1 PSYCHIATRIC NURSING by Sir Rex Zamoras, Aubrey

Citeria to diagnose mental disorders

HEALTH
- A state of complete physical, mental and social well –
being and mot merely the absence of disease or
infirmity (WHO)
➢ Once you do not have any physical symptoms or
disease you are not truly healthy because you are
thinking of other things, mental problems, self-
isolation
➢ Physical health is not the totality of health
- There is not health without mental health (DOH)
➢ Biggest component of health is mental health
- Dissatisfaction:
o Characteristics, accomplishments, abilities
- Ineffective or dissatisfying relationship
- Dissatisfaction with one’s place in the world
- Ineffective coping with life’s events
- Lack of personal growth
DSM V
- Diagnostic statistical manual
- We based our diagnosis with this
- Latest version

Imbalances between personality elements

MENTAL HEALTH
Id is higher than the superego
- A state of wellbeing in which every induvial: - Manic
Realizes his or her own potential, - Anti – social disorder
Can cope with the normal stresses of life, o Lack/absence of remorse. Guilt or
Can work productively and fruitfully conscience
Able to make a contribution to her community - Narcissistic personality
➢ Once there is ineffective coping that means you are in o Exaggerated self love
a crisis o Self centered
➢ You know your potential you are able to work
harmoniously with yourself and others. Superego is higher than ID
- Obsessive compulsive personality
- A state of emotional, psychological and social - Anorexia nervosa
wellness evidenced by satisfying interpersonal
relationships, effective behavior and coping, positive Ego is decrease
self- concepts and emotional stability - You are dwelling on reality
- Schizophrenia
Components of mental health
Ego defense mechanism
Autonomy and independence - Functions during anxiety or stressful event
- Can work interdependent without losing autonomy o Without defense mechanism, anxiety might
➢ Able to work independently and with group overwhelm and paralyze us and interfere
with daily living
Maximization of one’s potential
- Oriented towards growth and self –actualization
➢ You are able to work with your weakness 2 features

Tolerance of life’s uncertainties 1. They operate on an unconscious level (except suppression)

- Can face the challenges of day to day living with hope 2. They deny, falsify or distort reality to make it less threatening
and positive look

Self esteem
- Has realistic awareness of her abilities and limitations

Mastery of the environment Regression

- Can deal with and influence the environment - Returning to an earlier developmental stage
- Infantile behavior
Reality orientation
- Can distinguish the real world from a dream, fact from Repression
fantasy - Unconscious forgetting of an anxiety provoking
concept

Mental illness Suppression

- Conscious forgetting of an anxiety provoking situation
- State of imbalance characterized by a disturbance in
person’s Identification
thoughts - Attempts to resemble or pattern personality of a
Feelings person being admired of
behavior
➢ A person who has different perception, thinking to Introjection
what is other person - Acceptance of another values and opinions as one’s
own
2 PSYCHIATRIC NURSING by Sir Rex Zamoras, Aubrey

Sublimation Bipolar – reaction formation

- Placing sexual energies toward more productive Borderline – splitting
activities Schizophrenia – regression
- Placing an unacceptable traits to a more acceptable Substance abuse – denial
one Depression – introjection
OC – undoing
Substitution Catatonic – repression
- Replace a goal that can’t be achieved for another that
is more realistic
Nurse patient relationship
Rationalization
By: Hildegard Peplau
- Self-saving with incorrect illogical explanation
Phases
Intellectualization
- Excessive use of abstract thinking; technical
explanation Pre – interaction
- Reasoning with highly abstract, intellectual thinking - Major task of the nurse: develop self-awareness
without touching one’s emotion - Preparation of the relationship
- The nurse need to aware of
Displacement o Limitation
- Feelings are transferred or redirect to the person or o Subjectivity
object that is less threatening o Beliefs
o Ideas and thoughts
Projection - Effective delivery
- Blaming - No interaction with the client
- Falsely attributing to another his/or own unacceptable
feelings Orientation
- Task: develop a mutual acceptable contract
Conversion - Start of the termination phase
- Anxiety converted to physical symptoms - Indicates the start and end of the relationship
- 1st interaction of the nurse and patient
Compensation
- Overachievement in one area to overpower weakness Working
or defective area - Task: identification and resolution of patient’s problem
- Longest and most productive phase of NPR
Undoing
- Doing the opposite of what have done Termination
- Task: assist the patient to review what he has learned
Denial and transfer his learning to his relationship with others
- Failure to acknowledge an unacceptable trait or - End of the relationship
situation
Problems:
Fantasy - Resistance – establish rapport and trust
- Magical thinking - Transference – patient to the nurse
- Counter – transference → the feeling of the nurse to
Reaction formation the patient
- Opposite of intention

Acting out Attitude therapy

- Deals with emotional conflict or stressor by action Paranoid – passive friendliness
rather than reflection or feelings - Maintain distance
o Let the patient feel that you are there to help
Symbolization o Patient thinks that you will always hurt them
- Creates a representation to an anxiety provoking thing
or concepts Withdrawn – active friendliness
- Schizo
Splitting/dichotomous thinking - Try to be close to the patient
- Labile emotions; all bad – all good
- Common in borderline personality Depressed/anorexia – kind firmness
- To gratify work and help them return to the hostility
Defense mechanisms commonly used in each outward
respective d/o - Let the person express what they feel
- Provide helping approach so the person can verbalize
Paranoid – projection what they feel and the hostility can be expressed
Phobia – displacement - Do not sympathize to the misery but allow the patient
Amnesia – dissociation to feel the patient to divert and express themselves
Anorexia – suppression
3 PSYCHIATRIC NURSING by Sir Rex Zamoras, Aubrey

Manipulative – matter of fact

- Patient is demanding Encouraging comparison
- Always stick to the regulation, be firm, explain the - Asking that similarities and differences be noted
rules and follow the policy
- Stick to the rules and be consistent Encouraging description of perceptions
- Asking the client to verbalize what he or she perceives
Assaultive – no demand
- Never approach the patient alone or they will perceive Encouraging expression
that you are provoking them - Asking client to appraise the quality of his/her
- Always go the patient by groups experience
- Inform patient that the group will not harm them but - What are your feeling in regard to?
instead they are there to help
Exploring
Anti – social – firm, consistent - Delving further into a subject or idea
- Extra ra ni 5 ra jud ang attitude therapy - Tell me more about that?
- Would you describe it more fully?
- What kind of work?
Thera com
Orientation Focusing
- Broad opening - Concentrating on a single point
- Recognition
- Giving information Formulating a plan of action
- Silence - Asking the client to consider kinds of behavior likely to
- Offering self be appropriate in future situations
o Do you want me to sit beside with you?
General lead
Working - Giving encouragement to continue
- Focusing
o Let us discuss this topic more Giving information
- Exploring - Making available the facts that the client needs
o Identify patients problem
o Tell me more about it Giving recognition
- Encourage evaluation - Acknowledging, indicating awareness
o Is this what you want? - Increase the self esteem and self worth of the patient
- Reflecting
- Restating Making observation
o Ang words ra ang gistorya ang dapat - Verbaliozign what the nurse perceives
e,restate nothing more - You appear tense
- Verbalizing implied - Be tactful on what you are trying to say
o Are you going to kill yourself - Patient can be hurt and defensive
- Seeking clarification
o May you please repeat that statement Offering self
- General lead - Making oneself available
o Important – time in which the patient can tell - Ill sit with ou for a while
on whether or not you are listening - Ill stay here with you
- Limit setting - Im interested in what you think
o Say stop
- Interpreting

Termination Placing event in time and sequence

- Summarizing - Clarifying the relationship of events in time
o Do you have any questions - What seemed to lead up to
- Look for changes in behavior - Was this before or after
o This is the time to evaluate if there is
progress Presenting reality
- offering for consideration that which is real
- accepts what the patient is saying but do not agree
Accepting nor disagree with the client rather offer reality
- Indicating reception - I see no one else in the room
- Your mother is not here; I am a nurse
Broad opening
- Allowing the client to take the initiative in introducing Reflecting
the topic - Directing client actions, thoughts, and feeling back to
the client
Consensual validation - Client: do you think I should tell the doctor
- Searching for mutual understanding, for accord in the - Nurse: do you think you should
meaning of the words
- Validate if you are on the same wave length Restating
4 PSYCHIATRIC NURSING by Sir Rex
- Repeating the main idea expressed
Seekig information
Silence
- Absence of verbal communication which provide time
for the client to put thoughts or feeling into words,
regain composure or continue talking
- Maintain eye contact, convey interest to the patient
Suggest collaboration
- Offering to share, to strive, to work together
Summarizing
- Organizing and summing up
Translating into feeling
- Seeking to verbalize clients feeling that they
expresses only indirectly
Verbalizing the implied
Voicing doubt
- Expressing uncertainty about the reality of the clients
perception
Schizophrenia
Benedict Augustin Morel
- 1850
- Demece precoce – described a young boy who
suddenly had symptoms of mental deterioration
Emil kreapelin
- A german psychiatrist
- Dementia precox (latin word) – early onset of
symptom followed by progressive course culminating
in dementia
Schizophrenia – Eugene Bleuler in 1911
- Greek work – sxizo, pronounced schizo meaning to
spilt or crack , phren, meaning mind
- Split mind
Bleuler
- Emphasis on symptom presentation and described
fundamental or primary symptoms
Bleuler 4 As in schizophrenia
(Symptom presentation and described fundamental or primary
symptoms)
A – ambivalence: marked inability to decide for or against
- Indecisive
- 2 opposing feeling
A – Autistic behavior: withdrawal into SELF
- A person may have an attitude of being autistic
- A tendency to make a world of his own, making him
detach to the environment
- SCHIZOID personality – Pre morbid personality –
pwde ma develop to schizo (being alone, being
detach to the world, aloof and indifferent, people when
experience something they are not able to share it
with somebody)
Zamoras, Aubrey
- Alone aloof and indifferent
A – Affect disturbance: mood: inappropriate affect
(incongruent affect), blunted affect or flat affect
(apathy)
A – Association disturbances: Loosening of associations:
thought disorder – disturbance in thoughts,
speech, even in decision making
CAUSES AND RISK FACTORS
1. Genetic or hereditary
Identical twins 35%
Fraternal twins 15%
Sibling 10%
Both parents 35%
1 parent 15%
- If the other identical twin has a schizo the other one
has a 35% chance of having a schizo
2. Molecular genetics
- some chromosome are responsible for schizo:
chromosomes 1,2,6,8,13, and 22
3. Prenatal exposure
- During the pregnancy the patient has been exposed to
- Viral infection
- Rhesus (RH) incompatibility – damage in mother’s
immune system and blood related diseases
◼ Would happen if a woman with RH- na
expose sa RH+ blood of the infant
◼ One her 1st pregnancy the mother did not
develop the antibodies for RH+ but on the 2nd
pregnancy since na expose na ang mother,
nag develop na ang antibodies thus there is
an effect na daun towards the baby
- Pregnancy and birth complications
- Early nutritional deficiency – there are conditions that
the mother cannot breastfeed, there is no proper
supplementation nutrition
- Maternal stress – avoid stress during pregnancy
4. Neuro developmental perspective
- structural and functional brain abnormalities
- loss of brain volume (atrophy)
→ advanced age
→ Traumatic brain injury (causes damage to
the structures of the brain)
- →brain is not properly exercised
- Affected brain areas – region memory, language and
other sensory inputs
5. Brain functioning
- Low frontal lobe functioning (hypofrontality)
6. Cytoarchitecture
- disruption of migrations of neurons
7. Neurochemistry
- dopamine
→ produced in substantia nigra → found in basal ganglia
→main culprit for schizo
4 DOPAMINE PATHWAY/DOPAMINERGIC PATHWAY
5 PSYCHIATRIC NURSING by Sir Rex Zamoras, Aubrey

NIGROSTRIATAL PATHWAY 5. Negative symptoms (e.g, diminished emotional

- Control of movement
- Decrease in dopamine – EPS, Parkinsonian
symptoms
- Pagmababa si dopamine sa NP walang mag cocontrol
sa movement, there is a tendency that there will be
uncontrolled movement (parkinson’s d/o – dec of
dopamine in the NP)
- Increase of dopamine causes schizo: give
antipsychotic w/c decs dopamine then there will be
EPS, lack of control of movement as a s/e of
antipsychotic meds
TUBEROINFUNDIBULAR PATHWAY
- Control of prolactin
- Decrease dopamine - gynecomastia
- One of the s/e of antipsychotic: gynecomastia – no
control of prolactin so m,taas na duan cya.leading to
lactation
expression or avolition)
B. socio-occupational dysfunction
For a significant portion of the time since the onset disturbance,
level of functioning in one or more major areas, such as work,
interpersonal relations, or self- care, is markedly below the
level achieved prior to the onset
C. Must be present for 6 months
- has prodromal or residual symptoms
D. schizoaffective disorder and depressive or bipolar d/o with
psychotic feature have been ruled out
E. the disturbance is not related to the physiological effects of a
substance (drug abuse, a medication) or other medical
condition

MESOLIMBIC PATHWAY ASSESSMENT AND EVALUATION

- Perception CLINICAL FEATURES
- Increase dopamine – altered though process
(hallucination and delusion)
1. Hallucination
- Delusion, hallucination – taas ang dopamine sa MP
- A distortion in perception that can occur through any
which causes an increase of perception daun mag
of the senses
trigger na daun ug hallucination
◼ auditory, visual olfactory gustatory and tactile
- Results in abnormal thought process
- auditory hallucinations are the most common
- Only the time in which the patient is relieved of
→ most fatal
hallucination
→ aka: command hallucination
MESOCORTICAL PATHWAY
2. Delusion
- Feeling and reward
- erroneous belief that usually involve a
- Decrease in dopamine
misinterpretation of perceptions or experiences
- Responsible for negative symptoms
- fixed false belief
8. Environmental factor
TYPES OF DELUSION
- main cause is ineffective coping
- a person maybe in a certain life experiences that a
person cannot cope a. Erotomania
- having belief that someone is in love with him or her
- loss of loved ones - delusions of love
- loss of job/unemployment - their subject are usually those who are higher in
- ineffective coping position
- traumatic event o than them
- substance abuse (ineffective coping)
- Dysfunctional family b. Grandeur
- Loca de amor – iniwan ng awasa - over-inflated sense of worth, power, knowledge or
Identity

DIAGNOSIS c. Jealousy
- having belief that their spouse is unfaithful
DSM5 (CRITERIA FOR SCHIZO) - morbid jealousy or pathological jealousy
- no proof their spouse is really cheating
DIAGNOSTIC STATISTICAL MANUAL - baseless accusation
– The lenga franka of psychiatry
◼ Latest d. Persecutory
- most common kind of delusion
DIAGNOSTIC CRITERIA: - having belief that they are mistreated, or someone is
spying is them
A. Two or more of the following, each present for a significant - they think that someone is trying to kill them
portion of time during 1 month period (or less successfully - most common form of delusion d/o
treated). At least one of these must be 1,2, or 3
1. Delusions e. Somatic
2. Hallucinations - believes that they have any kind of health issues
3. Disorganized speech (e.g., frequent derailment or - similar with hypochondriasis d/o
incoherence)
4. Grossly disorganized or catatonic behavior g. Mixed delusions
6 PSYCHIATRIC NURSING by Sir Rex Zamoras, Aubrey

- 2 or more kinds of symptoms listed about TYPES OF SCHIZO

h. Unspecified type

3. Disorganized speech

Types of disorganized speech:

Neologism
- coining of new word
- coining of new word that only patients can understand

Word salad
- Mixing of words

Flight of ideas
- Jumping of topic with connection

Looseness of association
- Jumping of topic without connection

Clang association
- Rhyming of words

Concreate association
- A philosophical answer to a question

Echolalia
- Repeating the words of others 1. Paranoid
- People may have prominent hallucination and
Verbigeration delusion that are not real
- Repetition of own words - Suspicious and mistrustful
- Palilalia - Delusion of persecution
- Has no trust
Perseveration - Hallucinations and other kinds of delusion
- Same response to a question
Management:
Tangentially ◼ Avoid unnecessary touching→ Can be
- Long answers, no answer misinterpreted as a threat
◼ Avoid whispering or laughing in front of the
Circumstantiality patient
- Long answer, with answer at the end ◼ PRIO: establish trust and rapport
- Going around the bush ◼ Attitude therapy: passive friendliness
◼ Give pre packed or sealed food

SYMPTOMS
2. Hebephrenic/Disorganized
POSITIVE SYMPTOMS
- Also called as disorganized schizo, in this behavior
Mesolimbic pathway ang affected
the person is confused and purposeless
Disorganized speech and behavior
- Disorganized speech and behavior (psychomotor
o Pt can be catatonic and so on
retardation/agitation)
Hallocinations
- Blunted/flat or incongruent affect
Delusion
- Disorganized thought and emotion
Paranoid thinking
Management:
NEGATIVE SYMPTOMS
1. delusion- never challenge the delusions
Anhedonia – absence of pleasure
2. therapies : music and art
Avolition – absence of interest and motivation
3. nurse patient relationship
Apathy - absence of affect
Alogia – poverty of speech; one to two word answers
3. Catatonic
Anergia – loss of energy; person could have fatigue;
- Person may show unusual movement and extreme
psychomotor retardation
behaviors such as hyperactivity
- Rare severe mental disorder
7 PSYCHIATRIC NURSING by Sir Rex Zamoras, Aubrey

- Pt has motor behavior (psychomotor - Major tranquilizers, neuroleptics

retardation/agitation)
First – generation antipsychotic medications
Psychomotor retardation: - (old/tradition/typical), more side effects
◼ Waxy flexibility – assumes same position for a
longer period of time Second –generation antipsychotic meds
◼ Mutism - (New, modern, atypical) lesser s/e but more
➢ Psychomotor agitation: expensive
◼ Echolalia -
◼ Echopraxia
- Pt can’t have both retardation or agitation, 2. Somatic treatments
- electroconvulsive therapy (ECT)
Management:
1. Circulation 3. Adjunctive treatment
2. Safety - anticholinergics, antidepressant,
3. Nutrition
4. psychosocial interventions
4. Undifferentiated
- Individuals may have paranoia disorganized thoughts 4. other measure
and hallucination
- Does not fall in 4 other types
- 2 or more symptoms of different types of schizo Typical antipsychotic
Recommended therapeutic dose range for various
5. Residual antipsychotic
- People may feel they are completely recovered from
their condition once correctly treated
- History of schizo
- No positive symptoms
- Present: negative symptoms

Management:
1. Safety
2. Active friendliness/ kind firm
3. Nutrition

FORMS OF PSYCHOSIS Low potency drug

- Chlorpromazine (thorazine)
Brief psychotic d/o o Oldest
- May be seen when a person exhibits clinical - Thioridazine (millaril)
symptoms of illogical thinking, incoherent speech, - Can have 3x/day
delusions, or disorganized behavior after
psychological trauma Moderate
- Experience after traumatic events - Perphenazine (trilafon)
Induced psychotic d/o High
- Happening to a second person - Haloperidol (haldol
- The 2nd person has psychosis - Fluphenazine hcle (prolexin) – drug given when there
o Develops in a second person as a result of a is per orem non compliance
close relationship with a person who has - patient sometimes do cheecking
psychosis - route: IM
Delusional psychotic d/o Typical Antipsychotic Side Effects
- The only symptom: delusion

Schizoaffective d/o
- Depression or elation as the psychosis symptoms of
schizophrenia and MDD
- Problem with the mood
- Psychotic and mood disorder

Schizophreniform
- Person exhibits feature of schizophrenia for more than
one week but less than 6 months

MANAGEMENT: Ang naka red kai mao ang most common

1. Antipsychotic meds 1. Anticholinergic s/e

- Purpose: decrease dopamine level
8 PSYCHIATRIC NURSING by Sir Rex Zamoras, Aubrey

- Dry mouth – sugarless gum/candy - Rapid eye blinking

- Constipation – increase OFI/high fiber diet - Tongue protrusion
- Orthostatic hypotension – safety, dangle at bed
- Tachycardia – decrease of cardiac output 8. NEUROLEPTIC MALIGNANT SYNDROM
- Decreased urine output/ concentrated urine – - fatal
expected s/e, increase OFI - muscle rigidity
- Pupillary dilation – WOF: glaucoma (narrow/tunnel - increasing v/s
vision), pain - hypertensive crisis
- diaphoresis
2. Photosensitivity - renal failure
- avoid exposure to the sun, wear sun protective
clothing Mgt: muscle relaxant
- person is sensitive to sunlight Bromocriptine hcl (parlodel)
Dantrolene (dantrium)
3. Hyperprolactamia
- Decrease dopamine in the tuberoinfundibular No pregnancy for a year
pathway, no control over prolactin Check for renal function test

4.. EXTRAPYRAMIDAL SYMPTOMS

- Decrease dopamine at the NP, decrease dopamine to MANAGEMENT (EPS)
control movement
1. ANTIPARKINSONIAN DRUGS
1. AKATHISIA - Congentin – DOC during acute attacks
- Most common EPS - Artane
- Ants in the pants - Benadryl
- Inability to sit or stand still - Akineton
- symmetrel
2. BRADIKINESIA
- Slowed movement SIDE EFFECTS OF CLOZAPINE ATYPICAL

3. AKINESIA Myocarditis
- absence of movement Excessive salivation
Seizure
4. PSEUDOPARKINSONISM Agranulocytosis
- decreasing level of dopamine - Regular checking for WBC count
➔ mask like face - Assess for fever and sore throat
➔ resting tremors – tremors happens when hands at - Refer to the physician
rest, but when the hands are active there is no
tremors
➔ shuffling gate
➔ pill rolling
➔ cogwheel rigidity

5. PISA SYNDROME
- comes from the word leaning tower of pisa
- leaning on one side

6. DYSTONIA
- involuntary muscle spasm, earliest EPS to
- Appear (3 days)
- -Acute
-Dreaded side effects MOOD/AFFECTIVE DISORDER
- Opisthotonos – arching of the back
- Torticollis – wryneck; muscle of the neck loosed MANIA
strength; nag tilt or bowing down ang head
- The person has too much energy, restless, agitated,
- Writer’s cramp – focal hand dystonia (FHD) →muscle
increasing energy in which can be delivered thru
hand spasm; involuntary contraction of the muscles in
the hand physical activities, can be very manipulative
- Oculogyric crisis – upward rolling of the eyeball - Symptoms must be present for 1 week
- Laryngeal – pharyngeal constriction → fatal, airway - 3/7 symptoms present
obstruction - Not under the influence of any substance

7. TARDIVE DYSKENISA
- Permanent / irreversible, LATE EPS to appear (6
months) SIGNS AND SYMPTOMS
- Chronic to appear
- Lip smacking 1. Inflated self-esteem or grandiosity
- Facial twitching
2. decrease need for sleep – exhaustion
9 PSYCHIATRIC NURSING by Sir Rex Zamoras, Aubrey

3. very talkative – pressured speech - Can channel their activities

- thought racing – maong sigi sila ug istorya o Household chores, cleaning in the area,
Zumba, walking,
4. flight of ideas – thought racing
- the person tries to jump from one topic to another
PSYCHOPHARMACOLOGY
5. Easy distractibility DOC: Lithium carbonate
- the person cannot concentrate to one topic or Anticonvulsant drugs
one single thing → Valproic acid
→ Carbamazepine
6. psychomotor agitation
- the person jumps, leaps, LITHIUM
- DOC of mania
7. engage in activities with painful consequences
- Only acts in the GI tract – taken only PO (tablets,
- they do not think about the consequences, they
capsule, or syrup)
just engage to any activities they have thought
Contraindication:
- Pregnancy – cardiovascular anomalies to the fetus
HYPOMANIA - Renal failure – inability to excrete lithium, risk for
toxicity
- Present for 4 days - Cardiovascular diseases
- Less severe that does not warrant hospitalization
- 3/7 symptoms Therapeutic level: 0.6 – 1.2 mEq/L
- Not under the influence of any substance or any
medical condition Therapeutic level: 0.6 – 1.2 mEq/L

Maintenance: 0.5 – 1.5 mEq/L

MANAGEMENT OF MANIA - Specimen: serum, best taken in the morning before
Priority: safety for self and others the first dose

Nutrition: the person with mania does not sit still, so mag lisod - Assess for renal function
sila ug kaon; they have too much energy so taas silag ma burn → Potassium – fatal
na calorie ▪ Indication for hemodialysis
- High caloric, high protein, high carb diet → BUN – blood urea nitrogen
- Food on the go “finger foods” ▪ End product of CHON metabolism
- Best food: burger ▪ 10 – 20 mg/dL
→ Creatinine
▪ End product of muscle metabolism
Sleep and rest ▪ 0.7 – 1.4 mg/dL
- Milieu management: less stimulating environment ▪ Serum crea – blood
▪ Crea clearance – 24 hour urine
Attitude therapy: collection
- matter of fact attitude • Best indicator for renal
- They are very manipulative function
- Follow and state the policy :consistency
- To avoid comparison
- All must have consistency :set limits

Activities: - Inverse relationship with sodium

- Decelerating → Body cannot detect sodium
o Pababa ang energy → A person that are taking lithium; higher
o Strenuous activies in the morning, less affinity than sodium; the body could not
strenuous in the afternoon dapat pag hapon recognize if unsa ang gikuha sa body
they have less energy para maka rest pagka → Normal or sufficient level ra ang sodium kai
gabii mag compete cya sa lithium if gamay ra pud
cya daghan ang yang I absorb na lithium
- Schedules/structured causing toxicity
o Best answer!
o Schedules or structured activities Therapeutic effect: 7 to 10 days

- Solitary Expected side effects: 0.5-1.5 mEq/L

o The person can do it alone → Polyuria – excessive urination, can lead to
o To avoid manipulation of the group compensation
→ Polydipsia – compensatory reaction of
- Non-competitive polyuria
o Once the manic patient losses mag wild sila → Fine tremors – mawala ra cya
10 PSYCHIATRIC NURSING by Sir Rex Zamoras, Aubrey

Mild toxicity: 1.6 – 2 mEq/L 4. Disturbance in sleep – person can have

→ VANDA - insomnia → difficulty falling asleep or falling
▪ Vomiting back asleep upon walking up
▪ Anorexia - hypersomnia → sleeping more than 10 hours
▪ Nausea every night
▪ Diarrhea
▪ Abdominal discomfort 5. Psychomotor retardation
→ GIT discomfort if mag mild toxicity na
- course tremors
→ Only acts sa GI since oral cya 6. Fatigue/ anergia (loss of energy)

Moderate toxicity: 2 – 3 mEq/L 7. Worthlessness/ inappropriate guilt – a person who are

→ Severe vomiting and diarrhea depressed would feel depressed, they think their
→ Lack of coordination existence is not important
→ Blurring of vision - result: helplessness and hopelessness
→ Tinnitus – ringing of the ear
→ Ataxia – imbalance gait 8. Indecisiveness – they cannot decide on their own

Severe toxicity: 3 mEq/L above 9. Suicidal thoughts/ideation

→ Renal failure
→ Coma
→ Seizure DYSTHEMIA
- Less severe depression
MANAGEMENT for Lithium Toxicity: - Chronicity than severity
→ Chronic but less severe
Normal/sufficient Na intake - 2 years
→ 3g/day of Na - Does not warrant hospitalization
→ 3L/day of fluid

Toxicity DEPRESSION
→ No specific drug that is an antidote for lithium - Decrease in SEROTONIN and NOREPINEPHRINE
toxicity - Serotonin
→ Whole bowel irrigation → needed for sleep and wake cycle, appetite,
→ IV fluids emotion and stabilizes the mood
→ Hemodialysis → Feeling of well-being and happiness
▪ Severe form of toxicity - Norepinephrine
▪ To remove all lithium in the blood → A stress hormone, SNS, energy
→ Aminophylline (bronchodilator),
mannitol(osmotic diuretics) – increase lithium
excretion MANAGEMENT FOR DEPRESSION
→ Gastric lavage

Priority: safety for self-suicide

Attitude therapy
- Withdrawn: Active friendliness
- (a person who has depression has social isolation)
- Pt is depressed: firm kindness

MAJOR DEPRESSIVE DISORDER Activities:

- Schedules or structured activities
- 5 or more of the following for 2 weeks, one which
must be depressed mood or anhedonia (absence of Milieu management:
pleasure) - Stimulating environment
- 5/9 symptoms
Acknowledge achievements and accomplishments
SIGNS AND SYMPTOMS Encourage verbalization of feelings
1. depressed mood – social isolation - Depression: internalized hostility
- Patient is withdrawn

2. Anhedonia – absence of pleasure SUICIDE

3. Significant change in weight (5% changes on a month)

TYPES:
- the person can either gain or lose weight Passive suicidal ideation
- pero usually mag lose ug appetite ang patient pero
sometimes increasing appetite
11 PSYCHIATRIC NURSING by Sir Rex Zamoras, Aubrey

- When the person thinks about wanting to die or - 7 -1v0

whishes they were dead but has no plans to cause → Hospitalize
his/her death
- The person wishes to be dead
- reckless, self- mutilation, drug abuse
Principles of suicide
Active suicidal ideation 1. Plan: successful suicide are planned suicide
- The person seeks and do reckless things to die
- Thinks about and seeks to commit suicide 2. Method:
- Lethal
RISK FACTORS o Gunshot
o Jumping from high places
o Drowning – common worldwide but bot
common in the Philippines
SAD PERSON’s SCALE ▪ Happens when they take sleeping
pills daun adto silag bathtub till they
(Reasons why the person commits suicide)
drown
o Hanging – most accessible
Sex
o Carbon monoxide poisoning
- Men kill themselves 3x more than woman (mas
o Over dosage of medication – CNS
successful sa man)
depressant (morphine is the most common)
- Women make attempts 3x more often than women
- Non-lethal
(mas daghan ug attempt ang women)
o Wrist cutting
o Over dosage of medication – they take
Age
vitamins
- High risks groups: 19 years or younger; 45 years or
3. Poor rescue
older, especially the elder 65 and above

Depression Precipitating factors

- Studies report 35-79% of those who attempt suicide
manifested a depressive syndrome 1. Severe life’s event
- Divorce, death, sickness
Previous attempts
- 65-70% have made previous attempts 2. Sensitivity to loss: may react tragically to separation or loss
of a loved one
EtOH
- Alcohol is associated with up to 65% of successful
suicide (ineffective coping) Assessing verbal and non verbal cues

Rational thinking loss Verbal cues:

- People with functional or organic psychosis are more
Overt statements: “I cant take it anymore”
apt to commit suicide than those in the general
Covert statements: “its okay now, soon everything will be fine
population
- Developmental d/o
MGT:
- They do not know what is right and wrong
Direct question: are you planning to kill yourself?
Do you have any plans on killing yourself?
Social support lacking
- A suicidal person often lacks significant others,
meaningful employment and religious supports
- Walang karamay, you feel alone

Nonverbal cues:
Organized plan
- The presence of a specific plan for suicide signifies a Behavioral clues: sudden behavioral changes especially when
person at high risk depression is lifting and when the person has more energy
available to carry out the plan
No spouse - There is clinical improvement or once depression is
- Repeated studies indicate that persons who are lifter because they have the energy to do the task
widowed, separated, divorced or single at greater risk
than those who are married Signs: giving away prized possession, writing farewell notes,
making out a will and putting personal affairs in order
Sickness: chronic, debilitating and severe illness
SCORING *thought of suicide happens in DEPRESSION
- 0–2 *act/attempt – clinical improvement/ increase energy
→ home with follow up care
- 3-4 Somatic clue: physiological complaints can mask
→ close follow up and possible hospitalization psychological pain and internalized stress (headache, muscle
- 5–6 aches, trouble sleeping, irregular bowel habits,
→ Strongly consider hospitalization
12 PSYCHIATRIC NURSING by Sir Rex Zamoras, Aubrey

Emotional clues: social withdrawal, feeling of hopelessness SSRI:

and helplessness, confusion, irritability and complaints of - Selective serotonin reuptake inhibitor
exhaustions - Mechanism of action: increase serotonin level
- Safest and least sedating
- Has lesser s/e
Suicide Precautions - Therapeutic effect: 1 – 4 weeks
- Execute a no suicide contract. The client will inform - 1st line of treatment for depression
the nurse when they have suicidal ideation
→ This allows the nurse to have safety plans - Side effects:
→ Sexual dysfunction
- Ask direct questions. Find out if the persons has ▪ Impotence, decrease libido, delayed
specific plan for suicide. Determine what method. orgasm
- → GI discomfort
- Be alert for cries for suicide → Weight gain
▪ Best answer
- Provide a safe environment and protect client from
self - Common: “x” and “z”
→ Paxil
- Encourage to ventilate feeling and thought → Prozac
→ Zoloft
- Give emotional support → Celexa
→ Make the patient realize that the tendency to → Lexapro
commit suicide is due to the disturbance in → Luvox
the brain chemistry and is treatable once
they know what an episode of suicide TCA:
thinking will pass, they will likely not act on - Tricyclic antidepressant
impulse - Therapeutic effects: 2-4 weeks / 2-6 weeks
→ - Common: “ends with -in, starts with diana-“
→ Desipramine
- Provide structured schedule and involve in activities → Imipramine
with others to increase self worth and die → Amitrityline
→ Nortriptyline
- On discharge: help patient create plan for life → Amoxapine
→monitor patient 2 – 3 months after discharge: this is
the time when the are more prone to suicide - TCA - Purpose: increase serotonin and
norepinephrine level
- Always remember: the a suicidal person want to die - Expect anticholinergic effects
only during the suicidal period - T- two, 2nd line of treatment for depression
→ Suicidal people give warning
→ Person recovering from depression are high - C- cardiac – assess for cardiac arrhythmias
risk 9-12 months → Childhood enuresis – treatment
→ Not always happy but not mentally ill → One of the side effects: decrease in urination
→ Compulsion – treatment for OCD
- A- anticholinergic side effects

- Antidote: physostigmine (antilirium) – nerve

muscle

MANAGEMENT: MAOI’s
1. Visit: irregular - Mono amine oxidase inhibitor
- to avoid predictability - Increases all neurotransmitters
2. Close monitoring - Therapeutic effect: 2-6 weeks
3. Room: near the nurses station → close monitoring - Hypertensive crisis – interactions with tyramine
4. Remove all hazardous objects, potentially harmful - Do not take tyramine rich foods
5. Time for suicide: → Over ripe Avocado and banana
Nurses rounds → Aged cheese
Endorsement → Wine
Early morning → Chocolates
→ Fermented food
→ Soy sauce
PHARMACOLOGY MOMENTS: → Processed foods/ with preservatives
Antidepressants: - Common: “PANAMA”
1. SSRI → Parnate
2. TCA → Nardil
3. MAOI’s → Marplan
13 PSYCHIATRIC NURSING by Sir Rex Zamoras, Aubrey

Mania Depression
Apperance Colorful, Sad and gray
flamboyant

Behavior Psychomotor Psychomotor

agitation retardation

Communication Pressured Monotonous speech

speech
Alogia (poverty of
Stuttering speech)

Cluttering

Flight of ideas

Very talkative

Nursinf Dx Risk for injury Risk for injury (self)

(others Suicidal precaution

Nursing prio Safety and Safety and nutrition

nutrition (increase nutrient)
Subtypes Of Bipolar:
nutrition finger food, high Increased in
caloric nutrients 1. Bipolar 1 – mania and depression
treatment - 4 rapid cycles in a year
Lithium, ect Tca, ssri, maois, etc - more severe
2. Bipolar 2 – hypomania and depression

milieu Non – stimulating Stimulating 3. Cyclothymia – hypomania and dysthymia

environment

appropriate Quiet type: Monotonous,

activity noncompetitive noncompetitive

attitude therapy Matter of fact Kind firmness, active

friendliness

ELECTRO CONVULSIVE THERAPY

Possible indication:
→ Catatonic symptoms
→ Need for rapid control of symptoms
BIPOLAR DISORDER → Presence of suicidal behavior which puts the
life of the patient at risk
→ Presence of severe agitation or violence
which puts the life of others at risks
→ Affective symptoms
→ Refusal to eat
→ History of good response in the past
→ Patient not responding to antipsychotic med
→ Augmentation of partial response to med
→ Clozapine resistant schizo

- Induction od a grand mal seizure in the brain

- Abnormal firing of neuron in the brain causes inc in
neurotransmitter
- # tx: 6-12 mins, 3 times a week about -5-2 secs
- Unilateral or bitemporal

Preparation for ECT

- Pretreatment evaluation and clearance
14 PSYCHIATRIC NURSING by Sir Rex Zamoras, Aubrey

o Cardiopulmonary clearance Nurse patient relationship

- Consent
o Invasive, folks, patient in lucid interval 1. Prio
- NPO form midnight until after the treatment - Reduce the level of anxiety (milieu mgt)
o Risk for aspiration 2. Promotes trust through acceptanceof feelings and
- DRUGS: acknowledger of discomfort
o Atropine sulfate - dec secretions
o Succinylcholine (anectine) – to promote 3. Convey empathy and listen to patient’s concern
relaxation, prevent injury - acknowledge the clients feelings, empathize
o Methohexital sodium(brevital) - anesthetic;
dec seizure threshold 4. assess coping behaviors
- Empty bladder – clonic seizure; everything relaxes; to
avoid voiding 5. assess for suicidal tendencies
- Remove jewely, hairpins, dentures and other
accessories
Psychopharmacology
Care after
❖ Give o2 therapy 100% until patient can breathe 1. Antidepressants
unassisted a. SSRI – maintenance, first line of treatment
❖ Monitor for respi problems, gag reflex – b. TC
succinylcholine (muscle relaxant)
❖ Reorient the patient 2. Benzodiapepines
❖ Observe until stable a. Anxiolytics
❖ Careful documentation i. Diazepam, valium, lorazepam
❖ Male erectile dysfunction (WOF) ii. CNS depressant
b. Short term mgt
i. Prevent dependency
ANXIETY RELATED DISORDERS
Milieu management:
3 categories in DSM V - Recreational activities
1. Anxiety related d/o - Relaxation exercises, meditation and biofeedback
• Separation anxiety d/o - Problem solving, self – esteem management,
• Selective mutism assertiveness and goal setting
- CBT
• Phobia
o Cognitive behavioral therapy
• Panic d/o
▪ Best therapy
• GAD (generalized anxiety d/o)

2. Obsessive compulsive related d/o Panic disorder

• OCD
• Body dysmorphic disorder - Recurrent, unexpected panic attacks
o 4 in 4 weeks, sudden onset peak within 10
• Hoarding disorder
mins
• Trichotillomania
• Excoriation disorder - Panic attacks followed by a month or more of worry
about having additional attacks, about the results of
3. Trauma and stressor Related Disorder the attacks, and behavior changes related to the
• Reactive attachment d/o attacks
• Disinhibited social engagement d/o
• PTSD - Possibility accompanied by agoraphobia (fear of
• ASD crowded place)
• Adjustment disorder

General anxiety disorder Nurse patient relationship

1. excessive worry and anxiety - anxious with nothing in - Stay with the patient, acknowledge discomfort
particular o Sense of security
2. difficulty in controlling the worry o Avoid questions the client during attack
a. 6 months or more - Be calm and speak in short and simple sentences
3. 3 or more of the following: - Intervene with hyperventilation
a. Restlessness o Respi alkalosis
b. Fatigue ▪ Paper bag breathing
c. Irritability - Less stimulating environment
d. Decreased ability to concentrate o Withdraw the pt to the environment that
e. Muscle tension caused the attach
f. Disturbed sleep - Manage clients expression about perception of fear:
Management o Recurrent attacks
o Result of the attacks
15 PSYCHIATRIC NURSING by Sir Rex Zamoras, Aubrey

o Behavior during the attack

DSM – V and Separation anxiety d/o
Psychopharmacology
Developmentally inappropriate and excessive fear or anxiety
- SSRI concerning separation from those to whom the individual is
- Benzodiazepines: attached, as evidenced by at least three of the following:
o Clonazepam
o Lorazepam 1. Excessive distress in anticipation or when
experiencing separation
Milieu management 2. Persistent/excessive worry about the loss of a major
attachment figure (MAF) or harm to said figure
- Gross motor activities
3. Excessive worry about experiencing an untoward
- CBT
event such as kidnapping
Phobic disorder/ Phobia 4. Persist refusal to go out, away from home because of
fear of separation
- Agoraphobia 5. Excessive fear about being alone without MAF
o Fear of open spaces 6. Refusal to sleep away from home or to go to sleep
o Fear of crowded places without being near MAF
o Fear of inability to escape 7. Repeated nightmare involving separation from MAR
8. Repeated complaints of physical symptoms such as
- Social phobia – fear of facing the crowd headaches or stomachaches when separation occurs
o Stage fright or is anticipated
o Fear of being humiliated

- Specific phobia
Selective mutism

Specific phobia - Consistent failure to speak in specific settings despite

talking normally in others
- Claustrophobia – close space - At least for one month
- Agoraphobia – open spaces - Not due to a lack of knowledge of comfort with the
- Acrophobia – heights required language
- Hydrophobia – water - Not better explained by a communication disorder
- Xenophobia – strangers - Not occur dung autism, schizo or another psychotic
- Arachnphobia – spiders d/p
- Zoophobia – animals - Interferes with daily functioning at school and in social
- Allurophobia – cats situations
- Chromophobia – colors
- Mysophobia – dirt
- Bacillophobia – germs
- Trytophobia – holes Obsessivee compulsive related d/o
- Ophidiophobia – snakes
- Astrophobia – lighting and thunder
- Aerophobia – planes OCD

Psychopharmacology A. Obsession:
- Intrusive, inappropriate, recurrent and persistent
- SSRI thoughts, impulses or images that are distressful or
- produce anxiety
- Unsuccessful attempts to ignore or neutralize
Milieu mgt; thoughts or impulses by other thought and action
- Assertiveness training and goal setting - Recognition that obsessions are produced by own
- Behavior therapy thoughts
o Systemic desensitization - Not simply excessive worry about real – life problems
▪ Gradual exposure
o Flooding B. Compulsion
▪ Sudden exposure of the patient to - Repetitive behaviors in response to an obsession
the phobic situation until he has no - excessive behaviors or mental acts used to reduce
fear distress or prevent dreaded events, decrease anxiety
o Implosion
▪ Flooding carried out in imagination C. Behavior is unreasonable or excessive
D. Behavior cause distress and interfere with function
Management
Obsession (thought) – compulsion (ritualistic action/
1. Accept patients and their fears with a non-critical attitude
repetitive actions) – decrease of anxiety
2. Provide and involve in activities that do not produce anxiety
but will increase involvement rather than avoidance
3. Help patients with physical safety and comfort needs
4. help the patient to recognized that their behavior is a method Management
of coping with needs
5. assertive
16 PSYCHIATRIC NURSING by Sir Rex Zamoras, Aubrey

Nurse patient relationship initiated by some minor skin pathology but it can also
- ensure that basic needs are met be independent of any pathology
- provide time for rituals
- explain expectations, routines and changes - A recurrent skin – picking, resuling in lesions
- convey sympathy
- structure activities - Repeated attempts to decrease or stop skin picking
- reinforce and recognize positive non ritualistic
behaviors - The skin picking cause clinically significant distress or
- allow the ritual, don’t attempt to stop the ritual impairment in important areas of functioning
- set limits, if ritual is excessive
- The skin picking cannot be attrivuted to the
psychopharmacology physiologic effects of a substance or another medical
- antidepressant condiotn
o ssri
o TCA - Cannot be better explain by the symptoms of another
▪ Clomipramine ocnditojn
- Milieu management
o Relaxation exercise and stress management
o Recreational and social skills Body dysmorphic d/o
o CBT - Preoccupation with one ort more alleged deformities
o Problem solving skills or imperfections in appearance that are not
perceivable by other, or are considered insignifant by
Trichotillomania (hair pulling d/o) them

- Recurrent pulling out of one’s hair, resulting in hair - At a certain moment during the course of the d/o, the
loss person concerned performed repetitive actions in
- Repeated attempts to decrease or stop hair pulling response to the anxiety about appearance, or
- The hair pulling causes psychological activities performed (such as
o Significant distress or impairment in social compering one own appearance with that of others
o Occupational
o Other important areas of functioning - The preoccupation causes clinically significant
- The hair pulling or hair loss is not attributed to suffering or limitations in social or occupation
another medical condition functioning or in functioning in other important areas
o A dermatological condition
- The hair pilling is not better explained by the - The preoccupation with the appearance cannot be
symptoms of another mental disorder explained better by the worries about body fat or
o Attempts to improve a perceived defect or weight in someone whose symptoms meet the
flaw in appearance in body dysmorphic criteria for an eating disorder
disorder
- A standalone condition DSM IV – somatoform d/o
DSM V – obsessive compulsive related d/o
- Pre occupation – physical appearance
Hoarding - Imperfections – surgical enhancement (multiple
surgeries)
- Persistent difficulty discarding or parting with
possessions, regardless of their action value
- Difficulty is due to a perceived need to save the items
and distress associated with discarding them
- Results in accumulation of possession that congest
and clutter living areas and substantially
compromises their intended use
- Clinically significant distress/ impairment in social,
occupational or other important area of functioning
o Maintaining a safe environment for
self/others
- Not attributed to another medical condition
- Not better explained by another mental disorder
- Specify if: with excessive acquisition insight is
good/fair, poor, absent

Excoriation (skin picking) d/o

- Conscious creation of neurotic excoriations through
repetitive scratching. Neurotic excoriations can be