- Physical illness or injury
Management:
- Group and individual psychotherapy
- Cognitive treatment. problem-solving,
training
- Parent training Family therapy
- Anger management
Pervasive Developmental Disorders
- Pervasive and usually severe impairment of
● Reciprocal social interaction skills
● Communication deviance
● Restricted stereotypical behavioral
patterns
- AKA: Autism Spectrum Disorders
- Autistic disorder (classic autism), Rett's disorder,
childhood disintegrative disorder, and
- Asperger's disorder
- 75% of children with Pervasive Developmental
disorders also have Mental Retardation
Autistic Disorder
- Pervasive developmental disorder
Etiology:
- Genetic
- Biochemical
- Defect in metabolism
- Identified 18 months - 3 years old
Autistic Disorder
- Little eye contact with others
- Few facial expressions Limited gestures to
communicate
- Limited capacity to relate with others
- Lack spontaneous enjoyment
- express no moods or emotional affect
- Cannot engage in play
- Little intelligible speech
- Stereotyped motor behaviors (hand flapping.
body twisting, head banging)
- Persist into adulthood
- Remain dependent to some degree
- Social skills rarely improve enough to permit
marriage and child rearing
- Viewed as odd or reclusive.
Social Impairment
- Does not want people; go with inanimate;
- Impaired verbal communication
- Cannot establish eye contact
- Disturbance in personal identity (pronouns)
- Repetitive act
- Peculiar reaction to change-resist change,
peculiar actions
- Nutrition
skills Nursing Interventions:
1. Optimum functions
- Develop capabilities that he does not have
- How?-accepting, reality-based, safe and
consistent
- Delay touch
- If establish contact → eye contact
- Talk to the child-don't expect to answer
2. Call the child by name
- Face to the mirror > body parts
3. Safe environment-consistency
4. Establish more relationship
5. Medication - Haloperidol
Asperger's Disorder
- Severely sustained impairment in social
interaction
- Restricted, repetitive patterns of behavior,
interests and activities
- No significant delays in language, Cognitive
development or age- appropriate self-help skills
- May benefit from Autistic treatment
Mental Retardation
- Sub-average intellectual capacity
- Ave. 10-90-110
- Deficit in adaptive ability
- Some are passive and dependent, others
aggressive and impulsive
Causes of MR
- Fetal Alcohol Syndrome (FAS)
- Genetic
- Exposure to measles during pregnancy
- Perinatal (delayed birth,multiple birth, placenta
previa, traumatic pregnancy)
- Postnatal (head injuries, malnutrition)
- Environment (parent incapability)
Classification of MR
a. Profound - Below 20-25
b. Severe -25-40
- Mental Age: 0-3 y/o
c. Moderate-40-55
- Mental Age: 3-8 y/o
- Trainable to unskilled-semiskilled work
- Minimum stress → Assistance
d. Mild-55-70, Mental Age: 8-12 y/o
- Educable, Vocational skills
e. Slow Learners-70-89 (not mental retardation)
Nursing Interventions: - Time out
- Therapeutic play
1. Optimize mental functioning-Mental age or ● Release energy
developmental age (Highest to attain regardless ● Expression of self
of chronological age) ● Promote communication
2. Planning with parents-Grieving process - Assist in focusing, redirect
3. Routine and repetition in teaching them - Improve role performance Gradually decrease
4. Down Syndrome reminders
Teach socially acceptable behavior
Speech Tantrums is communication Learning Disorders
Joints> Enhance - Deficits in acquiring expected skills compared
with other children of the same age and
Attention Deficit Hyperactivity Disorder (ADHD) intellectual capacity
- Disruptive Disorder - Categories
- Causes ● Reading disorder
● Genetic ● Mathematics disorder
● Biochemical-response to stimulants ● Language disorder
(Ritalin)-paradoxical effect-increase ● Disorder of written expression
attention ● Learning disorder not otherwise
● Preservatives specified
● In organic or developmental -
disequilibrium in the family-stressful for Motor Skills Disorder
the child - Low performance in daily activities that require
coordination below what is expected for age &
Manifestations: intellectual level
- Inattention or distractibility - Clumsy gross & fine motor skills, resulting in poor
- Impulsivity performance in sports & even poor handwriting
- Hyperactivity - Often coexists with a communication disorder

ADHD Medications TIC DISORDER AND TOURETTE DISORDER

- Decrease hyperactivity and impulsiveness,
improve attention TIC
- Methylphenidate (Ritalin) - Rapid & repetitive muscle contractions resulting
- Amphetamine compound (Adderall) in movements or vocalizations that are
- Dextroamphetamine (Dexedrine) Pemoline experienced as involuntary
(Cylert)
- SE: Insomnia, loss of appetite, and weight loss or TOURETTE SYNDROME
failure to gain weight - Multiple motor tics and one or more vocal tics.

Nursing interventions: Treatment:

- Safety - child and others
- Limit setting
- Outside limits - quiet non- stimulating
- Call the attention of the child
- Point out what is not acceptable
- School - Break down to shorter activities
- Stimulants - Ritalin
- Side Effects
● Anorexia - after meals
● Organic-based ticks - repetitive
- No junk foods
- Environment manipulation
- Consistent rewards and consequences
behavior
- Antipsychotics, ReVia, Adrenergic agonist
Elimination Disorder
- When the child is chronologically and
developmentally beyond the point at which it is
expected that these functions can be mastered
ENCOPRESIS
- Constipation and overflow incontinence
- W/o constipation and overflow incontinence
ENURESIS
for - Repeated voiding into a child's clothes or bed;
may be involuntary or intentional
 - Must occur twice weekly for a period of 3 months ● Used by people who wanted to lose
or must cause distress & impairment in weight or stay awake
functioning. - Cocaine-more potent than amphetamines (1-2
hours)
● Highly addictive and popular due to
SUBSTANCE-RELATED DISORDERS intense and immediate feeling of
euphoria
- Regular use - Shabu (Metamphetamine Hydrochloride) (8-12
- Impairment of functioning hours) Highly addictive, causes psychotic
- Hazardous behavior, brain damage
- Ecstasy-heightened sexuality, feeling of
Substance Dependence closeness to one another (club drug)
- Substance abuse - Takes the substance longer
than intended to Intoxication Effects
- Needs more time to take and get the substance - Euphoria
- Withdrawal symptoms Substance-specific - Hyperactive, hypervigilant, talkative, grandiose
symptoms upon reduction or cessation of the - Loss of appetite Increased vital signs (cardio-
substance respiratory effects)
- Tolerance - Higher dose to bring about the same - Delusions and hallucinations (drug-induced
effect psychosis)
- Symptoms for 1 year - Formication-specific for cocaine; "bulbs" under
the skin (cocaine intoxication)
Physical Dependence - Dilation of pupils
- Withdrawal symptoms - Rush - momentary ecstasy
- Tolerance - Crashing - painful depression
- Unsuccessful attempts to stop using the - Rush-crashing may lead to psychological
substance dependence
- Perforated nasal septum - cocaine
Physiologic Dependence - Urine Test - must be done as soon as possible
- Takes the substance to avoid the unpleasant not more than 4 days
effects of withdrawal
Hallucinogens
Substance Intoxication Forms
- CNS Depressants → Depressant effects to occur - Mescaline – anesthetic agent
- CNS Stimulants → Stimulating effects to occur - LSD- more psychotic features
- PCP - anesthetic
Substance Withdrawal - Ketamine - anesthetic; dissociation, memory
- CNS Depressants → Stimulating effects to occur loss, separation to the body, most violent
- CNS Stimulants → Depressant effects to occur - Cannabinols - mild hallucinogens
- Cannabis sativa (tetrahydrocannabinol)
ETIOLOGY - Marijuana-dried leaf taken in a cigarette-like
● Biologic Factors manner
● Genetics ● Hashish-resin
● Neurochemical influences ● Hashed brownies
● Mood altering substances
● Psychologic Factors Family dynamics Effects:
● Inconsistent behavior of parents - Conjunctival irritation - 'red eyes'
● Poor role modeling - Dry mouth • Increased appetite
● Lack of nurturing - Tachycardia
● Environmental influences - Affect judgment
● Social customs - Decreased motivation
- Decreased level of testosterone
CNS Stimulants - Affect the mucosa of the respiratory tract → lung
- Amphetamines "uppers” cancer
 - Mirthfulness - happy and alone ● Leukopenia
- No known withdrawal symptoms ● Thrombocytopenial
- Warped appearance - senses have distortions ● Ascites
- Claimed that space is very colorful
- Delusions-e.g. They could fly
- Synesthesia - blending of senses See and 'smell'
colors
- Bad trip-frightening sensation
- Hallucination
- Flashback
- Manifestations linger

CNS Depressant
- Alcohol Effects of Alcohol
- Blood Alcohol Concentration Levels (BAC/BAL)
to Behavioral Manifestations of Intoxications GI
- Malnutrition
Etiology - Inflammations
- Biologic CNS
- Psychodynamic-very strong (fixation) - Due to deficiency in Vitamin B
- Behavioral-anxiety relief (rewarding). learned - Neuritis
behavior - Wernicke's syndrome-acute delirium and ataxia
- Social-peer pressure - Korsakoff's syndrome - acute amnesia memory
impairment- they do confabulation
Effects of Alcohol
- Rapidly absorbed in the bloodstream Reproductive system
● Initial effect of relaxation and loss of - Impotence (decreased testosterone)
inhibitions Intoxication
- Slurred speech, unsteady gait, lack of CVS
coordination, impaired attention, concentration, - Cardiomyopathy
memory and judgment - Fetal Alcohol Syndrome
- Aggressiveness or display inappropriate sexual
behavior Psychodynamics of substance dependence
- May experience a blackout - May be a basis for the nurse-client relationship
- Overdose - Unresolved needs of early attachments
● Short term - Increased Id
- Vomiting - Strong oral tendencies
- Unconsciousness - Demanding/manipulative - Matter of Fact - casual
- Respiratory depression but not indifferent; consistent, no bargaining; no
Eventually may lead to exemptions
● Aspiration pneumonia, pulmonary - Learn how to wait
obstruction - Rules and regulations
● Alcohol induced hypotension→
Cardiovascular shock → Death Management Goals: Detoxification
- Ensure the physiologic integrity and safety of the
Overview long term physiologic effects of alcohol use client.
- Limit visitors
● Cardiomyopathy - Check VS every 1-2 hours
● Wernicke's encephalopathy - Safety: Side rails up and ask someone to
● Korsakoff's psychosis accompany the client; Last resort: restraints,
● Pancreatitis adequate light, non-stimulating room, seizure
● Esophagitis (Dilantin Magnesium Sulfate → absorption of
● Hepatitis Vitamin B)
● Cirrhosis
 ● Warm shower
- Healthworkers have access to these drugs
- Antidote: Narcan

Inhalants
- Diverse group of drugs that are inhaled for their
effects
● Cause significant brain damage,
peripheral nervous system damage and
liver disease
***Mouth puffs: Mgt- gargle to prevent mouth ulcers
**Disulfam Therapy – blocking aldehyde dehydrogenase Effects
(=Sx- headache ; thereby: di na sila iinom because of sx) - GI Upset
- Mirthfulness
Management of Alcoholism: Rehabilitation - Ulcers in the mouth
- Support group for the family of the Alcoholics - CNS depression →→ Death
● Al Anon - for the wife
● Ala Teen-for the children Examples
- Activity therapy group - Solvents
- Remotivation therapy - Gasoline
- Withdrawn and regressed-to be interested again
in socializing, sharing stories. Intoxication and Overdose
- Dizziness, nystagmus, lack of coordination,
Nursing Interventions slurred speech, unsteady gait, tremors, muscle
- Providing for physical and nutritional needs weakness, blurred vision
- Confrontation - Stupor and coma can occur
- Tough love
- Group work Behavioral symptoms
- Education - Belligerence, aggression, apathy, impaired
judgment, inability to function

Sedative/Hypnotics Acute Toxicity

Narcotics-Opioids
- Papaver somniferum opium, heroine (most
commonly abused; IV push), codeine (cough
syrup), morphine, Demerol (synthetic)
- Popular because they desensitize both
physiologic and psychologic pain> Euphoria
- Anoxia, respiratory depression, vagal stimulation,
dysrhythmias
- Bronchospasm, cardiac arrest, suffocation,
aspiration → Death
- No antidote, no withdrawal symptoms or
detoxification procedures

Effects
- Depressant but may have euphoria
- Psycho-motor retardation
- Sleepy languor
- Insensitivity to pain-physical and emotional
- Decreased LOC
- Respiratory rate- below 12 per minute
Withdrawal
- Initial: anxiety, restlessness, aching back and
legs, craving for more opioids
- Runny nose
- Teary eyes
- Goose flesh-Piloerection'
- Abdominal or leg cramps → diarrhea